Diagnosis of eosinophilic granuloma of bone by fine-needle aspiration with concurrent institution of therapy: a cytologic, histologic, clinical, and radiologic study of 27 cases

Rosai-Dorfman disease of the pancreas: Cytologic analysis of three cases presenting as pancreatic masses

Rosai-Dorfman Disease (RDD), or sinus histiocytosis with massive lymphadenopathy, is a rare entity characterized by proliferating S100-positive histiocytes. It is most commonly found in lymph nodes with extranodal involvement usually occurring in the head and neck. Pancreatic involvement is extremely rare. The pathology department archives were searched for fine needle aspirations and pancreatic resections showing evidence of RDD. Clinicopathologic features, cytologic smears, cell blocks, immunocytochemical stains and surgical resections were reviewed. Three cases were identified. They were all females, aged 65, 69 and 75, with involvement of the pancreatic tail or head by solid masses of median size 2.3 cm (range 2.1-4.5 cm). Cytologic findings on smears included multiple histiocyte clusters resembling loosely cohesive epithelioid granulomas, singly dispersed histiocytes with moderate to marked nuclear atypia and characteristic emperipolesis. These atypical histiocytes stained positively for CD68, CD163 and S100. Smear background contained variable mixed inflammatory cells, necrotic debris and stromal fragments. The RDD diagnosis was further confirmed on pancreatic resection in two patients and core biopsy in one. The latter patient required three separate procedures before a definitive diagnosis was made. RDD of pancreas is a rare benign inflammatory condition that is diagnostically challenging on cytology. This can cause delays in cytologic diagnosis and/or misdiagnosis. Identification of characteristic cytologic features, primarily histiocytes with emperipolesis, and matching immunocytochemical profile can ensure accurate diagnosis and distinction from mimics.

Current concepts for the diagnosis and management of eosinophilic granuloma of bone

This review summarizes current concepts in the diagnosis and management of the patients with eosinophilic granuloma. Given the benign biology, the clinical course, and the pediatric group of patients that this condition more commonly affects, a treatment approach that carries a lower risk of complications while ensuring a successful cure is desirable. Variable treatment options have been reported with satisfactory results and a recurrence rate of less than 20 %. In this setting, symptomatic lesions that are accessible in the spine or the extremities may be treated with intralesional methylprednisolone injection after tissue biopsy for histological diagnosis.

A case of Langerhans' cell histiocytosis associated with Hodgkin's lymphoma: Fine-needle aspiration cytologic and histopathological features

Langerhans cell histiocytosis (LCH) can be associated with a variety of malignant neoplasms, the most common being malignant lymphoma, especially Hodgkin's lymphoma (HL). In this report, we describe the fine needle aspiration (FNA) cytologic features of a case with concurrent LCH and HL in a lymph node. A 20-year-old man presented with an enlarged left upper cervical lymph node. FNA smears from the swelling revealed numerous CD1a+ and S-100+ Langerhans-type cells (LCs) along with many eosinophils, neutrophils, and lymphocytes; there were also large atypical cells with enlarged nuclei having prominent nucleoli. The cytodiagnosis was LCH and the possibility of association with or trans-differentiation into a lymphoma was suggested. The histopathological diagnosis of the excised left cervical lymph node was classical HL-nodular sclerosis type (CHL-NS) with LCH. The lacunar type Reed-Sternberg (RS) cells were positive for CD30 and CD15, and the LCs were positive for CD1a and S-100 protein. PET/CT imaging demonstrated hypermetabolic lymph nodes in neck, abdomen, thorax and pelvis as well as pulmonary nodules and a splenic mass. The patient received 13 courses of chemotherapy and two years later, the enhanced CT revealed regressive course of the disease.

Intralesional methylprednisolone for painful solitary eosinophilic granuloma of the appendicular skeleton in children

BACKGROUND

Previous case reports and small series have reported on the treatment of eosinophilic granuloma of bone. We present our long experience in a large group of children and teenagers with symptomatic eosinophilic granuloma of the appendicular skeleton to evaluate clinical and imaging outcome after methylprednisolone injection.

METHODS

Sixty-six patients with symptomatic solitary eosinophilic granuloma of the appendicular skeleton treated by incisional or percutaneous biopsy and methylprednisolone injection were retrospectively studied. There were 38 boys and 28 girls (mean age, 7.2 y). The mean follow-up was 10.7 years (median, 11.2 y; range, 3 to 15 y). All patients presented with symptomatic lesions including pain or tenderness and fever and had 1 intralesional injection of methylprednisolone acetate after biopsy: 52 patients had incisional biopsy and 14 patients had percutaneous computed tomography-guided biopsy.

