Ectopic lesions as potential pitfalls in fine needle aspiration cytology: a report of 3 cases derived from the thyroid, endometrium and breast

BACKGROUND: Ectopic lesions are rarely encountered. Those that are derived from thyroid, breast, endometrium and salivary glands present with palpable masses that can mimic malignancy. Fine needle aspiration cytology (FNAC) is a practical procedure for the differential diagnosis of such lesions but can reveal surprising images for a cytopathologist. CASES: Three cases of discrete, ectopic lesions at different locations occurred. Case 1 was a 27-year-old woman. Upon diagnosis of a submandibular mass with a diameter of 1 cm, FNAC was performed. The smears showed crowded thyroid follicular cells comprising papillary clusters. A cytologic diagnosis of papillary thyroid lesion was rendered, Histopathology revealed that this lesion was ectopic thyroid tissue with focal chronic thyroiditis. Case 2 was a 38-year-old woman who presented with a painful mass with a diameter of 2.5 cm in the abdominal wall. The patient had undergone cesarean section 3 years earlier. The case was diagnosed on FNAC as low grade malignancy in which an adenocarcinoma/mesenchymal tumor distinction could not be made. The pathologic examination revealed endometriosis. Case 3 was a 31-year old woman who presented with a palpable nodule in the axillary region with a diameter of 1 cm. The patient had given birth 1 month earlier and was nursing. An FNAC diagnosis of lactation ectopic breast tissue was made. The mass disappeared by the end of lactation. CONCLUSION: FNAC of ectopic lesions may prove to be a diagnostic pitfall for cytopathologists. A cytopathologist who encounters a cellularpicturefrom a lesion that is outside the normal anatomic location must use a cautious diagnostic approach. Unless there are clear findings, the cytopathologist must refrain from a diagnosis of malignancy.     

Fine needle aspiration cytology of metastatic choriocarcinoma presenting as a breast lump. A case report

BACKGROUND: While choriocarcinoma is a rapidly invasive, widely metastasizing malignancy, it responds well to chemotherapy, so it is important to obtain an early diagnosis. We report the fine needle aspiration cytology (FNAC) of a case of choriocarcinoma metastatic to the breast. CASE: A 48-year-old female presented with a cough, hemoptysis and epistaxis. Chest computed tomography revealed multiple nodules in both lung fields. Also, a firm, slightly tender mass in the lower outer quadrant of the left breast was palpated. The breast mass was clinically suspected to be a metastatic lung cancer. FNAC of the breast showed a malignant tumor that had been misdiagnosed as a metastatic non-small cell carcinoma of the lung. Histologic examination of a nasal biopsy revealed metastatic choriocarcinoma. CONCLUSION: The cytologic features of choriocarcinoma are quite characteristic, with side-by-side, malignant, mononucleated cells and multinucleated giant cells corresponding to cytotrophoblasts and syncytiotrophoblasts, respectively. The disease is possible to diagnose by a careful examination of FNAC samples.     

Pathology of supraclavicular lymphadenopathy in Chandigarh, north India: an audit of 200 cases diagnosed by needle aspiration

OBJECTIVE: Fine needle aspiration cytology (FNAC) of lymph nodes can be used routinely as a first-line diagnostic test. The majority of studies reveal a malignant cause for palpable supraclavicular lymph nodes. The present audit further emphasizes the use of FNAC as a first-line investigation for the evaluation of enlarged supraclavicular lymph nodes. METHODS: A total of 200 cases of palpable supraclavicular lymph node(s) were included in the present study. RESULTS: Left supraclavicular lymph nodes were found to be more commonly involved (59.5% cases). Sixty-four per cent cases showed metastatic deposits and 13.5% cases were diagnosed as tuberculosis. Ten per cent cases showed reactive lymphoid hyperplasia; 0.5% (one) case showed only necrosis and on autopsy, a microscopic focus of choriocarcinoma was found in the testis. In 7.5% cases, diagnostic material could not be aspirated despite repeated attempts. Common metastatic tumours were from lung (22% cases), breast (16.4% cases), cervix (11% cases) and oesophagus (8.6% cases). In 13.3% cases the primary site was unknown and the diagnosis of malignancy first came from FNAC. CONCLUSION: The present study further highlights the importance of FNAC as a first-line diagnostic modality in the evaluation of supraclavicular lymphadenopathy. A full history, radiological findings and immunochemistry in difficult cases can help to arrive at a definitive diagnosis.     

