Risk of Malignancy and Risk of Neoplasia in the Bethesda Indeterminate Categories: Study on 4,532 Thyroid Fine-Needle Aspirations from a Single Institution in India

OBJECTIVES

To determine the frequency of category 3 (atypia of undetermined significance [AUS]/follicular lesion of undetermined significance [FLUS]), category 4 (follicular neoplasm), and category 5 (suspicious for malignancy) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), the risk of malignancy (ROM) and the risk of neoplasia (RON) in these categories.

STUDY DESIGN

A retrospective 6-year audit of 4,532 thyroid fine-needle aspirations (FNA) reported as per the TBSRTC from a single institution with cytohistological correlation in 335 cases.

RESULTS

The frequency of categories 3, 4, and 5 was 2.5, 3.9, and 0.5%, respectively; the upper and lower bound estimates of ROM being 58.3, 23.6, 75% and 5.1, 5, and 12.5%, respectively. AUS/FLUS (n = 116) cases were subcategorized as AUS, AUS-HC (Hürthle cell), AUS-PTC (AUS-papillary thyroid carcinoma not excluded), FLUS, FLUS-FH (favor hyperplasia), FLUS-HC, and FLUS-PTC. The AUS/FLUS malignancy ratio was 1:3.8. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of FNA thyroid was 80.5, 85.9, 80.7, 85.7, and 82.4%, respectively.

CONCLUSION

Implementation of TBSRTC aided in achieving internal quality control in reporting thyroid FNA cytology. The AUS/FLUS frequency was 2.5%, which is at the lower range of the recommended rate and was associated with a higher than recommended upper bound estimate, but a comparable lower bound estimate of ROM.

Secretory cell outgrowths, p53 signatures, and serous tubal intraepithelial carcinoma in the fallopian tubes of patients with sporadic pelvic serous carcinoma

CONTEXT

High-grade serous carcinomas of ovarian, tubal, and peritoneal origin are together referred as pelvic serous carcinoma. The fallopian tubes, ovarian surface epithelium, and the tuboperitoneal junctional epithelium are all implicated in pelvic serous carcinogenesis.

AIMS

The aim of this study is to identify putative precursor lesions of serous carcinoma including secretory cell outgrowths (SCOUTs), serous tubal intraepithelial carcinoma (STIC), and p53 signatures and assign its probable site of origin.

SETTINGS AND DESIGN

Prospective case-control study of consecutive specimen comprising 32 serous carcinomas and 31 controls (10 normal adnexa, 10 benign and 6 atypically proliferative surface epithelial tumors, and 5 other carcinomas).

SUBJECTS AND METHODS

Sectioning and extensive examination of the fimbrial end (SEE-FIM) protocol along with immunohistochemistry for Bcl-2, p53, and Ki-67 was employed for evaluating invasive carcinoma and precursor lesions in cases versus controls.

RESULTS

SCOUT, p53 signatures, and STIC were most frequent in the serous carcinomas. p53 signatures and STIC were always seen in the fimbrial end. STICs were exclusively present in serous carcinomas, more common in ipsilateral tubes of cases with dominant ovarian mass. Multifocal p53 signatures with STIC were seen in 7 (21.9%) cases. STIC was present with or without an invasive carcinoma in 25% and in 6.25% of cases of pelvic serous carcinomas, respectively. The junctional epithelia did not show any lesion in any group.

CONCLUSIONS

SEE-FIM protocol is recommended for evaluation of sporadicpelvic (ovarian/tubal/peritoneal) serous carcinoma. Based on the presence of STIC or invasive carcinoma, nearly 60% of all pelvic serous carcinomas are of fallopian tubal origin.

Prevalence of Human Papilloma Virus Infection in Young Primiparous Women During Postpartum Period: Study from a Tertiary Care Center in Northern India

INTRODUCTION

Assessment of high-risk Human Papilloma Virus (HPV) prevalence is important for monitoring long-term decrease in cervical cancer after implementation of the prophylactic HPV vaccination.

AIM

To determine the prevalence of high-risk HPV infection and cytological abnormalities in young primiparous women in the age group of 16-26years.

MATERIALS AND METHODS

In this cross-sectional study, 214 primiparous women aged 16-26years were recruited from a public tertiary health care center postpartum clinic between June 2013 and May 2014. Cytological analysis was performed by Pap smear test and patients underwent sampling with cervical brushes for HPV-DNA detection and typing by a PCR-based assay for HPV types 16, 18, 33 and 45.

RESULTS

High-risk HPV was detected in 41 (19.2%) women. HPV 16 was found to be most prevalent with 17 (7.9%) samples testing positive, followed by HPV 18 in nine (4.2%), HPV 45 in six (2.8%) and HPV 31 in four (1.8%) women. Five women tested positive for more than one HPV types. There were no cases of intraepithelial lesions or cervical cancer. One patient who had Atypical Cells of Undetermined Significance (ASCUS) on cytology tested negative for all four HPV genotypes.

CONCLUSION

This study provides a geographic baseline data of high-risk HPV prevalence in young Indian women before implementation of a vaccination program. The results are important for comparison with other global regions and monitoring the effect of HPV vaccination.

