Intraabdominal hydatid cyst: a case report

BACKGROUND: Hydatid disease is caused by Echinococcus granulosus, endemic in cattle and sheep-raising regions of the world such as Central Europe, South America, Australia, New Zealand and South Africa. Although hydatid disease is more common in liver and lung, it also affects brain, kidney, spleen and muscle. We present a case of intraabdominal hydatid cyst, diagnosed by fine needle aspiration cytology, producing an indentation of the liver, which is uncommon. CASE: A male patient presented with right side abdominal pain. On ultrasonography an intraabdominal solid mass (right hypochondrial) was revealed, and subsequently FNA was done. Smears were diagnostic of hydatid cyst. CONCLUSION: FNAC is a sensitive and rapid technique in diagnosis of hydatid cysts. The present case is unusual, owing to its presentation as a solid abdominal mass seeding over the liver and mimicking malignancy radiologically.     

Fine needle aspiration cytologic diagnosis of toxoplasma lymphadenitis. A case report with detection of a Toxoplasma bradycyst in a Papanicolaou-stained smear

BACKGROUND: Fine needle aspiration (FNA) cytologic diagnosis of toxoplasmic lymphadenitis with demonstration of a tissue cyst containing bradyzoites has been very rarely reported. CASE: A 17-year-old female presented with a mobile, painless, 2-cm-diameter swelling over the right suprascapular area. Clinical diagnosis was lipoma. FNA smears showed features of reactive lymphoid hyperplasia, including tingible body macrophages and groups of epithelioid histiocytes. A Toxoplasma cyst with bradyzoites was also demonstrated in a Papanicolaou-stained smear. Following FNA cytodiagnosis, serologic tests revealed a high titer of IgG and the presence of IgM-specific antibodies to Toxoplasma gondii, indicating active/recent disease. CONCLUSION: FNA cytology is a valuable tool for the diagnosis of toxoplasmic lymphadenitis. Papanicolaou stain is appropriate for demonstration of the parasite. Serology is an excellent adjunct in clinching the diagnosis.     

Role and accuracy of rapid on‐site evaluation of CT‐guided fine needle aspiration cytology of lung nodules

A. Fassina, M. Corradin, D. Zardo, R. Cappellesso, F. Corbetti and M. Fassan
Role and accuracy of rapid on‐site evaluation of CT‐guided fine needle aspiration cytology of lung nodules Objective: To prospectively investigate the role of trans‐thoracic fine needle aspiration cytology (FNA) and the value of rapid on‐site evaluation (ROSE) in the clinical management of patients with pulmonary nodules/masses. Computed tomography (CT)‐guided FNA is commonly employed for the diagnosis of lung lesions although its position in the diagnostic work‐up is still a matter of debate. Methods: We reviewed 311 patients (211 males and 100 females, mean age 69.5 years) admitted to the University of Padova from 2004 to 2008, correlating the results of cytology with the available histological findings obtained from biopsies, surgery or autopsy. Results: Smears were adequate in 305 cases (98%) and inadequate in six (2%); a diagnosis of malignancy was achieved in 263 cases (86.2%); 39 cases (12.8%) were classified as non‐malignant; and three cases (1%) were classified as suspect for malignancy. When correlated with histology, FNA with ROSE discriminated malignant versus non‐malignant lesions (Cohen’s kappa 0.78), with three false negatives (sensitivity 96.3%, specificity 100%). Moreover, a satisfactory overall agreement of 71.4% was achieved in differentiating the cancer histological types. Pneumothorax occurred in 13 cases, haemoptysis in four, and chest pain in three. A single aspiration was sufficient in 79.6% of patients; two aspirations were needed in 17.4% and three in 3%. The low complication rate was related to the limited number of aspirations needed due to ROSE. Conclusions: FNA with ROSE is a safe and useful tool in the diagnostic work‐up of lung cancer patients, with no contraindications to its use as the first diagnostic procedure for all patients with peripheral lung lesions. FNA with ROSE should be reconsidered in the guidelines for diagnosing and managing lung cancer.     

