Sclerosing angiomatoid nodular transformation (SANT) is a benign vascular lesion of the spleen with uncertain etiology. It predominantly affects women between the ages of 30 and 60 years. Clinically, it is asymptomatic or can cause abdominal pain, but usually discovered incidentally on imaging, which can identify a mass but may not provide a definitive diagnosis. In uncertain vascular lesions, there is always a risk of spontaneous rupture of large vessels and the potential for spreading malignancy. Hence, the final diagnosis is rendered on microscopy after splenectomy. A middle-aged female came to the clinic complaining of abdominal pain. Radiology showed a solid splenic mass and the patient underwent splenectomy. Gross examination showed a 3 cm white firm mass with focal hemorrhage. Microscopy revealed multiple nodules of variable sizes surrounded by fibrosclerotic stroma. The nodules showed round to slit-like vascular spaces with numerous red blood cells. The internodular stroma consisted of dense fibrous tissue with scattered plump myofibroblasts and lymphoplasmacytic inflammatory cells. These distinctive features lead to the diagnosis of SANT. SANT possesses characteristic histologic features with distinctive immunohistochemistry (IHC). IHC reveals three different types of vessels within the nodules as follows: (1) small veins (CD34-, CD31+, CD8-), (2) sinusoids (CD34-, CD31+, CD8+), and (3) capillaries (CD34+, CD31+, CD8-). All three types of vessels are negative for CD21/CD35 and CD68. Hemangioma and littoral cell angioma are two frequent vascular tumors in the spleen that should be considered differential diagnoses. Both lesions lack the microscopic features of SANT and have only a single type of vessel. The vessels in hemangioma are (CD31+, CD34+, CD8-), while in littoral cell angioma they are (CD31+, CD34-, CD8-, CD21+, CD68+). There are no specific clinical or radiologic findings for SANT. It is important to recognize these characteristic features and to differentiate them from other benign and malignant lesions, such as angiosarcoma. A thorough histopathologic examination and IHC are helpful in making the correct diagnosis.

Epidermal growth factor receptor (EGFR) gene mutations play an important role in the treatment management of non-small cell lung cancer (NSCLC) patients. After a first- or second-generation EGFR tyrosine kinase inhibitor (TKI) therapy, the most common resistance mechanism involves the selection of a resistant clone carrying the exon 20 p.T790M point mutation. However, also for these patients, treated with a third-generation TKI (osimertinib) several mechanisms of acquired resistance are described. Here we report the case of a 68-year-old man with an EGFR exon 19 deletion treated with gefitinib in first line and osimertinib in second line besides on the presence of a p.T790M mutation, who developed an uncommon EGFR exon 20 p.L792Q point mutation at the progression to osimertinib, with the concomitant modification of the original sensitizing EGFR exon 19 deletion and the loss of p.T790M mutation.

BACKGROUND: Papillary Thyroid Carcinoma presenting initially as a hypervascular mass is exceedingly rare. The objective of this paper was to present the rare pathology along with the utilization of multimodal imaging to establish a correct diagnosis along with current management and review of literature.
METHODS: We describe a 33 year old male who presented with a left-sided neck mass. CT with contrast of the neck revealed a hypervascular, ring enhancing, complex cystic lesion in the left sub-clavicular and supraclavicular neck deep to the SCM, with accompanying edema. The differential diagnosis was broad and difficult to achieve given the fine needle aspiration biopsy was inconclusive. Eventually, the patient underwent a total thyroidectomy with a left modified radical neck dissection, central neck dissection, and partial resection of sternocleidomastoid muscle.
CONCLUSIONS: A large hypervascular mass presenting as a papillary thyroid carcinoma is difficult to discern but with combination of ultrasonography, soft tissue CT and angiography imaging, along with fine needle aspiration, and possible use of MRI would be successful in narrowing down the differential list to the final diagnosis of papillary thyroid carcinoma, supporting the need for punctual surgical intervention.

BACKGROUND: The roles of pathologists and cytotechnologists (CTs) continually evolve to optimize patient care, particularly with regard to rapid on-site evaluation (ROSE). Having ROSE performed helps ensure sufficient material is obtained for diagnosis and permits appropriate specimen triage for ancillary studies. At our institution, both on-site and telecytology evaluations are increasingly utilized, particularly in endobronchial ultrasound-guided procedures (EBUS). Consequently, time demands placed on the pathologist and CT staff has significantly increased, creating workload management challenges.
METHODS: A consecutive number of ROSE procedures were documented for a 3-month time period at our institution. Case type and time spent for travel, adequacy assessment, processing, screening, and sign-out was recorded in order to assess time demands placed on staff by different procedures.
RESULTS: Average travel/processing time by CTs was variable among ROSE procedures (72.9 minutes), as was adequacy assessment time by pathologists (16.9 minutes). EBUS posed the greatest time challenges with the longest CT travel/processing time as EBUS took almost 40% longer and adequacy assessment took the pathologist 3-4 times longer when compared with other procedures because of the targeting of multiple sites during EBUS with associated procedural delays. Using telecytology, average pathologist adequacy assessment time was reduced from 44.8 minutes to 24.6 minutes for EBUS. The provision of ROSE for EBUS is more challenging from a workload management perspective than for other procedures.
CONCLUSIONS: ROSE reimbursement is low, and no greater for EBUS than for other procedures. Use of telecytology can save time for pathologists and make the service more cost-effective if the number of procedures is sufficient to justify investment in the technology.

