Malignant melanoma in fine needle aspirates and effusions. An immunocytochemical study using monoclonal antibodies

The value of monoclonal antibodies (MAbs) for the immunodetection of keratin, vimentin and two melanoma-associated antigens recognized by NKI/C3 and NKI/Bteb for the diagnosis of malignant melanoma has been previously established on histologic preparations. In the present study, cytologic preparations from 20 fine needle aspirates and effusions from patients with malignant melanoma were evaluated using these antibodies. Twenty of 20 smears were negative for keratin, and 20 of 20 smears were positive for vimentin. Positivity for NKI/C3 was seen in 12 of 12 cases studied, and for NKI/Bteb in 12 of 13 cases. These results indicate that a panel of MAbs consisting of anti-keratin, anti-vimentin, NKI/C3 and NKI/Bteb is useful for a more accurate diagnosis of malignant melanomas on cytologic preparations. The expression of these antigens in melanoma cells in cytologic smears can be a valuable aid in the detection of primary (noncutaneous) and metastatic melanomas by fine needle aspiration.     

Optimal recovery of DNA for polymerase chain reaction-based assays from fine needle Aspirates. A comparison of four preparation types

OBJECTIVE: To assess the ideal preparation for molecular techniques applied to cytologic specimens using polymerase chain reaction (PCR) on different types of cytologic preparations with specimens obtained from fine needle aspiration biopsy (FNAB). STUDY DESIGN: Besides conventional cytologic examination, PCR was performed on 30 consecutive cases of FNAB to analyze the beta-actin gene in four types of cytologic preparations, including fresh samples, previously stained Papanicolaou and Diff-Quik routine smears and cell blocks. Cellularity and cytologic findings were correlated with PCR results. RESULTS: The beta-actin gene was successfully amplified from all cases studied. Cellularity of the samples correlated directly with PCR results except for one case of metastatic melanoma with intense pigment retention. All specimens showed equivalent results as compared to fresh samples. Generally cell blocks were less cellular and consequently less effective. CONCLUSION: All conventional cytologic preparations tested were suitable for PCR-based assays when cellularity was adequate. Alcohol-fixed and air-dried smears can be successfully used for PCR studies, providing rapid and simple specimens for molecular studies, which can add important information concerning diagnosis, prognosis and management.     

Utility of immediate evaluation of endoscopic ultrasound-guided transesophageal fine needle aspiration of mediastinal lymph nodes

OBJECTIVE: To assess the value of immediate cytologic evaluation (ICE) in mediastinal endoscopic ultrasound-guided transesophageal fine needle aspiration (EUS-FNA). STUDY DESIGN: Fifty eight patients with mediastinal lymphadenopathy underwent transesophageal EUS-FNA. Cellularity, number of needle passes and number of slides prepared were reviewed retrospectively. RESULTS: Of moderate to highly cellular passes, 75% were diagnostic. ICE had a 100% positive predictive value and 97% negative predictive value. ICE allowed a diagnosis in all cases. Calculated diagnostic accuracy was 70% if the procedure ended after a single specimen of at least moderate cellularity or after completion of 4 needle passes. CONCLUSION: Immediate cytologic evaluation of EUS-FNA specimens allowed a diagnosis in all cases and contributed to the utility of EUS-FNA as a diagnostic procedure for mediastinal adenopathy.     

Endometriosis of the rectovaginal septum. Diagnosis by fine needle aspiration cytology

The cytologic picture seen in two cases of rectovaginal endometriosis diagnosed by fine needle aspiration (FNA) cytology is presented in detail. The cell pattern differed considerably from that previously described in fluid specimens and more closely resembled the exfoliation observed in direct endometrial samples. No previous report appears to exist on the diagnosis of rectovaginal endometriosis by FNA.     

Endometriosis in an inguinal crural hernia. Diagnosis by fine needle aspiration biopsy.

The fine needle aspiration (FNA) biopsy findings of endometriosis is an inguinal crural hernia in a 40-year-old woman are presented. The cytologic findings were similar to those previously reported in aspirates of solid endometriosis in other sites: nonatypical, small, epithelial groups in an inflammatory and proteinaceous background. The cytologic diagnosis of a benign epithelial lesion, possibly endometriosis, was confirmed by histologic study of the extirpated mass. This case shows that endometriosis must be included in the differential diagnosis of FNA samples of palpable lesions of the groin in women of reproductive age.     