Fine needle aspiration cytology of mammary carcinoma with choriocarcinomatous features: a report of 2 cases

BACKGROUND: Neoplasms of the breast containing multinucleated giant cells (MGCs) include both benign and malignant entities, such as benign soft tissue giant cell tumors, atypical fibrous histiocytoma, sarcomas, metaplastic carcinomas and the uncommon carcinomas containing osteoclast-like giant cells (OGC). Breast carcinoma with choriocarcinomatous features (BCCF) is a distinct variant of breast cancer. CASES: We report the cytologic features, pathologic findings and immunohistochemical profile in 2 cases of this unusual variant of breast carcinoma. Two women aged 53 and 50 years women presented with a history of left and right breast lump but no local lymphadenopathy, respectively. Fine needle aspiration cytology (FNAC) of both cases revealed abundant MGC with highly pleomorphic tumor cells in the hemorrhagic necrotic background. Both of the cases were histopathologically diagnosed as BCCF. CONCLUSION: Choriocarcinomatous differentiation with multinucleated syncytiotrophoblast-like giant cells is extremely rare in breast tumors. Although rare, FNAC of breast cancer with pleomorphic MGC requires careful search for differential diagnosis; breast carcinoma with giant cell features (choriocarcinomatous features, OGC features) must be differentiated from metastatic tumors and other breast lesions containing giant cells.     

Fine needle aspiration cytology of metastatic scalp nodules

OBJECTIVE: To analyze cases of palpable cutaneous/ subcutaneous scalp nodules and evaluate the clinical features and role of fine needle aspiration cytology (FNAC) in their diagnosis. STUDY DESIGN: A total of 1,022 cases of metastatic malignancies at various sites were analyzed over a period of two years. FNAC was performed as a routine outpatient procedure for palpable lesions and under ultrasound or computed tomographic guidance for nonpalpable, internal sites. Histologic correlation was done when possible. RESULTS: Eighteen cases were found to be metastatic scalp nodules. The scalp as a metastatic site constituted 1.76% of all metastatic sites, 7.72% of extranodal sites, and 15.3% of extranodal and extrahepatic sites. Of the 18 cases, 7 (38.9%) had primaries in the head and neck region (thyroid, 3; orbit, 1; tonsil, 1; tongue, 1; and parathyroid, 1). Cutaneous/subcutaneous metastasis was encountered in 58 patients, and the 18 cases of scalp metastasis constituted 31.03% of all cutaneous sites. CONCLUSION: Careful examination of the skin on the entire body, with particular attention to the scalp, should be done when a primary internal malignancy or recurrence is suspected. FNAC is a very helpful and cost-effective modality in determining the nature of such lesions.     

Primary non-Hodgkin's lymphoma of the breast: a case report

Extranodal non-Hodgkin's lymphoma (NHL) of the breast is a rare entity. It represents 0.04-1.1% of malignant tumors of the breast. 1.7-2.2% of extranodal lymphomas and 0.7% of all NHL. However, primary NHL (PNHL) is the most frequent hematopojetic tumor of the breast. CASE: A 23-year-old woman presented with a mass in the left breast for 3 months followed by enlarged left axillary lymph nodes. Mammography showed a diffuse increase in the density of the left breast. Other investigations were unremarkable. Both fine needle aspiration cytology (FNAC) and histopathology were diagnostic of NHL. Immunohistochemistry was confirmatory of NHL, diffuse large cell type, of B-cell lineage. CONCLUSION: Primary and secondary lymphomas of the breast, though rare, should be considered in the differential diagnosis of breast malignancies. PNHL of the breast is usually right sided, but this patient had left breast involvement. Diagnosis by FNAC was successful as the cytologic picture is similar to that of any other lymphoid or extranodal NHL. When histopathology and immunohistopathology are conclusive, FNAC, supplemented by immunocytochemistry, can be applied as a simple, reliable and cost-effective tool in the early diagnosis of breast lymphomas.     

