Kendall, FL, United States
Kendall, FL, United States

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Renshaw A.A.,Baptist Hospital of Miami
Archives of Pathology and Laboratory Medicine | Year: 2010

UroVysion (Abbott Molecular Inc, Des Plaines, Illinois) is a US Food and Drug Administration-approved test for the diagnosis of urothelial carcinoma. Although widely used, there are a variety of different ways to evaluate and interpret the test, and questions remain about the test's cost effectiveness and reproducibility in actual clinical practice. I suggest that the College of American Pathologists has a unique opportunity to create educational programs focusing on borderline or difficult urine cytology and UroVysion samples to provide data upon which to make evidence-based decisions concerning the best use of these tests.


BACKGROUND: Atypical cells of undetermined significance (AUS) in thyroid fine-needle aspirates (FNAs) may have poor interobserver agreement. Some authors have suggested that "atrophic" microfollicles should be diagnosed as benign. This laboratory sought to determine whether criteria for this diagnosis could be improved by subcategorizing cases into specific patterns, including the atrophic pattern, and determining their risk of malignancy. METHODS: A series of 7089 FNAs were reviewed and correlated with subsequent resection specimens. Cases of AUS were reviewed and subclassified. RESULTS: Cases could be subcategorized into the following categories: 1) atypical, papillary carcinoma cannot be ruled out, 2) atypical, Hurthle cell neoplasm can not be ruled out, 3) cellular atrophic pattern, 4) scant atrophic pattern, and 5) cytologic atypia alone. Cytologic atypia alone (50%) and both atrophic patterns (21% and 34%) had a significant risk of malignancy. CONCLUSIONS: The majority of AUS cases in thyroid FNA can be subcategorized into 5 different patterns, all with associated significant risk of malignancy. "Atrophic" microfollicles are a significant risk factor for malignancy and should not be diagnosed as benign on the basis of lack of cytologic atypia. © 2011 American Cancer Society.


BACKGROUND: Although a wide variety of papillary carcinomas of the thyroid can have abundant granular cytoplasm and may be difficult to distinguish from HCurthle cell lesions in fine-needle aspirations (FNAs), the literature on these tumors is limited. The author described 18 cases with a spectrum of cytologic appearances. METHODS: A series of 7089 FNAs was correlated with 1331 subsequent resection specimens. Cases in which the original cytologic and histologic diagnoses included the differential diagnosis of papillary carcinoma or HCurthle cell lesions were identified. RESULTS: A total of 18 (1.3% of cases with resection) cases were identified. On review, 3 cases had classic features of papillary carcinoma, including nuclear crowding, along with a moderate amount of granular cytoplasm. Four cases had a population of cells that mimicked repair and/or cyst-lining cells with almost no other epithelial cells. In 2 of those 4 cases, the cells were extremely large, and in 2 other cases, they could not be distinguished from typical cyst-lining cells. The remaining 11 cases had cells with overlapping features including pale to granular chromatin, small to medium nucleoli either centrally or eccentrically, occasional grooves, and rare intranuclear inclusions. Typical HCurthle cells also were commonly present. Nuclear crowding was not present, and the cells were in sheets, follicles, or appeared alone. No papillae were identified. On resection, 7 cases were follicular variants of papillary carcinoma, 2 cases occurred in the setting of Hashimoto thyroiditis, and 2 cases had features of the tall-cell variant. CONCLUSIONS: The author concluded that a subset of papillary carcinomas of the thyroid were difficult to distinguish from HCurthle cell lesions or repair and/or cyst-lining cells because of the presence of abundant granular cytoplasm and a lack of nuclear crowding. These tumors were often follicular or cystic variants of papillary carcinoma. © 2011 American Cancer Society.


Renshaw A.A.,Baptist Hospital of Miami
American Journal of Clinical Pathology | Year: 2010

Repeated fine-needle aspiration of the thyroid is sometimes recommended after an atypical diagnosis. However, histologic follow-up for patients with a benign second aspirate is limited. I reviewed the results of all thyroid aspirations with repeated aspirations and surgical resection for the last 13 years at Baptist Hospital, Miami, FL, and Homestead Hospital, Homestead, FL, and combined these with the results of intraoperative cytology and the literature. During the period, a total of 7,089 cases were aspirated and 1,331 resections were performed. There were 6 (1.7%) of 361 false-negative cases. Relevant intraoperative cytology was available for 24 cases. The order of the diagnoses (benign then atypical, atypical then benign) did not significantly affect the risk of malignancy (15% and 9%; P = .30). Patients with an atypical and benign diagnosis had a risk of malignancy (15%) higher than a single negative aspirate (3%; P < .001) and lower than that of patients with a single atypical diagnosis (27%; P > .001). Repeated aspirates are not independent events. Patients with a benign diagnosis after an atypical diagnosis have a risk of malignancy between the risks of a single benign or atypical diagnosis. Cytologists should strive to better communicate this risk. © American Society for Clinical Pathology.