Spectrum of gallbladder malignancies on fine-needle aspiration cytology: 5 years retrospective single institutional study with emphasis on uncommon variants

BACKGROUND

Ultrasound-guided fine-needle aspiration cytology (FNAC) is the standard modality for diagnosis of gallbladder malignant neoplasms. Adenocarcinoma is the most common malignancy; however, other types may also be encountered. The aim of this study was to perform a retrospective analysis of gallbladder malignancies diagnosed on FNAC in the last 5 years to document the cytomorphological spectrum and the variations thereof.

METHODS

The records of the Department of Cytology, PGIMER were searched from July 2010 to June 2015 and all cases of gallbladder malignancies were analyzed in detail for cytomorphological characteristics. Giemsa and Hematoxylin-Eosin stained slides were evaluated with immunocytochemistry on cell blocks wherever available.

RESULTS

A total of 791 gallbladder FNAC performed in cases of radiologically suspected gallbladder malignancies were evaluated. Gallbladder carcinoma (GBC) was more common in females with a male to female ratio of 1:2.3. Median age was 53.4 years (range 24-85 years); 81 cases (10.2%) were nondiagnostic and 31 (3.9%) were suspicious of malignancy. A total of 645 FNACs were positive for malignancy, out of which there were 619 (96%) adenocarcinoma and 26 cases with unusual malignancies. These included adenosquamous carcinoma (8, 1.2%), squamous cell carcinoma (7, 1.1%), small cell neuroendocrine carcinoma (9, 1.3%), and one case each of undifferentiated carcinoma and Non Hodgkin lymphoma respectively. The unusual malignancies were confirmed on cell block immunocytochemistry.

CONCLUSION

Adenocarcinoma is most common type of gallbladder malignancy; however, other unusual types of carcinomas occur and in such cases, FNAC supplemented by cell block immunocytochemistry is required for an accurate diagnosis. Diagn. Cytopathol. 2017;45:36-42. © 2016 Wiley Periodicals, Inc.

Fine needle aspiration in retroperitoneal lesions

The retroperitoneal space is a potential space extending from lumbar to the pelvic region, behind the peritoneum. It encloses many vital organs like adrenals, kidneys, ureters, pancreas, aorta and its branches, inferior vena cava and its tributaries and many lymph nodes along with loose connective tissue and fat. The literature regarding role of fine needle aspiration cytology (FNAC) for diagnosis of retroperitoneal lesions as a whole, is exceedingly limited. The present study was conducted to elucidate the spectrum of retroperitoneal lesions and to determine the diagnostic accuracy of fine needle aspiration cytology, presenting to a tertiary care referral centre. A total of 389 aspirates from retroperitoneal lesions were reviewed for clinical and radiological details. The smears were studied for the cytological diagnosis. Cytological-histological correlation was assessed and the causes for discordant diagnoses were determined. The patients' age ranged from 1 to 88 years. There were 234 (60.2%) males and 155 (39.8%) females. In 61 (15.7%) aspirations, the yield was inadequate for reporting and 328 were satisfactory. About 113 (29.0%) aspirates were from pancreatic masses alone, 97 (24.9%) from the retroperitoneal lymph nodes, 70 (17.9%) from the kidneys, 45 (11.5%) from the adrenals, 41 (10.5%) from the retroperitoneal soft tissues and 23 (5.9%) from retroperitoneal segments of the gut. There were 249 (64.0%) neoplastic lesions and 79 (20.3%) non-neoplastic lesions, the ratio being 3.1:1. Eight (2.0%) aspirates were reported as suspicious for malignancy, and 5 (1.2%) aspirates were reported as neoplastic but could not be categorized as benign or malignant. Of the neoplastic lesions, malignant neoplasms (n = 216; 87.1%) were much more common than the benign (n = 20; 8.0%), the ratio being 10.8:1. Of all the satisfactory aspirates, subsequent histopathology was available only in 33/327 (10%) cases. A positive correlation between cytological and histological diagnosis was observed in 27/33 (81.8%) cases. We believe FNAC is a useful method for an early, rapid, minimally invasive and reliable pre-operative diagnosis for retroperitoneal lesions and can often obviate the need for open surgical biopsy.

The Flash-Lag Phenomenon: Object Motion and Eye Movements

An object flashed briefly in a given location, the moment another moving object arrives in the same location, is perceived by observers as lagging behind the moving object (flash-lag effect). Does the flash-lag effect occur if the retinal image of the moving object is rendered stationary by smooth pursuit of the moving object? Does the flash-lag effect occur if the retinal image of a stationary object is caused to move by smooth-pursuit eye movements? A disk was briefly flashed in the center of a moving ring such that the ring center was completely ‘filled’ by the disk. In this display, observers perceived the flashed disk to lag such that it appeared only to partially ‘fill’ the ring center. The ‘unfilled’ portion (perceived void) of the moving ring was seen in the color of the background. With smooth pursuit of the ring, the flash-lag effect was eliminated, and observers saw the flashed disk centered on the moving ring. A strong flash-lag effect was observed when observers smoothly pursued a moving point target past a continuously visible stationary ring. Once again, the flashed disk appeared to only partially fill the center of the continuously visible stationary ring, yielding a vivid ‘perceived void’. These results are discussed in terms of neural delays and their compensation.

