Osteoclastomalike giant cell tumor of the parotid gland: report of a case with fine needle aspiration diagnosis

BACKGROUND: Osteoclastomalike giant cell tumor of the parotid gland has been reported rarely. The tumor has occurred rarely at many sites, such as thyroid, pancreas, soft tissue, breast, skin, heart, colon, lung, kidney, ovary and bladder. The exact origin of the tumor is unclear. However, osteoclastlike giant cells have been considered either part of a stromal process reactive to a neoplasm or a component of a primary neoplasm. CASE: A 35-year-old female presented with a mass in the left parotid gland clinically diagnosed as a pleomorphic adenoma. Fine needle aspiration (FNA) was advised before surgical excision. FNA smears revealed numerous osteoclastlike, multinucleated giant cells and many malignant-looking mononuclear cells. The smears were diagnosed as positive for malignancy, suggestive of osteoclastomalike giant cell tumor. The tumor was excised, and histopathologic study confirmed the cytologic diagnosis. CONCLUSION: The cytologic findings of osteoclastomalike giant cell tumor of the parotid gland have not been previously reported. FNA aided the diagnosis and planning of treatment. FNA is important in the diagnosis of parotid tumors.     

Low grade fibromyxoid sarcoma: report of a case with fine needle aspiration cytology and histologic correlation

BACKGROUND: Low grade fibromyxoid sarcoma has been fully described histologically; however, the fine needle aspiration (FNA) cytologic findings are scantily defined, and the distinction from other benign and malignant soft tissue tumors can be difficult. CASE: We examined FNA cytologic material from a slowly growing, large chest wall mass in a 28-year-old woman. The surgical specimen was processed for routine histology and immunohistochemical studies. The cytologic smears were adequately cellular, showing spindly cells with uniform, elongated nuclei; small, inconspicuous nucleoli; and scanty, wispy cytoplasm associated with myxoid material. No significant nuclear pleomorphism or mitoses were noted. The excised tumor was well circumscribed, focally infiltrating the surrounding muscles. The cut surface was variable, featuring fibrous, solid, fleshy and myxoid areas. Microscopically, the solid, fibrous areas displayed increased cellularity with storiform, intersecting and parallel patterns. In the myxoid areas the cells grew in a haphazard fashion and appeared floating in abundant mucoid matrix associated with a capillary vascular network similar to the chicken-wire pattern seen in cases of myxoid liposarcoma. The tumor cells were spindly, with fusiform, uniform nuclei. Focal, moderate nuclear pleomorphism was noted. The mitotic index was low. The tumor cells were positive for vimentin, alpha-1-antitrypsin and lysozyme and negative for S-100, actin, desmin and CD34. CONCLUSION: Although low grade fibromyxoid sarcoma is a rare neoplasm, it should be recognized and distinguished from other soft tissue tumors because of its low malignant potential. The definitive FNA cytologic diagnosis can be challenging but is possible if the tumor is adequately sampled, with multiple passes from different areas. Clinical and radiologic correlations are of great help. All spindle cell tumors with myxoid changes, such as myxoid liposarcoma, myxofibrosarcoma, cellular myxoma, myxoid leiomyosarcoma and peripheral nerve sheath tumors, should be considered in the differential diagnosis. In contrast to the cytologic features, the histologic findings are characteristic and well established.     

Fine needle aspiration cytology of soft tissue chondroma. A case report

BACKGROUND: Soft tissue chondroma, though rare, is well known to histopathologists and radiologists. Cytologic features of soft tissue chondroma mimic those of its malignant counterpart to a considerable extent. To our knowledge, this is the first case in which the aspiration cytology of soft tissue chondroma is described as an aid to definitive diagnosis. CASE: A 54-year-old male presented with a 6 x 5-cm swelling on his right forearm that had existed for 20 years. Its extraskeletal location was confirmed. Aspiration cytology showed myxofibrillary material and pleomorphic cells. CONCLUSION: The clinical, radiologic and cytologic triad is important for the correct cytologic diagnosis of soft tissue chondroma despite worrisome cell atypia.     

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.     

