Fine needle aspiration cytology of epithelioid variant of schwannoma--a diagnostic dilemma

Epithelioid variant of schwannoma is a rare type of benign nerve sheath tumor which has an aggressive clinical course in comparison to the conventional schwannoma. We report one such case in a 53 year old female with an aspirate from a swelling in the nape of the neck. It posed a diagnostic dilemma because of its cellularity numerous groups of plump epithelioid cells along with multinucleated cells. The cells were lying in a myxoid stroma, coming singly and in nests and cords thus mimicking an epithelial tumor. The initial cytologic diagnosis of possibly a skin adnexal tumor was rendered. This case highlights the diagnostic pitfall encountered in the aspiration cytology of neurogenic tumors.

Aspiration cytology for diagnosis of tuberculosis--perspectives in India

Tuberculosis (TB) a common cause of mortality can readily be diagnosed by fine needle aspiration. The technique is a simple, cost effective, out patient procedure with a high diagnostic accuracy both in adults and children. The diagnostic morphologic findings comprise of epithelioid cell granulomas and giant cells with or without necrosis. Often an acute inflammatory exudate is obtained. Stain for acid fast bacilli immensely augments diagnosis especially in cases where necrosis or an inflammatory exudate is obtained. Culture studies on aspirated material are time consuming though diagnosis is enhanced. PCR can be applied to detect mycobacterial DNA and has been applied on aspirated material and found to be more sensitive in the detection of tuberculosis. In children TB of lymph nodes is readily identified and so also from other sites such as bone and soft tissues. In children FNAC also plays a role in detection of BCG adenitis, infection with atypical mycobacteria and co-existing infections such as HIV and AIDS.

Subcutaneous myxopapillary ependymoma presenting as a childhood sacrococcygeal tumor: a case report

Subcutaneous myxopapillary ependymoma in a sacrococcygeal location is an uncommon lesion. We report such a case in a 16-mo-old female child, who presented with a sacrococcygeal mass since birth. The cytological picture was that of a malignant small round cell tumor and the diagnosis was missed on cytology, which was retrospectively confirmed on comparison with histology. Although rare, this lesion can be a potential diagnostic pitfall and needs to be distinguished from other malignant tumors occurring at this age and at a similar location, like sacrococcygeal teratoma with immature elements, primitive neuroectodermal tumor (PNET), and PNET with ependymal differentiation.

Fine needle aspiration cytology of minor salivary gland tumours of the palate

Fine needle aspiration cytology of minor salivary gland tumours of the palate This retrospective study was carried out to review aspirates from minor salivary gland tumours of the palate and to assess the problems encountered in their diagnosis, especially the cytological diagnosis of newer entities such as polymorphous low grade adenocarcinoma (PLGA). Fifty-five cases of palatal salivary gland tumours aspirated over a period of 16 years were reviewed. Histology was available in 26 cases. Pleomorphic adenoma (27 cases) was the most common benign cytodiagnosis. Eleven aspirates were malignant tumours of which eight cases were adenoid cystic carcinoma and three cases were mucoepidermoid carcinoma. Seven cases were diagnosed on fine needle aspiration as suggestive of PLGA. However histological confirmation was available in only one of these cases. Concordance between the initial and revised typings of the tumours was seen in only 28 cases (54%) in the present study. Initially 18 of the 51 tumours (35.3%) could not be typed; and after review, only three could not be typed. Three cases of oncocytoma could be diagnosed on review only. Palatal salivary gland tumours, although relatively uncommon, are difficult to diagnose cytologically. This is more so in cases of newer entities such as PLGA, as their cytological diagnosis is still not well characterized.

