Fine needle aspiration cytology of breast masses in children and adolescents: experience with 1404 aspirates

OBJECTIVE

To study the distribution and efficacy of fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions in pediatric and adolescent patients.

STUDY DESIGN

From January 1993 to December 2006, the cytology reports of 1404 breast aspirates (178 males and 1226 females) performed on children and adolescents (ranging from 1 to 21 years) were reviewed. Of these 41, 179, 506 and 678 aspirates belonged to the age group 1-<12, 12-<16, 16-< 19 and 19-21 years, respectively.

RESULTS

The morphologic spectrum seen in females was inflammatory lesions (4%), benign ductal cells (20%), ductal hyperplasia (0.6%), papillary lesions (0.7%), benign neoplasms (69%), suspicious cytology (0.3%) and cancer (0.3%). Of the benign neoplasms, 98% (831 of 851) were fibroadenomas, with 12 cases of phyllodes (benign), 5 cases of lipoma and 3 cases of adenoma. There were 3 cases of malignancy (2 adenocarcinoma and 1 non-Hodgkin's lymphoma). Only 3% of the male breast aspirates provided a diagnostic challenge, while 89% of them showed benign ductal cells.

CONCLUSION

FNAC of children and adolescent breast masses is helpful and can reduce the need for open surgery to prevent later deformity. The aspirates are mostly benign and can be managed conservatively.

Tuberculous brain abscess in a patient with HIV infection

Tuberculous Brain Abscess (TBA) is a rare manifestation of CNS tuberculosis. Only a few cases have been reported in literature. A twenty six year old male presented with high grade fever, throbbing headache and altered sensorium. Examination revealed neck stiffness and papilloedema. His chest X-ray showed evidence of healed pulmonary tuberculosis. MRI Brain showed a well circumscribed hyper intense lesion in the left parietal region with perilesional edema and mass effects. Stereotactic aspiration of the abscess yielded frank creamy pus. PCR for Mycobacterium tuberculosis MPB 64 was positive which confirmed the lesion to be of tuberculous etiology. Patient responded well to four-drug regimen of antitubercular treatment.

Crystalline bodies in Pap smear: a forgotten entity

Crystalline bodies were detected in the Pap smear of a 34-wk pregnant woman who presented with postcoital bleeding.

Cytomorphology of hyaline-vascular Castleman's disease: a diagnostic challenge

OBJECTIVE

Hyaline-vascular Castleman's disease (CD) is difficult to diagnose on fine needle aspiration and may be mistaken to be a lymphoreticular malignancy because of the presence of large cells having nuclei showing atypical features. The cytomorphological findings in three histopathologically documented cases of hyaline-vascular CD were evaluated to a set of cytomorphological criteria which could help in the identification of this condition on aspirate smears.

METHODS

The Papanicolaou and Diff-Quik stained smears from three cases of histologically documented hyaline-vascular CD were reviewed by one author. After review the following cytomorphological criteria were suggested to be indicators of the lesion. (i) The presence of large oval to round cells having ill-defined cytoplasmic margins and large nuclei with irregular nuclear outlines having fine or coarse chromatin giving a crumpled tissue paper appearance. (ii) A polymorphous population of lymphoid cells predominantly of small lymphocytes in the background. The smears from these three cases were then mixed with smears from four cases of reactive lymphoid hyperplasia and three cases of Hodgkin's lymphoma. These ten cases were blindly evaluated by two other cytopathologists in order to evaluate the utility of the proposed criteria in identifying CD.

RESULTS

The cytomorphological criteria seen in the methodology section were present in all the cases. These features were helpful in distinguishing CD from reactive lymphoid hyperplasias and Hodgkin's Lymphomas in all cases except one case.

CONCLUSION

Although hyaline-vascular CD is a difficult diagnostic entity on aspirate material the presence of large histiocytic cells with a crumpled tissue paper appearance of the nuclei in a background of small lymphocytes are useful indicators for suspecting this lesion. However, these findings should be analysed in larger studies to determine if they could in anyway reduce the diagnostic dilemma in cases of CD.

Cytomorphological and immunocytochemical study of non-Hodgkin's lymphoma in pleural effusion and ascitic fluid

INTRODUCTION

Non-Hodgkin's lymphoma (NHL) is often complicated by pleural effusion and ascites. The present study is an attempt to categorize the lymphomatous effusions according to the WHO classification, using archival material.