Role of fine needle aspiration cytology in nodular sclerosis variant of Hodgkin's lymphoma

OBJECTIVE: To assess the efficacy of fine needle aspiration cytology (FNAC) in the diagnosis of nodular sclerosis variant of Hodgkin's lymphoma (NSHL) and to analyze cytologic features that could help in subtyping a case of Hodgkin's lymphoma into this variant. STUDY DESIGN: FNAC smears of 18 histopathologically proven cases of NSHL were analyzed for a variety of features. RESULTS: On initial cytologic assessment, 14 of 18 cases were diagnosed as Hodgkin's lymphoma. No further subtyping was performed. In this retrospective analysis it was possible to revise the diagnosis in the remaining 4 cases. Of the various cytologic features analyzed, presence of numerous lacunar-type cells along with fibroblasts and collagenous material were useful pointers toward a diagnosis of nodular sclerosis variant. Fibroblasts were seen in 83.33%, collagenous material in 27.77% and numerous lacunar cells in 77.77%. CONCLUSION: Subtyping of NSHL based on cytologic features alone has been a matter of debate for a long time. Of the various subtypes, nodular sclerosis poses the greatest diagnostic difficulty. Though certain cytologic features may help in suggesting a diagnosis of nodular sclerosis variant, the primary role of fine needle aspiration is to diagnose a case of Hodgkin's lymphoma as such and advise histopathologic examination for further categorization.     

Fine needle aspiration cytodiagnosis of sialadenitis with crystalloids.

OBJECTIVE: To assess the utility of fine needle aspiration cytology in the diagnosis of sialadenitis with crystalloid formation in four patients that presented with a swelling of the parotid gland. STUDY DESIGN: The swelling was aspirated in all the cases using a 22-gauge needle, and aspirates were submitted as needle and syringe washings in a cytology fixative (30% ethyl alcohol in physiologic saline). From these washings filter preparations were made on Sartorius or Gelman filters (pore size, 3 microns) and stained by the Papanicolaou method. Additionally, cell block preparations were made from the aspirate. After processing, sections were cut and stained by hematoxylin-eosin, Prussian blue, alcian blue, mucicarmine, and Von Kossa and congo red stain. No air-dried smears were made, and no electron microscopic studies were done. RESULTS: Stained cytologic preparations and cell blocks showed numerous nonbirefringent crystalloids of varying sizes and shapes appearing as rectangles, needles, squares and rods mixed with neutrophils and rare multinucleated giant cells. No salivary gland components were seen, and all special staining was negative. CONCLUSION: Fine needle aspiration cytology not only provided an accurate diagnosis of sialadenitis with crystalloids but also resulted in adopting conservative management and avoiding unnecessary surgery.     

Cytodiagnosis and comparison of nondecidualized and decidualized endometriosis of the abdominal wall. A report of two cases.

We describe two cases of endometriosis of the abdominal wall occurring in young, multiparous women in which the diagnosis was made by fine needle aspiration biopsy. One case illustrates the cytologic features of non-decidualized endometriosis: a biphasic population of stromal and glandular cells. In contrast, the other case showed large, plump stromal cells in a distinctive myxoid background, creating a picture of decidualized endometriosis. The differential diagnoses of palpable masses in the abdominal wall and the importance of clinicopathologic correlation are discussed.     

Carcinosarcoma of the palate: report of a case with a diagnosis of sarcomatoid metastasis by fine needle aspiration cytology

