Background: The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) is based on risk stratification. We presented our experience with fineneedle aspiration cytology (FNAC) for the diagnosis of salivary glands lesions by applying the MSRSGC categorization to the cytological diagnoses, and determined risk of malignancy (ROM) for each category. Methods: Fine-needle aspiration cytology of salivary gland lesions performed over a 6-year period was retrieved. FNAC results were retrospectively categorized according to the MSRSGC criteria, and correlated with corresponding histologic follow-up. ROM for each diagnostic category was calculated. Results: A total of 208 FNAC of salivary gland lesions were reviewed and retrospectively categorized as: non-diagnostic (ND) 23 (11%), non-neoplastic (NN) 54 (26%), atypia of undetermined significance (AUS) 10 (4.8%), benign neoplasms (BN) 77 (37%), salivary gland of uncertain malignant potential (SUMP) 13 (6.3%), suspicious for malignancy (SM) 7 (3.4%), and malignant (M) 24 (11.5%). Histopathological follow-up was available for 84 of 208 cases (40.4%). Overall concordance rate between FNAC and histology was 78.8%. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated as 93.3%, 94.6%, 82.4%, and 98.2%, respectively. Diagnostic accuracy to distinguish benign from malignant disease was 94.4%. ROM for each category was ND 0%, NN 0%, AUS 75%, BN 2.2%, SUMP 28.6%, SM 50%, and M 100%. Conclusion: Fine-needle aspiration cytology continues to be an accurate diagnostic tool for most salivary gland neoplasms showing classical morphologic features. However, difficult cases with unusual or overlapping features will occur. In these situations, the use of MSRSGC risk-stratification could be helpful to define appropriate management.
A 31-year-old man presented with hemoptysis, cough, shortness of breath, and pleuritic chest pain. On investigation, he was found to have azotemia. Renal biopsy confirmed concurrent antiglomerular basement membrane disease and membranous nephropathy consistent with Goodpasture syndrome. Therapeutic plasma exchange was initiated (ASFA Category I). Initially, dark tea-colored plasma was noted in the apheresis waste bag (figure, left), suggestive of red cell destruction (lactate dehydrogenase, 693 U/L; normal range, 300-600 U/L; bilirubin level not available). In subsequent procedures, the red-brown color faded and a green opaque discoloration was noted (figure, right). Green discoloration of plasma is a rare but well-recognized occurrence associated with various phenomena. Possible causes include increased ceruloplasmin levels associated with high estrogen states or inflammatory conditions. Green pigment may also be produced by gram-negative cryophilic contaminants in plasma, such as Pseudomonas. Infrequently, medications such as sulfonamides may result in a dark green discoloration in blood. Green pigment was noted in the waste plasma for 2 weeks. Possible causes were investigated. The patient was not taking any medications that could produce sulfhemoglobinemia. His ceruloplasmin level was normal. The patient had been ventilator dependent for several days and subsequently developed pneumonia. Sputum cultures were positive for Pseudomonas aeruginosa, which produces the characteristic green pigments pyocyanin and pyoverdin. All blood cultures remained negative, most likely due to antibiotic therapy. It is our hypothesis that the green discoloration noted in the apheresis waste bag was a result of green pigment, produced by P. aeruginosa in the lungs, which disseminated into the circulation.Left: Dark tea-colored waste plasma from initial plasma exchange. Right: Transition to opaque green waste plasma in subsequent plasma exchanges.
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