RESULTS

Complete resolution of symptoms was observed in 58 patients (92%) at 48 to 72 hours (50 patients) and in 7 days (8 patients) after the procedure. Complete imaging reconstitution of bone was observed in 60 patients (95.2%) at 1 to 2 years after the procedure. No patient had recurrence. Multifocal disease was diagnosed in 7 patients (11%) at 3 months to 6 years. Complications occurred in 2 patients: one patient with a clavicular lesion had a pathologic fracture after open direct methylprednisolone injection and the second patient developed trochanteric bursitis after computed tomography-guided methylprednisolone injection.

CONCLUSIONS

Biopsy and direct intralesional methylprednisolone injection is safe for symptomatic eosinophilic granulomas of the appendicular skeleton in children with effective clinical and imaging resolution of the lesions.

Cytomorphology of Erdheim-Chester disease presenting as a retroperitoneal soft tissue lesion

Erdheim–Chester disease (ECD) is a rare, multisystem disorder of macrophages. Patients manifest with histiocytic infiltrates that lead to xanthogranulomatous lesions in multiple organ systems. The cytologic features of this disorder are not well characterized. As a result, the cytologic diagnosis of ECD can be very challenging. The aim of this report is to describe the cytomorphology of ECD in a patient presenting with a retroperitoneal soft tissue lesion. A 54-year-old woman with proptosis and diabetes insipidus was found on imaging studies to have multiple intracranial lesions, sclerosis of both femurs and a retroperitoneal soft tissue mass. Fine needle aspiration (FNA) and a concomitant core biopsy of this abnormal retroperitoneal soft tissue revealed foamy, epithelioid and multinucleated histiocytes associated with fibrosis. The histiocytes were immunoreactive for CD68, CD163, Factor XIIIa and fascin, and negative for S100, confirming the diagnosis of ECD. ECD requires a morphologic diagnosis that fits with the appropriate clinical context. This case describes the cytomorphologic features of ECD and highlights the role of cytology in helping reach a diagnosis of this rare disorder.

Diagnosis of Langerhans cell histiocytosis on fine needle aspiration cytology: a case report and review of the cytology literature

A case of multifocal Langerhans cell histiocytosis in a two-year-old child is presented where fine needle aspiration was helpful in achieving a rapid and accurate diagnosis in an appropriate clinical and radiological setting. This can avoid unnecessary biopsy and guide the management especially where access to histopathology is limited. The highly characteristic common and rare cytological features are highlighted with focus on differential diagnoses and causes of pitfalls.

Spectrum of head and neck lesions diagnosed by fine-needle aspiration cytology in the pediatric population

Fine-needle aspiration cytology (FNAC) of the head and neck region is well accepted as a diagnostic procedure in the adult population. FNAC in the pediatric population is gaining acceptance as clinicians add this technique to the diagnostic armamentarium. An experience with FNAC of the head and neck region in the pediatric population is described from 2 large inner-city hospitals. Eighty-five cases were retrieved from patients age <18 years. In 52 cases, clinical or surgical follow-up was obtained and among these cases the specificity and sensitivity of FNA was 93% and 100%, respectively. The high specificity of FNAC allows the clinician to be confident of malignancy in a clinically suspicious lesion of the head and neck in a pediatric patient.

Langerhans cell histiocytosis of the skull on cytologic squash preparations

We present a case in which a primary cytodiagnosis of Langerhans cell histiocytosis (LCH) of the skull was made using squash preparations. The patient, a 25-year-old male, presented with raised intracranial pressure and decreased visual acuity. Magnetic resonance imaging revealed a large skull lesion with osteolytic features in the left frontal bone. The patient underwent surgical resection by the extended basal frontal epidural approach. The squash preparation smears were cellular and demonstrated a mixed population of small, mature lymphocytes, eosinophils, and a high histiocytes content. The histiocytes occurred as isolated or loosely cohesive and clustered. They possessed abundant cytoplasm with rounded cell shape and had characteristic nuclear features, composed of fine chromatin and delicate nuclear membranes. The cytologic features of these histiocytes were consistent with Langerhans cells (LCs). A final impression of LCH of the skull was rendered. Subsequent histopathology confirmed the diagnosis. LCs reacted with both S-100 protein and CD1a immunohistochemically. The demonstration of Birbeck granules on electron microscopic study was also noted. Whenever squash preparation yields a mixed population of mature lymphocytes, eosinophils, and histiocytes, the cytologists should be aware of and consider LCH as a diagnostic possibility.

