Amyloid in cytologic specimens. Differential diagnosis and diagnostic pitfalls.

OBJECTIVE: To describe and illustrate the characteristic features of amyloid in cytologic preparations and point out its diagnostic pitfalls. STUDY DESIGN: Five fine needle aspirates and one bronchial washing that contained amyloid were retrospectively reviewed. The aspirates were obtained from each of the five following sites: lung, occipital lymph node, thyroid gland, proximal humerus and subcutaneous soft tissue. Smears of all of the aspirates were stained with Papanicolaou stain, and in two cases they were also stained with Diff-Quik. Cell block sections were stained with hematoxylin and eosin. Congo red, CD45 and CD20 were used on selected cases. RESULTS: Amyloid appears as either flocculent material or irregularly shaped fragments with scalloped and pointed edges. The amorphous fragments are acellular and frequently associated with connective tissue cells. They stain eosinophilic to cyanophilic with Papanicolaou stain and deep blue with Diff-Quik. In two cases an exuberant giant cell reaction almost obscured the amyloid. In the thyroid aspirate, the amyloid was misinterpreted as colloid. In bronchial washings and lung aspirates, amyloid has to be distinguished from mucus, alveolar proteinosis, chondroid material and corpora amylacea. When circumferentially surrounded by lymphocytes or plasma cells, flocculent amyloid deposits may simulate adenoid cystic carcinoma. CONCLUSION: Amyloid can be easily overlooked or mistaken for other entities with similar staining qualities. Congo red staining can help to confirm the diagnosis.     

Extramedullary plasmacytoma of the parotid gland. Report of a case with extensive amyloid deposition masking the cytologic and histopathologic picture

BACKGROUND: Extramedullary plasmacytomas are uncommon. Although approximately 90% occur in the head and neck region, parotid gland localization is extremely rare. CASE: This report describes fine needle aspiration and histopathologic findings in an extramedullary plasmacytoma arising in the left parotid gland of a 62-year-old man. Aspiration smears showed multiple amorphous clumps of material admixed with ductal epithelial cells, multinucleated giant cells and inflammatory cells rich in plasma cells, suggestive of pleomorphic adenoma. In surgical material, excessive amyloid deposition was observed. Six months later the tumor recurred, and in the second surgical specimen clusters of atypical plasma cells among amyloid deposits was noted. Clinical and laboratory examination excluded multiple myeloma. After local recurrence, radiotherapy was applied. Ten months later the patient was well and without systemic involvement. CONCLUSION: Two points are important. First, in the salivary gland region, because of the focal metachromasia of amyloid with Giemsa stain, amyloid can be confused with the chondromyxoid matrix of pleomorphic adenoma. Second, although localized forms of amyloid tumor exist, one should keep in mind that amyloid may be so abundant that it may mask an underlying plasma cell neoplasm, as in our case.     

Localized amyloidosis in nasopharyngeal carcinoma diagnosed by fine needle aspiration and electron microscopy. A case report

BACKGROUND: The association of amyloidosis and tumors is well known, but only rarely has it been found in the nasopharynx. Moreover, only a single case of tumor-associated amyloidosis in the nasopharynx has been diagnosed by exfoliative cytology and reported in the English-language literature. We describe a case of localized amyloidosis in metastatic nasopharyngeal carcinoma diagnosed by fine needle aspiration and confirmed by histology and electron microscopy. CASE: Bilateral neck enlargement appeared six months before consultation in a 57-year-old man. Both masses were resected, and during exploration of the nasopharynx, several blind biopsies were taken. Smears from the fine needle aspirate showed malignant epithelial cells, consistent with metastatic carcinoma, and Congo red stain showed the presence of amyloid. Histologic examination of the resected cervical masses and nasopharyngeal biopsies confirmed the diagnosis of nasopharyngeal carcinoma, nonkeratinizing variant with amyloid, and metastases in two lymph nodes. Electron microscopic examination of a lymph node showed extracellular, ribbon-like amyloid deposits as well as masses of amorphous amyloid, apparently intracellular. CONCLUSION: The origin of this form of amyloidosis is unclear in this patient since he had no other known etiologic factors for the condition. Increased awareness of the potential association of these two conditions and the use of fine needle aspiration may reveal a higher frequency than hitherto reported.     

