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Letters to the Editor

Many salivary con- Medical City, Abu Dhabi, United Arab Performance tain both stroma and epithelial and Emirates Characteristics of myoepithelial cells, which have differ- ent and variable characteristics with 1. Tabatabai ZL, Auger M, Kurtycz DF, et al. Adenoid Cystic Performance characteristics of adenoid cystic carci- different stains. In addition, the spatial noma of the salivary in fine-needle aspirates: of the Salivary relationship between the stroma and results from the College of American Pathologists the cells is of importance in different Nongynecologic Cytology Program. Arch Pathol Glands in Fine-Needle Lab Med. 2015;139(12):1525–1530. doi:10.5858/ salivary gland tumors. Therefore, we arpa.2013-0173-CP. Aspirates strongly believe that these issues play 2. Kopec´ T, Mikaszewski B, Jackowska J, Was´- aroleininflatingthedegreeof niewska-Okupniak E, Szyfter W, Wierzbicka M. Treatment of parotid malignancies—10 years of misinterpretation at both ends of the experience. J Oral Maxillofac Surg. 2015;73(7): spectrum (both false negatives and 1397–1402. doi:10.1016/j.joms.2014.12.036. To the Editor.—We read with depth false positives). We are quite sure that 3. Bruzgielewicz A, Osuch-Wojcikiewicz´ E, and interest the article by Tabatabai et the authors are aware of these limita- Majszyk D, et al. of the 1 head and neck—a 10 years experience [in Polish]. al addressing the performance char- tions but we were compelled to raise Otolaryngol Pol. 2011;65(5 suppl):6–11. acteristics of adenoid cystic carcinoma these important points in this letter to 4. Ellington CL, Goodman M, Kono SA, et al. (ACC) of the salivary glands in fine- the editor for a couple of important Adenoid cystic carcinoma of the head and neck: needle aspirates, resulting from the incidence and survival trends based on 1973-2007 reasons. First, we are afraid that such a Surveillance, Epidemiology, and End Results data College of American Pathologists high number of errors may cause fear [erratum in . 2012;118(21):5448–5449]. Nongynecologic Cytology Program. and intimidation among pathologists Cancer. 2012;118(18):4444–4451. doi:10.1002/ The authors elegantly described and cncr.27408. to the point of discouragement in their 5. Al-Abbadi MA. Pitfalls in salivary gland fine- documented the statistical perfor- attempts to interpret salivary gland needle aspiration cytology [author reply in Arch mance regarding these ACCs during cytology. Second, the notion that fine- Pathol Lab Med. 2006;130(10):1428]. Arch Pathol a 10-year period. As described by the Lab Med. 2006;130(10):1428. needle aspiration is the recommended 6. Hughes JH, Volk EE, Wilbur DC; Cytopathology authors, this important and valuable initial diagnostic tool for salivary gland Resource Committee, College of American Pathol- educational program is performed and lesions may be affected, consequently ogists. Pitfalls in salivary gland fine-needle aspira- managed by our association, the Col- tion cytology: lessons from the College of American pushing our clinician colleagues to Pathologists Interlaboratory Comparison Program in lege of American Pathologists (CAP). avoid using this approach as the Nongynecologic Cytology. Arch Pathol Lab Med. The CAP staff and the scientific preferred preoperative diagnostic tool. 2005;129(1):26–31. committee have to be commended Third, making a specific preoperative on their efforts to help raise the diagnosis of ACC based on the cytol- The authors have no relevant financial standard of care for our profession. ogy of a salivary gland mass is interest in the products or companies However, as mentioned briefly by extremely critical for the treating described in this article. the authors in the Material and surgeon. There is a need not only for Methods and Comment sections, this differentiating ACC from other benign doi: 10.5858/arpa.2016-0138-LE Nongynecologic Cytology Program is mimickers such as pleomorphic ade- carried out by sending 1 slide, together noma, but also for differentiating ACC with a brief history of the patient, to from other malignancies, as this will participants. Consequently, it is re- be helpful to the surgeon, who will quired that participating institutions, approach ACC differently from other pathologists, and cytotechnologists such as low- to interme- evaluate the slide and render an diate-grade mucoepidermoid carcino- In Reply.