Fine needle aspiration cytology of invasive cribriform carcinoma of the breast with osteoclastlike giant cells: a case report

BACKGROUND: Nonneoplastic osteoclastlike giant cells are occasionally associated with carcinoma of the breast, pancreatobiliary and gastrointestinal systems. In the breast, this uncommon stromal response is seen mainly in invasive carcinoma with low grade cytology, among which invasive cribriform carcinoma is the classic example. Details of the fine needle aspiration cytology of this phenomenon, especially in thin-layer preparations, have been described rarely. CASE: The fine needle aspiration cytology of an invasive cribriform carcinoma of the breast occurred in a 66-year-old woman. Cytology showed cohesive sheets and three-dimensional cribriform clusters of bland-looking and mitotically inactive ductal cells in a blood-stained background. Scattered multinucleated, osteoclastlike giant cells, some containing hemosiderin granules, were also seen. Myoepithelial cells and naked nuclei were not obvious. The cellular composition was more discernible in liquid-based cytologic preparations. Histologic examination of the excisional biopsy showed an invasive cribriform carcinoma associated with many osteoclastlike giant cells in a hypervascular stroma. CONCLUSION: In view of the extremely low grade cytology of the malignant ductal cells, invasive cribriform carcinoma may closely mimic benign proliferative breast diseases on fine needle aspiration biopsy. Recognition of this special relationship with osteoclastlike giant cells, which are rarely present in certain subtypes of breast cancer but not benign lesions, can help to arrive at a correct cytologic diagnosis.     

Aspiration cytology of 147 adnexal cysts with histologic correlation.

OBJECTIVE: To assess the usefulness of cytology in the diagnosis of 147 histologically established adnexal cysts. STUDY DESIGN: Retrospective, macro-microscopic study based on fluid aspirated from 132 ovarian and 15 extraovarian cysts and projected as a cytohistologic correlation. RESULTS: Typical macroscopic features were identified in 76% of endometriotic cysts, in 53% of mucinous neoplasms and in 67% of dermoid cysts. Cytology helped to identify 67% of nonneoplastic and 56% of neoplastic cysts. The lowest diagnostic sensitivities were observed in functional cysts and benign serous neoplasms (50%), while the highest were shown by endometriotic cysts (76%) and malignant epithelial neoplasms (71%). Inadequate samples were obtained from all types of cysts, even malignant ones (two mucinous cystadenocarcinomas). Diagnostic cytology was useless in extraovarian cysts (33% sensitivity). An adult granulosa cell tumor was erroneously diagnosed as a follicular cyst by cytologic examination. CONCLUSION: Examination of the cyst fluids obtained by aspiration demonstrated low sensitivity, with 43% of inadequate samples obtained from all types of cysts. Malignant cystic neoplasms may be overlooked in inadequate samples. Our study also revealed that specificity in this type of analysis is high in inadequate samples, provided that the technique is carried out correctly.     

Nipple discharge cytology in mass screening for breast cancer

Since 1977 mass screening for breast cancer has been conducted in Miyagi Prefecture, Japan; inspection, palpation and cytologic examination of any nipple discharge are part of the initial screening procedures. Among 149,681 subjects examined, 404 cancer cases and 63 papilloma cases were detected. The nipple discharges from 20,537 women were examined cytologically; of the 61 cancer cases, the smears were positive in 18 cases, suspicious in 7, negative with atypical findings in 12 and negative in 24. Ten of the cancer cases were detected exclusively by the cytologic examination of a nipple discharge. In eight of these ten cancer cases, there was no other initial evidence of the primary tumor. The cytologic diagnosis of discharges without blood from 28 cancer cases was positive or suspicious in 10 cases and negative in 18. Thirty-seven of the papilloma cases were initially detected only by the cytologic examination of a nipple discharge; neither physical examination nor mammography showed any abnormal findings.     

Aspiration cytology of breast cysts

A cytologic evaluation was made of 57 samples of fluid aspirated from cystic breast masses during the past 12 years in our hospital. The cytologic diagnosis of the cyst aspirates from 17 cancer cases was positive in 10 cases, suspicious in 2 and negative in 5. No false-positive cytologic diagnosis was made in 40 cases of benign cystic disease. Blood-tinged aspirates were observed in 14 of the 17 cases of malignant cystic disease but in only 2 of 40 benign cases. Ductal cell clusters were detected in aspiration smears from 16 of the cases of malignant cystic disease and 15 of the cases of benign cystic disease. Apocrine cells were seen in the aspiration smears from 12 of the cases of benign cystic disease but in none of the aspirates from the 17 cancer cases.     