METHODS

May-Grünwald-Giemsa and Papanicolaou-stained smears of 31 lymphomatous effusion specimens were reviewed. Of these, detailed cytological assessment was done on 12 pleural effusions and ten ascitic fluid specimens from 22 patients using the WHO lymphoma classification system. Immunocytochemical studies were performed in 21 specimens.

RESULTS

Based on cytomorphological features, the 22 lymphomatous effusion specimens were categorized into lymphoplasmacytoid lymphoma (1), follicle centre cell (FCC) grade-1 (centrocytic) lymphoma (3), FCC grade-2 (centrocytic-centroblastic) lymphoma (3), FCC grade-3 (centroblastic) lymphoma (4), large cell immunoblastic lymphoma (4), lymphoblastic lymphoma (2), anaplastic large cell lymphoma (3) and miscellaneous types (2). Immunocytochemically, the lymphoma cells were T-cell (positive for CD3) and B-cell type (CD20 positive) in five and six cases respectively.

CONCLUSION

Cytological examination of pleural effusion and ascitic fluid samples, supported by immunocytochemical studies, may be useful for the classification of lymphomas under the WHO system.

Role of urinary cytology in detecting human polyoma bk virus in kidney transplant recipients. A preliminary report

OBJECTIVE

To report data on the evaluation of the efficacy of urine cytology in detecting BK virus (BKV).

MATERIAL AND METHODS

Papanicolaou-stained cytospin preparations of randomly collected urine samples from 8 renal transplant (RTR) patients (5 males, 3 females, age: 23-63 years) who previously tested positive for BKV by PCR in urine or blood or both were studied. Urine sediment from 3 of the patients was processed for ultrastructural examination (EM). Renal biopsies before and after BKV detection were also evaluated.

RESULTS

The interval between renal transplant and urine cytology ranged between 2 and 5 years. Urine from females was difficult to assess due to vaginal contamination. In 2 of the 5 urine specimens from male recipients BKV-infected decoy cells were identified. Viral particles suggestive of BKV were identified on EM in 2 of the 3 specimens studied. Kidney biopsies showed morphologic features suggestive of BKV infection in 2 cases, 1 each detected on cytology and EM, respectively.

CONCLUSION

Screening for the presence of decoy cells in urine provides a simple sensitive means for the diagnosis of BKV nephropathy in RTR.

Fine needle aspiration cytology: a survey of current European practice

Fine needle aspiration cytology (FNAC) is practised widely throughout Europe. The majority of countries have dedicated cytopathologists as well as histopathologists practicing cytology. Despite this, FNAC is performed mostly by clinicians and radiologists except in the larger centres with dedicated staff with a special interest in cytopathology. The advent of One-Stop diagnostic services and image-guided procedures are prompting further development of FNAC clinics where cytopathologists take their own samples, issue reports in the same clinical session and take extra material for ancillary tests to complete the diagnosis. The volume of FNAC work varies accordingly; in dedicated centres FNAC represents up to 80% of the workload whilst, in the majority of countries, it represents one quarter or less. Hence, the rate of inadequate FNAC varies widely, depending on the local sampling policies and the organ, but does not exceed 25% in any of the countries. The most sampled organs are breast and thyroid, followed by lymph nodes. Most countries have dedicated training in cytopathology for pathology trainees, the duration varying between 6 months and 2 years of the total training time. This discussion, focusing on European practices, highlights the heterogeneity of FNAC activity but also its success in many centres where it is practiced to a high standard, particularly in breast, thyroid and lymph node pathology. The relatively high rate of inadequate material in some centres reflects local policies and calls for greater uniformity of FNAC practice, particularly specimen sampling. To achieve this, the future direction should concentrate on specialist training, to include performing as well as interpreting FNAC, as part of the curriculum. Current emphasis on web-based training may not provide first hand experience of the FNAC procedure and should be supplemented by attending FNAC clinics and developing the technique to its full potential.