The utility of assessing the gross appearances of FNA specimens

F. Mayall, A. Cormack, S. Slater and K. McAnulty The utility of assessing the gross appearances of FNA specimens Objective: Ideally, fine needle aspiration (FNA) cytology should be performed with near‐patient assessment of the adequacy of the specimen by a cytopathologist. However, this is often not feasible. A cruder alternative is for the FNA practitioner to examine the gross appearances of the specimen and to try to predict the its quality. This study set out to determine the value of this approach. Methods: The study was conducted in tertiary public hospitals in New Zealand and the UK. FNA gross material grading was performed by a variety of pathologists on FNA samples taken using manual guidance and image guidance. The FNA gross material grade was compared with the findings on microscopic examination. Results: Nine out of 123 FNA samples were assessed as Grade 1 (unlikely to contain diagnostic material). All were subsequently reported as having insufficient diagnostic tissue on microscopic examination. Forty‐two of the FNA samples were assessed as Grade 2 (possibly contains diagnostic material) and 46 as Grade 3 (probably contains diagnostic material). None from either of these grades was reported as showing insufficient diagnostic material on microscopic examination. Twenty‐six cases were reported as Grade 4 (material suggesting a specific diagnosis). None of these was reported as showing insufficient diagnostic material on microscopic examination. The most common Grade 4 provisional diagnosis was that of a colloid cyst or colloid nodule of the thyroid (seven cases). Only two cases had misleading Grade 4 provisional diagnoses. Both were thought to be pus on gross examination but showed necrotic carcinoma on microscopic examination. Conclusions: The gross appearances of FNA samples can usually predict the adequacy of the samples and sometimes predict the final microscopic diagnosis. However, near‐patient microscopic assessment of FNA specimens is preferable if available.     

Infarction after fine needle aspiration biopsy of pleomorphic adenoma of the parotid gland.

BACKGROUND: Fine needle aspiration (FNA) is a well-established and safe method for the rapid diagnosis of pleomorphic adenoma. A few clinically important complications, including bleeding, infection and inflammatory reactions, result from FNA. In a small number of cases FNA has been followed by varying degrees of necrosis in some organs. In the literature there are a few reports associated with necrosis in a pleomorphic adenoma of the parotid gland following FNA. CASE: A 27-year-old female had a two-year history of a right parotid mass. FNA revealed pleomorphic adenoma. A histologic diagnosis of pleomorphic adenoma of the right parotid with infarction was made. CONCLUSION: Necrosis associated with infarction may cause diagnostic problems. It is not a sufficient sign of malignant transformation.     

Fine needle aspiration biopsy versus sputum and bronchial material in the diagnosis of lung cancer. A comparative study of 168 patients

A group of 168 consecutive lung cancer patients in whom a definitive diagnosis of primary lung cancer was established either in a conventional cytologic specimen of sputum or bronchial material or in a specimen obtained by fine needle aspiration (FNA) biopsy was reviewed to compare the relative accuracies between the modalities of sputum and bronchial material on one hand versus FNA cytology on the other in the diagnosis of lung cancer. The patients included in the study were selected from a total of 1,093 patients who had been diagnosed and treated for lung cancer at Duke University Medical Center over the five-year period of January 1, 1980, through December 31, 1984. In 325 (29.8%) of the 1,093 patients, a definitive cancer diagnosis was established from histopathologic study alone, without any cytologic diagnoses. In 420 patients (38.4%), both histologic and cytologic material had been interpreted as being conclusively diagnostic for lung cancer. In 348 patients (31.8%), a cytologic diagnosis of lung cancer was made without a histologic confirmation. Thus, in a total of 768 (70.3%) of the 1,093 cases, a definitive cytologic diagnosis of cancer had been made. Of these 768 patients, 168 had been evaluated by both conventional respiratory cytologic methods (examination of sputum and bronchial material) and with FNA biopsy cytology. In 9 patients (5.4%), only conventional respiratory cytologic specimens were conclusively diagnostic for cancer. In 122 patients (72.6%), only the FNA biopsy specimen was diagnostic. In 37 patients (22.0%), both conventional respiratory specimens and FNA specimens yielded a definitive lung cancer diagnosis. The FNA specimen was the only positive cytologic specimen in 90.2% of large cell undifferentiated carcinomas, 79.5% of adenocarcinomas, 66.7% of small cell undifferentiated carcinomas and 58.2% of squamous cell carcinomas. In 26.5% of the patients, a diagnosis of cancer could have been established on conventional cytologic specimens, without the necessity of proceeding to percutaneous FNA biopsy. From this study, it is concluded that the techniques of conventional respiratory cytology and FNA biopsy cytology are complementary in the diagnosis of lung cancer. While the percentage of lung cancers diagnosed by FNA biopsy cytology alone is much greater than that obtained by conventional respiratory cytology alone, more than one-fourth of these cancers could be detected by the less invasive techniques of sputum collection and bronchoscopy.     