Villanueva T.,Baptist Hospital of Miami
Journal of Hospital Medicine | Year: 2010

Patients with acute coronary syndrome (ACS) undergo several transitions in care throughout the hospital stay, from prehospitalization to the postdischarge period when patients return to primary care. Hospitalist core competencies promote safe transitions in care for patients with ACS, including hospital discharge. These competencies also highlight the central role of the hospitalist in facilitating the continuity of care and as a key link between the patient and the primary care provider (PCP). Core competencies address key decision points and processes that occur during hospitalization for ACS including the initial evaluation and risk stratification, medication reconciliation, and discharge planning. Discharge is a crucial transition and one where hospitalists can both facilitate the transition to primary care and improve adherence to quality measures established for ACS. Poor communication during discharge reportedly results in postdischarge adverse events, most often related to medications and lack of follow-up related to pending test results. Standards for a safe discharge such as Project RED (Re-Engineered Discharge), initiatives to improve outcomes after discharge like Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), and adaptive tools including the ACS Transitions Tool support timely and accurate communication of complex information between the hospitalist, the PCP, and the patient. While the role of hospitalists is evolving, it is clear that they have a central role in ensuring safe transitions in care for ACS. © 2010 Society of Hospital Medicine.


Uthoff H.,Baptist Hospital of Miami
Journal of vascular surgery | Year: 2012

This study presents the short-term and midterm results of direct percutaneous sac injection (DPSI) for postoperative endoleak treatment after endovascular aortic aneurysm repair (EVAR). Between March 1994 and November 2011, EVAR was performed in 986 patients. The median follow-up was 63 ± 45 months (range, 0-211 months). A retrospective analysis was performed. DPSI was used in 21 patients for 19 type II endoleaks and two endoleaks of undefined origin (EOUO), of which 12 (57%) were after failure of a previous endovascular treatment attempt. DPSI using thrombin (n = 16), coils (n = 7), gelfoam (n = 6), or glue (n = 3), or a combination, was technically feasible in all patients. Saccography during DPSI revealed a previously undetected type I endoleak in three patients. Immediate DPSI success was achieved in 16 of 18 procedures (88.9%), with two complications. Glue incidentally intravasated in the inferior vena cava, causing a clinically nonsignificant subsegmental pulmonary artery embolism in one patient, and the temporary development of a type III endoleak, possibly from graft puncture, in another. During a median follow-up of 39 months (interquartile range, 13-88 months) after DPSI, recurrent endoleaks were observed in nine patients (50.0%), one type I endoleak due to graft migration, five type II endoleaks, and three EOUO. The occurrence of a re-endoleak during follow-up was significantly associated with dual-antiplatelet medication (0% in patients without re-endoleak vs 44.4% in patients with re-endoleak; P = .023) and with a nonsignificant trend for the use of aspirin alone (33.3% in patients without re-endoleak vs 80% in patients with re-endoleak; P = .094). Re-endoleak occurred in 33.3% of the patients without antiplatelet medication and in 100% of patients with dual-antiplatelet medication (P = .026). Thrombin was used as the sole embolic agent during the initial DPSI in all patients with dual-antiplatelet therapy. No other factor was significantly associated with re-endoleaks. Reintervention was deemed necessary in six patients within a median of 10 months (interquartile range, 4-16 months) after DPSI, including six additional DPSI treatments in four patients with type II re-endoleaks, cuff placements in one type I endoleak, and endograft relining in one EOUO. This initial experience suggests that DPSI is feasible as a technique for endoleak treatment after EVAR. However, complications and endoleak recurrence remain a concern. The role of antiplatelet therapy and different embolic agents on long-term embolization success needs to be studied in more detail. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.