Value of scoring system in classification of proliferative breast disease on fine needle aspiration cytology

Fine-needle aspiration (FNA) cytology is successful in identification of benign and malignant breast lesions, but its role in proliferative breast lesions which increase cancer risk is poorly defined. We have analyzed the cytomorphologic features of proliferative breast lesions in conjunction with cytologic scoring system proposed by Masood et al and with histopathology. Sixty two patients (14 cases of fibroadenoma, 15 cases of fibroadenoma with atypia, 11 cases of proliferative breast disease (PBD), 8 cases of PBD with atypia and 14 cases of carcinoma) diagnosed on routine FNA were subjected to scoring following Masood's criteria. All cases with the cytologic diagnosis of fibroadenoma were confirmed on histology. Of 11 cases of PBD on FNA, 10 were PBD without atypia on histology. One case, which showed atypical hyperplasia on histology, was missed by both the scoring system and cytomorphology and one case was over-diagnosed as PBD with atypia by the scoring system. FNA cytology correctly identified all the carcinoma cases, while the scoring system under-diagnosed 2 cases as PBD with atypia. Hence, in cases not suspected to be atypical or confirmed to be cancer on routine cytology, scoring added no information over and above cytomorphology and was not useful. All fourteen cases of fibroadenoma with atypia suspected on routine cytology were fibroadenoma on histology. Scoring system correctly placed 11/14 of these cases as PBD without atypia. Similarly 3/8 cases thought to be PBD with atypia were correctly placed as PBD without atypia by scoring. Only 2/8 cases thought to be PBD with atypia on cytology were confirmed to have atypical hyperplasia on histology. Scoring improved the diagnostic yield to 2/5. Hence, in cases of fibroadenoma or PBD, suspected on FNAC to have cytological atypia, Masood scoring gives additional information by eliminating benign cases and improving diagnostic yield. Application of scoring in a step-wise manner, on atypical aspirates, can help in selection of cases suitable for biopsy.

Utility of galectin 3 expression in thyroid aspirates as a diagnostic marker in differentiating benign from malignant thyroid neoplasms

Galectin-3 is a 31kD beta-galactoside binding lectin, which is known to be expressed in various neoplasms including thyroid tumors. This study was conducted to study the role of galectin-3 in differentiating benign from malignant thyroid nodules onfine needle aspirates (FNAC). Galectin-3 immuocytochemistry was performed in 70 cases with adequate smears. The cytology diagnosis of these cases was: papillary carcinoma (25), follicular neoplasm (16), adenomatous goiter (20), hyperplastic nodule (5), medullary carcinoma (5) and anaplastic carcinoma (1). Galectin-3 positivity was seen in 80% of papillary carcinomas, 37.5% offollicular neoplasms and in 60% of benign nodules. The single case of anaplastic carcinoma was positive but all the cases of medullary carcinoma were negativefor galectin-3. Three of thefollicular neoplasms that were diagnosed on histology as carcinoma were positive on cytology and one case offollicular adenoma was also positive. Our study shows that galectin-3 is strongly expressed in smears of papillary carcinoma. However, since it is also expressed in a variety of benign lesions, its role as a pre-surgical markerfor differentiating benignfrom malignant thyroid nodules is limited.

Role of fine-needle aspiration cytology in the diagnosis of secondary tumors of the thyroid—twenty years' experience

Secondary tumors of the thyroid, presenting as thyroid nodules although rare, have been documented in literature. This study highlights the frequency, primary sites, and the role of fine-needle aspiration cytology (FNAC) in evaluating secondary tumors of the thyroid at a tertiary care hospital. There were 24 documented cases of secondary tumors of the thyroid from 1982 to 2002 (20 years). The aspirates and histology slides of all these cases were reviewed and the findings noted. On FNAC, 17 cases were diagnosed as secondary tumors, 3 as primary, and in 4 cases it was difficult to categorize the tumors as either primary or secondary. In 12 out of 24 cases, the primary tumor was seen to arise in the larynx (9), and in other sites anatomically close to the thyroid including the trachea (1), and the esophagus (2). Metastases from distant organs were also observed. Secondary tumors of the thyroid are rare and should be suspected in patients when the FNAC shows cytological features not seen in primary thyroid tumors. FNAC alone was required to accurately diagnose secondary tumors of the thyroid in a majority of cases (17/24); however, in some cases ancillary techniques may be required for a definite diagnosis.