The role of fine needle aspiration cytology (FNAC) in the investigation of superficial lymphadenopathy; uses and limitations of the technique

Aspirates (n = 163) from 157 patients with enlarged superficial lymph nodes were obtained over a 5-year period in a combined surgical/FNAC clinic. A definitive diagnosis was achieved in over 77% of the cases: benign 52.7%, malignant 25.1%. The diagnostic accuracy was 94.4%, sensitivity 85.4%, and specificity 100%. The false-negative rate was 12.5% but decreased to 3.5% when lymphoma cases were excluded. There were 36 cases of metastatic disease, the majority of which were from a primary breast carcinoma. The main diagnostic difficulty was in distinguishing low-grade lymphoma from reactive hyperplasia. An added advantage was that aspirated material could be used in ancillary tests to help with the differential diagnosis. FNAC has a well-defined role in the investigation of superficial lymphadenopathy. Used in the proper setting it will provide a definitive diagnosis in the majority of cases, especially relating to recurrent malignancy or metastatic disease. Patients with a reactive cytological picture and no clinically suspicious symptoms could be spared unnecessary surgery and reviewed through follow up. This technique is cost-effective, of high diagnostic accuracy, and results in considerable resource savings.     

Fine needle aspiration cytology of sclerosing lobular hyperplasia of the breast: a case report

BACKGROUND: Sclerosing lobular hyperplasia presenting as a palpable, circumscribed nodular mass in a young female's breast is characterized histologically by prominent hyperplasia of the lobules and sclerosis of the intralobular connective tissue. The cytomorphologic features and differential diagnosis of the lesion are presented. CASE: A 14-year-old female presented with a painless, progressively increasing, nodular, firm, mobile lump measuring 5 x 5 cm in the right breast. The clinical and radiologic diagnosis was fibroadenoma. Fine needle aspiration smears showed a clean background with uniform, round to oval epithelial cells in flat sheets, round clusters and rosettelike (acinar) arrangements. A few naked nuclei were present, while stromal fragments were not seen. CONCLUSION: When analyzed in the context of the clinical findings, the cytologic features of sclerosing lobular hyperplasia help to differentiate it from other benign palpable nodular lesions of the juvenile breast.     

Preoperative diagnosis of renal angiomyolipoma with fine needle aspiration cytology: a report of 3 cases

BACKGROUND: Angiomyolipoma is a rare benign neoplasm, commonly involving the kidney. Preoperative diagnosis on fine needle aspiration cytology can confirm the diagnosis, reducing the chances of unnecessary surgery. CASES: We studied cases of renal angiomyolipoma (AML) presenting within 1 year with palpable renal masses confirmed on ultrasound to be of renal origin. Fine needle aspiration cytology (FNAC) smears showed a few cohesive syncytial fragments with adipocytes, spindle cells and isolated single cells with foamy cytoplasm; a diagnosis of AML was made. The diagnosis was confirmed on histopathology, which showed mature adipose tissue, tortuous and thick-walled blood vessels lacking elastic tissue lamina and bundles of smooth muscles that seemed to emanate from the blood vessels. CONCLUSION: A preoperative diagnosis of renal AML is of great importance for correct management. In fact, when the lesion is small and asymptomatic, a conservative approach may be considered. Partial nephrectomy is possible with masses < 5 cm. Preoperative FNAC along with computed tomographic findings and immunocytochemical analysis of FNAC smears with HNB-45 can confirm the diagnosis of AML, thus preventing unindicated nephrectomy.     

Colloid carcinoma of the breast with concomitant metastasis and a tuberculous lesion in the axillary lymph nodes. A case report.