Calcinosis cutis in chronic renal failure diagnosed by fine needle aspiration. A case report

BACKGROUND: Deposition of calcium salts in the skin and subcutis, referred to as calcinosis cutis, is a common complication in patients with end-stage renal disease. The lesion can present as a mass and is amenable to fine needle aspiration (FNA). CASE: A 48-year-old man undergoing hemodialysis following a failed renal transplant presented with a 1.5-cm neck nodule. A diagnosis of calcinosis cutis was made following FNA, which obtained semiliquid, chalky material. CONCLUSION: In cytologic preparations, deposits of calcium salts can be both amorphous and refractile on Diff-Quik and Papanicolaou stain. However, the material may not be birefringent with these stains. Alizarin red S stain for calcium will permit demonstration of the characteristic birefringence.     

Primary amyloid tumor of the breast. Case report and literature review

An example of localized amyloid deposition in the breast of an elderly woman is reported. Fine needle aspiration biopsy yielded clumps of amorphous material, which stained violet with the May-Grünwald-Giemsa technique. The amyloid appeared to be of the AA type on histochemical analysis. The lesion was clinically associated, probably coincidentally, with a stage II carcinoma of the cervix. The nature and classification of amyloid is briefly reviewed, and the role of fine needle aspiration cytology in its diagnosis is discussed.     

Diagnosing invasive cystic hypersecretory duct carcinoma of the breast with fine needle aspiration cytology. A case report

BACKGROUND: Cystic hypersecretory duct carcinoma (CHC) of the breast, first described in 1984, is a rare variant of duct carcinoma. Histologically it is characterized by the formation of dilated ducts and cysts containing an eosinophilic secretory product resembling thyroid colloid. The lining epithelium of the cysts atypically proliferates to form intraductal carcinoma. Only four cases of invasive cystic hypersecretory carcinoma have been reported. CASE: We present a case of invasive CHC with tumor emboli in many lymphatic spaces and axillary nodal metastases. The lesion was also evaluated by fine needle aspiration. Direct smears with Papanicolaou stain were highly cellular and had abundant, intensely staining, orange-to-gray-green thyroid colloid-like material. Epithelial cells, showing a variety of cellular patterns, were indistinguishable from usual ductal carcinoma cells. These cytologic findings may be characteristic enough to suggest cystic hypersecretory carcinoma. CONCLUSION: The cytologic features of CHC are distinctive and correlate with histology. This was the first presentation of colloidlike secretory material in cytologic material with Papanicolaou stain in such a case. Invasive CHC tends to have aggressive behavior. Cystic hypersecretory hyperplasia coexisted in this case.     

Aspiration biopsy findings in amyloid tumor of the cervical vertebra. A case report

BACKGROUND: The differential diagnosis of destructive lytic lesions of the spine includes amyloid tumors. The diagnosis of amyloid tumor with fine needle aspiration biopsy (FNA) is challenging. Previous reports of FNA of osseous amyloid tumors have detailed the cytologic appearance of amyloid along with lymphocytes, plasma cells and histiocytes, occasionally multinucleate or forming granulomatous lesions. CASE: An 84-year-old man presented with neck pain. Radiologic studies showed a destructive, lytic lesion of C-6, with a large, soft tissue mass. FNA yielded many acellular smears containing abundant amyloid that was confirmed with special stains of corresponding tissue cores and subsequent surgical biopsies. CONCLUSION: Osseous amyloid tumors are destructive, lytic lesions that mimic other processes. Amyloid can be distinguished from other substances in FNA samples and amyloid tumor identified, even when amyloid is present without typical cellular components.     