Significance of epithelial cell clusters in pseudomyxoma peritonei

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare clinical syndrome characterised by distension of the peritoneum by jelly-like ascites. Cytological evaluation of peritoneal fluid is often an initial diagnostic test for possible ovarian and/or appendiceal primary tumours.

AIMS AND OBJECTIVES

The present work was conducted to study the usefulness of peritoneal fluid cytomorphology in the early diagnosis of PMP and to evaluate the significance of the presence of epithelial cell (EC) clusters and their prognostic implications.

MATERIALS AND METHODS

We evaluated the detailed cytological features of 21 cases of PMP retrospectively. Both conventional and liquid-based cytology smears of peritoneal fluid were reviewed, cytological features were compared with histological findings and cases were classified into disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA).

RESULTS

In our study, the common causes of PMP were primary gastrointestinal malignancies (appendix and colorectal, 57.14%), followed by primary ovarian mucinous neoplasms (28.57%) and synchronous ovarian and appendicular tumours (14.28%). Thick mucinous material was present in all cases (100%). ECs were present in 18 of 21 (85.17%) patients, with mild nuclear atypia in the majority of cases. Histiocytes, mesothelial cells and fibroblast-like, spindle-shaped cells with entrapped mucin were also noted in the background. The cases of PMCA showed greater numbers of EC clusters in cytology smears and these patients had recurrent episodes of PMP.

CONCLUSION

On cytomorphology, high-grade tumours were more cellular and frequently showed EC clusters with moderate to severe atypia, prominent nucleoli and mitosis, and were more prone to PMCA.

Cytodiagnosis of distant metastases from follicular thyroid carcinoma

INTRODUCTION

Follicular carcinoma of the thyroid is second most common primary malignancy of the thyroid gland after papillary carcinoma and metastasis is uncommonly seen in these patients.

AIMS AND OBJECTIVES

To describe the cytomorphologic features for the accurate diagnosis of distant metastases from follicular carcinoma of thyroid.

MATERIALS AND METHODS

A total of 10 aspirates reported as metastatic follicular carcinoma of thyroid were reviewed for the available clinical and radiological details.

RESULTS

All the patients were females. Six of these patients presented with subcutaneous and soft tissue swellings, one presented with a lung mass, one with right breast swelling, one with lumbar vertebral lesion and one with left iliac bone involvement. The cytology smears revealed tumour cells predominantly arranged in a repetitive microfollicular pattern with some scattered individually and in sheets. The tumour cells were small, had mild nuclear pleomorphism, round nuclei, low nuclear-cytoplasmic ratio, fine chromatin, inconspicuous nucleoli, and scanty to moderate amount of cytoplasm with some showing marginal vacuoles with "fire-flare" appearance. Occasional microfollicles showed scanty eosinophilic colloid in the center.

CONCLUSIONS

Identification and establishment of a correct clinical diagnosis of a distant metastasis from a follicular thyroid carcinoma is a challenging task. We believe that with prior knowledge of characteristic cytologic features, such metastases can be rapidly and accurately diagnosed by fine needle aspiration cytology.

The protective role of the -1306C>T functional polymorphism in matrix metalloproteinase-2 gene is associated with cervical cancer: implication of human papillomavirus infection

Cervical cancer is the major reproductive health problem among women caused by persistent infection of high-risk human papillomavirus (HR-HPV). Metalloproteinase-2 (MMP-2) is an endopeptidase highly expressed in cervical cancer; however, the genetic link between aberrant expression of MMP-2 and cervical carcinogenesis is not known. The genotypic distribution, expression pattern of MMP-2 and HPV infection, was analyzed in a total of 300 fresh surgically resected cervical tissue biopsies. The MMP-2 C1306T (rs243865) promoter polymorphism dominant model (CC v/s CT + CT + TT) revealed that the CC genotype had a 4.33-fold significant increased risk for development of cervical cancer (OR = 4.33; 95 % CI = 2.36-4.02, p = 0.0001) compared to those with variant genotypes (-1306 CT + TT). The C allele was associated with 3-fold significant increased risk (OR = 2.95; 95 % CI = 1.90-4.60, p = 0.0002) compared to T allele. Interestingly, a significant correlation was found between high expression of MMP-2 protein and CC genotype in cancer patients (p = 0.001) compared to normal controls (p = 0.012). Further analysis showed that the risk of cancer was extremely pronounced in HPV positive patients (OR = 9.33; 95 % CI = 2.88-30.20, p = 0.0001) compared to HPV negative ones, implicating the possible interaction between -1306CC genotype and HPV infection in increasing the cancer risk (p = 0.0001). The leads from the present study suggest the protective role of gene variant -1306C>T at the promoter region of the MMP-2 against HPV-mediated cervical cancer. These findings substantiate the functional role of MMP-2 C1306T polymorphism in a significant downregulation of MMP-2 protein in women with variant genotype (CT/TT) compared to the normal wild CC genotype.

Cervical embryonal rhabdomyosarcoma and ovarian Sertoli-Leydig cell tumor with congenital absence of unilateral ovary

We report this first case of synchronous cervical rhabdomyosarcoma and Sertoli-Leydig cell tumor (SLCT) of ovary with congenital absence of unilateral ovary and fallopian tube in a 16-year-old female patient. A review of the English-language literature identified only six cases of double malignancies with cervical rhabdomyosarcoma and SLCT but none of the case was associated with congenital absence of ovary and fallopian tube. When such multiple conditions involving one system occur in an individual, the possibility of single etiology arises, but beside some hypothesis, no definite link could be established in any of the cases reported.