A 30-year-old woman presented with a lump in the left breast and left axillary lymphadenopathy that, on fine needle aspiration cytology (FNAC), proved to be duct cell carcinoma with metastasis. Histology of the radical mastectomy specimen showed a mixed colloid carcinoma. Axillary lymph nodes revealed a variety of pathologic changes consisting of reactive hyperplasia, tuberculosis and metastasis. A combination of a tuberculous lesion and metastasis in the same lymph nodes was also found. During follow-up, after radiotherapy, the patient developed left supraclavicular and right cervical lymphadenopathy that, on FNAC, revealed a tuberculous lesion and metastasis, respectively. The rarity of this condition with double pathology is highlighted, and the reason behind the limitations of FNA in subtyping the primary malignancy and its failure to detect the tuberculous lesion in the axillary lymph node are discussed.     

The diagnostic value of fine needle aspiration cytology (FNAC) in the assessment of palpable supraclavicular lymph nodes: a study of 218 cases

The aim of this study was to evaluate the diagnostic value of fine needle aspiration cytology (FNAC) in the assessment of palpable supraclavicular lymph nodes. The material was analysed in 218 cases with enlarged supraclavicular lymph nodes in which FNAC was performed by the conventional method. In all cases cytological examination was performed on-site after staining the smears by the Papanicolaou method. In addition, air-dried smears, fixed smears, filter preparations from needle washings and cell blocks were studied. The FNAC diagnosis was supported by examining cell blocks which added the reliability of histological architecture; further support was obtained by tissue biopsy and/or comparison with the primary tumour in some of the cases. Eleven cases were diagnosed as inflammatory lesions and 41 cases were unsatisfactory because of scanty/acellular samples (despite two to three repeat samplings). However, in five of these, malignant tumours were later found on biopsy, which was done for persistent enlargement of the supraclavicular lymph node(s). Fifty-three cases were diagnosed as negative for malignancy (normal cellular elements, n=15; reactive elements, n=38) and 12 cases were suspicious of malignancy. In 11 cases a diagnosis of lymphoma was made on histology and in 90 cases metastatic tumours were diagnosed. The overall sensitivity was 92.7%, specificity 98.5%, positive predictive value 97.3% and the negative predictive value was 94.8%. Based on our study we feel that FNAC of palpable supraclavicular lymph nodes as a first line of investigation is a cost-effective procedure and is not only useful in the diagnosis of various lesions but can also help in deciding on appropriate management. Furthermore, the histological architecture from cell blocks can be correlated with cytology, and such material can be used for appropriate histochemical and immunomarker studies, which can be useful in enhancing the diagnosis.     

Metastatic breast cancer: mechanisms and opportunities for cytology

Despite significant advances in diagnosis, surgical techniques, general patient care, and local and systemic adjuvant therapies, metastatic disease remains the most critical condition limiting the survival of patients with breast cancer. Therefore, the development of effective treatment against late‐arising metastasis has become the centre of clinical attention and is one of the current challenges in cancer research. A deeper understanding of the metastatic cascade is fundamental, and the need for repetitive tumour assessments for the evaluation of tumour evolution is a relatively new practice in routine medical care. As such, fine needle aspiration cytology (FNAC) is ideally placed to monitor biological changes in metastasis that may affect treatment and response. As FNAC is a minimally invasive method, it can be performed repeatedly with relatively little trauma, and selective ancillary tests can be applied to FNAC specimens, including for tumour whose primary nature is known. Herein, we review how the linear and parallel models explain metastatic dissemination, thus influencing therapeutic and clinical decisions, and how cytology, together with immunocytochemistry and molecular analysis, can be a tool for routine clinical practice and clinical trials aimed at metastatic disease with a special emphasis on breast cancer.     