BACKGROUND: Carcinosarcoma (sarcomatoid carcinoma) is a rare tumor with a high predilection for the aerodigestive tract. Cytologic diagnosis of metastatic carcinosarcoma has been reported in very few cases. CASE: An 84-year-old woman presented with a 2-cm-diameter, right cervical lymph node that was referred for fine needle aspiration cytology (FNAC). She had received radiotherapy for a palatal squamous cell carcinoma 2 years earlier. The FNAC smears had a sarcomatoid appearance. Repeat fine needle aspiration was performed, with cytologic and immunocytochemical staining. Careful consideration of the cytologic and immunophenotypic features led to an impression of carcinosarcoma. Histologic sections of the palatal biopsy that had been previously diagnosed as squamous cell carcinoma were reviewed, and a final diagnosis of carcinosarcoma was established. CONCLUSION: Metastasis of rare lesions, such as carcinosarcoma may be confusing and difficult to diagnose on FNAC, especially when the cytologic sample shows a predominantly sarcomatoid component. The difficulty is compounded when the sarcomatoid component happens to have been overlooked on the initial histologic assessment. With representative cytologic sampling, immunocytochemical staining and review of the histologic material, the correct diagnosis was achieved in this case.     

Fine needle aspiration diagnosis of malignant lymphoma with confirmation by immunoperoxidase staining

Cytospin preparations of fine needle aspirates in 14 cases of suspected lymphoma were studied by immunoperoxidase techniques. The combination of cytologic smears and immunoperoxidase studies resulted in a working diagnosis in 13 of the 14 cases. The immunologic markers in conjunction with the cytologic appearance of the aspirates were reliable and consistent in differentiating between malignant and benign lymphoproliferative lesions and in determining the B-cell or T-cell nature of the process.     

Cytopathology of thymoma

From 1967 to 1981, 37 cases were diagnosed as thymoma by transthoracic fine needle aspiration biopsy. All were verified histologically, with no false-positive results. The various cytomorphologic patterns of thymoma are presented. All aspirates from the thymomas were reviewed and found to be composed of epithelial elements, with an admixture of lymphocytes in various proportions. There were 13 cases of lymphocytic predominance, 11 of epithelial-cell predominance, 4 of spindle-cell predominance, and 9 of mixed cell types. In the cytologic preparations the epithelial elements from different tumors exhibited different cytologic appearances and were tentatively subclassified into five types: small, intermediate, large, large pleomorphic and spindle shaped. The cytologic features of thymoma observed in aspiration biopsies are sufficiently distinctive from those of other anterior mediastinal tumors to be diagnostic. It appears feasible to investigate an anterior mediastinal mass with percutaneous fine needle aspiration for the purpose of establishing the diagnosis of thymoma prior to median sternotomy or thoracotomy.     

Cytologic findings in carotid body tumors

OBJECTIVE: To describe the cytologic findings in 13 cases of carotid body tumors (CBTs) and discuss the differential diagnoses. STUDY DESIGN: Cytologic smears were obtained from 13 cases of carotid body tumors by fine needle aspiration. All tumors were clinically suspected and later confirmed by arteriography or color Doppler ultrasonography. The cytomorphologic findings are described. RESULTS: The smears revealed hypercellularity, a bloody background, isolated and clusters of round to oval cells with indistinct cytoplasm, reticular chromatin, no prominent nucleoli, giant bare nuclei, anisocytosis, acinar structures and plasmacytoid cells. These findings suggested metastatic tumors. CONCLUSION: The cytologic diagnosis of CBTs is very difficult. The aspiration findings can be easily mistaken for those of metastatic tumors. However, when used with clinical and color Doppler findings, fine needle aspiration plays an important role in the preoperative diagnosis and management of CBTs.     

The gray zone in breast fine needle aspiration cytology. How to report on it?

OBJECTIVE: To study the "gray zone" in breast fine needle aspiration cytology in which an unequivocal diagnosis cannot be reached with fine needle aspiration cytology findings. STUDY DESIGN: This study compared cytology and histopathology of 72 breast lesions in which an initial cytologic diagnosis of atypia was given. RESULTS: There were 36 benign (50%) and 36 malignant (50%) histologic biopsy cases in the cytologic atypia group. Anisonucleosis, chromatin and nuclear membrane irregularity, and presence of myoepithelial cells were significantly different in benign and malignant cases. CONCLUSION: The gray zone in breast fine needle aspiration cytology is a broad spectrum that changes from proliferative fibrocystic disease to sclerosing adenosis to malignancy. Diagnosing gray zone pathology as atypical in fine needle aspiration cytology causes no delay in treatment as excisional biopsy is recommended for all equivocal cases.     

