Focal adenomatoid hyperplasia of salivary glands. A differential diagnostic problem in fine needle aspiration biopsy

Adenomatoid hyperplasia of minor salivary glands is an idiopathic lesion usually involving the palate and mimicking a primary salivary gland neoplasm. In particular, the lesions may resemble low-grade mucoepidermoid tumors clinically and by fine needle aspiration (FNA) cytology. An illustrative case is presented, and the nature of this unusual entity is reviewed. Its importance in the differential diagnosis of FNA biopsies of minor salivary gland lesions is also discussed.     

Fine needle aspiration biopsy diagnosis of mucoepidermoid carcinoma. Statistical analysis

Fine needle aspiration (FNA) biopsy is an increasingly popular method for the evaluation of salivary gland tumors. Of the common salivary gland tumors, mucoepidermoid carcinoma is probably the most difficult to diagnose accurately by this means. A series of 96 FNA biopsy specimens of salivary gland masses, including 34 mucoepidermoid carcinomas, 51 other benign and malignant neoplasms, 7 nonneoplastic lesions and 4 normal salivary glands, were analyzed in order to identify the most useful criteria for diagnosing mucoepidermoid carcinoma. Thirteen cytologic criteria were evaluated in the FNA specimens, and a stepwise logistic regression analysis was performed. The three cytologic features selected as most predictive of mucoepidermoid carcinoma were intermediate cells, squamous cells and overlapping epithelial groups. Using these three features together, the sensitivity and specificity of accurately diagnosing mucoepidermoid carcinoma were 97% and 100%, respectively.     

Fine needle aspiration cytology of parotid sarcoidosis

Granulomatous lesions of the salivary gland are rare; as such, there have been few reports of the cytologic features of granulomatous sialadenitis in general, and salivary gland sarcoidosis in particular. A case of systemic sarcoidosis involving both parotid glands, diagnosed initially by fine needle aspiration (FNA) cytology, is presented. The specific cytologic features included histiocytes of both epithelioid and giant multinucleated types, without background necrosis. The FNA cytologic differential diagnosis of bilateral parotitis is discussed.     

Necrosis of a Warthin's tumor following fine needle aspiration

Fine needle aspiration (FNA) biopsy of a parotid mass demonstrated features diagnostic of a Warthin's tumor. Resection of the mass six weeks later yielded a necrotic nodule lacking distinguishing characteristics. This case illustrates infarction of the target lesion, a rare complication of FNA biopsy of salivary gland neoplasms. Correlation of the histology with the cytology will prevent diagnostic difficulties in such instances.     

Myoepithelioma of the parotid gland initially diagnosed by fine needle aspiration cytology and immunocytochemistry: a case report

BACKGROUND: Myoepithelioma is a rare, benign tumor of the salivary gland, most commonly affecting the parotid gland. Although the cytologic features of myoepithelioma are documented in a few case reports, it has rarely been diagnosed preoperatively by fine needle aspiration (FNA) cytology. CASE: A 33-year-old man presented with a left parotid swelling 2.5 cm in diameter and of about 5 years' duration. FNA smears showed bundles of spindle-shaped cells as well as plasmacytoid and stellate cells in sheets and dissociated forms. A few cells had nuclear grooves, and occasional cells showed intranuclear cytoplasmic inclusions. In May-Grünwald-Giemsa-stained smears, most of the cells had reddish cytoplasm. Red to purple, myxoid matrix was present as a scanty fibrillar substance and as globules surrounded by tumor cells vaguely reminiscent of adenoid cystic carcinoma. A cytodiagnosis of myoepithelioma was given and corroborated by immunocytochemical staining, which revealed a positive reaction for vimentin, smooth muscle actin and S-100 protein. Epithelial membrane antigen yielded a negative reaction except for a few plasmacytoid cells with weakly positive staining. Histopathology of the resected tumor and immunohistochemical staining confirmed the cytodiagnosis of myoepithelioma. CONCLUSION: FNA cytologic features together with immunocytochemical studies on smears can offer a preoperative diagnosis of myoepithelioma.     