Telomerase--a potential molecular marker of lung and cervical cancer

Telomerase, a ribonucleoprotein enzyme that adds hexameric TTAGGG nucleotide repeats onto telomeres is reactivated in most malignancies. Lung cancer is a common malignant disease worldwide as well as in India. Most patients present in advanced stages. As noninvasive diagnostic techniques are preferred, we assayed the telomerase activity in pre-bronchoscopy sputum and compared it with that of bronchial washings and bronchoscopic biopsies by telomeric repeat amplification protocol (TRAP) in 53 cases of lung cancer. These were corroborated with cytopathological/histopathological examinations. Telomerase activity was detected in 58.5% of sputum samples, 70% of bronchial washings and 74% of bronchoscopic biopsies thereby making it a good noninvasive diagnostic marker of lung cancer. Cervical cancer is the 7th most common cancer worldwide, with 100,000 new cases being reported annually in India. It is routinely screened by Papanicolaou's (Pap) smear. Human papilloma virus (HPV) is one of its etiological agents. We have assayed telomerase activity in relation to HPV-16/18 in cervical samples from 93 subjects ranging from normal to precancerous to frank cancers in tissue biopsies and cervical scrapings. HPV infection was detected by polymerase chain reaction (PCR) in 81% of tumor samples, in 6% of control hysterectomy samples and in 2% of cervical scrapings of normal healthy controls with HPV-16 being the predominant type. Telomerase activity was detected in 96.5% of cervical tumor samples, in 68.7% of premalignant cervical scrapings but was not detected in control hysterectomy samples, or in cervical scrapings of normal healthy controls. There was 71% correlation between telomerase activity and HPV-16/18 infection.

Cytomorphological spectrum in gynaecomastia: a study of 389 cases

Cytomorphological spectrum in gynaecomastia: a study of 389 cases The objective of this study was to document the spectrum of cytomorphological features in aspirates from gynaecomastia. During a 22-year period (July 1979 to June 2001) fine needle aspirations (FNA) were conducted on 651 males with a breast lesion. Fine needle aspirate slides from 529 benign cases were reviewed along with the histological sections of 54 cases where available. Of the 529 FNA, 140 were excluded (105 unsatisfactory, five cystic fluid aspirated, 30 inflammatory lesions). In 134 of 389 cases reviewed florid gynaecomastia was observed while the remainder showed benign ductal cells (BDC) in varying quantities from less than five to more than 25 groups. Of the 134 cases with florid gynaecomastia, 49 had a fibroadenoma-like picture (FLP), where a large number of BDC fragments with a staghorn configuration, prominent stromal fragments with contoured stroma and bare bipolar nuclei were seen abundantly in all cases. In 85 cases the features resembled fibroadenomatoid hyperplasia (FH), with only an occasional staghorn configuration of BDC seen in 82% of the cases. In 83% of cases stromal fragments of varying proportions were seen but a contoured stroma was seen in only 3.5% of cases. Both stromal and epithelial atypia were seen in 41% and 86% cases, respectively, of FLP, and in 7% and 69% cases of FH. Columnar cells, apocrine cells and foam cells were seen in approximately similar quantities in both the lesions. Vascularized stroma was seen in 22% of the cases with FLP but in only 4.5% of cases those with FH. Cytohistological correlation performed in 54 cases showed marked variation. Fine needle aspirates showed florid changes in 13 of the 41 cases of simple gynaecomastia and two of the eight cases with florid gynaecomastia on tissue sections. In conclusion, a wide spectrum of morphological features are encountered in FNA from benign male breast lesions. It is important to recognize these to avoid a false-positive diagnosis.

Schwannomas: a pitfall in the diagnosis of pleomorphic adenomas on fine-needle aspiration cytology

Fine-needle aspiration cytology (FNAC) is being employed with increasing frequency for the preoperative diagnostic workup of salivary gland lesions. Although most cases show morphologic features very characteristic of specific entities, few lesions, both benign and malignant, can cause problems in interpretation. We report four cases initially diagnosed on FNA as spindle-cell tumors, possibly benign nerve sheath tumors (BNST) in the salivary gland region. These cases were later diagnosed on histologic examination as schwannoma (two cases) and as pleomorphic adenoma (two cases). Review of the cytomorphology of these four cases enabled the correct diagnosis of pleomorphic adenoma in the two cases misinterpreted as BNST. Benign peripheral nerve sheath tumors should always be considered in the differential diagnosis of pleomorphic adenoma. A diligent search for epithelial elements is recommended prior to diagnosing BNST in the head and neck region.