Renal FNA-based typing of renal masses remains a useful adjunctive modality: evaluation of 31 renal masses with correlative histology

Objectives:  Given the advances in renal imaging modalities in the recent years, a greater number of renal cell carcinomas (RCCs) with tumour size of <3 cm are being detected radiologically. Consequently, there is a pressing need for accurate typing of RCCs which, in turn, will aid in selection of cases of nephron-sparing surgery.
Methods:  A total of 31 cases of renal masses with available fine needle aspiration (FNA) material and concomitant histopathology details were retrieved. They included 27 RCCs (17 clear cells, eight papillary and two chromophobe), one oncocytoma, one liposarcoma and two benign lesions – one xanthogranulomatous pyelonephritis (XPN) and one benign cyst. Two investigators reviewed all FNA material. The degree of concordance between cytological typing and histological typing was assessed.
Results:  There was excellent agreement between the FNA typing and the final diagnosis, with correct classification in 28 of 31 cases. Among the three discordant cases, two were RCCs. The first was a papillary RCC (PRCC) that was misdiagnosed on FNA as clear cell RCC. Another case that was typed as a PRCC on final histopathology was diagnosed 'suspicious cells' on FNA. The third case was an XPN that was misdiagnosed on FNA as RCC with necrosis.
Conclusions:  There is an excellent concordance (90.3%) between the FNA diagnosis and the final histological diagnosis, especially in RCCs. There is a tendency for misdiagnosis with PRCC. Lesions with extensive necrosis and relatively insufficient diagnostic material on FNA specimens must be interpreted with caution. Better concordance might be observed with more extensive sampling.     

Fine needle aspiration cytology of cystic parathyroid lesions. A cytomorphologic overlap with cystic lesions of the thyroid

Three cases of palpable cystic parathyroid nodules examined by fine needle aspiration (FNA) cytology are reported. Two of the three aspirates were incorrectly identified as thyroid neoplasms due to the presence of papillary clusters or microfollicles and grossly golden-brown cyst fluid. Histologic examination of these two nodules revealed partially cystic parathyroid adenomas. Aspirated material from the third patient yielded clear watery fluid, which was correctly identified as consistent with a parathyroid cyst. The diagnostic difficulties in the differentiation of parathyroid adenoma from thyroid carcinoma or adenoma are discussed, as is the utilization of assays for parathyroid hormone in making the FNA diagnosis of parathyroid lesions.     

Percutaneous core needle biopsy vs. fine needle aspiration in diagnosing benign lung lesions.

OBJECTIVE: To determine the diagnostic value of percutaneous core needle biopsy (PCNB) in comparison with fine needle aspiration (FNA) in patients with benign pulmonary lesions. STUDY DESIGN: A retrospective review was undertaken of computed tomography-guided PCNBs and FNAs performed between 1988 and 1997. Both FNA and PCNB biopsies were carried out sequentially at the same visit in every patient. RESULTS: A specific benign diagnosis was made in 10/60 cases (16.7%) by FNA and in 49/60 (81.7%) by PCNB. PCNB findings resulted in significant modification of the diagnosis established by FNA. The only significant complication encountered was pneumothorax, at a rate of 11.7%, which is compatible with that reported in the literature for complications induced by FNA alone. CONCLUSION: Radiologically guided PCNB is a safe procedure, can provide sufficient histologic material for a specific diagnosis of peripheral lung disease and can avoid more-invasive surgical procedures in many cases. Our experience demonstrated that the histologic analysis provided by PCNB can greatly increase the diagnostic accuracy in benign pulmonary diseases as compared with the yield of FNA.     

