Sclerosing polycystic adenosis: A rare tumor misdiagnosed as retention cyst on fine needle aspiration cytology

Usefulness of Fractal Analysis of Kirsch Edge Images for the Tissue Fragment Inner Structure in Breast FNAB

OBJECTIVE

Recent advances in high-precision mammography and ultrasound screening have led to an increase in the detection of early lesions (ductal carcinoma in situ and small cancers) appearing as microcalcified lesions or microcystic images, and there needs to be an improvement in the accuracy of breast fine-needle aspiration biopsy (FNAB) assessing these lesions. The objective of this study was to investigate whether fractal analysis of Kirsch edge images for the tissue fragment inner structure (FKT) is useful in breast FNAB. FKT measures tissue fragment chromasia of hyperchromatic crowded tissue fragments (HCG), tissue fragment shape unevenness, and tissue fragment inner structure complexity. Study Design Materials: Nineteen epithelial tissue fragments of fibroadenoma (FA) from 7 patients and 52 tissue fragments of invasive breast carcinoma of no special type (IBC-NST) (grade 1-2) from 11 patients were assessed. First, tissue fragments were classified into small (smaller than 60 × 102 μm2), medium, and large (100 × 102 μm2 or larger), and the appearance rate of each size was determined. Second, for FKT, the luminance value of tissue fragment chromasia, the unevenness and fractal value, and the tissue fragment inner structure complexity were determined. In statistical analysis, the Steel-Dwass test, nonlinear discriminant analysis, and receiver operating characteristic analysis were performed, setting the significance level at p < 0.05.

RESULTS

"Unevenness of the tissue fragment shape," "fractal value of the tissue fragment shape," and "fractal value of the tissue fragment inner structure" were significantly higher in small and large tissue fragments in IBC-NST compared with those in FA. The specificity and sensitivity were the highest (100%) in small tissue fragments in multivariate analysis using 4 variables ("luminance value of tissue fragment chromasia," "unevenness of tissue fragment shape," "fractal value of the tissue fragment shape," and "fractal value of the tissue fragment inner structure").

CONCLUSION

FKT, which evaluates "tissue fragment darkness," "tissue fragment shape unevenness," and "tissue fragment inner structure complexity" focusing on small tissue fragments of HCG in breast FNAB, is useful as a system that assists cytopathological assessment of breast FNAB.

Fractal Analysis Method for the Complexity of Cell Cluster Staining on Breast FNAB

OBJECTIVE

Because of the increased precision of ultrasound breast cancer screening, early cancer cases with no clear mass or extraction of microcysts on imaging have recently increased, and improvement of the accuracy of breast fine-needle aspiration biopsy (FNAB) cytology is needed. The objective of this study was to investigate the usefulness of cluster gray image-fractal analysis evaluating the darkness of clusters, cluster unevenness, and complexity of hyperchromicity (cluster density) of deep-stained cell clusters, known as hyperchromatic crowded cell groups (HCG), on FNAB as a cytology assistance system for breast FNAB.

STUDY DESIGN

One hundred clusters collected from 10 patients with fibroadenoma (FA), 90 clusters from 9 patients with ductal carcinoma in situ (DCIS), and 122 clusters from 11 patients with invasive breast carcinoma of no special type (IBC-NST) were used. (1) Cluster size classification: clusters were classified into small, middle, and large clusters (small cluster: smaller than 40 × 102 μm2; large cluster: 100 × 102 μm2 or larger; middle cluster: intermediate), and their frequency was calculated. (2) Cluster gray image-fractal analysis: (a) the darkness of clusters (luminance), (b) cluster unevenness (complexity), and (c) complexity of cluster density (roundness-corrected fractal value) were assessed. For statistical analysis, the multiple comparison Steel-Dwass test was used, with a significance level of p < 0.05.

RESULTS

(1) Cluster size classification: in FA, small, middle, and large clusters appeared at a similar frequency, and the frequency (30%) of large clusters was significantly higher than that in other diseases. In IBC-NST, many small clusters (61%) appeared and their frequency was significantly higher than that in other diseases, whereas the frequency of large clusters was significantly lower. (2) Cluster gray image-fractal analysis: in IBC-NST, the luminance of small clusters was low (dark), the cluster unevenness was high, and the complexity of cluster density was high, whereas the luminance of large clusters was high (bright), the cluster unevenness was high, and complexity of cluster density was high compared with those in FA.

CONCLUSION

Cluster gray image-fractal analysis evaluating the darkness of clusters, cluster unevenness, and complexity of cluster density in breast FNAB HCG is a useful cytology assistance system for breast FNA.