Fine needle aspiration cytology of an intraductal papilloma originating in a sublingual gland. A case report.

BACKGROUND: Intraductal papilloma of the salivary gland is a very rare tumor; only eight cases have been reported to date. Only histopathology has been used to investigate this tumor to our knowledge. There has not been any reported case of this tumor in a sublingual gland. CASE: A 3-cm oral floor mass with a lanulalike lesion in a 72-year-old female was aspirated. The cytologic features included various cellular smears containing compact clusters of papillary, radial, palisading, trabecular, tubular and buddinglike projected patterns; monomorphic columnar cells with oval-to-spindle nuclei basally located; abundant, finely vacuolar cytoplasm; indistinct nucleoli; and no squamous differentiated cells. A sublingual glandectomy was performed. Cytology, histology, immunohistochemistry and electron microscopy were performed with standard methods. The intraductal papilloma seems to have arisen within an excretory duct and differentiated into acinar cells. CONCLUSION: The cytologic findings of intraductal papilloma are unique and may allow its specific diagnosis on fine needle aspiration.     

Significance of squamous cells in fine needle aspiration cytology of the breast. A review of cases in a seven-year period

OBJECTIVE: To delineate the significance of detecting squamous cells in fine needle aspiration biopsy of breast lesions. STUDY DESIGN: The authors reviewed 15 cases of fine needle aspiration cytology of the breast with a discernible number of squamous cells from the files of Pamela Youde Nethersole Eastern Hospital, Hong Kong, during a seven-year period from the start of 1994 to the end of 2001. The cytologic features were correlated with clinical, radiologic and histologic findings, if any. RESULTS: Among the 15 fine needle aspirates of the breast with a discernible number of squamous cells, 5 of them represented metaplastic carcinoma. The remaining consisted of 3 cases of fibroepithelial tumors, 1 case of duct ectasia, 3 cases of subareolar abscess, 2 cases of sclerosed intraduct papilloma and 1 case of benign breast cyst. In general, benign squamous cells were bland looking and often associated with anucleated squames. They were mitotically inactive and could show a good maturation pattern. Tumor cell cannibalism was rare. The presence of abundant, foamy macrophages in the background suggested a benign lesion. The primary diagnosis could be deduced by recognition of other features, such as the presence of myxoid stromal tissue and papillary structures. In contrast, malignant squamous cells in metaplastic carcinoma were more pleomorphic and mitotically active. Dyskeratosis and tumor cell cannibalism were obvious. Tumor diathesis and bizarre-shaped cells were sometimes found. CONCLUSION: Squamous cells occur in fine needle aspirates from a number of benign and malignant breast lesions. Benign conditions with abundant squamous cells may sometimes mimic malignant squamous lesions and vice versa. Careful assessment of the cytologic features of squamous cells and background appearance is crucial for achieving a correct diagnosis.     

Structures and concentrations of fifteen different steroid sulfates in human breast cyst fluids

By applying capillary gas chromatography (GC) and gas chromatography mass spectrometry (GC-MS), a simultaneous quantitation of all important steroid sulfates present in a number of breast cyst fluids, has been obtained. The fact that prevailing androgen sulfate structures in the cyst fluids are different from those in blood suggests at least intracystic metabolism of blood-born precursors. Particularly greater amounts of 5 alpha-reduced steroids are found in breast cysts. 5 alpha-Androstane-3 alpha,17 beta-diol is a major androgen sulfate of breast cyst fluids, its concentration being some 2000-fold that of blood. After prolonged topical application of progesterone on the breast, an accumulation of the sulfates of several pregnanediol isomers could be observed.     

The Ultrasonic Evaluation of Nonfunctioning Thyroid Nodules

Thyroid echography was carried out on 100 patients with thyroid abnormalities to evaluate the diagnostic accuracy of ultrasound in differentiating simple thyroid cysts from solid thyroid nodules.In all 46 proven cases, the ultrasonic diagnosis of the solid or cystic nature of thyroid nodules was correct.A proposed diagnostic workup of a hypofunctioning (cold) thyroid nodule is suggested with primary needle aspiration and cytologic examination of the cyst fluid being recommended if the nodule is shown to be entirely cystic by ultrasound.     