Posters. P1 A 2‐year audit of thyroid fine needle aspiration cytology

Introduction Fine needle aspiration (FNA) cytology of the thyroid is a well‐established test in the clinical work‐up of patients with solitary nodules of the thyroid. Thyroid FNA does however have limitations and audit of diagnostic performance is important. Methods The histopathology archives of the Royal Victoria Hospital were searched for all thyroid resections and the histopathological diagnosis was correlated with the pre‐operative cytological diagnosis, where available. Special emphasis was placed on the accuracy of tumour diagnosis. Results A total of 173 cases were identified during the 2‐year period, of these 93 had available pre‐operative FNA. A total of 57 tumours were identified. A small number (six of 57) of significant discrepancies were identified. These included a malignant lymphoma diagnosed as Hashimoto's thyroiditis, a metastasis which the FNA had suggested was a medullary carcinoma and an insular carcinoma diagnosed as medullary carcinoma on FNA. False positives included a colloid cyst diagnosed as suspicious of malignancy and a cytological diagnosis of papillary carcinoma not confirmed on histology. Discussion At present, the majority of thyroid FNAs in our clinics are performed by surgeons and material is not routinely available for immunocytochemistry. In spite of these limitations, there were few major discrepancies. These might be reduced if pathologist aspirators were able to perform FNAs and collect material for further studies, where necessary. This would allow identification of medullary carcinomas and malignant lymphomas. Conclusion FNA of thyroid lesions is a useful investigation in our clinical setting, however, some areas of potential for improvement have been identified.     

Posters

Introduction  Fine needle aspiration (FNA) cytology of the thyroid is a well-established test in the clinical work-up of patients with solitary nodules of the thyroid. Thyroid FNA does however have limitations and audit of diagnostic performance is important.
Methods  The histopathology archives of the Royal Victoria Hospital were searched for all thyroid resections and the histopathological diagnosis was correlated with the pre-operative cytological diagnosis, where available. Special emphasis was placed on the accuracy of tumour diagnosis.
Results  A total of 173 cases were identified during the 2-year period, of these 93 had available pre-operative FNA. A total of 57 tumours were identified. A small number (six of 57) of significant discrepancies were identified. These included a malignant lymphoma diagnosed as Hashimoto's thyroiditis, a metastasis which the FNA had suggested was a medullary carcinoma and an insular carcinoma diagnosed as medullary carcinoma on FNA. False positives included a colloid cyst diagnosed as suspicious of malignancy and a cytological diagnosis of papillary carcinoma not confirmed on histology.
Discussion  At present, the majority of thyroid FNAs in our clinics are performed by surgeons and material is not routinely available for immunocytochemistry. In spite of these limitations, there were few major discrepancies. These might be reduced if pathologist aspirators were able to perform FNAs and collect material for further studies, where necessary. This would allow identification of medullary carcinomas and malignant lymphomas.
Conclusion  FNA of thyroid lesions is a useful investigation in our clinical setting, however, some areas of potential for improvement have been identified.     

Fine needle aspiration biopsy of peripheral congenital bronchial cyst

Bronchial cysts usually occur centrally near the mediastinum, but may present as a peripheral "coin" lesion requiring distinction from other causes of coin lesions of the lung. A case is reported in which fine needle aspiration (FNA) biopsy was used to make the diagnosis of such a peripheral bronchial cyst. FNA produced an opaque opalescent fluid; cytologic study of the smears showed abundant bipolar birefringent needle-shaped crystals an a few macrophages. Neither special staining of some smears nor cultures of part of the aspirate revealed the presence of any organism. The cytologic diagnosis was confirmed by histologic examination of the subsequent resection specimen.     

Fine needle aspiration cytologic findings of micropapillary carcinoma in the lung: a case report

BACKGROUND: Micropapillary carcinoma is a variant of adenocarcinoma described in many anatomic sites and most recently in the lung. The cytologic recognition of this distinct pathologic entity in transthoracic needle aspiration specimens is important in providing prognostic information and therapeutic guidance. CASE: A 58-year-old woman presented with a < 1-cm lesion in the left breast identified on screening mammogram. A core biopsy of this lesion revealed an estrogen and progesterone receptor positive tubular carcinoma. Before a hookwire localization biopsy, a chest x-ray revealed a 1.7-cm spiculated mass in the right lower lobe. The diagnosis of adenocarcinoma with micropapillary features was made by fine needle aspiration cytology (FNAC). The lobectomy specimen showed a combination of adenocarcinoma, papillary adenocarcinoma and micropapillary carcinoma. CONCLUSION: Micropapillary carcinoma is a unique variant of adenocarcinoma, having important clinical associations because of its propensity for angiolymphatic invasion and higher stage at disease presentation. This case demonstrates the cytomorphologic characteristics of micropapillary carcinoma in a transthoracic FNA of the lung.     