Cytomorphologic features of papillary cystadenocarcinoma of the parotid

The fine-needle aspiration cytology findings in four cases of recently classified cystadenocarcinoma of the parotid gland are reported. In three cases a recurrent tumor was aspirated. Smear preparations in all four cases were cellular, with numerous papillary projections, single cells, and sheets of cells in varying proportion in a proteinaceous to mucoid background. The background mucin was in varying proportions. The cells were cuboidal to tall columnar with basal nuclei and mild pleomorphism. The cytoplasm was dense in three cases with variable amounts of mucin. In one case (Case 4) the epithelial cells resembled mucin-secreting goblet cells, while in another case (Case 1) the cytoplasm showed multiple vacuolations. Mitosis was rare. Lymphoid tissue was seen in one case while macrophages and giant cells were seen in two cases. Epidermoid differentiation was absent in all four cases. Pathologic evaluation of the resected tumor confirmed the cytologic diagnosis. Clinical and radiologic evaluation failed to reveal any other potential primary site. Papillary cystadenocarcinomas of the parotid are rare but can be accurately diagnosed on FNAC. However, they need to be differentiated from mucoepidermoid and papillary acinic cell tumors.

Role of fine needle aspiration cytology in diagnosis of pleomorphic adenomas

This retrospective study was carried out to review the cases diagnosed as pleomorphic adenoma in major or minor salivary glands and determine the difficulties encountered on typing this tumour on fine needle aspiration cytology (FNAC). Over a 19-year period (1982-2000) 488 pleomorphic adenomas were diagnosed on FNAC from different sites (parotid - 372 cases, submandibular - 95 cases; oral cavity - 21 cases). Histology was available in 232 cases. Twenty-nine cases where a histological diagnosis of pleomorphic adenoma was made but the cytological diagnosis was variable were also reviewed. In 216 of the 232 cases a good cytohistological correlation was available. On review only 4 of the 16 cases initially diagnosed as pleomorphic adenoma on FNAC where the histology revealed a different tumour were categorized as pleomorphic adenoma, while 3 each were classified as adenoid cystic carcinoma and benign tumour ?type, and 2 each were diagnosed to be muco-epidermoid carcinoma, monomorphic adenoma and acinic cell carcinoma. On review of the FNAC smears from 29 cases where a histological diagnosis of pleomorphic adenoma was available while the cytological diagnosis was variable, only 11 (38%) were categorized as pleomorphic adenoma. In the majority of the remaining cases the cytological diagnosis did not alter markedly, 7 of 10 cases where the tumour could not be typed on cytology initially could not be typed even on review. In conclusion, FNAC is an ideal, fairly accurate preoperative procedure for the diagnosis of pleomorphic adenomas. Certain diagnostic problems occur in differentiating pleomorphic adenomas from adenoid cystic carcinoma, monomorphic adenoma and mucoepidermoid carcinoma. Carcinoma ex-pleomorphic adenoma is difficult to identify on FNAC and in our series all 4 such cases on histology were considered benign on cytology.

Microfilariae of Wuchereria bancrofti in cyst fluid of tumors of the brain: a report of three cases

Microfilariae of various nematodes, including Loa loa, Dirofilariae, and Onchocerca volvulus, have been identified in the central nervous system (CNS). The CNS, however, is a rare site for the isolation of microfilariae of Wuchereria bancrofti. To the best of our knowledge, the presence of microfilariae of W. bancrofti in tumor cyst fluids or cerebrospinal fluid has not been reported to date. We report three cases in which microfilariae were identified in the cyst fluid of tumors of the brain. Cyst fluid aspirated from space-occupying lesions in the thalamus and C6-D1 spinal segments in a 46-yr-old man and a 35-yr-old man, respectively, showed numerous microfilariae of W. bancrofti, along with fragments of tumor suggestive of glioma. In the third case, in a 12-yr-old boy, the fluid from the space-occupying lesion in the third ventricle showed microfilariae in a necrotic dirty background with a few squames and cholesteral crystals. Histopathologic examination of the tumor showed an anaplastic astrocytoma and a low-grade astrocytoma in the first two cases, respectively, and a craniopharyngioma in the third case. No microfilariae were identified on the histology sections.

Parasites in fine needle breast aspirates--assessment of host tissue response

Parasites in the human breast are uncommon but not rare. Cysticercus and filariasis in fine needle breast aspirates have been documented and their cytomorphology is well characterised. However, the host tissue response to these parasites and the factors responsible for their initiation are not clear. Over a 21 year period, 28 cases of breast parasites (16 cases of cysticercus and 12 of filariasis), diagnosed by fine needle aspiration cytology, were reviewed to assess the host tissue response.