Juvenile sclerosing polycystic adenosis cytologically mimicking Warthin tumor

Sclerosing polycystic adenosis (SPA) is a rare salivary gland disease. Histologically it resembles a low-grade ductal carcinoma in situ or sclerosing adenosis of the breast, characterized by lobular proliferation of ducts with apocrine cellular features surrounded by fibrosclerotic stroma. Although SPA is typically benign, recurrence is not uncommon, and cases with a malignant component have been documented. Thus, complete excision is desirable but preoperative diagnosis is challenging. A 12-year-old boy presented with a painless mass in the right neck. We identified a well-demarcated mass in the right parotid region measuring approximately 2 cm using cervical echography and magnetic resonance (MR) imaging. Fine-needle aspiration (FNA) revealed two cell types. There were loosely cohesive clusters of polymorphic epithelioid cells with irregular nuclei and abundant vacuolated cytoplasm containing zymogen granules. Some of these cells were binuclear. The other cell types represented normal ductal cells. The original cytological diagnosis was Warthin tumor. Right parotidectomy was performed. Histologically, we observed proliferation of ducts with granular, vacuolated, zymogen granules, and apocrine-like features in the cytoplasm with hyalinizing sclerotic stroma and some binuclear cells. Four years after parotidectomy, there has been no recurrence or malignant transformation.Cytological diagnosis of SPA is challenging on FNA specimens since SPA is a very rare entity of the salivary gland that can mimic other salivary gland neoplasms. A mixture of apocrine-like cells and sebaceous-like cells, nuclear pleomorphism, and zymogen granules can help to diagnose this rare lesion during the initial cytological diagnosis.

Usefulness of Cytological Scoring Method by Breast Fine Needle Aspiration Cytology on Breast Duct Dilatation and Cystic Lesions

Aim

The objective of this study was to apply a scoring method to fine needle aspiration cytology on breast duct dilatation and cystic lesions, to set an optimum cut-off value to differentiate between benign and malignant cases, and to identify features useful for cell judgment.

Materials and Methods

Samples were 23 preparations of specimens (12 benign and 11 malignant cases) suspected with intraductal lesions or cystic change by ultrasonography or mammography and cytology. The scoring system comprised the following 10 items, and each item was scored 1-3, with a total score of 10-30. Three items were concerning structural atypia: 1, scattered epithelial cells; 2, uneven irregular cluster edge; and 3, overlapping nuclei of epithelial cells, and seven items were concerning cellular atypia: 4, irregular nuclear size; 5, irregular nuclear morphology; 6, deep dyeing chromatin; 7, chromatin granularity; 8, chromatin distribution; 9, nucleolus; and 10, absence of myoepithelial cells.

Results

(1) Scoring cut-off value: malignancy is to be suspected when the score is 20.75 or higher (diagnostic accuracy: 95.7%). (2) Findings useful for cancer judgment: the sensitivity of the following four findings was high: uneven irregular cluster edge, irregular nuclear overlapping, chromatin granularity, and absence of myoepithelial cells. (3) Correlation among the findings: the findings correlated with malignancy were as follows: scattered epithelial cells versus uneven irregular cluster edge (rs = 0.8).

Conclusion

Cytological evaluation by scoring lesions accompanied by intraductal dilatation and cystic change was a useful method capable of differentiating between benign and malignant cases at a high accuracy.

Intraductal Carcinoma of Salivary Glands Harboring TRIM27-RET Fusion with Mixed Low Grade and Apocrine Types

Intraductal carcinomas (IDCs) of salivary gland are rare neoplasms. Here, we report a case of IDCs harboring TRIM27-RET fusion with mixed low grade and apocrine types. A 79-year-old male presented with slowly-growing left parotid mass for 2.5 years. Histologically, the tumor demonstrated two distinct morphologies; a classic intercalated duct and low grade apocrine component. The intercalated duct component was positive for S100, SOX10 and vimentin, and negative for DOG-1 and HER2. The apocrine component was positive for androgen receptor (AR) and focally positive for HER2. The tumor harbored a TRIM27-RET fusion by FISH, and was negative for ETV6 and PLAG1 rearrangements. This case is unusual in that it displays two true phenotypically distinct components, which has only rarely been reported. This is the first report of intraductal carcinoma with two true phenotypically distinct components composed of low-grade and apocrine types with RET rearrangement and TRIM27-RET fusion.

Diagnostic Approach to Fine Needle Aspirations of Cystic Lesions of the Salivary Gland

Fine needle aspiration (FNA) has diagnostic and therapeutic value in the management of salivary gland cysts. Rendering an accurate diagnosis from an aspirated salivary gland cyst is challenging because of the broad differential diagnosis, possibility of sampling error, frequent hypocellularity of specimens, morphologic heterogeneity, and overlapping cytomorphology of many cystic entities. To date, there have been no comprehensive review articles providing a practical diagnostic approach to FNA of cystic lesions of salivary glands. This article reviews the cytopathology of salivary gland cysts employing 2017 World Health Organization terminology, addresses the accuracy of FNA, and presents The Milan System approach for reporting in cystic salivary gland cases. The utility of separating FNA specimens from salivary gland cysts, based upon the presence of mucin and admixed lymphocytes in cyst fluid is demonstrated. A reliable approach to interpreting FNA specimens from patients with cystic salivary gland lesions is essential to accurately determine which of these patients may require subsequent surgery.