Malignant fibrous histiocytoma,giant cell type,of the breast mimicking metaplastic carcinoma. A case report

BACKGROUND: We report a case of malignant fibrous histiocytoma, giant cell type (MFHGC), of the breast. A review of the literature failed to reveal cytology-based reports on this entity. The cytologic similarity of breast MFHGC on fine needle aspiration biopsy (FNAB) to other malignant breast neoplasms, including carcinoma with osteoclastlike giant cells, metaplastic carcinoma and breast sarcomas, as well as benign reactive processes, makes the recognition of this tumor challenging. CASE: A 72-year-old woman presented with a 5-month history of an enlarging breast mass. FNAB of the mass showed a hypercellular smear composed of cohesive, branching clusters of spindle cells with ovoid, focally hyperchromatic nuclei and inconspicuous nucleoli. Interspersed osteoclastlike giant cells, some associated with clusters of spindle cells, were uniformly seen throughout the smear. The background was hemorrhagic, with cellular debris and occasional spindle cells and lymphocytes. No ductal epithelial or myoepithelial cells were seen. An incisional biopsy was performed, followed by radical mastectomy. The histologic examination was diagnostic of MFHGC. The diagnosis was supported by immunohistochemical and electron microscopic studies. CONCLUSION: MFHGC, also called primary giant cell tumor of soft tissues, is composed of a mixture of histiocytes, fibroblasts and bland-appearing osteoclastlike giant cells with a multinodular growth pattern. Although MFHGC rarely occurs in the breast and the definitive diagnosis is difficult based on cytology alone, the diagnosis can be considered when a cytologic examination reveals a hypercellular, spindle cell smear with osteoclastlike giant cells in the absence of ductal epithelial or myoepithelial cells.     

Fine needle aspiration cytology of extraskeletal chondrosarcoma

The cytologic presentation of a case of extraskeletal chondrosarcoma diagnosed by fine needle aspiration in a 57-year-old asymptomatic female is described. A mass detected on routine chest X ray and defined by CAT scan was subjected to a preoperative percutaneous fine needle aspiration under fluoroscopic guidance; a core biopsy was also obtained. Cytologic findings included pleomorphic malignant cells, with occasional spindle-shaped forms and binucleated and multinucleated cells having various degrees of nuclear atypia. The sarcomatous nature of this neoplasm was readily recognized in the cytologic material, although histologic and ultrastructural studies, which are also illustrated, were necessary to establish its specific histologic type. The biopsy was interpreted as a probable chondrosarcoma, and an exploratory laparotomy revealed a soft tissue tumor arising in the retroperitoneum. A diagnosis of soft tissue chondrosarcoma was rendered. In retrospect, the distinctive cytologic findings in the aspirated material suggest that extraskeletal chondrosarcoma should be considered in the differential diagnosis of soft tissue tumors.     

Malignant fibrous histiocytoma of the chest wall masquerading as medullary breast carcinoma: a case report

BACKGROUND: Cytologic diagnosis of malignant fibrous histiocytoma can be problematic, as these neoplasms are known to mimic multiple other conditions. CASE: A fine needle aspirate from a 60-year-old woman was diagnosed at 2 institutions as medullary carcinoma of the breast. The patient received neo-adjuvant chemoradiotherapy before the tumor war excised. Gross pathologic examination and histomorphology on routine staining were compatible with the cytologic diagnosis. The accurate diagnosis of pleomorphic-storiform-type malignant fibrous histiocytoma was a surprise and was established with immunocytochemical stains. In retrospect, it was thought that clinical and radiologic overlap, creating a high index of suspicion for a breast neoplasm and compounding the cytologic appearance of a medullary carcinoma with spindle cell metaplasia and syncytial cells, was responsible for the error. CONCLUSION: This case highlights a potential cytodiagnostic pitfall and the importance of establishing a definitive tissue diagnosis in the face of equivocal cytologic findings.     

Cytologic features of a primary myxoid malignant fibrous histiocytoma arising in the uterus: a case report.

BACKGROUND: Primary malignant fibrous histiocytoma (MFH) of the uterus is extremely rare. The 10 cases reported in the literature all involved the pleomorphic variant, and to the best of our knowledge, the myxoid variant has not been reported before. We describe the cytologic findings of primary uterine myxoid MFH in relation to the myxoid component, potentially leading to an incorrect diagnosis. CASE: A 68-year-old woman presented with a primary uterine tumor. Endometrial cytology showed numerous loosely arranged, spindle-shaped fibroblastlike cells; atypical histiocytelike cells; and giant cells with a necrotic background. The overall cytologic picture was of a degenerated pleomorphic leiomyosarcoma with an inconclusive diagnosis. A diagnosis of myxoid MFH was established after electron microscopic and immunohistochemical studies of the primary tumor and tumor transplanted, as primary cultured cells, in nude mice. The patient underwent an exploratory laparotomy and died of tumor progression 38 days after the initial consultation, without treatment. CONCLUSION: Because of overlapping cytologic features among uterine sarcomas with myxoid stroma, it is important to recognize the histiocytic lineage of tumor cells by immunohistochemistry and electron microscopy in various presentations of fresh samples.     