—We thank Dr Al-Abbadi opinion on a general categorization ma and basaloid . and Dr Aziz for their interest in our and then try to give a specific inter- Surgical excision of ACC is more article,1 for their thoughtful com- pretation. Despite the fact that these radical than that of other carcinomas; ments, and for highlighting the limi- slides are thoroughly evaluated by the and ear, nose, and throat oncologic tations of the study. We do point out committeetomakesurethatthe surgeons would prefer that an accurate in our article that the lower sensitivity cytologic features are clear and inter- diagnosis of ACC be made preopera- in our data may be due to the fact that pretable, this educational exercise is tively.2–4 The latter point was not well our study is based on a single-slide very far from the usual and routine emphasized by the authors and we interpretation and that this setting practice that we all follow. As we all certainly hope that this letter may be probably does not truly mimic the know, fine-needle aspiration of sali- of value in addressing this issue. actual practice of cytology, where vary gland lesions has certain pecu- Lastly, similar issues were raised in a more clinical and radiologic informa- liarities and deserves close attention. It previous letter5 in 2006 addressing tion may be available and where is highly recommended by experts in similar shortcomings of the CAP interpretation is usually made on the field that interpretation of salivary program; these were reported by several slides, including various and gland aspirates be made with extreme Hughes et al.6 complimentary preparation types such caution, taking into consideration the as Papanicolaou- and modified Giem- clinical and radiologic data and the Mousa A. Al-Abbadi, MD1;Luaay sa–stained slides, and possibly cell patients’ symptoms during the aspira- Aziz, MD2 block and/or ancillary testing. The tion process, and most importantly, intention of our article certainly was thoroughly evaluating multiple slides 1 Departments of Pathology & Labo- not to discourage the use or perfor- and smears with Diff-Quik, Papanico- ratory Medicine, and 2 ENT and Head mance of fine-needle aspirations laou, and hematoxylin-eosin stains. and Neck Surgery, Sheikh Khalifa (FNAs) in the evaluation of salivary Arch Pathol Lab Med—Vol 140, November 2016 Letters to the Editor 1183 Letters to the Editor gland lesions, but rather to (1) em- The authors have no relevant financial data reveal a similar trend in Oncotype phasize that when presented with interest in the products or companies DX RS among histologic excellent diagnostic material our par- described in this article. subtypes: The 2 most common were ticipants were able to provide concor- invasive of no special dant diagnoses, (2) present a review of doi: 10.5858/arpa.2016-0334-LE type (IDC, n ¼ 228) with an average RS cytomorphologic characteristics of ad- of 17 6 9.5, followed by invasive lobular enoid cystic carcinoma, and (3) point carcinoma (ILC, n¼51) with a mean RS out that even in particularly difficult To Oncotype or Not: of 16.6 6 6.9 (Table 1). Other subtypes cases of adenoid cystic carcinoma included mixed invasive ductal and where basaloid features are evident Knowledge of Histologic lobular carcinoma (ID&LC), mucinous and predominate but the stromal Grade and Subtype May carcinoma (MC), mixed ductal and component is scant to absent on mucinous carcinoma (ID&MC), and FNA material, a descriptive diagnosis Help invasive carcinoma with micropapillary of salivary gland with basa- component (ICMP). Recurrence scores loid features, in the appropriate clin- in 2 cases of tubular carcinoma (TC) ical and imaging context and with were 12 and 18; the RS in 1 case of clinical symptoms consistent with To the Editor.