Liquid-based cytology versus conventional cytology for evaluation of cervical Pap smears: experience from the first 1000 split samples

CONTEXT AND AIM

Screening programs using conventional cytology conventional Pap smear (CPS) have successfully reduced cervical cancer, but newer tests like liquid-based cytology (LBC) and human papillomavirus testing might enhance screening. The main aim of the present study was to assess the diagnostic accuracy of LBC versus CPS using "split samples."

MATERIALS AND METHODS

This was a prospective study comprising of 1000 consecutive cervical "split samples" over a period of 1 year. Split sample was obtained using cervex-brush. CPS was prepared from the brush and the brush head was suspended in the LBC vial and processed by SurePath™ LBC.

RESULTS

There were 4.3% unsatisfactory (U/S) cases in CPS and 1.7% in LBC; the main cause is insufficient cells, and excess of blood in CPS. About 25/100 (2.5%) split samples had epithelial abnormalities both in CPS and LBC (1.2%-atypical squamous cells of undetermined significance; 0.4%-low grade squamous intraepithelial lesion; 0.2%-high grade squamous intraepithelial lesion; 0.5%-squamous cell carcinoma; 0.1%-atypical glandular cells favouring neoplasia; 0.2%-adenocarcinoma). Inflammatory organisms were almost equally identified in both techniques but were better seen in LBC samples.

CONCLUSIONS

LBC technique leads to significant reduction of U/S rate. LBC samples offered better clarity, uniform spread of smears, less time for screening and better handling of hemorrhagic and inflammatory samples. LBC had equivalent sensitivity and specificity to CPS.

Characterization of Toll-like receptor transcriptome in squamous cell carcinoma of cervix: A case-control study

OBJECTIVE

Human papillomavirus (HPV) is a proven etiological agent for cervical cancer However, not all HPV infections result in cervical cancer. The mechanisms of host immune system to prevent/control HPV infection remain poorly understood. Toll-like receptors (TLRs) are a system of innate immune defense. HPV has been demonstrated to modulate TLR expression and interfere in TLR signaling pathways, leading to persistent viral infection and carcinogenesis. The aim was to study the relative gene expression of TLRs in cervical squamous cell carcinoma (SCC).

METHODS

Gene expression profile of TLRs 1 to 9 was examined in 30 cervical SCCs and an equal number of normal cervical tissue samples using a PCR array platform. Gene expression studies for TLRs 3 and 7 were validated by western blotting.

RESULTS

HPV was detected in all cases and in none of the controls (p<0.0001). HPV16 was the preponderant (83.3%) subtype. A significant downregulation in the relative gene expression of TLR3 (p<0.0001), TLR4 (p<0.0005) and TLR5 (p<0.0001) was observed in cases. A significant upregulation for TLR1 was observed (p=0.006). Although TLRs 2, 7, 8 and 9 were upregulated and TLR6 was downregulated, it was not significant. The western blot performed with antibodies against TLRs 3 and 7 confirmed the findings of the gene expression studies.

CONCLUSIONS

A significant downregulation in the gene expression of TLRs 3, 4 and 5 and upregulation of TLR1 was observed in cervical SCC as compared to controls. Study results evoke the proposition for investigating TLRs 3, 4 and 5 agonists for therapeutic exploration.

Artificial neural network in diagnosis of urothelial cell carcinoma in urine cytology

AIMS AND OBJECTIVE

To build up an artificial neural network (ANN) model in the diagnosis of urothelial cell carcinoma (UCC) in urine cytology smears.

MATERIAL AND METHODS

We randomly selected a total of 115 urine cytology samples, out of which 59 were histopathology proven UCC cases and remaining 56 were benign cases from routine cytology samples. All the carcinoma cases were proven on histopathology. Image morphometric analysis was performed on Papanicolaou's stained smears to study nuclear area, diameter, perimeter, standard deviation of nuclear area, and integrated gray density. Detailed cytological features were also studied in each case by two independent observers and were semi-quantitatively graded. The back propagation ANN model was designed as 17-11-3 with the help of heuristic search. The cases were randomly partitioned as training, validation, and testing sets by the program. There were 79 cases for training set, 18 cases for validation set and 18 cases for test set.

RESULT

In the training set, ANN was able to diagnose all the malignant and benign cases. In the test set, all the benign and malignant cases were diagnosed correctly. However, one of the low grade cases was diagnosed as high grade UCC by ANN model.

CONCLUSIONS

We successfully built an ANN model in urine from the visual and morphometric data to identify the benign and malignant cases. In addition, the system can also identify the low grade and high grade UCC cases.