Use of fine needle aspiration cytology in leprotic lesions: a report of 4 cases

BACKGROUND: Although a few studies have shown fine needle aspiration cytology (FNAC) to be a sensitive diagnostic tool in the detection of nerve involvement, its role as an initial diagnostic procedure in pure neuritic leprosy (PNL) and in the detection of skeletal lesions with unusual findings has not been documented before. CASES: Three patients who presented with thickened nerves and a fourth with biopsy-proven lepromatous leprosy with lesions in hand bones underwent FNAC. Of the 3 patients with nerve thickening, 2 had a clinical suspicion or diagnosis of neuritic leprosy, whereas in the third patient a clinical differential diagnosis of a soft tissue tumor or parasitic cyst was considered. FNAC in all 3 cases revealed epithelioid cell granulomas, Langhans giant cells and caseous necrosis. Fites and Ziehl-Neelsen stains were negative for acid-fast bacilli. Cytologic diagnosis of pure neuritic leprosy was made in all 3 cases and confirmed by histopathologic examination. FNAC of skeletal lesions from the fourth patient confirmed involvement of bone with unusual cytologic findings of epithelioid cell granulomas and giant cells along with a significant proportion of foamy macrophages and strong Fites stain positivity. CONCLUSION: FNAC is a simple, useful, minimally traumatic and routinely applicable procedure in the diagnosis of pure neuritic leprosy and leprous osteitis.     

Chondrosarcoma of the proximal femur with myxoid degeneration mistaken for chondromyxoid fibroma in a young adult. A case report

BACKGROUND: Fine needle aspiration cytology (FNAC) is effective in the diagnosis of bone tumors when combined with careful radiologic and clinical evaluation. However, cases where clinical or radiologic findings are atypical or unusual may lead to an erroneous diagnosis. CASE: A 19-year-old male presented with a pain in the left hip area that had been slowly progressive over a 10-month period. Clinical and radiologic findings suggested either giant cell tumor or chondroblastoma. The smeared aspiration specimen showed loosely cohesive, oval to round cells with moderate amounts of pale pink cytoplasm admixed with pinkish-blue, chondromyxoid material. The individual cells contained a single nucleus with evenly distributed, fine chromatin. A few osteoclastic giant cells were scattered in the smears. A cytologic diagnosis of myxoid lesion with a few giant cells, suspicious for chondromyxoid fibroma, was made. The diagnosis of chondrosarcoma was made by subsequent histologic examination. CONCLUSION: Absence of the usual clinicoradiologic features of chondrosarcoma combined with an unusual cytologic presentation in this case led to a misdiagnosis. In most centers, FNAC has achieved undisputed status as a diagnostic tool, and cytologic diagnosis often forms the basis of the therapeutic protocol. However, at some sites FNAC diagnosis is more problematic. Awareness of the limitations and pitfalls of FNAC is just as important as knowledge of the scope of FNAC in bone tumors. Tumors with chondromyxoid features provide particular difficulties.     

Nodular sarcoid myositis of skeletal muscle diagnosed by fine needle aspiration biopsy. A case report

BACKGROUND: Symptomatic striated muscle involvement in sarcoidosis is rare. Muscle biopsy is usually required for the diagnosis. Fine needle aspiration biopsy (FNAB) has been successfully used in diagnosing soft tissue lesions. To the best of our knowledge, FNAB of sarcoid myositis has not been reported. CASE: A 31-year-old, black female with a history of sarcoidosis presented with an enlarging, painful, left calf mass. Infected thrombi were suspected. FNAB showed numerous loosely arranged epithelioid histiocytes, multinucleated giant cells and skeletal muscle cells. The overall cytologic picture was that of granulomatous myositis. The cytologic features coupled with the patient's history and magnetic resonance imaging findings suggested sarcoid myositis. Subsequent muscle biopsy showing noncaseating granulomata and negative stains for organisms confirmed the diagnosis of nodular sarcoid myositis. CONCLUSION: Nodular sarcoid myositis can be suggested by FNAB cytology in a patient with a past history of sarcoidosis.     