Epithelioid hemangioma: Morphological presentation on aspiration smears

Epithelioid hemangioma (EH) or angiolymphoid hyperplasia with eosinophilia is an uncommon but distinctive lesion seen principally in the skin and subcutaneous tissue. The histopathology of this disease is very characteristic, but error in diagnosis is possible on cytopathology. There are very few case reports describing the cytomorphology of this lesion. We describe the findings of fine-needle aspiration of two cases of EH both arising in the subcutaneous tissue of the head and neck. Both the cases were misdiagnosed on cytology with one case being misinterpreted for an epithelioid sarcoma and the other for a reactive lymph node. The cytological findings of these cases are described and the problems encountered in the diagnosis of this entity are highlighted in this case report.

Changing spectrum of squamous cell abnormalities observed on papanicolaou smears in Mubarak Al-Kabeer Hospital, Kuwait, over a 13-year period

OBJECTIVE

The aim of this study was to determine the incidence of squamous cell abnormalities in cervical cytology in Mubarak Al-Kabeer Hospital, Kuwait, and to document any change in the pattern of these lesions.

MATERIALS AND METHODS

Over a 13-year period (1992-2004), 86,434 cervical smears were studied in Mubarak Al-Kabeer Hospital, Kuwait. Conventional Pap smears were first examined by cytotechnicians and finally reported by cytopathologists. The smears were classified according to the modified Bethesda system. The age of presentation of squamous cell abnormalities in Kuwaiti women was analyzed.

RESULTS

Smears from 83,052 (96.09%) patients were found satisfactory for reporting while the remaining 3.9% was unsatisfactory. Atypical squamous cells of undetermined significance (ASCUS) were seen in 1,790 (2.2%) cases, atypical glandular cells of undetermined significance (AGUS) in 630 (0.8%) cases, low grade squamous intraepithelial lesion including human papillomavirus changes (LSIL) in 824 (1.0%) cases, high grade squamous intraepithelial lesion (HSIL) in 189 (0.2%) cases, and carcinoma in 79 (0.1%) cases of which 44 (0.05%) were squamous cell carcinoma. A comparison of average cases/annum during the study period revealed a significant increase in ASCUS from 1.13 to 2.83% (p < 0.001) and AGUS from 0.33 to 1.08% (p < 0.001). However, the percentage of LSIL, HSIL and carcinoma detected in Pap smears remained the same.

CONCLUSION

A significant linear trend (p < 0.001) was observed in satisfactory smears, ASCUS and AGUS over the years. However, no significant change was found in the detection of LSIL, HSIL and carcinoma. A reduction in the age of LSIL/HSIL and an increasing trend in the number of Kuwaiti women over the years was also observed which makes screening of young women essential in Kuwait.

Diagnosis of Pneumocystis pneumonia by bronchoalveolar lavage cytology: experience at a tertiary care centre in India

BACKGROUND

Diagnosis of Pneumocystis pneumonia requires morphological demostration of P. carinii (now re-named as P. jiroveci). Although bronchoalveolar lavage (BAL) fluid cytology constitutes a formidable tool for detecting this infection, few studies on the utility of BAL cytology in diagnosing PCP are available from India. The present study reports the clinical spectrum, cytomorphological features and the utility of BAL cytology in diagnosing Pneumocystis infection from a tertiary care centre in India.

METHODS

Retrospective study of 13 patients with PCP, diagnosed on examination of BAL fluid.

RESULTS

The mean age of the patients was 41.2 years. One patient had human immunodeficiency virus (HIV) infection, while the other 10 were renal transplant receipients on immunosuppressive therapy. The immune status of two patients was unknown. Fever, cough and shortness of breath were the main presenting symptoms. Radiological diagnosis of Pneumocystis pneumonia was offered in only one case. Foamy alveolar casts were present in all cases. Silver methanamine stain enhanced the rounded, helmet or cleft forms of sporozoites. Inflammatory infiltrate was mainly polymorphonuclear.

CONCLUSIONS

BAL cytology, thus, constitutes a useful diagnostic modality for morphological documentation and reliable diagnosis of Pneumocystis pneumonia in an immunocompromised host. Pneumocystis pneumonia appears to be a common opportunistic infection in renal transplant receipients in India.