Leiomyosarcoma of the vagina: A rare entity with comprehensive review of the literature

Primary malignant lesions of the vagina are uncommon, and vaginal sarcomas are even rarer. We describe a rare case of stage I, high-grade leiomyosarcoma of the vagina treated with combined modality treatment. A 39-year-old female presented with vaginal mass and underwent resection. Histopathological examination revealed atypical leiomyoma of the vagina with definite risk of recurrence. Eleven months later, she presented with a recurrent vaginal mass and underwent exploratory laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy plus resection of recurrent tumor and partial vaginectomy. The detailed histopathological examination was suggestive of leiomyosarcoma of the vagina. The patient received adjuvant radiotherapy and chemotherapy. The patient is alive and disease-free 29 months postsurgery. Experience with vaginal leiomyosarcomas is limited. The optimal treatment methods have not yet been established because of the rarity of the tumor. We add another case of leiomyosarcoma of the vagina to the limited existing literature.

Bilateral sertoli-leydig cell tumor in a primigravida: a rare case

We present a unique case of incidentally discovered bilateral Sertoli Leydig cell tumour in a primigravida who displayed no features of virilization. The apha fetoprotein levels were elevated. Magnetic resonance imaging was suggestive of ovarian tumors, possibly germ cell tumor. Bilateral salpingo-oophorectomy was performed and histopathology showed features of Sertoli Leydig cell tumor with intermediate to poor differentiation. Immunohistochemistry was positive for calretinin and inhibin, while cytokeratin was negative. Four courses of bleomycin-, etoposide- and cisplatin-based chemotherapy regimen was started, but the patient aborted while receiving the second cycle of chemotherapy. She received the remaining two cycles of chemotherapy and is now on close follow up with monitoring of serum inhibin levels to detect any tumor recurrence. Bilateral Sertloli Leydig cell tumor has not been reported previously in a pregnant female. The aim of this article is to describe the clinical, radiological and pathological features and management of this rare entity.

Pulmonary hamartoma, a rare benign tumour of the lung - Case series

Introduction - Pulmonary hamartoma, with incidence of 0.25-0.32%, accounts for 6% of solitary pulmonary nodules. The role of radiology is limited as only 10-30% of cases show characteristic ‘popcorn’ calcification and Computed Tomography can detect approximately  50% of hamartomas. Hence cytological and/or histopathological examination is required to make a definitive diagnosis and exclude malignancy. Objective – As pulmonary hamartoma is a rare entity detected serendipitously on radiography and requires cytological and histopathological examination for confirmation of diagnosis, we present nine cases of solitary pulmonary nodules which were diagnosed as pulmonary hamartoma.  Methods - We retrospectively screened departmental records and slides and found nine cases of pulmonary hamartoma in our tertiary care institute. Three cases were diagnosed on CT guided Fine Needle Aspiration Cytology and four cases were diagnosed on histopathological examination of surgical specimens, over a period of 16 years (1997-2012). Two cases were incidentally discovered to have pulmonary hamartoma at autopsy.  Observations – The age of the patients ranged from 17-63 years (mean-46.3), with male to female ratio being 3.5:1. The size of the hamartoma varied from 0.4 – 1.3 cm, with mean diameter of 1 cm. Cytology showed mixture of bronchial epithelial cells, adipocytes and stromal fragments in fibromyxoid and chondroid background. Histopathology demonstrated lobules of cartilage and adipose tissue with intervening clefts lined by respiratory epithelium and mesenchymal stroma. Conclusion – Every solitary pulmonary nodule is not malignant. It is important to correctly diagnose pulmonary hamartoma, a rare, yet benign neoplasm presenting as a solitary lung nodule and distinguish it from malignancy.Asian Journal of Medical Science, Volume-5(3) 2014: 112-115 http://dx.doi.org/10.3126/ajms.v5i3.9243 

Fine needle aspiration cytology of oral and oropharyngeal lesions with an emphasis on the diagnostic utility and pitfalls

AIM

This study was undertaken to evaluate the diagnostic utility and pitfalls of fine needle aspiration cytology (FNAC) in oral and oropharyngeal lesions.

MATERIALS AND METHODS

This was a retrospective audit of oral and oropharyngeal lesions diagnosed with FNAC over a period of six years (2005-2010).

RESULTS

Oral/oropharyngeal lesions [n=157] comprised 0.35% of the total FNAC load. The age ranged 1-80 years with the male: female ratio being 1.4:1. Aspirates were inadequate in 7% cases. Histopathology was available in 73/157 (46.5%) cases. Palate was the most common site of involvement [n=66] followed by tongue [n=35], buccal mucosa [n=18], floor of the mouth [n=17], tonsil [n=10], alveolus [n=5], retromolar trigone [n=3], and posterior pharyngeal wall [n=3]. Cytodiagnoses were categorized into infective/inflammatory lesions and benign cysts, and benign and malignant tumours. Uncommon lesions included ectopic lingual thyroid and adult rhabdomyoma of tongue, and solitary fibrous tumor (SFT), and leiomyosarcoma in buccal mucosa. A single false-positive case was dense inflammation with squamous cells misinterpreted as squamous cell carcinoma (SCC) on cytology. There were eight false-negative cases mainly due to sampling error. One false-negative case due to interpretation error was in a salivary gland tumor. The sensitivity of FNAC in diagnosing oral/oropharyngeal lesions was 71.4%; specificity was 97.8% with diagnostic accuracy of 87.7%.

CONCLUSIONS

Salivary gland tumors and squamous cell carcinoma (SCC) are the most common lesions seen in the oral cavity. FNAC proves to be highly effective in diagnosing the spectrum of different lesions in this region. Sampling error is the main cause of false-negative cases in this region.