O‐6RESPECTIVE ROLES OF FINE NEEDLE ASPIRATION CYTOLOGY AND CORE BIOPSY IN DIAGNOSIS OF SYMPTOMATIC BREAST LESIONS

Introduction: To evaluate and compare the respective roles of fine needle aspiration cytology and core biopsy for diagnosis of symptomatic breast lesions. Methods: Retrospective study on 589 breast fine needle aspiration cytology (FNAC) cases and 88 core biopsies (CB) with no associated FNAC, performed between January and December 2004. A computer database was searched for initial results, subsequent investigations and outcomes. Results: Of the cases that had FNAC performed as an initial investigation, the final diagnosis was reached by FNAC alone in 81.8% of cases. Of these, 59.2% were benign, 6.1% malignant and 2.4% remaining suspicious with 14.1% inadequate samples. There were 31 cases reported as suspicious (C3/C4) on FNAC, of these 14% of C3 and all of C4 were malignant on CB. Of the 86 cases that had both FNAC and CB, CB improved on the FNAC diagnosis of malignancy in 19.8% of cases, half of which were considered inadequate on FNAC. The positive predictive value of malignant cases was 100%, and the negative predictive value 98%. The absolute sensitivity of FNAC in this study was 65% and complete sensitivity 72%. The false negative rate was 8% and false positive rate 0%. The diagnosis of 88 CB without FNAC showed 37.5% to be malignant and 60.2% as benign, with 2.3% as inadequate biopsies. Discussion: FNAC remains the first line investigation in symptomatic breast lesions. Its best use is in the diagnosis of benign disease which constitutes over two thirds of patients in our practice. In suspicious and clinically malignant lesions, it is complemented by CB which may provide additional information relevant to management. In conclusion, the majority benign findings in our patients who had CB without prior FNAC, does not justify the use of CB as a first line investigation. CB is indicated in cases of inadequate or suboptimal FNAC. The continuous use of suspicious categories (C3/C4) in breast cytology is justified by the subsequent outcomes, both benign and malignant.     

Oral metastasis of breast carcinoma diagnosed by fine needle aspiration cytology. A case report

BACKGROUND: Fine needle aspiration cytology (FNAC) is an important technique in the diagnosis of oral and maxillofacial conditions. The purpose of the present paper is to report a case of oral metastasis of breast carcinoma diagnosed by FNAC. CASE: A 45-year-old, black woman was referred for evaluation of symptomatic swelling in the left mandible. The medical history revealed that the patient had undergone extensive surgery to remove a lobular carcinoma. She had finished chemotherapy treatment about 5 months earlier. Due to the main diagnostic considerations of metastatic and inflammatory disease, FNAC was performed. The cytologic picture was consistent with a metastatic glandular neoplasm. CONCLUSION: FNAC is a safe, reliable, cost-effective and easy procedure and sometimes eliminates the need for open biopsy.     

Fine needle aspiration cytology of metastatic skin nodules. A report of 2 cases

BACKGROUND: Skin is an uncommon site for metastatic deposits from internal malignancy. The scalp as a metastatic site is uncommon. Metastatic skin/scalp nodules can be diagnosed accurately by fine needle aspiration cytology (FNAC). However, few reports exist on the FNAC diagnosis of metastatic skin/scalp nodules. Metastatic skin nodules may mimic primary skin tumors, or vice versa, and some primary skin tumors may be mistaken for metastatic skin deposits. CASES: In case 1 a 60-year-old male presented with nodules on the scalp, back and upper extremity. The scalp nodule was noticed first, followed by the ones on the back and upper extremity. FNAC of nodules on the scalp and upper extremities showed deposits of carcinoma. The nodule on the back was excised. In case 2 a 66-year-old female presented with a nodule on the scalp. She also had enlarged bilateral cervical lymph nodes. FNAC of the scalp nodule and cervical lymph nodes revealed the cytologic features of non-Hodgkin's lymphoma. CONCLUSION: Metastatic cutaneous/staneous/subcutaneous deposits can pose diagnostic hurdles in the absence ofprevious or simultaneous malignancy. FNAC is a quick and cost-effective tool for the evaluation of such nodules.     