Renshaw A.A.,Baptist Hospital of Miami
Diagnostic Cytopathology | Year: 2011

Fine-needle aspiration (FNA) of the thyroid for papillary carcinomas is highly sensitive. We sought to determine if the sensitivity of FNA for papillary carcinoma is correlated with the size of the tumor. We reviewed the results of thyroid resections for the last 12 years and correlated the findings with clinical and cytologic information. During the time period, a total of 1,331 resections were performed, and a total of 501 papillary carcinomas were identified, including 291 classic tumors, 65 follicular variants, and 145 "incidental" tumors. Sensitivity for all tumors was strongly correlated with tumor size and ranged from a sensitivity of 0-3% for tumors 2 mm or less, 90% for tumors 1-3 cm (220/244, P < 0.001) and 83% for tumors above 3 cm (47/59, P = 0.02). Abnormal FNAs of classic tumors were always recognized as papillary (262/262) compared to only 49% of follicular variants (32/65, P < 0.001). The sensitivity of FNA for papillary thyroid carcinoma is strongly correlated with tumor size. Tumors smaller than 0.5 cm and tumors larger than 3 cm may be more difficult to successfully aspirate on FNA, and the follicular variant may be more difficult to recognize as papillary. © 2010 Wiley-Liss, Inc.


Renshaw A.A.,Baptist Hospital of Miami
American Journal of Clinical Pathology | Year: 2011

Nondiagnostic thyroid fine-needle aspirations are associated with a risk of malignancy that can be reduced with repeated aspiration. However, the significance of repeated nondiagnostic aspirates is less well studied. This study assessed the risk of malignancy for repeated nondiagnostic aspirates from a large series of cases using the results of histologic follow-up. From a series of 7,089 aspirates, there were 1,671 nondiagnostic aspirates (23.6%), and 235 of these (14.1%) had histologic follow-up. The risk of malignancy for a single nondiagnostic aspirate was 20.0% (47/235). A total of 51 cases had repeated aspiration. The risk of malignancy for cases with a second nondiagnostic aspirate was 0% (0/23), which was significantly less than for patients with a single nondiagnostic aspirate (20.0%; P =.03). Patients with 2 sequential nondiagnostic thyroid aspirates have a very low risk of malignancy. Cytologists should strive to better convey this risk in their reports. © American Society for Clinical Pathology.


Renshaw A.,Baptist Hospital of Miami
Cancer Cytopathology | Year: 2010

BACKGROUND: The risk of malignancy for a benign diagnosis in a thyroid fine-needle aspiration is controversial because of lack of histologic follow-up. METHODS: The author reviewed the results of all thyroid aspirations with surgical resection performed during the past 13 years at Baptist Hospital of Miami and Homestead Hospital, Homestead, Florida, combined these procedures with those in the literature, and correlated risk of malignancy with percentage of biopsies performed. RESULTS: A total of 7089 aspirations and 1331 resections were performed. In the literature, the percentage of all benign cases that underwent resection ranged from 3% to 41%. Risk of malignancy decreased with an increased percentage of resections. The risk of malignancy for series with <8% of all benign aspirates resected was significantly higher than the risk for series with ≥8% of cases biopsied (15.1% vs 5.9%, P=.02). Logarithmic and linear estimates of risk of malignancy if 100% of cases were biopsied were 3% and 2.5%. CONCLUSIONS: The best estimate of the risk of malignancy for a benign diagnosis in a thyroid fine-needle aspiration is 2.5%-3%. This level of risk is affected by the percentage of benign cases that are resected. © 2010 American Cancer Society.


Renshaw A.A.,Baptist Hospital of Miami
Cancer Cytopathology | Year: 2010

Background: Recently reported Bethesda terminology suggests the use of the term "atypical follicular cells" for thyroid fine-needle aspirates. Previous work has suggested that some types of "atypical follicular cells" have different risks of malignancy. METHODS: The author reviewed the results of all thyroid aspirations with surgical resection performed during the past 13 years at our institution, subclassified the "atypical follicular cells," and compared their relative risk of malignancy. RESULTS: During the 13 years in question a total of 7089 cases were aspirated with 1331 resections. A total of 548 (14%) of all cases were classified as "atypical follicular cells," and 204 (37%) were resected with an overall risk of malignancy of 25%. The risk of malignancy for atypical follicular cells subclassified as "rule out papillary carcinoma" was significantly higher (38%) than the other atypical cells. The risk of "rule out Hurthle cell neoplasm" was, at 7%, significantly lower than the other cases of atypical follicular cells (P<.001 and P<.02, respectively). CONCLUSIONS: Different types of "atypical follicular cells" have significantly different risks of malignancy. This disparity of risk should be communicated by the cytologist. © 2010 American Cancer Society.

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