Primary intraocular central nervous system lymphoma masquerading as diffuse retinal vasculitis

A 49-year-old woman had blurred vision and floaters of 4 days duration in the right eye. Ocular examination revealed granulomatous panuveitis, vitritis and diffuse retinal vasculitis. Following a strongly positive tuberculin skin test, she received antitubercular therapy with oral steroids and immunosuppressants. A year later, despite therapy, vitritis and vasculitis persisted. Additionally, yellowish white lesions appeared beneath the retinal pigment epithelium. Fluorescein angiography revealed a leopard skin appearance. Following a negative vitreous biopsy, she was subjected to a chorioretinal biopsy which revealed non-Hodgkin's lymphoma. MRI was normal. The ocular lesions resolved following intravitreal methotrexate injections. MRI of the brain was repeated every 3 months to rule out central nervous system (CNS) involvement. About 2.5 years after initial presentation, she complained of ataxia, hypersomnia and speech difficulty. MRI of the brain now showed lesions in the thalamocapsular region and the corpus callosum splenium suggestive of CNS lymphoma. She underwent a whole brain radiation with symptomatic improvement followed by chemotherapy.

Incidental pathologically proven pulmonary hamartoma in a patient with carcinoma tongue

Pulmonary hamartomas are usually clinically silent and found incidentally on chest radiographs. They can lead to diagnostic confusion especially in patients who have been previously treated for primary cancers at other sites. This can lead to consideration of metastatic malignancy as the primary diagnostic possibility. In this case, evaluation of a solitary pulmonary nodule (SPN) in a patient with carcinoma of tongue led to the diagnosis of pulmonary chondroid hamartoma. This highlights the fact that a pulmonary nodule in a patient with progressive cancer at another site does not always indicate pulmonary metastasis.

Malignant Pleural Mesothelioma in a Patient with Systemic Sclerosis: The First Report

Malignant pleural mesothelioma (MPM) is a relatively rare but aggressive pleural tumor. Systemic sclerosis (SSc) is associated with the development of lung cancer and other malignancies. We describe a 58-year-old never-smoker female, previously diagnosed with limited cutaneous SSc, who presented with chest pain on the left side, dyspnea and circumferential nodular left pleural thickening. Fluorodeoxyglucose positron-emission tomography-computed tomography showed intense uptake in the thickened left pleura, mediastinal lymph nodes and left femur. Pleural fluid cytological examination along with nuclear and membranous positivity for Wilms tumor-1 antigen and epithelial membrane antigen on immunocytochemistry confirmed the diagnosis of MPM. To the best of our knowledge, this is the first report of MPM in a patient with SSc.

Placentomegaly and placental mesenchymal dysplasia

A 23-year-old primigravida presented to the labour ward at 37 weeks gestation referred with intrauterine growth restriction, oligohydramnios and placentomegaly. Differential diagnoses of placentomegaly were considered. Her antenatal blood screening tests were normal. There were no fetal malformations. However, triple screen and fetal karyotype were not done as patient presented late in pregnancy. The patient soon went into spontaneous labour and delivered a girl weighing 2.15 kg with a normal Apgar score. The cord was long and twisted; placenta was bulky, 1.7 kg, with prominent grape-like vesicles involving whole placenta with a rim of normal placenta at the periphery. Microscopy showed some areas of multiple villi with marked hydropic changes and myxoid degeneration, preserved vasculature and no trophoblastic proliferation. Placental mesenchymal dysplasia was thus diagnosed. The baby had no evidence of Beckwith-Wiedemann syndrome. The child is now 3 years old with normal development and is doing well.

Micronucleus scoring in urine cytology specimen by DNA-specific stain

OBJECTIVE

To evaluate the role of micronuclei (MN) scoring in urinary cytology of bladder transitional cell carcinoma (TCC).

STUDY DESIGN

Eighty cases of freshly voided urine samples were used for scoring of MN using acridine orange (AO)-stained smears under fluorescence microscope and routine Papanicolaou-stained smears under light microscopy. MN score for cytologic lesions was compared.

RESULTS

In AO-stained slides, the mean MN scores were 0.171 +/- 0.395 and 1.489 +/- 1.871 in smears with "no malignant cells seen" and TCC cases, respectively. In Papanicolaou-stained slides the mean MN scores were 0.194 +/- 0.419 and 1.84 +/- 1.876 in smears with "no malignant cells seen," and TCC cases, respectively. Independent sample t test showed significant difference of MN scoring in Papanicolaou-stain and AO stain in no malignancy vs. TCC. Pearson's correlation test showed strong positive correlation between mean MN score by AO and Papanicolaou stains and Pearson's correlation coefficient.

CONCLUSION

MN score was significantly high in TCC cases, which may be due to chromosomal damage in bladder carcinoma. In difficult cases, MN may help distinguish benign from malignant cells in urine samples. Routine Papanicolaou stain may also be used for MN score because DNA-specific AO-stained smear gives almost similar results.

Myxoma of ovary: an uncommon entity

PURPOSE

In this brief report, we have described a rare case of myxoma of ovary.