Metastatic Breast Cancer Presenting As an Ovarian Cyst: Diagnosis By Fine Needle Aspiration Cytology

A fifty-year-old woman with a history of breast cancer presented with a clinically benign ovarian cyst. Laparoscopic aspiration of cyst fluid was performed and the cytology was suspicious of epithelial neoplasia. At subsequent hysterectomy and bilateral salpingo-oophorectomy, the specimen showed extensive metastatic breast carcinoma. Although the cytological examination of fluid from ovarian cysts is often unrewarding, this case shows that metastatic carcinoma may occasionally be diagnosed in this fashion.     

Intracytoplasmic eosinophilic inclusion bodies in benign breast cyst fluids

Intracytoplasmic eosinophilic inclusion bodies (EIBs) observed in cytologic preparations of benign breast cyst fluid aspirates were morphologically similar to the well-known EIBs in urine specimens. EIBs have not been previously described in breast cyst fluids. A chi-square test proved a statistically significant correlation between the presence of intracellular EIBs and cellular degeneration. The possible significance of this finding with regard to the origin of EIBs is discussed.     

Clinical and cytologic features of papillary neoplasms of the breast

OBJECTIVE: To compare the cytologic features benign and malignant papillary breast lesions. STUDY DESIGN: We reviewed the clinical and cytologic features in 29 cases of intraductal papilloma and 26 cases of atypical papilloma or papillary carcinoma that had been diagnosed by histologic examination. The diameter of the mass was examined as a clinical feature. The cytologic features evaluated were as follows: bloody background, row of tall columnar cells, naked bipolar nuclei, hemosiderin-laden macrophages, myoepithelial cells, single scattered atypical cells, cellularity, nuclear atypia, nuclear grade, apocrine metaplasia, eosinophilic cytoplasmic granules, papillary clusters, small papillae, cell balls and large sheets. RESULTS: Of the features evaluated, the diameter of the mass, naked bipolar nuclei and cell balls differed significantly between benign and atypical or malignant papillary neoplasms. The average diameter of a benign papillary neoplasm was 1.8 cm, and that of an atypical or malignant papillary neoplasm was 2.2 cm (p = 0.042). Naked bipolar nuclei were found in 27 cases of benign papillary neoplasm (93.1%) versus 19 cases of atypical or malignant papillary neoplasm (73.1%) (p = 0.050). Cell balls were found in 14 (48.3%) and 21 (80.8%) cases, respectively (p = 0.012). All 6 cases in which cell balls were present and naked bipolar nuclei were absent proved to be atypical or malignant papillary neoplasms. Of 17 cases in which cell balls were absent and naked bipolar nuclei present, 13 (76.5%) were benign papillary neoplasms. CONCLUSION: Most cytologic features overlapped in benign and atypical or malignant papillary neoplasms. Although they were not pathognomonic, naked bipolar nuclei and cell balls were cytologic features that differed significantly between benign and atypical or malignant papillary neoplasms. When papillary neoplasms of the breast are suspected in a cytologic smear, the combination of clinical examination, mammography and cytologic features should be considered to make the correct diagnosis.     

Preparation and cytologic evaluation of intraocular fluids

The cytologic analysis of intraocular fluids obtained during vitreous surgery and anterior chamber aspiration can confirm the diagnosis of many intraocular conditions, including phacolytic glaucoma, fungal infection, proliferative diabetic retinopathy, intraocular neoplasm, ghost-cell glaucoma and certain inflammatory conditions. This paper describes our technique for processing intraocular fluids for cytologic examination and presents our findings in over 300 intraocular fluid specimens.     

Fine needle aspiration cytology of an ovarian luteinized follicular cyst mimicking a granulosa cell tumor. A case report

