Cytologic findings of malignant vascular neoplasms: a study of twenty-four cases

Primary epithelioid angiosarcoma of the mediastinum, cytomorphologic features of a rare entity-A case report and literature review

Epithelioid angiosarcoma (EA) is a highly aggressive vascular neoplasm. Primary mediastinal EA is extremely rare with only few cases reported in the English literature. We herein present a case of a 78-year-old patient, who was found to have a right superior mediastinal mass associated with mediastinal and hilar lymphadenopathy. Endobronchial ultrasound guided fine needle aspiration cytology of a station 4R lymph node revealed a cellular, discohesive malignant neoplasm displaying primarily epithelioid morphology with occasional spindled, plasmacytoid, and tumor giant cells. The tumor cells had ample eosinophilic cytoplasm with pleomorphic nuclei and prominent nucleoli. Vasoformative features were noted, exemplified by widespread cytoplasmic vacuoles containing neutrophils and rare red blood cells (hemophagocytosis) and vascular channels identified solely in the cell block. By immunohistochemistry, the tumor cells stained strongly positive for vimentin, positive for ERG, CD-31, FLI-1, and focally positive for pan-cytokeratin. The cytomorphological features and immunostaining patterns were diagnostic of EA. No history of malignancy was reported, and no other lesions were identified on imaging. The diagnosis of primary mediastinal EA on cytology and small biopsy specimens may be challenging due to the rarity of this tumor, limited diagnostic material, and overlapping morphologic features with other entities in the differential diagnosis. A high index of suspicion, especially in cases with vasoformative features, and utilization of ancillary studies can help establish the diagnosis.

Cytologic and histological features of rare nonepithelial and nonlymphoid tumors of the thyroid

Thyroid tumors can be classified into epithelial, nonepithelial, and nonprimary lesions. Nonepithelial thyroid tumors are rare. They can be of primary origin within the thyroid gland, arise secondary to contiguous growth from adjacent tissues, or represent metastatic disease. The incidence of nonepithelial tumors of the thyroid is only 1% to 2%, most of which are lymphomas; the remainder includes mesenchymal and histiocytic tumors. This review examines the cytohistological features of various nonepithelial and nonlymphoid tumors of the thyroid, including vascular lesions, neural tumors (including granular cell tumor and paraganglioma), smooth muscle tumors, solitary fibrous tumor, histiocytic neoplasms (eg, Langerhans cell histiocytosis and Rosai-Dorfman disease), and follicular dendritic cell sarcoma. Their differential diagnosis is discussed, including recommendations to prevent the pitfall of mistaking these rare tumors for more common epithelial thyroid neoplasms.

Mediastinal sarcomas: experience using fine needle aspiration cytopathology

Fine needle aspiration (FNA) cytology is a sparsely used diagnostic method in the evaluation of mediastinal sarcomas in most medical centers worldwide with most literature citations regarding this category of malignancies consisting of small series and individual case reports. Most of these published studies highlight vascular sarcomas such as epithelioid hemangioendothelioma, and angiosarcoma, various subtypes of liposarcoma including well-differentiated liposarcoma, myxoid liposarcoma, and pleomorphic liposarcoma, malignant peripheral nerve sheath tumor, and sarcomas of uncertain differentiation, primary synovial sarcoma and the Ewing sarcoma family of tumors. This paucity of cytopathology reports regarding mediastinal sarcomas is in marked contrast to the almost daily application of endobronchial ultrasound (EBUS)-guided FNA biopsy for sampling mediastinal lymph nodes and mediastinal masses for primary and metastatic carcinomas which, of course, are considerably more common that any type of sarcoma in this location. EBUS, endoscopic ultrasound-guided (EUS) needle biopsy, and percutaneous image-guided biopsy using either core needle, fine-needle, or both can serve a potentially useful role for diagnostic sampling of mediastinal sarcomas, be they primary or metastatic. This review catalogues much of the published data regarding FNA cytopathology and its application to mediastinal sarcomas. An attempt is made to primarily highlight case series rather than individual case reports; however, due to the paucity of these, case reports are cited and discussed where appropriate.