METHODS

We have studied the detailed histopathological features of this case and discussed the relevant differential diagnosis.

RESULTS

A 20-year-old female patient presented with right sided adnexal mass. Tumor marker level and other biochemical parameters were within normal limits. Exploratory laparotomy and debulking of the mass showed a large solid cystic right ovarian tumor. Microscopically, the tumor showed abundant myxoid matrix with interspersed randomly traversed sparse stellate or spindle-shaped tumor cells. The diagnosis of myxoma was offered.

CONCLUSION

Ovarian myxoma is a rare but distinct entity and this should be differentiated from the other lesions of ovary with myxoid changes.

Non-Hodgkin's lymphoma presenting as breast masses: a series of 10 cases diagnosed on FNAC

Primary breast lymphoma (PBL) is a rare disease, which comprises 0.04-0.53% of all primary malignant tumors of the breast. The most frequent histological subtype is diffuse large B-cell type (DLBCL) (40-70%). Differentiation of PBLs from other breast tumors such as poorly differentiated carcinomas and lobular carcinoma may at times be difficult on cytomorphology alone. An audit of breast lymphomas diagnosed on fine needle aspiration cytology (FNAC) over a period of 9 years (2001-2009) was performed. Ten cases were retrieved and the cytomorphology was reviewed along with immunochemistry (IHC), flow cytometry as well as histopathology, wherever available. The age of patients ranged from 17 to 83 years. Eight cases were diagnosed as non-Hodgkin's lymphoma, high-grade on FNAC. Histopathology was available in four of these cases and cell block was available in one case. Lymphoid cells were positive for leukocyte-common antigen (LCA) and CD20 and negative for CD3 in these cases. The same was confirmed by flow cytometry on aspirated material in one case. A diagnosis of DLBCL was offered in these five cases. One case was a low-grade NHL and another case was a young male, a known case of acute leukemia and had leukemic infiltration in the breast lump. We wish to emphasize the potential importance of FNAC in breast lymphoma and the same can be helpful to avoid unnecessary surgery in these cases. The differential diagnostic entities have been discussed. IHC and flow cytometry can be performed on the aspirated material and provide valuable information.

Malignant biphasic peritoneal mesothelioma in a child: fine-needle aspiration cytology, histopathology, and immunohistochemical features along with review of literature

Peritoneal mesotheliomas in children are of rare occurrance. We herein report the clinical, radiological, and pathological findings of a rare case of malignant peritoneal mesothelioma occurring in nine-year-old female child. The child presented with abdominal distension and awareness of a painless mass in the abdomen which on radiology appeared as a large heterogeneous pelvic mass with peritoneal deposits at multiple sites. To the best of our knowledge, this is the first case of a peritoneal malignant mesothelioma on which fine needle aspiration (FNA) was performed as first line investigation of the primary tumor. The cytological features, major differential diagnoses, and the pitfalls therein are discussed. Histopathology revealed biphasic pattern of mesothelioma which is again a rare pattern. Immunochemistry was carried out on the cell block made from the FNA as well as the biopsy specimen essentially showed the same features. There was positivity for vimentin, EMA, and cytokeratin 5/6 while WT1, calretinin, and CEA were negative; however, D2-40 showed diffuse membranous positivity in the epithelial areas and cytoplasmic positivity in the spindle areas confirming a mesothelioma. We emphasize the use of immunochemistry on cell block material for a confident diagnosis of mesothelioma in such cases.

Fine-needle aspiration cytology of orbital meningiomas

Meningiomas are benign tumors derived from arachnoid cells. Most commonly they arise within the cranial cavity, but they may arise extracranially in various anatomic sites. We present four cases of orbital meningiomas diagnosed on fine-needle aspiration cytology (FNAC) and confirmed on histopathology. All the cases are presented with orbital mass. FNAC smears showed classical whorling and syncytial pattern of cells, with round to oval nucleus, inconspicuous nucleoli and one each case showed intranuclear inclusion and psammoma bodies. FNAC diagnosis of such lesions is difficult, because cytological features may mimic other soft tissue lesions located in orbital region. Awareness of this entity and its cytological appearance is important to allow correct diagnosis.

Primary Ewing's sarcoma/primitive neuroectodermal tumor of the kidney: Report of a case diagnosed by fine needle aspiration cytology and confirmed by immunocytochemistry and RT-PCR along with review of literature

Primary Ewing's sarcoma/primitive neuroectodermal tumor (ES/PNET) of the kidney is a distinct entity that can be mistaken for variety of round cell tumors. We report a rare case of ES/PNET of the kidney in a 35-year-old female patient diagnosed by fine needle aspiration cytology (FNAC) and confirmed by immunohistochemistry (IHC) and reverse-transcriptase polymerase chain reaction (RT-PCR). Ultrasound guided FNAC smears from the kidney mass showed a population of malignant small round cells with perivascular arrangement and focal rosette formation. IHC performed on the cell block, showed strong immunopositivity for CD99 (MIC2) and vimentin. Molecular analysis of the aspirate by RT-PCR confirmed the EWS-FLI type1 transcript. The application of RT-PCR on FNAC material for establishing a diagnosis of renal ES/PNET is being reported for the first time. FNAC also confirmed metastases in the right level I cervical lymph node. The utility of IHC and molecular techniques in diagnosis of such a rare case is stressed and relevant literature is discussed.