Oncocytic nodule. An unusual case of a submaxillary gland mass in an elderly patient

A submaxillary gland mass in an elderly woman was diagnosed as an oncocytic nodule by cutting needle biopsy and was followed with serial fine needle aspiration (FNA) biopsy for seven years. All specimens showed pure populations of oncocytes. Oncocytic nodules of the salivary gland are unusual lesions that may represent hyperplastic proliferations or true neoplasms. Although oncocytic metaplasia is commonly identified in the salivary glands of elderly patients, oncocytes rarely form masses that are targets for needle biopsy. This case suggests that FNA biopsy may be a useful method of evaluating salivary gland lesions in elderly patients who are not candidates for surgery.     

Diagnostic difficulties in the interpretation of fine needle aspirates of salivary gland lesions: the problem revisited

Diagnostic difficulties in the interpretation of he needle aspirates of salivary gland lesions: the problem revisited
Cases of salivary gland lesions ( n =325), mainly neoplastic but including a small number of non-neoplastic lesions, investigated by fine needle aspiration (FNA) and with histological correlation, are reviewed. The review identified a number of differential diagnostic problems which are discussed in some detail. One false-positive and eight false-negative diagnoses had been made resulting in a 99.5% specificity and a 85.5% sensitivity. If type-specific diagnoses are made only when all defined diagnostic criteria are present and if any uncertainty is clearly conveyed to the clinician, FNA is a safe and accurate tool in the investigation of salivary gland lesions.     

Fine needle aspiration cytology of lactating adenoma of the breast. A comparative light microscopic and morphometric study

Six cases of lactating adenoma of the female breast diagnosed by fine needle aspiration (FNA) were reviewed. The FNA cytologic diagnostic features included a usually moderately cellular aspirate with an abundant foamy background material, intact epithelial lobules or acini and small groups and solitary epithelial cells that contained uniform nuclei, fine chromatin and prominent nucleoli. When present, the cytoplasm was finely vacuolated or wispy; many nuclei appeared stripped of their cytoplasm. These features were compared light microscopically with the cytopathologic features of six cases of invasive well-differentiated ductal adenocarcinoma, seven cases of invasive lobular carcinoma, one case of granulocytic sarcoma and one case of primary histiocytic lymphoma of the breast. In addition, cytomorphometric analysis demonstrated no statistically significant differences in the nuclear areas of lactating adenoma as compared with those of well-differentiated ductal carcinoma and lobular carcinoma.     

Fine needle aspiration biopsy of the parotid gland. Diagnostic problems and 2 uncommon cases

OBJECTIVE: To describe the diagnostic problems and present our findings in 2 uncommon tumors, malignant myoepithelioma and small cell undifferentiated carcinoma, by examining fine needle aspiration (FNA) biopsies of parotid gland masses. STUDY DESIGN: The study group consisted of 34 females and 41 males 12-80 years old, with an average of 44. Excluding inflammatory results, all adequate aspirates were confirmed histologically to determine the correlation. RESULTS: Sensitivity of FNA cytology was 91%, with specificity of 98%. We encountered some difficulties, and therefore misdiagnoses, in evaluating specific neoplasms, such as adenoid cystic carcinoma and Warthin's tumor, which have well-established cytologic diagnostic criteria. Two cases of uncommon neoplasms of salivary glands, small cell undifferentiated carcinoma and malignant myoepithelioma, were cytologically found to be malignant but not further classified. In addition, tuberculous parotitis, with its well-defined features, should to be referred since unnecessary surgery can be avoided by using FNA cytology. CONCLUSION: FNA is a sensitive and specific diagnostic tool for parotid gland masses. However, specific classification of neoplasms may sometimes be difficult. Pathologists should be aware of specific entities, such as malignant myoepithelioma, when evaluating high grade neoplasms.     