Cellular atypia is negatively correlated with immunohistochemical reactivity of CD31 and vWF expression levels in canine hemangiosarcoma

Canine hemangiosarcoma (HSA) is one of the most common mesenchymal tumors in dogs. Its high metastatic and growth rates are usually associated with poor prognosis. Neoplastic cells of HSA can show various levels of cellular atypia in the same mass and may consist of various populations at different differentiated stages. Up to present, however, there is no report analyzing their differentiation states by comparing cellular atypia with differentiation-related protein expressions. To evaluate whether cellular atypia can be used as a differentiation marker in HSA, we analyzed correlation between cellular atypia and intensities of CD31 and von Willebrand Factor (vWF) staining in HSA cases. We also compared cellular atypia and expression levels of CD31 and vWF in each growth patterns. Our results show that cellular atypia was negatively correlated to CD31 and vWF expression levels but no significant correlation was found between growth patterns and cellular atypia or CD31 and vWF expression levels. Our study suggests that cellular atypia is useful for identifying differentiation levels in HSA cases. This study also provides useful information to determine differentiation levels of cell populations within HSA based only on morphological analysis, which will aid further HSA research such as identifying undifferentiation markers of endothelial cells or finding undifferentiated cell population in tissue sections.

Binucleated HeLa cells are formed by cytokinesis failure in starvation and keep the potential of proliferation

Many cytological studies have reported that the numbers of binucleated cells were elevated in various tumors. However, binucleated cells are observed in not only malignant tumors but also normal tissues. Thus, the clinical significance of binucleated cells is controversial. Here we attempted to elucidate the characteristics of binucleated HeLa cells using time-lapse microscopy. To examine the frequency, viability, proliferation, and formation mechanism of binucleated cells, we grew HeLa cells on chamber slides and tissue culture dishes in DMEM supplemented with (10, 3, 1 and 0.5 % media) and without fetal bovine serum (0 % medium). The proliferation was evaluated by the medium improvement examination (cultured for 2 more days in 10% medium after culturing in 0% medium; starvation). In the 0 % medium, 150 binucleated cells were formed by cytokinesis failure. There were significantly more binucleated cells in the 0 % medium than in the 10, 3, 1 and 0.5 % media. About twice the number of binucleated cells underwent mitosis in the improvement examinations than in the serum-free examination. We found here that starvation induced the binucleation of HeLa cells and that some binucleated cells can reproduce. These findings might be helpful for understanding binucleated cells in tumors.

The utility of ERG, CD31 and CD34 in the cytological diagnosis of angiosarcoma: an analysis of 25 cases

AIMS

Erythroblast transformation specific related gene (ERG), a proto-oncogene member of the erythroblast transformation specific transcription factor family, is a sensitive marker of endothelial differentiation and is expressed in vascular tumours, including angiosarcomas (AS). Immunohistochemistry is necessary for the diagnosis of AS in fine needle aspirates where low cellularity and lack of preserved tissue architecture impedes diagnosis. The aim of this study was to assess the utility of an ERG-enriched immunohistochemistry panel in the cytological diagnosis of AS.

METHODS

25 AS diagnosed on fine needle aspirates were stained for ERG, CD31, CD34, and AE1/AE3. Staining intensity and percentage tumour cell positivity were evaluated. Spearman's correlation was assessed for significant correlations between antibodies.

RESULTS

Sensitivities for ERG, CD31, CD34 and AE1/AE3 were 100%, 100%, 60% and 21%, respectively. Spearman's analysis revealed that ERG and CD31 staining correlated significantly; there was no significant correlation between CD31 and CD34 staining.

CONCLUSIONS

With equal sensitivity to, and strong correlation with CD31, ERG staining is highly suitable for the cytological diagnosis of AS. ERG and CD31 are more sensitive vascular markers than CD34. ERG, a nuclear stain, complements the cytoplasmic/membranous staining of CD31. Used in conjunction with CD31, ERG can corroborate the diagnosis of AS.

A case of metastatic angiosarcoma diagnosed by liquid-based preparation: peculiar cytoplasmic changes

Angiosarcoma with predominantly epithelioid features is a rare soft tissue neoplasm and the interpretation of its cytopathologic findings may be difficult. We report a case of metastatic angiosarcoma with predominantly epithelioid features diagnosed by liquid-based cytology. The cytopathologic findings in this case differed from those of the conventional preparation and we found a clean background, no hyperchromatic nuclei and several cytoplasmic changes, including intracytoplasmic vacuoles with peculiar shapes, juxtanuclear condensation and perinuclear clearing. Identification of these changes using liquid-based cytology supplemented with immunochemistry may be helpful in reaching a correct cytopathologic diagnosis.