Fine needle aspiration cytology in lesions of the nose, nasal cavity and paranasal sinuses

OBJECTIVE

To assess the spectrum of lesions in the sinonasal region diagnosed on FNAC.

STUDY DESIGN

This is a retrospective audit of sinonasal lesions diagnosed on FNAC over a period of 12 years (1998-2009).

RESULTS

Out of a total of 79,851 FNACs, 158 (0.2%) were from the sinonasal region. FNAC was non-diagnostic in 20 (12.6%) cases. Infective/inflammatory lesions comprised of 30 (19%) cases including non-specific inflammation (19), fungal infection (7), tuberculosis (2), actinomycosis (1) and filariasis (1). Benign cysts (24; 15.2%) included epidermal inclusion cysts, mucocele and aneurysmal bone cyst. Benign bone tumors (4) comprised of giant cell tumor, fibrous dysplasia, chondroma, and osteoblastoma. Other benign tumors included lipoma (6), hemangioma (5), schwannoma (2), meningioma (1), pleomorphic adenoma (1), sebaceous adenoma (1) and other skin adnexal tumors (3). Malignant epithelial tumors (24; 15.2%) included squamous cell carcinoma (10), basal cell carcinoma (5), poorly differentiated carcinoma (4) and metastatic carcinoma (5). Two cases of chordoma and one case each of dermatofibrosarcoma pertuberance and hemangiopericytoma were seen. Sarcomas included sarcoma, not otherwise specified (4), rhabdomyosarcoma (3), osteosarcoma (2), chondrosarcoma (2), leiomyosarcoma (1), malignant fibrous histiocytoma (1), fibrosarcoma (1) and malignant peripheral nerve sheath tumor (1). There were cases of malignant small round cell tumor (11), non-Hodgkin lymphoma (3), plasmacytoma (2) and malignant melanoma (2).

CONCLUSION

A variety of non-neoplastic and neoplastic conditions can involve the sinonasal region. FNAC is a reliable diagnostic procedure in a good number of cases, especially in the light of clinico-radiological data.

Spectrum of orbital and ocular adnexal lesions: an analysis of 389 cases diagnosed by fine needle aspiration cytology

The aim of the present study was to evaluate the scope and the limitations of fine needle aspiration cytology (FNAC) in orbital and ocular adnexal lesions. This study was a retrospective audit of 389 cases of orbital and ocular adnexal lesions subjected to FNAC over a period of 12 years (1998-2009). The cyto-smears were reviewed and the lesions were categorized under different diagnostic categories in adult and pediatric population. Three hundred and one adult patients (age ≥15 years) and 88 pediatric patients (age ≤14 years) constituted the study group. In the adult population, there were 23.3% cases of infectious and lymphoproliferative lesions and 12.6% of benign cysts. In the pediatric population, 18.2% cases had infectious and lymphoproliferative lesions and 8% had benign cysts. Various benign tumors (9.6% in adults) included pleomorphic adenoma, meningioma, and schwannoma. Benign vascular tumors predominated in the pediatric population. A majority of malignant tumors in adults were lymphoreticular malignancies (12.6%); non-Hodgkin's lymphoma being the most common followed by malignant epithelial tumors (10.3%). Nearly 3.6% cases of soft tissue/bone sarcomas and 6.3% of metastatic tumors were seen in adult population. However, most of the orbital tumors in the pediatric population were malignant small blue round cell tumors (33%). FNAC is a cost-effective technique with good diagnostic value in the assessment of ophthalmic lesions, especially when sampling and interpretation are performed by experienced personnel in the light of clinico-radiological information.

Fine needle aspiration cytology of insular carcinoma of thyroid

Poorly differentiated (insular) thyroid carcinoma is defined as a thyroglobulin-producing non-follicular non-papillary thyroid carcinoma, having an intermediate behavior between well-differentiated and anaplastic carcinomas. FNAC is widely used as aid for workup of thyroid gland lesion. However, scant information is available in the literature about cytologic findings of this rare entity. Ten cases of surgically resected insular carcinoma with a corresponding cytology were selected. The cytologic smears and histological sections were reviewed for presence of cytomorphologic features including cellularity, predominant cytoarchitectural pattern, additional cytologic co-patters pattern, cell size, cell shape, nuclear pleomorphism, nuclear/cytoplasmic (N/C) ratio, chromatin pattern, amount of cytoplasm, mitotic figures, colloid, background debris, nuclear grooves, and intranuclear pseudoinclusions. In all the cases, the cells were arranged predominantly in solid clusters. Focal microfollicular pattern was identified in five cases of which three cases showed presence of inspissated colloid within the follicles. Singly scattered malignant cells and bare nuclei were seen in all cases. Cells were monomorphic, round with high N/C ratio, finely granular chromatin and inconspicuous nucleoli. Background showed presence of cellular debris in two cases. Mitotic figures were obvious and atypical mitosis was also identified. Cellular smears composed of monomorphic population of small cells arranged in large clusters and sheets with high N/C ratio and high mitosis suggest the possibility of insular carcinoma. Background cellular debris/necrosis also supports the diagnosis. Cell block preparation in these cases may be of additional help in accurate diagnosis.