Cytologic diagnosis of pulmonary nocardiosis: a report of 3 cases

BACKGROUND: Nocardiosis is an uncommon infection and presents as an opportunistic infection in an immunocompromised host. Pulmonary infection by Nocardia may be difficult to diagnose based on clinical and radiologic features, as these are not specific. Sputum examination, bronchoalveolar lavage and transthoracic ultrasound/computed tomography-guided fine needle aspiration cytology offer a simple means of procuring material for diagnostic evaluation. Very few articles have described the morphologic appearance of this uncommon pathogen in cytologic material. CASES: Three cases occurred in patients with an underlying immunocompromised state. Patient 1 was on steroid therapy for nephrotic syndrome, patient 2 was on immunosuppressant therapy after renal transplantation, and patient 3 was HIV positive. A diagnosis of pulmonary nocardiosis was suspected on Papanicolaou stain. Modified Ziehl-Neelsen stain and silver methanamine stains were useful in confirming the diagnosis. CONCLUSION: A high index of suspicion for nocardiosis must be maintained while assessing cytologic material in immunosuppressed individuals as it may be masked by the intense inflammatory exudate associated with this infection. A meticulous search may reveal the presence of delicate, thin, faintly stained, branching filaments of Nocardia on routine Papanicolaou stain. Special stains and culture studies are useful in confirming the diagnosis.     

Cytodiagnosis of eumycotic mycetoma: a case report

BACKGROUND: Mycetoma is a late-stage clinical manifestation of a subcutaneous infection produced by bacteria (actinomycetoma) or fungi (eumycetoma). Only a few articles have described the morphologic appearance of this uncommon pathology on cytology. The distinction between eumycetoma and actinomycetoma in fine needle aspiration cytology (FNAC) is as accurate as in histopathology, as demonstrated in the present case. CASE: A 30-year-old man presented with a large swelling on his left foot with a discharging sinus. FNAC of the swelling yielded pus-like material. Initial Papanicolaou and Giemsa stains showed the presence of septate, branching fungal hyphae and black granules against the inflammatory background. The presence of fungus was confirmed by PAS stain. The species was identified as Exophiala jeanselmei on fungal culture. CONCLUSION: Mycotic mycetoma can be accurately diagnosed by FNAC, which is a simple, inexpensive and rapid technique when there is a high index of suspicion. Special stains and culture studies are helpful in confirmation of diagnosis and species identification.     

Identification of amylase crystalloids in cystic lesions of the parotid gland

OBJECTIVE: To identify alpha-amylase crystalloid formations in parotid specimens obtained by fine needle aspiration. STUDY DESIGN: The study concerned three cases of sialadenitis with crystalloid formation observed between 1993 and 1998. In one of these cases, transmission electron microscopy, mass spectrometry and measurement of amylase activity were used to characterize the nature of the crystalloids. RESULTS: Light microscopy revealed the same crystalloid structure in all three cases. In one case, where the material was saved, a biochemical method made it possible to reveal high amylase activity, while protein electrophoresis and mass spectrometry were used to identify salivary alpha-amylase. CONCLUSION: Crystalloids of salivary alpha-amylase can be identified by May-Grünwald-Giemsa and Papanicolaou stain and can be rapidly confirmed through determination of amylase activity.     

Testicular fine needle aspiration cytology in male infertility

OBJECTIVE: To compare the accuracy of testicular fine needle aspiration and biopsy for diagnostic and therapeutic purposes. STUDY DESIGN: A comparison of testicular fine needle aspiration and biopsy was performed on 34 infertile men over a 2-year period. RESULTS: Concordance of the 2 tests was evident in 88% of cases. In discordant cases fine needle aspiration yielded more than biopsy, considering the existence of secondary spermatocytes and spermatids. Charcot-Bottcher crystalloids were frequently seen in the cytoplasm of Sertoli cells in normal and abnormal spermatogenesis. CONCLUSION: Testicular fine needle aspiration is a simple and cost-effective method of evaluating testicular pathology in male factor infertility. It may yield more diagnostic and therapeutic material than does biopsy.     

Nuclear grooves. Valuable diagnostic feature in May-Grünwald-Giemsa-stained fine needle aspirates of papillary carcinoma of the thyroid.

Recent reports have indicated the usefulness of nuclear grooves (clefts or notches) as an additional criterion for the diagnosis of papillary thyroid carcinoma in fine needle aspirates; most of these studies were carried out on alcohol-fixed material stained with the Papanicolaou stain or with hematoxylin and eosin, which yield good nuclear details. In the present study air-dried thyroid aspirates stained with the widely used May-Grünwald-Giemsa stain were evaluated. Nuclear grooves were observed in 88% of the May-Grünwald-Giemsa-stained aspirates from papillary thyroid carcinoma, usually in substantial numbers. A few grooved nuclei were seen in a small percentage of the other thyroid aspirates studied. These results show that nuclear grooves can also be used as a possible marker of papillary carcinoma of the thyroid in May-Grünwald-Giemsa-stained aspirates.     