Lymphoepithelial cyst with crystalloid formation. Cytologic features of two cases

BACKGROUND: The presence of amylase crystalloids (AC) in cystic lesions of the parotid gland is a rare occurrence and has been diagnosed to date as sialadenitis. We report the first two cases of parotid lymphoepithelial cyst (LC) containing this type of crystalloid. CASES: Case 1, a 56-year-old male, presented with a 3-cm parotid cyst. Fine needle aspiration (FNA) was performed on the mass. Smears showed numerous crystalloids identical to those described as crystallized amylase. Case 2, a 36-year-old female, had a 2-cm parotid mass. FNA smears exhibited the same features as did case 1. The two patients were treated with superficial parotidectomy, and an LC containing AC was diagnosed in both cases. CONCLUSION: When the above findings are present on FNA of parotid gland, the diagnosis of LC must be considered.     

Cystic fluid and fine needle aspiration cytopathology of cystic adult granulosa cell tumor of the ovary: a case report

BACKGROUND: Fine needle aspiration (FNA) is a valuable tool in the diagnosis of ovarian cysts, especially in the young and when a nonneoplastic cyst is suspected. A case is presented with its cystic fluid, FNA and imprint cytopathology findings diagnosed as cystic adult granulosa cell tumor of the ovary (AGCT). CASE: Cystic fluid and FNA material of a 24-year-old female patient with a left-sided cystic ovarian mass 11.5 cm in diameter was sent intraoperatively for cytopathologic examination. In aspiration cytopathology of AGCT, the presence of regular tumor cells with or without nuclear grooves arranged in a follicular pattern mimicking a Call-Exner body has been regarded as the characteristic cellular feature of the tumor. CONCLUSION: For correct interpretation of the cytopathologic findings, close communication with the clinician performing the aspiration is of vital importance.     

Transthoracic fine needle aspiration and core biopsy of pulmonary lesions. A study of 296 patients

OBJECTIVE: To retrospectively investigate and compare the usefulness of transthoracic fine needle aspiration (FNA), core biopsy and a combination of the two in the diagnosis of pulmonary lesions. STUDY DESIGN: Two hundred ninety-six patients who had undergone FNA, core biopsy or both for lung lesions were divided into malignant and benign groups according to the final diagnoses, which were based on the cytologic and histopathologic findings combined with clinical features. In each group, the diagnostic usefulness of FNA, core biopsy and a combination of the two were evaluated by comparing the results of each with the final diagnoses. RESULTS: In the malignant group, FNA was diagnostically helpful in 188 of 205 patients (91.7%) and core biopsy in 158 of 180 patients (87.8%). The combination of the two methods improved the result to 172 of 178 patients (96.6%). The sensitivities were 94.6%, 88.3% and 97.2%, respectively, for each result. In the benign group, 71.1% (64/90), 70.1% (47/67) and 74.2% (49/66) of cases received specific or nonspecific diagnoses by FNA, core biopsy and their combination, respectively. The rates of specific diagnoses were 20.1%, 21.0% and 31.8%, respectively. CONCLUSION: The combination of FNA and core biopsy markedly improved the diagnostic yields in the malignant group and, to a lesser degree, also in the benign group.     

Extraneous cells of hepatic origin in adrenal fine needle aspiration as a diagnostic pitfall: a case report

BACKGROUND: The fine needle aspiration (FNA) cytologic evaluations of most adrenal lesions are straightforward. However, there are diagnostic pitfalls to be avoided. CASE: A 34-year-old, pregnant woman was discovered to have an asymptomatic, right upper abdominal mass on ultrasound examination. After delivery, computed tomography-guided FNA showed bland epithelial cells, and a diagnosis of adrenal cortical adenoma was made. However, subsequent resection showed a myelolipoma of the adrenal gland. CONCLUSION: This case illustrated 2 cytodiagnostic pitfalls in adrenal fine needle aspirates. First, the myeloid cells characteristic of a myelolipoma were not present in the FNA smears because a large portion of the lesion was composed of fibroadipose tissue. Second, extraneous, benign cells of hepatic origin were misinterpreted as adrenal cortical adenoma cells.     