Fine needle aspiration cytology of bone tumors

OBJECTIVE: To study the role of fine needle aspiration cytology (FNAC) in the diagnosis of bone tumors and its impact on therapeutic decisions. STUDY DESIGN: A group of 122 cases of bone tumor were evaluated by FNAC. Detailed diagnoses were compared with the available histology. RESULTS: Diagnostic accuracy of FNAC was 90.5% in this study. FNAC could differentiate between various round cell tumors such as Ewing's sarcoma and myeloma, among various giant cell-rich lesions of bone and between the benign and malignant chondroid bone tumors. Some uncommon variants were also correctly diagnosed. In metastatic bone tumors, the source of primary malignancy could not be indicated in the majority (52.9%) because of the poorly differentiated morphology. Osteoid or osteoid-like material was demonstrable in 63.6% cases of osteogenic sarcoma. A case of chondroblastic osteogenic sarcoma that was reported as chondrosarcoma was the only diagnostic error in the study. FNAC obviated the need of open biopsy in 63.8% patients, and therapeutic decisions were made according to the cytologic diagnoses. CONCLUSION: FNAC plays an important role in the early diagnosis of bone tumors by its accuracy, ease of use and rapidity and is helpful in making the therapeutic decisions.     

Ultrasound-guided fine needle aspiration cytology in the diagnosis and management of thyroid nodules

OBJECTIVE: To examine the accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of thyroid nodules and compare the inadequacy rates for ultrasound-guided and freehand FNAC. METHODS: A retrospective study of 434 patients with thyroid nodules who underwent diagnostic FNAC over a 2-year period. Cytological diagnoses have been compared with the histological assessment of resection specimens in 69 cases. RESULTS: The inadequacy rate was significantly lower from ultrasound guided FNAC (24/373 cases, 6.4%) than from freehand FNAC (8/61 cases, 13.1%) (P = 0.043). Seventy-six percentage of patients had a non-neoplastic cytological diagnosis and, after multidisciplinary review, the patients were reassured and assigned to clinical follow-up. Sixty-seven patients had a resection for cytological appearances consistent with non-neoplastic disease (n = 34), suspicious of follicular neoplasia (n = 23), or suspicious of malignancy (n = 10), and two patients had resections following inadequate cytology with ultrasound appearances suspicious of a neoplasm. The overall accuracy of FNAC analysis for malignancy was 97.0%, with sensitivity 83.3%, specificity 98.0%, positive predictive value 71.4% and negative predictive value 98.4%. The overall accuracy of FNAC analysis for the prediction of neoplasia was 97.5%, with sensitivity 80.5%, specificity 97.8%, positive predictive value 89.2% and negative predictive value 95.9%. Difficulties in cytological diagnosis were associated with lymphoid infiltrates and with degenerative changes in follicular adenomas. CONCLUSION: Ultrasound-guided FNAC has a significantly lower yield of inadequate aspirates than palpable FNAC. The ability of FNAC to predict neoplasia in 89% patients and to exclude neoplasia in 95.9% patients makes an important contribution to the multidisciplinary assessment of patients.     

Diagnosis of hepatocellular carcinoma by fine needle aspiration cytology. Cellular features

OBJECTIVE: To evaluate the importance of fine needle aspiration cytology (FNAC) in the diagnosis of hepatocellular carcinoma (HCC). STUDY DESIGN: We analyzed 17 cytologic and 5 architectural features in a series of 320 FNACs from HCC and compared them with 73 FNACs from benign lesions and with 705 FNACs from metastatic carcinomas. One thousand ninety-eight patients who were diagnosed by liver FNAC between December 1988 and July 1998 and had adequate follow-up were included in the study. The specimens were evaluated according to the presence or absence of the cytologic features and cellular arrangement. A stepwise logistic regression analysis was performed on the data to determine the variables predictive of HCC. RESULTS: Multinucleated tumor giant cells, cytoplasmic hyaline and central sinusoidal pattern were selected as the 3 most predictive parameters for differentiated reactive hepatocytes from HCC (P < .0001), while bile, centrally located nucleus in an atypical cell and intranuclear inclusion were selected as the 3 most predictive parameters for differentiated metastatic carcinoma from HCC (P < .0001-< .001) by stepwise logistic regression analysis. CONCLUSION: In the 1,098 patients suspected of having hepatic malignancy, a correct diagnosis was made by a combination of the above features. The sensitivity of this procedure for hepatic malignancy was 99.5%, and the specificity was 100%.