Fine-needle aspiration cytology of umbilical nodules: "Sister Joseph's nodule"

Metastatic tumor deposits in the umbilicus are not uncommon. Fine-needle aspiration cytology is an important, simple, cost-effective diagnostic tool for delineating the value of umbilical nodules. However, only a few reviews and case reports of diagnosis of umbilical metastases by fine-needle aspiration cytology are available. A review of 52 cases of umbilical nodule aspirates over a 16-yr period forms the basis of this brief report.

A comparative study of telomerase activity in sputum, bronchial washing and biopsy specimens of lung cancer

The potential of telomerase, the ribonucleoprotein enzyme, as a non-invasive screening marker was studied in pre-bronchoscopy sputum (S), bronchial washings (W) and bronchoscopic biopsy (B) samples from individuals under evaluation for lung cancer. Out of the 52 cases studied, 42 were clinically suspected primary lung cancer patients and 10 had pulmonary disorders but had no clinical evidence of lung cancer. Fifteen (39.5%) S samples, 24 (63.1%) W samples and 32 (84.2%) B samples, which were cytologically/histopathologically positive were also positive for telomerase activity. Interestingly, 16 (42%) S samples, 20 (52.6%) W samples and 20 (52.6%) B samples, initially reported cytologically/histopathologically negative, showed detectable telomerase activity. Lung cancer was finally confirmed in these cases by repeat cytology/histopathology. However, telomerase activity was detected in 31 (81.6%) S, 26 (68.4%) W and 33 (86.8%) B samples of suspected lung cancer patients. Telomerase activity was negative in S, W, and B of four of the suspected cases, which ultimately turned out to be negative for lung cancer. Cytopathology/histopathology alone (including repeat attempts) identified 15 (39.5%) cases of sputum, 24 (63.1%) cases of bronchial washings and 32 (84.2%) bronchoscopic biopsy samples. Out of 10 controls, low telomerase activity was detected in only one (10%) of the bronchial washings, which later turned out to be due to large number of inflammatory cells. Telomerase activity assay of sputum carried sensitivity, specificity and diagnostic accuracy of 81.6, 100 and 86.5%, respectively, while that for bronchial washing was 68.4, 100 and 76.9%, respectively, and for bronchoscopic biopsy samples was 86.8, 100 and 88.1%, respectively. A positive correlation (P<0.01) was seen between age and telomerase activity in sputum, bronchial washing and biopsy samples but no significant correlation was seen between sex and telomerase activity or duration of smoking and telomerase activity. A significant positive correlation was observed between staging and telomerase activity in sputum (P<0.01), bronchial washing (P<0.01) and biopsy samples (P<0.01). Our findings indicate that telomerase is a specific marker for malignant lung disease and can complement cytology/histopathology in the diagnosis of lung cancer. Sputum telomerase assay holds the potential for early and non-invasive diagnosis of lung cancer.

Langerhans cell histiocytosis in lymph nodes. Cytomorphologic diagnosis and pitfalls

OBJECTIVE

To delineate the cytomorphology of Langerhans cell histiocytosis (LCH) in lymph nodes.

STUDY DESIGN

Nine histologically documented LCH cases with a prior lymph node aspirate and five more cases in which a cytologic diagnosis of LCH was rendered in a background of corroborative clinical and radiologic findings were included in a retrospective study over a 12-year period (January 1988-January 2000). Papanicolaou- and May-Grünwald-Geimsa-stained smears were reviewed by two independent observers. Staining for S-100 protein was available in four cases.

RESULTS

Nine cases had multisystem involvement, while in five cases only lymph nodes were involved. The ages ranged from 5 months to 27 years, with 11 males and 3 females. An initial cytologic diagnosis of LCH had been rendered in six, suspected in four and missed in four. On review, all were reclassified as LCH except two cases, which were still thought to be reactive and necrotizing lymphadenitis. The pathognomic feature of LCH, the "LCH cell," was identified in 12 of 14 cases along with varying numbers of eosinophils, polymorphs and lymphocytes. Giant cells were seen in six cases, and plasma cells were rarely seen.

CONCLUSION

Lymph node involvement by LCH can be identified by fine needle aspiration in 85% of cases. The presence of the LCH cell is a must. The differentials to be considered are dermatopathic lymphadenitis, sinus histiocytosis with massive lymph-adenopathy, Hodgkin's lymphoma and malignant histiocytosis.