Computed tomography-guided fine needle aspiration of peripheral lung opacities. An initial diagnostic procedure?

OBJECTIVE: To evaluate the results of computed tomography (CT)-guided fine needle aspiration (FNA) cytology following negative fiberoptic bronchoscopy and sputum cytology. STUDY DESIGN: Retrospective study of 64 patients who underwent CT-guided needle aspiration of lung opacities over one year. Following a review of the CT studies, patients were selected according to image characteristics of a primary neoplasm and pleural effusion in cases with pleural lesions. The lesions were classified into three categories--intrapulmonary and peripheral pulmonary, pleuropulmonary and pleural--and were localized and aspirated under CT using a fine needle (22-23 gauge) for obtaining cellular material. Lesions diagnosed as benign on FNA cytology were followed by serial CT scans for a period of two years at six-month intervals. RESULTS: Thirty-nine of 64 (61%) lesions were diagnosed as malignant on FNA cytology and 25 of 64 (39%) as benign. There was one false negative case. There were no serious complications from the procedure. CONCLUSION: FNA under CT guidance may be applied as the initial procedure in the diagnosis of peripheral malignant pulmonary lesions, rendering a high diagnostic yield.     

Simultaneous occurrence of medullary and papillary carcinoma of the thyroid gland identified by fine needle aspiration. A case report

BACKGROUND: Fine needle aspiration (FNA) diagnosis of simultaneous medullary and papillary thyroid carcinoma in independent thyroid lobes is exceedingly rare. CASE: A 36-year-old female presented with a one-month history of dysphagia. Thyroid ultrasound revealed a multinodular goiter. She was clinically and biochemically euthyroid. FNA of the right thyroid nodule was consistent with medullary carcinoma, and FNA of the left thyroid lobe was consistent with papillary carcinoma. Immunohistochemistry revealed strong calcitonin and CEA positivity in the right lobe and lack of staining in the left lobe. Conversely, staining for thyroglobulin was negative on the right lobe and positive on the left lobe. CONCLUSION: The patient developed tumors in separate lobes of the thyroid. Immunoreactivity of calcitonin, CEA and thyroglobulin made a sharp distinction between the two tumors. Therefore, we conclude that these tumors were not linked by either embryology or genetics.     

Automated breast cancer diagnosis based on fine needle aspiration

OBJECTIVE: To design and analyze an automated diagnostic system for breast carcinoma based on fine needle aspiration (FNA). STUDY DESIGN: FNA is a noninvasive alternative to surgical biopsy for the diagnosis of breast carcinoma. Widespread clinical use of FNA is limited by the relatively poor interobserver reproducibility of the visual interpretation of FNA images. To overcome the reproducibility problem, past research has focused on the development of automated diagnosis systems that yield accurate, reproducible results. While automated diagnosis is, by definition, reproducible, it has yet to achieve diagnostic accuracy comparable to that of surgical biopsy. In this article we describe a sophisticated new diagnostic system in which the mean sensitivity (of FNA diagnosis) approaches that of surgical biopsy. The diagnostic system that we devised analyzes the digital FNA data extracted from FNA images. To achieve high sensitivity, the system needs to solve large, equality-constrained, integer nonlinear optimization problems repeatedly. Powerful techniques from the theory of Lie groups and a novel optimization technique are built into the system to solve the underlying optimization problems effectively. The system is trained using digital data from FNA samples with confirmed diagnosis. To analyze the diagnostic accuracy of the system > 8,000 computational experiments were performed using digital FNA data from the Wisconsin Breast Cancer Database. RESULTS: The system has a mean sensitivity of 99.62% and mean specificity of 93.31%. Statistical analysis shows that at the 95% confidence level, the system can be trusted to correctly diagnose new malignant FNA samples with an accuracy of 99.44-99.8% and new benign FNA samples with an accuracy of 92.43-93.93%. CONCLUSION: The diagnostic system is robust and has higher sensitivity than do all the other systems reported in the literature. The specificity of the system needs to be improved.