Cytologic diagnosis of a case of recurrent adamantinoma

The cytologic features of a case of recurrent adamantinoma of the tibia diagnosed by fine needle aspiration (FNA) in a 31-year-old patient are described. The FNA smears contained single-lying cells and cells arranged in small clusters and Indian files, with some nuclear molding. Three cell types were present: (1) large polygonal cells with chromatin clearing, (2) smaller cells with poorly defined cytoplasm and dense chromatin and (3) fusiform cells. The first two were interpreted as epithelial in nature and the third one as being derived from the stroma. These cytologic features appear to be sufficiently characteristic to suggest an FNA diagnosis of adamantinoma, especially in the case of a recurrent tumor.     

Adenoid cystic carcinoma metastatic to the lung. Report of a case diagnosed by fine needle aspiration biopsy cytology

Cytologic examination of a fine needle aspiration (FNA) biopsy specimen served to diagnose a lung metastasis in a patient with an adenoid cystic carcinoma primary in a minor salivary gland of the hard palate. The aspiration cytologic features of the metastatic adenoid cystic carcinoma were similar to those of primary adenoid cystic carcinoma, including uniform tumor cells with scant cytoplasm surrounding transparent, mucoid spherical bodies. FNA biopsy cytologic diagnosis of metastatic adenoid cystic carcinoma is accurate, particularly if mucoid spherical bodies are present.     

Salivary duct carcinoma of the parotid gland: report of a rare case with a comparative study of aspiration cytology and histomorphology

BACKGROUND: Salivary duct carcinomas affecting primarily the parotid gland are extremely rare (0.2-2% of all salivary gland tumors). These carcinomas are considered to be of high grade malignancy, with mortality in up to 70% of cases. They usually affect elderly males and less often young adults. Despite the fact that the histomorphologic characteristics of this tumor are always necessary for its classification, several authors have reported that the cytopathologic approach, using fine needle aspiration (FNA) cytology, can establish the final diagnosis. The aim of this paper is to present a rare case of salivary duct carcinoma of the parotid gland with no typical microscopic findings that was diagnosed by FNA cytology through a combination of techniques on biopsy material. CASE: A 56-year-old male presented with a right parotid mass measuring 6 cm in diameter. The mass appeared to expand subcutaneously and infiltrate the skin of the neck region. Biopsy material from both the mass and skin was obtained using FNA and processed with conventional, cell block and liquid-based cytology techniques. A core biopsy was also performed on the mass for histologic evaluation. CONCLUSION: The findings were consistent with a salivary duct carcinoma of the parotid gland and were confirmed by the histologic report. FNA cytology combined with such techniques as liquid-based cytology provides the potential for the final diagnosis. Liquid-based cytology can improve the cellular morphology of the material and allows immunocytochemistry and other diagnostic techniques. The application of such techniques is significantly restricted by conventional processing; thus, combining liquid-based cytology with other techniques expands the boundaries of cytology as a diagnostic test.     

Posters. P19 Cervical carcinoma with metastases to the tympanic membrane: an unusual presentation

Introduction Fine needle aspiration (FNA) is a well‐established diagnostic technique which is frequently used to diagnose head and neck neoplasms. Clinical decisions concerning treatment of malignant salivary gland tumours, the extent of surgery and advisability of pre‐operative irradiation can be helped by prior knowledge of tumour type. Aim The aim of this study was to do an audit of all salivary gland FNAs carried out in Beaumont Hospital over a 14‐year period. Methods All salivary gland FNAs between 1989 and 2002 were reviewed. Where available, the corresponding follow‐up histological specimens were studied. Results During this 14‐year period, 305 patients with salivary gland lesions had FNA of the lesion performed. The total number of aspirates performed was 343. Of these, 184 had histologies available for follow‐up. Eighty‐nine aspirates were reported as inadequate; 89 as inflammatory, normal or consistent with cyst contents. One hundred and thirteen aspirates were diagnosed as a benign entity. Thirty‐three aspirates were reported as malignant (21 of which were felt to be primary to the salivary gland and 12 metastatic). Sixteen cases were called suspicious. Good correlation between FNA findings and histology was seen in the majority of cases (145 of 183). Some diagnostic problem areas were identified. These included the following: lymphomas (seven called benign on FNA), Warthin's tumour (seven not diagnosed or misdiagnosed on FNA) and mucoepidermoid carcinoma (one reported as pleomorhic adenoma and one as benign/cystic on FNA). Seven pleomorphic adenomas were not diagnosed on FNA pre‐operatively, predominantly due to inadequacy of the specimen. Three other malignancies (acinic cell carcinoma, lymphoepithelial carcinoma and carcinoma ex‐pleomorphic adenoma), while not diagnosed on FNA, were called suspicious, with re‐biopsy advised. Conclusion FNA cytology of salivary glands is an accurate method for evaluation of both benign and malignant lesions, enabling optimum surgical and adjuvant therapy decision‐making pre‐operatively. Well‐defined problem areas are identified and, therefore, clinicopathological correlation is required in these cases.     