Immunocytochemical analysis and cytomorphologic diagnosis on fine needle aspirates of lymphoproliferative disease

Fine needle aspirates were used for the cytologic and immunologic analysis of 21 cases of lymphoproliferative disorders. Immunocytochemical studies performed on Cytospin preparations confirmed the cytomorphologic diagnosis in 19 cases. In one case, the morphology of both aspirates and surgically obtained material showed a reactive pattern while immunologic analyses were inconclusive on both types of material. Immunocytochemistry on tumor material obtained by fine needle aspirations was in agreement with immunohistochemistry on surgical biopsies in 15 of 16 patients with malignant lymphomas. We conclude that immunocytochemical studies performed on Cytospin material in conjunction with the cytologic diagnosis will lead to an increase in diagnostic accuracy as well as providing a means for subclassification of neoplastic lymphoid cells. Moreover, this technique appears to give results comparable to those obtained by histopathologic and immunohistochemical analysis on surgically removed lymph nodes.     

Subcutaneous endometriosis diagnosed by fine needle aspiration cytology

The fine needle aspiration cytology (FNAC) of two patients manifesting cutaneous/subcutaneous endometriosis is presented. Endometrial tissue sampled by the aspiration technique manifested different cytologic characteristics as compared to those of endometrial tissue obtained by standard exfoliative methods. A primary difference was the appearance of the endometrial cells in syncytial clusters in the aspirate, in contrast to the three-dimensional clusters seen in exfoliated material. These cases emphasize the need to include endometriosis in the differential diagnosis of palpable lesions of the abdominal wall, especially in women with healed surgical scars, and the role of FNAC in diagnosing such lesions.     

Pulmonary fine needle aspiration biopsy. Assessing the negative diagnosis.

OBJECTIVE: To assess the significance of the "negative for malignancy" category when applied to pulmonary transthoracic fine needle aspiration biopsy (FNAB). STUDY DESIGN: Transthoracic lung FNABs diagnosed as "negative for malignancy" were identified from the files of Barnes-Jewish Hospital's South and North Campus over a period of five and nine years, respectively. Histologic correlation and clinical follow-up were obtained. RESULTS: Of the 1,181 lung FNABs performed during the study period, 108 cases (9%) had a negative cytologic diagnosis. Histologic correlation was available in 46 cases (43%), of which 23 cases had benign histologic findings, and 19 cases were malignant. Thirty-five of the 62 cases without histologic correlation had clinical follow-up consistent with a benign process. CONCLUSION: Based on the histologic correlation and clinical data available, the negative predictive value was 77%. Inadequate sampling was responsible for all false negative cytologic diagnoses in this series.     

The cytology of malignant histiocytosis (sinusoidal hematolymphoid malignancy)

Malignant histiocytosis (MH: sinusoidal hematolymphoid malignancy) is a rare lymphoreticular disorder characterized by an aggressive clinical course in younger patients with weight loss, hepatosplenomegaly, generalized lymphadenopathy and pancytopenia. Five cases of MH were identified over a five-year period (1982 to 1987) at Indiana University Medical Center. The patients' ages were 12, 16, 20, 30 and 57 years; all presented with classic clinical symptoms. Four cases were diagnosed by fine needle aspiration biopsy; one case was diagnosed by the examination of ascitic fluid. All patients had confirmatory surgical biopsies. The salient cytologic features of MH included (1) a lack of background lymphoglandular bodies, (2) a population of variably sized dyscohesive cells, (3) a component of large bizarre cells with abundant eccentric, deep-blue cytoplasm on Wright-Giemsa-stained preparations, (4) prominent cytoplasmic vacuolization and (5) inconspicuous erythrophagocytosis occurring in the most benign-appearing histiocytic cells. Ancillary studies on cytologic and histologic material (immunostaining for alpha-1-antichymotrypsin and alpha-1-antitrypsin and staining for nonspecific esterases) confirmed the histiocytic nature of the malignant cells. Recognition of the distinctive morphology of MH and the performance of ancillary studies on cytologic preparations should facilitate the rapid diagnosis and early treatment of this aggressive disease.     