Fine-needle aspiration biopsy in pediatric oncology patients: a review of experience with 829 patients (899 biopsies)

The authors review their 20-year (1985-2004) experience with fine-needle aspiration biopsy (FNAB) in 829 children (all but 1 younger than 18 years), from whom 899 samples were obtained. All patients presented with clinical data suggesting malignancy. The procedure followed standard methods (22- to 24-gauge needle; mean of six alcohol-fixed and/or air-dried, H&E- or Giemsa-like-stained smears/procedure; leftover clots processed as a biopsy). Interpretation of cytologic smears was performed taking into consideration the clinical, laboratory, and imaging data. Smears diagnosed as positive for malignant cells were reported in 510 samples (56.7%) (463 patients); 1.89% of the smears were found inadequate for diagnosis. Positive for malignancy cases included 467 primary tumors, 52% of which were localized to the abdomen. NMYC status was determined on neuroblastoma samples by fluorescent in situ hybridization. Overall sensitivity of the procedure was 98% (500/510 FNAB); specificity was 92.6% (463/500 FNAB); positive predictive value was 1 and negative predictive value was 0.99. All FNABs diagnosed as benign tumors or inflammatory lesions correlated with histology and/or clinical outcome. FNAB proved to be highly cost-effective, avoiding a surgical biopsy. The procedure was found to be extremely helpful when deciding on preoperative chemotherapy.

Epiphyseal osteoblastoma of tibia with xanthomatous stromal reaction

Osteoblastoma occurring in long bones has a distinctive predilection for the metaphysis and the diaphysis. Epiphyseal location is rare. Although variation in histologic patterns is a well-known feature of this tumor, xanthomatous stromal reaction has not yet been described. We report a case of a 34-year-old man who developed an osteoblastoma primarily located in the epiphysis of his left tibia with extension into the metaphysis. The striking histologic features included a prominent xanthoma-like stroma consisting of foamy histiocytes in addition to focal areas with classical configuration of an osteoblastoma. The significance of this finding is discussed.

Fine-needle aspiration for the diagnosis of orbital hematolymphoid lesions

Ocular and periocular hematolymphoid diseases are a diverse group of lesions affecting various soft tissue structures within the orbital cavity. Lymphoid proliferations in particular are among the most commonly diagnosed entities in orbital pathology. When noninvasive techniques fail to confirm or rule out the suspicion of orbital neoplasia, fine-needle aspiration (FNA) may be of use in establishing a diagnosis in a reliable, timely, cost-effective and safe manner. From 1986 to 1999, 79 orbital/ocular needle aspiration biopsies were conducted by staff ophthalmologists at Allegheny General Hospital. Slides from these cases and corresponding reports were pulled from the cytology files and grouped into the two broad categories of hematolymphoid and other. Specimens came from patients ranging in age from 14 to 88 years (mean, 64 years) with eight patients having known histories of hematolymphoid disorders. Immunocytochemical (ICC) studies were performed in 33% of the cases (14/43). Review of the diagnoses for the 79 aspiration specimens revealed 30 cases diagnosed as lymphoma/atypical lymphocytic infiltrate, cases diagnosed as inflammation or abscess, three cases diagnosed as plasmacytoma, three cases called suboptimal with scant inflammatory cells, and one case of Langerhans' cell histiocytosis. Hematolymphoid diagnoses accounted for 54% (43/79) of all diagnoses. Histologic correlation was available in 33% (14/43) of the cases (nine cases diagnosed as cytologically atypical/malignant and five cases called cytologically benign/suboptimal) with 100% correlation. Hematolymphoid lesions of the orbit are readily diagnosed by FNA. Because many hematolymphoid malignancies are treated as systemic or multiorgan system diseases and because ocular lymphomas may also involve the central nervous system, nonsurgical attempts at diagnosis have the potential to spare the patient procedural morbidity which may be associated with open biopsy. Our experience indicates that the combination of FNA, judicious use of immunocytochemical studies, and correlation with pertinent clinical information and imaging studies allows for reliable and effective classification and diagnosis of orbital hematolymphoid lesions.

Hypersegmentation of inflammatory cells in Langerhans cell granulomatosis

Langerhans cell granulomatosis (LCG) is characterized by a mixture of Langerhans cells and eosinophils in varying proportions. The characteristic morphology of Langerhans cells have already been described in many articles, but little attention has been paid to inflammatory cells. We examined six cases of Langerhans cell granulomatosis, which had originally been diagnosed as eosinophilic granuloma. Inflammatory cells present in LCG showed hypersegmentation. Twenty percent to 70% of eosinophils had three or more segmented nuclei, and 10-25% of neutrophils had five or more segmented nuclei. Such findings have never been described, and we believe hypersegmentation to be a feature of LCG. Furthermore, we emphasize that eosinophils in LCG mimic neutrophils in ethanol-fixed preparations, and thus may be a pitfall in making a diagnosis in cytology and intraoperative consultation.

Intraoperative diagnosis of osseous eosinophilic granuloma by touch preparation: report of two cases with immunohistochemistry and electron microscopy

We report two cases of eosinophilic granuloma (Langerhans cell histiocytosis) of bone, the diagnosis of which was made by intraoperative cytological evaluation of touch preparation. The clinical, cytologic, histologic, immunohistochemical, and electron microscopic findings are presented. Our cases demonstrate and further support that intraoperative cytologic analysis by touch preparation is a very useful method of diagnosis during intraoperative consultation on a bony specimen.