Diagnosis of malignant mesothelioma by fine needle aspiration of a cervical lymph node. A case report

BACKGROUND: Clinically documented distant metastases are rare in mesothelioma and tend to occur late in the course of the disease, well after the diagnosis has been made. In this instance, diagnosis was not made until a metastatic deposit was identified microscopically in the enlarged lymph node. CASE: A 65-year-old male with no definite history of occupational asbestos exposure presented with chest pain, pleural effusion and supraclavicular lymphadenopathy. Cytologic examination of material obtained by fine needle aspiration from his cervical lymph node revealed malignant mesothelioma. This was confirmed on histology. CONCLUSION: This was a particularly rare presentation and, as far as we are aware, was the first case in which mesothelioma was diagnosed by fine needle aspiration of a cervical lymph node. It serves to remind the pathologist that when confronted with a lymph node involved by tumor, the possibility of mesothelioma should be included in the differential diagnosis. The case also demonstrates the usefulness of fine needle aspiration in the diagnosis of metastatic tumor.     

Presacral myelolipoma. Report of a case with fine needle aspiration cytology and immunohistochemical and histochemical studies.

The cytomorphologic features of a case of the rare presacral myelolipoma, diagnosed by computed tomography (CT)-guided percutaneous fine needle aspiration (FNA) biopsy, are presented. It occurred in a 40-year-old man on prolonged steroid therapy for bronchial asthma. On the air-dried, Diff-Quik-stained smear, hematopoietic cells of all lineages and fragments of collapsed stroma were seen in a background of fat droplets. Megakaryocytic, myelocytic and eosinophilic lineages were further demonstrated by Factor VIII immunostain, chloroacetate esterase and LUNA-E histochemical stain, respectively. The reticulum stain of the resected tumor demonstrated that the hematopoietic cells and fat were supported by numerous reticulum fibers of varying thickness; that accounted for the collapsed stroma in the aspirated material. Presacral myelolipoma, occurring predominantly in female adults and presenting secondarily as a space-occupying lesion, is best regarded as encapsulated, heterotopic bone marrow supported by a network of reticulum fibers; it has a characteristic image on CT scan and can be diagnosed by FNA.     

Fine needle cytology--is aspiration suction necessary? A study of 100 masses in various sites

One hundred consecutive superficial mass lesions in various body sites were sampled by both conventional fine needle aspiration (FNA) and by a fine needle without the application of syringe suction. The latter technique is based on the principle of capillarity and may be termed "fine needle capillary" (FNC) sampling. The two sampling techniques were compared using five objective parameters: (1) the amount of diagnostic cellular material present, (2) the retention of appropriate architecture and cellular arrangement, (3) the degree of cellular degeneration, (4) the cellular trauma and (5) the volume of obscuring background blood and clots. There was no statistically significant difference between the efficacies of the two sampling techniques for any of the parameters studied. FNA sampling was diagnostic in a greater number of cases than was FNC sampling, but this difference was not statistically significant at a level of P = .05. When FNC sampling was diagnostic, it more frequently produced superior-quality material; conventional FNA, although diagnostic in a greater number of cases, mostly produced adequate, rather than superior-quality, material. This trend was not, however, statistically significant at a level of P = .05. These findings differ from those of previous studies (which have shown overall superiority of FNC sampling over conventional FNA sampling) and suggest that the technique of fine needle sampling employed for cytodiagnosis can be left to the personal preference of the operator.     

Cytologic changes in small hepatocellular carcinomas after radiofrequency ablation

OBJECTIVE: To illustrate the cytologic changes in hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA). STUDY DESIGN: The study included 20 patients with 23 HCC who had undergone RFA under ultrasound guidance. Baseline cytomorphology of HCC was evaluated by fine needle aspiration (FNA) in all cases. Triphasic helical computed tomography (CT) and FNA cytology were done to evaluate the efficacy of the treatment within two weeks after RFA. The cytologic specimens were stained with Riu's method (Romanowsky stain). RESULTS: A range of cytologic findings after RFA was found, including granular and amorphous debris with artefactual aggregation, degenerated cells or necrotic material, and dyshesive, degenerated cells in a necrotic background. The cytologic patterns included necrotic cells and debris in 14 tumors and fine, granular necrosis in 9. Helical CT showed no enhancement in any of the tumors after RFA. CONCLUSION: The cell patterns indicated complete necrosis in HCC after RFA.     