Fine-needle aspiration cytology of primary renal angiosarcoma with histopathologic and immunocytochemical correlation: a case report

Primary renal angiosarcoma is an extremely rare neoplasm, with fewer than 28 cases reported thus far in the English literature. We report for the first time the cytomorphology and immunocytochemistry of this tumor in liquid-based (ThinPrep) fine-needle aspiration (FNA) samples in correlation with the conventional cytologic and histopathologic findings. Conventional smears showed pleomorphic tumor cells focally arranged in structures suggesting anastomosing vascular channels, while ThinPrep smears were less cellular with fewer and smaller tumor cells arranged in clusters or rosette-like formations. Immunocytochemical staining demonstrated positive results for vimentin, CD31, and CD34 and negative staining for epithelial markers, thus supporting the diagnosis of a mesenchymal tumor of vascular origin. The diagnosis of primary renal angiosarcoma was established after histopathologic evaluation of a metastatic liver nodule. The cytological differential diagnosis of this neoplasm and the utility of the ThinPrep method as a diagnostic adjunct to conventional FNA cytology are further discussed.

Epithelioid angiosarcoma of the kidney: a diagnostic dilemma in fine-needle aspiration cytology

Epithelioid angiosarcomas (EAS) of kidney are rare and aggressive tumors with noncharacteristic imaging features that overlap with those of inflammatory conditions and renal cell carcinoma (RCC). We report the fine-needle aspiration (FNA) cytology findings of a case of EAS that involved the left kidney of an 83-year-old male. The smears and cell block sections showed pleomorphic epithelioid cells with ample cytoplasm, eccentric nuclei, occasional cytoplasmic hyaline globules, and rare intracytoplasmic lumina. Immunohistochemical stains performed on cellblock sections showed that the tumor cells were positive for vimentin, CD31, CD34, Factor VIII, and CD10, but showed no staining for cytokeratins AE1/AE3 and 8/18, HMB45, CD45, smooth muscle actin, and S100. The morphological and immunohistochemical distinction between EAS, primary tumors of the kidney, and other epithelioid and rhabdoid neoplasms is discussed.

Angiosarcoma after breast-conserving therapy: Fine-needle aspiration biopsy, immunocytochemistry, and clinicopathologic correlates

BACKGROUND

Angiosarcoma that arises after breast-conserving therapy can present clinically as a cutaneous and/or subcutaneous breast lump, which is misinterpreted easily as a recurrence of carcinoma. To the authors' knowledge, the role of fine-needle aspiration (FNA) cytology in the early diagnosis of this life-threatening complication of breast carcinoma therapy has not been established fully.

METHODS

The authors studied three new patients with this type of secondary angiosarcoma diagnosed by FNA biopsy and immunocytochemistry, reviewed the literature on the topic, and examined relevant differential diagnostic issues.

RESULTS

Patients presented with a discrete skin lump that had arisen several years after breast-conservative therapy for early-stage breast carcinoma near the scar from the previous surgery. The lesions were interpreted clinically as recurrent carcinoma. FNA yielded moderately cellular to highly cellular samples with variable patterns of cellular aggregation. Cells were epithelioid and spindle-shaped. Angioformative changes were subtle, and the overall picture suggested an epithelial malignancy, possibly a metaplastic carcinoma. Immunostaining of smears, however, provided conclusive evidence of the endothelial differentiation of tumor cells, and an FNA diagnosis of angiosarcoma was rendered in all patients. The histopathology of all surgically excised tumors confirmed the diagnosis of high-grade angiosarcoma.

CONCLUSIONS

Based on the authors' experience, the FNA cytologic appearance of angiosarcoma that presented as a breast skin nodule in a breast carcinoma survivor easily could have been misinterpreted as carcinoma. A correct diagnosis of this tumor relies on the proper evaluation of clinical findings and, as also shown by a review of the literature, requires immunocytochemical evidence of endothelial differentiation.

Fine-needle aspiration cytology of epithelioid angiosarcoma: A diagnostic dilemma

A 28-year-old woman with a 2-yr history of unilateral chronic leg swelling, initially thought to be secondary to deep vein thrombosis, later thought to be due to congenital venous malformation, eventually developed a pelvic mass, which was biopsied by fine-needle aspiration. On the basis of cytologic features on smears, high-grade sarcoma was reported. The patient underwent surgery to resect the pelvic mass, which showed anastomosing vascular channels arising from external iliac vein in histology. However, the tumor cells unexpectedly showed strong and diffuse immunohistochemical expression of cytokeratin and epithelial membrane antigen. The case was sent for expert consultation, and the expert's opinion was epithelioid angiosarcoma. The expert's diagnosis was confirmed 2 yr later by local recurrence. The clinical presentation, cytology, histology, and immunohistochemistry of the current case and 15 other cases of epithelioid angiosarcoma found in the cytology literature are summarized. This case illustrates that morphology with clinicopathologic correlation tends to be a better guide than available special techniques.