Polyploidy In Pleomorphic Adenomas With Cytological Atypia

Occasionally, in fine-needle aspirates of pleomorphic salivary gland adenomas, considerable cytonuclear atypia is present, which may give rise to a false-positive diagnosis. In this study DNA cytophotometry was performed on Feulgen restained smears prepared from material obtained by needle aspirates of normal salivary glands (n = 4), pleomorphic adenomas with (n = 5) and without (n = 4) atypia and a carcinoma in a pleomorphic adenoma. The results showed a clear diploid DNA histogram in the specimens of normal salivary gland and pleomorphic adenomas without atypia. In contrast, in the pleomorphic adenomas with atypia a distinct polyploid pattern was present in three out of the five DNA histograms with DNA values in 2c, 4c and 8c ranges. In two of these cases a 16c peak was also present and in the two remaining cases tetraploidy was demonstrated. In the carcinoma a main stemline at 4c was found. This report once more emphasizes the possible atypia which may be present in FNA of pleomorphic adenomas of the salivary gland. The atypia is due to polyploidy in a histologically benign tumour.     

Cytologic findings of breast ductal lavage and concurrent fine needle aspiration in pleomorphic lobular carcinoma in situ: a case report

BACKGROUND: Breast ductal lavage (DL) is a noninvasive procedure for sampling ductal epithelial cells. Patients at risk for breast cancer or with prior history can be monitored by DL. This report compares cytomorphology in concurrent DL, fine needle aspiration (FNA) and histology in a case of pleomorphic lobular carcinoma in situ (PLCIS) with signet ring features. CASE: A 57-year-old woman had DL and FNA performed after quadrantectomy for lobular carcinoma in situ with signet ring cell features. DL and FNA were diagnosed as suspicious and positive for malignancy, respectively. Subsequent biopsy showed PLCIS. Cytomorphologic features of DL, FNA and histology were compared. DL showed epithelial cells in small clusters or single-file arrangement and single-lying; in FNA, single cells predominated. DL and FNA showed nuclear atypia and cytoplasmic vacuoles, the latter more prevalent in FNA. Both samples showed cells with signet ring features. The atypical epithelial cells present in DL and FNA were identical to those seen in the histologic material. CONCLUSION: Cytomorphologic findings in DL, although less striking, are comparable to those seen in FNA. Architecture, nuclear atypia and intracytoplasmic vacuoles are helpful features in DL for establishing a diagnosis of suspicious if not positive for malignancy in LCIS.     

Pleomorphic adenoma of salivary gland: to what extent does fine needle aspiration cytology reflect histopathological features?