Needle aspiration cytodiagnosis of the breast with abundant acellular calcific material mimicking soft tissue calcinosis

OBJECTIVE: To investigate calcific deposits in breast tissue by needle aspiration cytology (NAC). STUDY DESIGN: The aspirate was obtained using a disposable 10-mL syringe and 22-gauge needle. No smears were made, and material was collected as needle and syringe washings in a cytology container in which 30% ethyl alcohol in physiologic saline was present. From about half of this material, filter preparations were made on 3-microm Schleicher and Schuell filters and stained by the Papanicolaou method; the remainder of the aspirate was spun, and a cell block was made from the sediment and sections cut and stained with hematoxylin-eosin (H-E) stain. RESULTS: The filter preparations and sections of cell block in all the cases showed numerous amorphous, basophilic, deep-stained fragments of refractile material and some fragmented bod ies and concentric lamellations, which were diagnosed as calcium. No breast elements or malignant cells were found. The patients had no further treatment and on follow-up were clinically well, with no changes. CONCLUSION: The 9 cases described are interesting because the cytohistologic findings in the NAC sample mimicked soft tissue calcinosis.     

Hydatid cyst in soft tissues mimicking malignant tumors. Diagnosis by fine needle aspiration cytology

OBJECTIVE: To evaluate the role of fine needle aspiration cytology in the diagnosis of soft tissue hydatid cysts. STUDY DESIGN: Five cases of soft tissue hydatid cyst were diagnosed primarily by fine needle aspiration cytology. RESULTS: In all cases, large fragments of acellular material, finely lamellated, were found. There were no complications related to fine needle aspiration, and histologic studies confirmed the diagnosis of hydatid cyst. CONCLUSION: When acellular, laminated fragments suggestive of a laminated layer are identified on smears, hydatid cyst should be considered in the differential diagnosis, even in atypical locations and in the absence of hooklets, protoscolices or both.     

Diagnostic pitfalls in fine needle aspiration cytology of atypical apocrine metaplasia in a breast lesion. A case report

BACKGROUND: Apocrine metaplastic cells are frequently encountered in fine needle aspirates of breast lesions. Atypical apocrine metaplastic cells with signet ring features can also occur, and their presence may present a diagnostic dilemma in the differentiation of benign versus malignant lesions. CASE: A fine needle aspirate of a 2.5 x 1.0-cm, subareolar mass in a 47-year-old female showed atypical cells with signet ring morphology. Also present were clusters of cells that were enlarged and showed nuclear atypia, prominent nucleoli and cytoplasmic granules. Papillary cohesive clusters of ductal cells were also identified. The fine needle aspiration diagnosis was mucinous carcinoma. The nodule was excised, and the histologic diagnosis was sclerosing ductal papilloma with atypical apocrine metaplasia. CONCLUSION: Atypical apocrine cells can be misinterpreted as mucinous carcinoma or usual duct adenocarcinoma on fine needle aspiration cytology. We present clues that may help in rendering the correct interpretation.     

Fine needle aspiration cytology of bursal cyst

OBJECTIVE: To evaluate the cytomorphology of bursal cyst and assess the efficacy of aspiration cytology in its diagnosis and treatment. STUDY DESIGN: Nineteen cases of bursal cyst seen over four years were studied. Material was obtained by fine needle aspiration. The smears were stained with May-Grünwald-Giemsa stain and hematoxylin and eosin. RESULTS: Eight cysts were in the popliteal fossa, 4 on the elbow, 3 on the knee, 2 on the shoulder and 2 in the calf. Gelatinous material was aspirated in all the cases. In some cases the cyst collapsed after aspiration. The key diagnostic features were hypocellular smears in a mucoid background. Histiocytelike (synovial) cells were seen lying in all cases and as pseudopapillary structures in two. CONCLUSION: The presence of a cyst at a classic location with aspiration of gelatinous material and the presence of singly occurring histiocytelike cells in a mucoid background in smears is diagnostic of bursal cyst. The procedure is therapeutic in some cases.