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Background The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) represents a standardized reporting system for salivary gland lesions. The recent literature has demonstrated a wide range of data regarding range of malignancy (ROM) and interobserver variability. The objective of the current study was to evaluate the reproducibility and interobserver agreement of MSRSGC, and establish the ROM in a unique patient population residing within a designated Health Professional Shortage Area. Methods A total of 380 salivary gland fine‐needle aspiration cases were obtained over a 3‐year period. Corresponding cytology reports and slides were reviewed in a blinded fashion by a panel of cytopathologists and recategorized using MSRSGC. ROM was calculated by cytohistologic correlation in 176 cases. Agreement between review of reports and slides and interobserver reliability were determined using kappa statistics. Results The ROMs per MSRSGC category based on review of reports and slides were as follows: 4% and 0%, respectively, for nonneoplastic; 22% and 0%, respectively, for nondiagnostic; 42.9% and 48%, respectively, for atypia of undetermined significance; 1.6% and 1.9%, respectively, for benign‐neoplastic; 17.9% and 15.6%, respectively, for salivary gland neoplasm of uncertain malignant potential; 81.8% and 71.4%, respectively, for suspicious for malignancy; and 100% and 90.5%, respectively, for malignant. There was a 59.2% overall agreement between review of reports and slides with regard to recategorizing salivary gland lesions (kappa, 0.51). The interobserver reliability demonstrated a 64.6% agreement (weighted kappa, 0.59). Conclusions The ROMs at the study institution appeared comparable to those in the published literature. There was moderate overall agreement among cytopathologists and low interobserver agreement with regard to the indeterminate categories. Image‐guided fine‐needle aspiration specimens; rapid onsite adequacy; and integration of clinical, imaging, and ancillary studies can improve diagnostic accuracy among indeterminate lesions.

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Objective: To report a case of hypercalcemic crisis in an African American male who presented with a nonhealing ulcer which was later found to be squamous cell carcinoma.Methods: All relevant data, radiologic imaging, and pathology reports were reviewed in detail. An in-depth literature review for humoral hypercalcemia of malignancy and cutaneous squamous cell carcinoma was performed using MEDLINE.Results: A 58-year-old man with a history of chronic lymphedema presented with fever and a nonhealing left foot ulcer. Initial studies revealed acute kidney injury, anemia, and non-parathyroid hormone (PTH)-mediated hypercalcemic crisis (calcium, 17.7 mg/dL). A thorough work-up ruled out bone metastasis and confirmed increased PTH-related peptide, which is the hallmark of humoral hypercalcemia of malignancy (HHM). Hypercalcemia was initially managed with intravenous fluid hydration, bisphosphonates, and calcitonin. The patient had surgical resection of the left leg, and pathology revealed cutaneous squamous cell carcinoma. Hypercalcemia resolved completely after surgical resection of the tumor.

Thoracic SMARCA4‐deficient undifferentiated tumor (SMARCA4‐UT) is a rare entity that was recently described in the current World Health Organization Classification of Tumors. These lesions are highly aggressive with dismal prognosis, and most patients present with metastasis at the time of diagnosis. While there are about 100 cases of SMARCA4‐UT described in the literature, there are only few existing reports that describe the cytomorphology of these lesions. We present a patient with masses involving the mediastinum, right lung, right supraclavicular lymph node and right adrenal gland. Subsequent core‐needle biopsy of the right supraclavicular lymph node showed epithelioid to pleomorphic tumor cells with prominent nucleoli and associated granulomatous inflammation. The tumor cells were positive for CD34 and synaptophysin, and were negative for cytokeratins. SMARCA4 and SMARCA2 both showed loss of expression, which led to the diagnosis of SMARCA4‐UT. The patient underwent treatment with pembrolizumab (PD‐1 blocker), carboplatin, etoposide, and radiotherapy, resulting in an almost 55% reduction in the size of the primary tumor. Our case illustrates that an associated granulomatous inflammation might be an uncommon presentation of an already rare malignancy, and awareness of this phenomenon would prevent from mistaking SMARCA4‐UT for other more well‐known entities that can present with granulomas.