OBJECTIVE: The histological diversity encountered in pleomorphic adenoma may cause diagnostic difficulty in fine needle aspiration (FNA) cytology due to limited and selective sampling. The present study based on 25 histologically confirmed pleomorphic adenoma cases attempts to find out to what extent FNA cytology reflects the histopathological features. METHODS: May-Grunwald-Giemsa and Papanicolaou stained smears, and haematoxylin and eosin stained paraffin sections of 25 pleomorphic adenomas of parotid and submandibular glands were reviewed. The cellularity, which was assessed in a sliding scale of 1+ to 4+, and proportions of epithelial to mesenchymal components in FNA smears and histology was determined and compared. The frequency of morphological features such as squamous metaplastic cells, cells with oncocytic change, acinus formation, mucus globules, papilla formation, giant cells, myxoid and chondroid matrix as well as specific nuclear features was compared between the two diagnostic methods, and the statistical significance was determined using Fisher's exact test of probability. RESULTS: There was complete concordance between cytology and histology with respect to overall cellularity in 14 (56.0%) cases and in the proportions of epithelial to mesenchymal components in 13 (52.0%). Epithelial cells and myxoid matrix were present in all cases. There was no significant difference between smear and tissue section with respect to frequency of squamous metaplasia, oncocytic change, acinus formation, papilla formation, mucus globules, giant cells, nuclear pleomorphism, nuclear chromatin pattern, and mitotic figures. Morphological parameters that were significantly higher in FNAC compared with histology included intranuclear cytoplasmic inclusions (36.0% versus 8.0%, p = 0.0374), nuclear grooves (84.0% versus 48.0%, p = 0.0090), and reniform nuclei (20.0% versus 0.0%, p = 0.0502). Chondroid matrix was the only parameter which was significantly more common in histology than in cytology (44.0% versus 4.0%, p = 0.019). CONCLUSION: FNA cytology demonstrates well most of the histological features of pleomorphic adenoma of salivary gland and may be considered a useful tool in initial assessment of the tumour.     

Diagnosis of disseminated histoplasmosis by fine needle aspiration of the adrenal gland

The cytologic findings in a case of disseminated histoplasmosis diagnosed by fine needle aspiration (FNA) of the adrenal gland are presented. Bilateral adrenal enlargement was discovered on CT scan in a patient whose systemic symptoms had been attributed to tuberculosis, but were resistant to antituberculous chemotherapy. The aspirate contained numerous histiocytes containing intracytoplasmic organisms with the morphologic features of Histoplasma capsulatum. The case shows that radiographically directed FNA of the adrenal gland, which has been recognized as a valuable aid in the confirmation of primary and secondary neoplasia, may also be quite useful in the less common setting of infectious disease involving this organ.     

Clear cell carcinoma arising from pleomorphic adenoma of a minor salivary gland: Report of a case with fine needle aspiration, histologic and immunohistochemical findings

BACKGROUND: Malignant changes in pleomorphic adenoma (PA) of the salivary gland (carcinoma ex pleomorphic adenoma) are not common. Clear cell carcinoma is a rare form of salivary gland tumor and involves mostly minor salivary glands, especially those of the palate. Only 3 cases of clear cell carcinoma arising in PA have been reported, 2 in submandibular glands and 1 in a minor salivary gland of the palate. CASE : A 53-year-old man presented with an enlarged mass on the left side of the palate. He had a history of palate mass about 30 years earlier; it was excised and reported as PA. Since then the tumor had recurred twice in the same place; it had been excised and was diagnosed as PA again. A few years later the mass showed rapid growth over a few months. Fine needle aspiration of the mass showed epithelial clusters with bland nuclear features and myxohyaline material typical of PA. Also noted were large and small papillary, trabecular and well-circumscribed clusters of neoplastic cells with a moderate amount offoamy, vacuolated cytoplasm with distinct borders. Glandlike and acinar structures with hyaline globule material resembling cannonballs were also noted. The cytology was suspicious for malignancy. Incisional biopsy was reported as PA. Due to the suspicion of malignancy, the whole mass was excised up to the floor of the orbit. The final diagnosis was clear cell carcinoma expleomorphic adenoma. CONCLUSION: Due to nonspecific cytologic findings in clear cell carcinoma and a mixture of elements of PA in this case, we did not consider clear cell carcinoma as the malignant component.     

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.