The nomenclature \"Non-invasive Follicular Neoplasm with Papillary-like Nuclear Features (NIFTP)\" was introduced in 2016. While NIFTP differs from classic papillary thyroid carcinoma (PTC) in imaging, cytomorphology, histology, molecular profile, treatment, follow up, outcome, and behavior, it largely overlaps with follicular variant of PTC at imaging and cytomorphology. Herein, we review the literature for better understanding NIFTP, and its impact on patient care.
The English literature was thoroughly evaluated with the key word of \"Noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP)\".
NIFTP presents as a thyroid nodule. On imaging, it is a round-to-oval, well circumscribed mass with solid internal content. Aspirated material shows a microfollicular pattern with focal nuclear features of PTC mostly reported in categories 3-5 of the Bethesda System for Reporting Thyroid Cytology (TBRSTC). NIFTP has decreased risk of malignancy in TBRSTC categories 3-6. Histologic examination of NIFTP reveals an encapsulated neoplasm with follicular pattern and nuclear features of PTC with no capsular or vascular invasion. No papillary structure, atypia, or mitosis is present. In contrast to PTC, only 4% of NIFTP cases harbor a BRAF mutation. Because NIFTP carries an excellent prognosis and indolent behavior, the tumor behavior was changed from malignant to a neoplasm with tumor with extremely indolent behavior. The recommended treatment is lobectomy with no further ablation therapy. Until better understanding of NIFTP, patient\'s follow up should be occasionally performed by neck ultrasonography and serum thyroglobulin measurement.
NIFTP carries an excellent prognosis. It is critical for both clinicians and patients to be aware of extremely indolent behavior of NIFTP in order to prevent unnecessary, aggressive treatment.

Italian consensus for the classification and reporting of thyroid cytology was published in 2014 and it has been used in almost all Italian institutions. To date, there are not solid data on the reliability of Italian consensus for the classification and reporting of thyroid cytology in classifying low and high risk indeterminate nodules (Tir 3A and Tir 3B, respectively). Here, we reviewed and meta-analyzed the results of published articles to obtain evidence-based information on this topic.
A comprehensive literature exploration of online databases was conducted by searching all published papers citing Italian consensus for the classification and reporting of thyroid cytology. The search was updated until June 2017, and references of the retrieved articles were also screened. Only original articles reporting histologic follow-up of nodules cytologically classified as Tir 3A and Tir 3B were eligible for inclusion.
The literature search revealed 62 articles and six of these were eligible for the study. All papers were retrospective and published very recently. Overall, 423 indeterminate lesions, of which 180 Tir 3A and 243 Tir 3B, were found. Of these, 29 cancers were recorded in Tir 3A and 127 in Tir 3B. The pooled rate of malignancy was 17% (95% CI = 12 to 22%) in Tir 3A and 52% (95% CI = 46 to 58%) in Tir 3B. No significant publication bias was evident.
Italian consensus for the classification and reporting of thyroid cytology 2014 shows high reliability in discriminating indeterminate lesions at low risk of malignancy from those at high risk.

BACKGROUND: Pseudomyxoma peritonei (PMP) is a rare condition caused by mucinous adenocarcinoma cancerous cells that produce abundance of mucin or gelatinous ascites. This cancer can cause tissue fibrosis and can impair normal organ function. Diagnosis can involve multiple imaging modalities including CT scan. There have been few cases of endoscopic ultrasound (EUS) being used as a means for diagnosis of this condition. Here we report a second case of PMP with a previous history of appendectomy diagnosed with EUS guided fine needle aspiration (FNA) biopsy.
METHODS: A 66-year-old male with a history of an appendectomy presented with intermittent abdominal pain for two years and weight loss of 40 pounds over two months. EGD and colonoscopy performed at an outside hospital was unremarkable. CT abdomen revealed perigastric ascities and lesions of the liver. ESR was elevated at 75. At our facility, EUS was performed revealing a peri-gastric and omental mass measuring 36.6 mm × 25.5 mm. FNA performed of both mass and ascetic fluid revealed low grade mucinous adenocarcinoma with mucinous deposits in the peritoneum consistent with PMP.
CONCLUSIONS: Endoscopic ultrasound guided FNA, although very rarely used, can be a reliable and safe technique in diagnosis of PMP.