BACKGROUND: Fine needle aspiration is a valuable tool in the diagnosis of ovarian cysts, especially in the young and when a nonneoplastic cyst is suspected. High cellularity, epitheliallike clusters and cellular atypia in aspirates from functional cysts are known features that may lead to an erroneous diagnosis of malignancy. Granulosa cells in ovarian cystic fluids may originate in follicular cysts or cystic granulosa cell tumors. In luteinized follicular cysts the cells usually have ample cytoplasm and tend to form clusters. This report draws attention to a case where abundant, dispersed cells lacking cytoplasm led to the incorrect diagnosis of a granulosa cell tumor. CASE: In an ovarian cystic aspirate from a 34-year-old woman, the fluid was highly cellular, with a striking predominance of cells interpreted as granulosa cells. Granulosa cells are often found in aspirates from functional cysts, but striking cellularity, prominent nuclear grooves and lack of luteinization made us consider a granulosa cell tumor rather than a follicle-derived cyst. Surgery was performed, and histology revealed a benign serous cystadenoma but also numerous maturing follicles and follicular cysts with thick layers of granulosa cells. The aspirate obviously did not represent the cystadenoma but one of the prominent follicular cysts. CONCLUSION: An understanding of the cytologic features of functional ovarian cysts, including the pitfalls, is necessary to avoid a false diagnoses of a neoplastic lesion. For a correct interpretation of the cytologic findings, close communication with the clinician and with the radiologist performing the aspiration is of vital importance.     

Fine needle aspiration cytology of invasive micropapillary (pseudopapillary) carcinoma of the breast. Report of 11 cases with clinicopathologic findings

OBJECTIVE: To describe the cytologic features of invasive micropapillary carcinoma of the breast, a distinct, unusual variant of infiltrating duct carcinoma characterized histologically by pseudopapillary structures lacking fibrovascular cores and tubuloalveolar structures floating freely within clear spaces separated by a delicate fibrocollagenous stroma and characterized clinically by prominent lymphotropism and an aggressive clinical course. STUDY DESIGN: We reviewed the clinical, cytologic, histologic, immunohistochemical and flow cytometric features in 11 cases of invasive micropapillary carcinoma of the breast diagnosed preoperatively by fine needle aspiration. RESULTS: All patients were women, ranging in age from 31 to 83 years. A preoperative diagnosis of malignancy was made in all cases. Tumor size ranged from 1.2 to 5.5 cm. Ten patients had lymph node metastases. Cytology was characterized by a "dual" pattern formed by round or angulated, three-dimensional, cohesive clusters of neoplastic cells with pseudopapillary configuration and two-dimensional, dyscohesive aggregates and single cells with high grade nuclei and intact cytoplasm.     

Multilocular thymic cyst with follicular lymphoid hyperplasia in a male infected with HIV. A case report with fine needle aspiration cytology

BACKGROUND: Multilocular thymic cyst with follicular lymphoid hyperplasia is a rare complication in HIV-infected patients, causing pseudotumorous enlargement of the anterior mediastinum. There have been six reported cases, all with only histologic findings. This paper reports another such case and includes perhaps the first cytologic findings on this rare entity. CASE: A 35-year-old, HIV-infected male intravenous drug abuser, who complained of worsening central chest discomfort and pain on deep inspiration, was found to have a large, septated anterior mediastinal mass. Computed tomography-guided fine needle aspiration biopsy was performed. The cytologic presentation mimicked that of thymoma, with cystic degeneration and a dual population of epithelial cells and lymphocytes as well as large aggregates of "epithelial" cells intermixed with lymphocytes in a background of macrophages and cyst fluid. Histologic examination of the resected mass revealed a multilocular thymic cyst with follicular lymphoid hyperplasia. HIV-1 core protein p24 was localized immunohistochemically in the dendritic follicular cells of the germinal centers. In retrospect, the quantity of epithelium derived from the cyst lining was too scanty for thymoma, and the presence of plasma cells and lymphohistiocytic aggregates suggested follicular lymphoid hyperplasia. CONCLUSION: Multilocular thymic cyst with follicular lymphoid hyperplasia should be considered in the differential diagnosis of an anterior mediastinal mass in HIV-infected patients after lymphoma and tuberculosis.     

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.     

Stereotaxic fine needle aspiration cytology of clinically occult malignant and premalignant breast lesions