Utility of fine-needle aspiration cytology in the classification of leprosy

The role of fine-needle aspiration cytology (FNAC) in the diagnosis of benign skin lesions has been restricted primarily to the evaluation of bacteriologic and morphologic indices in leprosy. This study was undertaken to evaluate the efficacy of FNAC in the diagnosis and classification of lepromatous lesions. Aspirates of 94 newly diagnosed cases of leprosy were studied, and the bacterial load was determined by modified Ziehl-Neelsen (ZN) stain. A skin biopsy was taken from the same site at the same sitting. Frozen and paraffin sections stained with hematoxylin-eosin (H&E) and ZN stains were examined from the biopsy specimen. In 61 of 94 cases (64.9%), the aspirates were satisfactory. Both diagnosis and classification of leprosy were possible in 40 of these 61 cases; the rest of the aspirates showed nonspecific chronic inflammation. The 39 cases of leprosy where a biopsy was available from the same site were classified on FNAC into tuberculoid (TT and BT), lepromatous (LL and BL), and midborderline (BB) subtypes. Taking the histologic diagnosis and Ridley-Jopling classification to be the gold standard, a strong concordance in tuberculoid leprosy cases (18 of 20 cases, 90%) and in lepromatous cases (15 of 16 cases, 93.7%) was observed. Midborderline cases of leprosy posed a problem, and a correct cytohistological correlation was observed in only one of the three cases.

Papillary carcinoma of the thyroid and its variants: a cytohistological correlation

Fine-needle aspiration cytology (FNAC) is considered highly specific for the diagnosis of papillary carcinoma of the thyroid (PCT). In recent years, several variants of PCT have been described. An attempt was made to gauge the accuracy of classification of variants of PCT on aspirates. Cytology smears from 124 of 150 cases of histologically proven PCT with a prior FNAC were reviewed over a 16-yr period. A diagnosis of papillary carcinoma on FNAC was made in 93 cases. Further subclassification of these cases was done on cytology and tissue sections independently. The variants of PCT classified on FNAC were classical PCT (PCT-CL), 76 cases; Hurthle-cell variant (PCT-HCV), 3 cases; follicular variant (PCT-FV), 6 cases; tall-cell variant (PCT-TCV), 2 cases; high-grade variant (PCT-HG), 2 cases; and 2 cases each which were debatably PCT-CL/PCT-FV and PCT-CL/PCT-HG. Cytology typing was accurate in 65 of the 72 classical variants, while only 7 of the 22 follicular variants were correctly identified on cytology. Two of the 3 high-grade papillary carcinomas (PCT-HG) were identified on FNAC, and the solitary case of tall-cell variant could readily be classified on cytology. In conclusion, identification of the various variants of PCT is possible, though difficulty is encountered in correctly categorizing the follicular variant, which is often mistaken for a follicular neoplasm. Also, identification of the solid variant and the papillary carcinoma with nodular fasciitis-like stroma was a problem on cytology. Another interesting observation in our series is that an admixture of various cell types was seen in the smears and corroborated on histology to be present in focal areas.

Langerhans cell histiocytosis infiltration in cerebrospinal fluid: a case report

Langerhans cell histiocytosis (LCH) is a disease of unknown etiology characterized by a proliferation of histiocytic cells resembling the integumentary cells bearing the name of Langerhans cells. LCH can be unifocal or multifocal, with one- or many-organ involvement. We present a case of LCH diagnosed in the cerebrospinal fluid of a patient with generalized lymphadenopathy and central nervous system involvement.

Phyllodes tumor of the breast. A cytohistologic study of 80 cases

OBJECTIVE

To study the cytologic features of phyllodes tumor (PT) of the breast and determine the accuracy of their subclassification in fine needle aspirates.

STUDY DESIGN

Eighty cases of histologically diagnosed PT between 1982 and 1997 with a previous fine needle aspiration (FNA) were evaluated. The FNA smears of each case were reviewed without knowledge of the initial cytologic diagnosis and subclassified into benign, borderline or malignant PT.