Fine needle aspiration cytology of the thyroid: a cytohistologic study with evaluation of discordant cases

OBJECTIVE: To analyze the diagnostic efficacy of fine needle aspiration cytology (FNAC) in the initial evaluation of thyroid nodules, with special emphasis on discrepant cytologic diagnoses. STUDY DESIGN: A total of 192 thyroid fine needle aspirates with subsequent histopathologic follow-up were analyzed. The cytologic diagnoses were divided into 4 categories: positive for malignancy, negative for malignancy, indeterminate for diagnosis and nondiagnostic. The detailed cytologic features were studied along with histopathology sections in all these cases by 2 observers (S.J. and P.D) independently. RESULTS: Cytohistologic correlation was seen in 78.1% of cases and discordance in 21.9%. Indeterminate diagnoses accounted for 15.1% of cases. The majority of these were "follicular neoplasms." The overall sensitivity was 84.44% and specificity 99.11 %. A false positive diagnosis was made in 1 case (0.5%), proven a follicular adenoma on histopathologic examination. A false negative diagnosis was seen in 3.6% of cases. These were cases of papillary microcarcinoma. CONCLUSION: FNAC is a safe, sensitive and specific technique in the initial evaluation of thyroid nodules. A correct cytologic diagnosis can be achieved in a majority of cases, thus obviating the need for a second surgical intervention. A careful and diligent search for various cytologic features and accurate sampling can help in reducing the number of indeterminate, false positive and false negative diagnoses.     

Fine needle aspiration cytology of late-stage callus in stress fracture. A case report

BACKGROUND: Fine needle aspiration cytology (FNAC) is effective in the diagnosis of bone lesions when combined with careful radiologic and clinical evaluation. The cytologic features of callus have not been described before in the English-language literature. CASE: An 18-year-old female presented with a pain in the right lower leg that had been present for two months. Clinical and radiologic findings suggested either stress fracture or periosteal osteosarcoma. The aspiration specimen showed individually scattered, oval cells with moderate amounts of pale pink cytoplasm. The cells contained a single eccentrically located nucleus with evenly distributed, fine chromatin. Osteoclastic giant cells were scattered in the smears. A cytologic diagnosis of benign bone-forming lesion, compatible with callus in fracture, was made. The diagnosis of late-stage callus was confirmed by subsequent histologic examination. CONCLUSION: Typical cases of stress fracture do not need histologic examination, but some cases may be confused with benign and malignant bone tumors. The typical and unique cytologic features of late-stage callus combined with clinical and radiologic findings may prevent the use of more invasive diagnostic procedures and can be a choice for management.     

Morphologic and immunocytochemical evaluation of 220 fine needle aspirates of malignant lymphoma and lymphoid hyperplasia

A total of 220 fine needle aspiration (FNA) specimens from 212 patients with clinically suspected or previously histologically confirmed lymphoma were evaluated by cytology in conjunction with immunophenotyping analysis of the aspirate; the results were compared with the histologic diagnosis made on previous or current accessions of lymph node or extranodal tissue. Smears of the aspirates were stained with the Diff-Quik and Papanicolaou stains while immunoperoxidase staining using antibodies against kappa and lambda immunoglobulin light chains and Leu-4 was routinely performed on Cytospin preparations. Where indicated, additional marker studies (including T-200, Leu-1, Leu-2a, Leu-3a + 3b, Leu-M1, B1, Leu-12, IgM, CALLA and TdT) were performed. For the non-Hodgkin's lymphomas, specimens were classified by the cytologic characteristics of the neoplastic cells according to the International Working Formulation scheme. The combination of cytologic smears and immunoperoxidase studies resulted in a diagnosis of lymphoma in 173 cases (79%). The remaining aspirates were interpreted as suspicious for lymphoma (7%), benign (10%) or inadequate for diagnosis (4%). Of the 15 suspicious aspirates, 5 proved to be Hodgkin's disease and 2 to be T-cell lymphoma by subsequent biopsy. The cause of failure in the nine inadequate aspirates were necrosis (3 cases), sclerosis (2 cases) and faulty technique (4 cases). In the cases that had concurrent tissue biopsies, no false-positive diagnoses were rendered. These results indicate that FNA used in association with immunocytochemistry is a reliable tool for establishing the diagnosis and classification of the majority of cases of lymphoma. Optimal immunoglobulin light-chain ratios for defining monoclonality in FNA specimens of B-cell lymphomas are proposed.