Stereotaxic fine needle aspiration (FNA) cytology was used to study clinically occult (nonpalpable) breast lesions in 114 consecutive patients with mammographically suspicious findings prior to excisional biopsy. The aspirate contained insufficient material for cytologic evaluation in 15 cases (13.2%), which were histologically diagnosed as benign (7 cases), atypical hyperplasia (7 cases) or carcinoma in situ (1 case). The cytologic findings indicated a benign lesion in 77 cases (67.5%), which were histologically diagnosed as benign (71 cases) or atypical ductal hyperplasia (6 cases). The cytologic sample showed atypia in eight cases (7.0%), which were histologically diagnosed as severe atypical ductal hyperplasia (three cases), carcinoma in situ (one case) or proliferative fibrocystic disease (four cases). In the eight cases (7.0%) cytologically interpreted as probably malignant, histology confirmed six invasive carcinomas, one carcinoma in situ and one fibrocystic disease. Of six cases (4.4%) cytologically reported as malignant, five were histologically diagnosed as invasive carcinoma and one as carcinoma in situ. Overall, stereotaxic FNA cytology reported as malignant or probably malignant 14 of the 15 cases with a histologic confirmation of malignancy, for a sensitivity of 93.3%. Cytology correctly identified 78 of the 83 histologically negative cases, for a specificity of 94.0%. The 16 cases histologically diagnosed as ductal hyperplasia, which carries a high risk for subsequent malignancy, were studied in detail in an effort to define histologic and cytologic criteria for this entity. Using selected histologic criteria, 11 of these cases were graded as showing mild-to-moderate atypical hyperplasia and 5 as showing severe atypical hyperplasia. Three of the latter cases were similarly identified by an analogous cytologic grading; the other two cases had insufficient cytologic samples. The total results in this series of 114 cases support the use of stereotaxic FNA cytology in the diagnosis of these nonpalpable breast lesions, examples of which are illustrated. In particular, it may help to raise the low specificity yielded by mammography alone, which would represent a significant advance for the patient in terms of the accuracy, expediency and reduced cost of diagnosing these lesions.     

Calcium oxalate crystals in benign cyst fluid from the breast. A case report

BACKGROUND: Two types of calcification have been observed in breast lesions. The more common is composed mostly of calcium phosphate and is detected in routine histologic tissue sections of frequently malignant lesions. The rare type is calcium oxalate and is found exclusively in benign cysts. CASE: In a 47-year-old female, strongly birefringent polyhedral crystals of calcium oxalate were detected in benign breast cyst fluid. CONCLUSION: Calcium oxalate is not clearly visible on routine histologic sections, and examination of the cytologic specimens under polarized light reveals them. Awareness of this potential pitfall might lead to conservative management.     

Membrane connectivity estimated by digital image analysis of HER2 immunohistochemistry is concordant with visual scoring and fluorescence in situ hybridization results: algorithm evaluation on breast cancer tissue microarrays

Because metaplastic carcinoma of the breast encompasses a great variety of histopathology, diagnostic challenges abound, especially within the realm of cytology. The authors compiled and studied an eight-case series comprised of metaplastic breast carcinomas and lesions initially suspicious cytologically for metaplastic carcinoma in order to assess the degree of cytologic-histologic correlation and to identify recurring problematic themes surrounding the cytology-based diagnosis of this neoplasm. The cytologic and histologic slides from eight cases suspicious for metaplastic breast carcinoma diagnosed by fine needle aspiration (FNA) were collected and analyzed through a seven-year retrospective search of case files at our institution. Based on cytologic characteristics, the cases were separated into three groups. Group 1 consisted of three cases presenting with poorly differentiated adenocarcinoma and squamoid components on FNA. Group 2 was composed of two cases that featured a monophasic, malignant ductal cell population on cytology, while the cytologic specimens for the third group of cases presented with a mesenchymal component with or without a malignant glandular constituent. Cytologic-histologic correlation was present in two of three cases demonstrating a mesenchymal component, and there was 100% sensitivity in the cytologic detection of those mesenchymal elements. However, in only one of three cases was there an accurate cytologic diagnosis of metaplastic carcinoma when squamoid changes were present on FNA. Both cases demonstrating only malignant glandular elements on cytologic specimens revealed an additional component of malignant squamous differentiation upon the examination of mastectomy-derived tissue. These results indicate that squamous-like changes identified on FNA should be interpreted with caution and that sampling error remains a problematic recurrence in cytology. Regardless, there appears to be promise concerning the accurate cytologic diagnosis of metaplastic carcinoma when the lesion is characterized by a mesenchymal component. A study implementing a larger case number is essential in determining the significance of these findings.     

The application of fine needle aspiration cytology in the diagnosis of multiple primary malignant tumors

Four cases with multiple primary malignant tumors are presented. In all cases, fine needle aspiration (FNA) cytologic findings indicated the presence of more than one primary malignancy. In one case, the cytologic examination simultaneously diagnosed two separate primaries. Since FNA cytology can often be used to identify the tumor type, it can be utilized in the identification of many multiple primary malignancies, as these cases show.