RESULTS

Benign PTs were characterized by a dimorphic mixture of stromal and epithelial cells. The stromal fragments showed mild to moderate cellularity with absent to minimal pleomorphism and no mitosis. There were occasional, if any, single stromal cells. Borderline PTs had stromal fragments with moderately cellular stroma exhibiting moderate pleomorphism. Two additional features were the presence of single stromal cells and an occasional mitosis in the stromal fragments/single cells. Aspirates from malignant PT were very cellular, with a high stromal/epithelial ratio and marked stromal cellularity. The stromal cells were highly pleomorphic, with frequent mitosis and atypical single stromal cells in the background. Fifty-seven of the 80 histologically documented cases (71.3%) were diagnosed as PT on FNA (40 benign, 10 borderline and 7 malignant). In 81% (46 of 57 PTs), good cytohistologic correlation (32 benign, 8 borderline and 6 malignant) was observed. In another eight cases, one grade differentiation between cytologic and histologic grade was observed. Six of the nine malignant PTs on histology were correctly subclassified on cytology. There were one false positive and two false negative cases.

CONCLUSION

Cytologic diagnosis and grading of PT on FNA is possible. Special care should be undertaken in interpreting phyllodes fragments, cellularity of stroma, pleomorphism and mitosis. Single stromal cells are also important morphologic criteria for subclassification. Multiple-site aspiration is advisable to avoid diagnostic errors.

Villoglandular papillary adenocarcinoma of the cervix: case report

The incidence of cervical adenocarcinoma is on the rise over the last several decades. It generally carries a worse prognosis than squamous carcinoma. Villoglandular papillary adenocarcinoma (VGA) of the cervix has been identified as a distinct subset of cervical adenocarcinoma that occurs in young women and supposedly carries an excellent prognosis. We report a case of adenocarcinoma of the cervix in a young woman that had classical histological features of VGA but at operation showed presence of tumor cells in the peritoneal wash. A review of world literature on the 56 cases reported so far is presented where occasional cases showing disease spread have been reported, suggesting caution in the management and follow-up of this clinicopathologic entity.

Quality assurance and risk reduction guidelines

Cervical cancer continues to be a major cause of death in women worldwide. The major problem facing most women is the unavailability of screening Pap tests in poor and underdeveloped countries. While rates of cancer deaths have decreased 60-80% in developed countries since the Pap test became available, the accuracy of Paps was challenged recently. In order to instill public confidence and promote optimal patient care, measures to improve the quality of the entire screening process should be undertaken. Continuous quality improvement processes are more appropriate than traditional quality assurance monitors. Although no standards can be defined that are applicable to all laboratory settings and nations, this document provides current views on universal quality procedures and risk reduction. Procedure/policy manuals, workload assessment, hierarchic/peer review, discrepancy analysis, rescreening studies and cytohistologic correlation are examples of universally applicable quality tools. The variability in practices in different parts of the world is also discussed.

Tuberculosis of the breast. A cytomorphologic study

OBJECTIVE

Extrapulmonary tuberculosis occurring in the breast is rare despite the fact that 1-2 billion people worldwide suffer from tuberculosis. The aim of this study was to examine the cytomorphology of breast tuberculosis (breast TB) and to review the literature.

STUDY DESIGN

Old records from the Cytopathology Laboratory, All India Institute of Medical Sciences, were reviewed from January 1980 to December 1998. Cases of breast TB where a cytologic diagnosis was rendered or a histologic diagnosis with prior fine needle aspiration cytology (FNAC) was available were selected. These slides were reviewed for determining the cytologic findings.

RESULTS

One hundred sixty cases of breast TB were included in the study. Six males and 154 females with a clinical suspicion of carcinoma had undergone FNA that was reported as TB. The majority of the patients (111) were in the reproductive age group, 21-40 years. Of the 160 cases, 118 (73.75%) had cytomorphology diagnostic of tuberculosis--epithelioid cell granulomas with caseous necrosis. Eleven of the remaining 42 cases were positive for acid-fast bacilli (AFB) on Ziehl-Neelsen (ZN) staining, while 31 cases were confirmed to be tubercular on histology. ZN staining was done in 44 cases, and AFB were demonstrated in only 38.6% of cases.

CONCLUSION

Up to 73% of breast TB can be confidently diagnosed when both epithelioid cell granulomas and necrosis are present. Also, the possibility that a woman in the reproductive age group who presents with a palpable lump in the breast may have tuberculosis must be kept in mind, especially as the incidence of breast TB may increase in the future with the global spread of AIDS.