—We read with great 1 carcinoma with medullary features was perineural involvement, can be fol- interest the article by Bomeisl et al regarding Oncotype DX recurrence 63 (high risk). lowed up with appropriate surgical Among 68 of 328 histologic grade management. scores (RS) among histologic types of 1tumors(20.7%),44(64.7%)were We recognize and tend to point breast carcinoma. This brief report of classified as low risk and 24 (35.3%) out in similar papers from this Oncotype DX test results offers a were predicted as intermediate risk group2 that our situation, a profi- comparison with their results in a larger cohort. We reviewed all (n ¼ 328) for recurrence (Tables 2 and 3); there ciency-testing environment, is very Oncotype DX tests (Genomic Health were no high-risk grade 1 tumors in different from a clinical day-to-day Inc, Redwood City, California) request- our cohort. The pattern of RS in the working environment. The fact that ed at our institute from 2011–2015; our 2 histologic subtype–based prognosis cytologists can make the diagnosis when good material is available for evaluation should only encourage Table 1. Average Recurrence Score and Patient Age in Different Histologic the acquisition of and improve the Subtypes nature of such samples. We also Recurrence Recurrence encourage development of standards Histologic Total No. Score, Score, Patient Age, Patient Age, such as the proposed Milan System Subtype (% of Total) Mean (SD) Range Mean (SD), y Range, y for Salivary Gland Cytopathology, Invasive ductal 228 (69.5) 17 (9.5) 0–55 54.4 (9.4) 28–78 which can help to bring coherence carcinoma to the field and can improve utility of Invasive lobular 51 (15.5) 16.6 (6.9) 3–47 57 (9.6) 30–74 salivary gland FNA cytology and, carcinoma Mixed invasive 20 (6.1) 15.4 (9.0) 5–47 56.5 (9.9) 42–71 thus, patient care. ductal and lobular Daniel F. I. Kurtycz, MD1; Manon carcinoma Auger, MD2; Rodolfo Laucirica, MD3; Invasive mucinous 5 (1.5) 3.8 (1.7) 10–19 48.8 (9.4) 38–60 Z. Laura Tabatabai, MD4 carcinoma Mixed ductal and 6 (1.8) 20 (6.4) 12–30 61.3 (5.0) 56–68

1 mucinous Department of Pathology, Wisconsin carcinoma State Laboratory of Hygiene, Madison; Tubular 2 (0.6) 15 (4.2) 12–18 50 50 2 Department of Pathology, McGill carcinoma University Health Sciences Center, Invasive 15 (4.6) 14.2(11.4) 0–46 58.6 (9.7) 40–75 Montreal, Quebec, Canada; 3 Depart- carcinoma with micropapillary ment of Pathology and Immunology, component Baylor College of Medicine, Houston, Carcinoma with 1 (0.3) 63 63 54 54 Texas; 4 Department of Pathology, medullary University of California San Francisco features All 328 (100) 16.8 (9.4) 0–63 55.1 (9.5) 28–78 1. Tabatabai ZL, Auger M, Kurtycz DF, et al. Performance characteristics of adenoid cystic carci- Abbreviation: SD, standard deviation. noma of the salivary glands in fine-needle aspirates: results from the College of American Pathologists Nongynecologic Cytology Program. Arch Pathol Lab Med. 2015;139(12):1525–1530. Table 2. Histologic Grade Versus Recurrence Score 2. Hughes JH, Volk EE, Wilbur DC; Cytopathology Resource Committee, College of American Pathol- All Tumors Low (0–17), Intermediate (18–30), High (31–100), ogists. Pitfalls in salivary gland fine-needle aspira- (N ¼ 328) No. (%) No. (%) No. (%) tion cytology: lessons from the College of American Grade 1 44 (64.7) 24 (35.3) 0a Pathologists Interlaboratory Comparison Program in Grade 2 141 (63.8) 70 (31.7) 10 (4.5) Nongynecologic Cytology. Arch Pathol Lab Med. 2005;129(1):26–31. Grade 3 12 (30.8) 14 (35.9) 13 (33.3) a Likelihood ratio P , .001. 1184 Arch Pathol Lab Med—Vol 140, November 2016 Letters to the Editor