Fine needle aspiration cytology in recurrent amelanotic melanoma: a case report

BACKGROUND: Amelanotic melanoma can mimic a wide variety of epithelial and nonepithelial malignant tumors. Varied cytomorphology of melanoma has been described on exfoliative and fine needle aspiration cytology (FNAC). We report a case of recurrent amelanotic melanoma to highlight its varied cytomorphologic features, which may cause diagnostic problems on cytologic and on histologic examinations. CASE: A 63-year-old male presented with nodular swellings in the right anterior chest wall, right axilla and back. A nodule in the chest had been excised 6 months earlier. Clinically, the lesion was interpreted as recurrent soft tissue sarcoma. FNAC revealed malignant cells with highly varied morphology with plasmacytoid and pleomorphic malignant cells with occasional fibrocollagenous tissue strands showing adherent neoplastic cells. A cytologic diagnosis of pleomorphic malignant tumor was suggested, and the original histologic slides were reviewed; they showed a striking alveolar pattern that vaguely resembled an alveolar rhabdomyosarcoma. However, on immunohistochemistry, the tumor cells were S-100 and melan-A positive and desmin negative. A final diagnosis of amelanotic melanoma was made. CONCLUSION: Awareness of the highly varied cytomorphology of amelanotic melanoma minimizes the diagnostic difficulty on fine needle aspiration smears. Suitable immunohistochemical markers are of great value in difficult situations.     

Aspiration cytology, immunocytochemistry and electron microscopy of a malignant peripheral neuroectodermal tumor. A case report

The findings of fine needle aspiration (FNA) cytology, immunocytochemical staining and electron microscopy (EM) in a case of malignant peripheral neuroectodermal tumor (PNET) presenting as a soft tissue mass in the lateral abdominal wall are reported. The immediate evaluation of the aspirate revealed cells of a small round cell malignant tumor. To provide a specific preoperative diagnosis, additional cytologic material was aspirated for immunocytochemical and ultrastructural investigations. While the results of EM were nonspecific, allowing only the exclusion of other small round cell malignancies, immunocytochemical staining of the aspirate was suggestive of a PNET. The diagnosis of PNET was corroborated by histopathologic and immunohistochemical findings. This case indicates that an exact preoperative categorization of small round cell malignant tumors can be made by FNA biopsy in otherwise equivocal cases when immunocytochemical and ultrastructural techniques are also utilized.     

Deep juvenile xanthogranuloma presenting as a chest wall mass: a case report

BACKGROUND: Juvenile xanthogranulotna (JXG) is a non-Langerhans cell histocytic proliferation that may appear as an extracutaneous deep-seated lesion and give a broad clinical dijffrrential diagnosis. We report the fine needle aspiration cytologv (FNAC) findings of deep JXG. CASE: A 5-month-old African-American boy was incidentally found to have a chest wall mass on a chest radiograph obtained for an unrelated medical problem. Subsequent computed tomographic scans documented a 3.8-cm soft tissue mass that involved the right chest wall centered around the fifth rib. A broad clinical differential diagnosis prompted FNA to evaluate the lesion. Aspirate smears of the mass exhibited numerous finely vacuolated histocytes, eosinophils, multinucleated giant cells and scattered Touton giant cells. Many of the histiocytes had reniform or grooved nuclei, resembling Langerhans cells. The histiocytes were immunoreactive for CD68 but were nonreactive for CD1a and S-100 protein. Subsequent excisional biopsy confirmed the diagnosis of JXG. In addition, the tumor was strongly immunoreactive for factor XIIIa. CONCLUSION: JXG should be considered in the diferential diagnosis of any histocytic/fibrohistiocytic soft tissue lesion of childhood, and this entity can be accurately diagnosed by FNAC and immunohistochemical findings.     

Decisive role of intermediate filament typing of tumor cells in the differential diagnosis of difficult fine needle aspirates

Thirty-six diagnostically difficult fine needle aspirates from enlarged lymph nodes and malignant soft tissue tumors, containing tumor cells with scanty or no obvious light microscopic features indicative of their differentiation, were assessed by a panel of six cytopathologists. Their diagnoses were recorded and then compared with the definitive diagnosis established by combining the cytologic findings with the results of intermediate filament typing of tumor cells in the smears using monoclonal antibodies specific for each filament type. The results show that use of these antibodies can markedly improve the accuracy of the cytologic diagnosis of tumor type as well as revise or prevent erroneous cytologic diagnoses in difficult cases. This pertains especially to the differential diagnoses of carcinoma versus malignant lymphoma, carcinoma versus malignant melanoma, carcinoma versus sarcoma and squamous carcinoma versus carcinoma of simple epithelia. Intermediate filament typing of tumor cells in aspirates as an objective histogenetic criterium makes the differential diagnosis of the difficult aspirates much more reliable and reproducible, provided that appropriate questions are asked, monoclonal antibodies with well-defined specificities are used and the antigenicity of the intermediate filaments in smears is preserved.     

Fine needle aspiration and touch imprint cytology of a malignant fibrous histiocytoma of the spermatic cord. Case report

BACKGROUND: No cytologic reports on spermatic cord sarcomas have been published. CASE: A 64-year-old man presented with a slowly growing, painless, left spermatic cord enlargement. Fine needle aspiration (FNA) obtained < 1 mL of bloody fluid consisting of solitary, mark-edly anaplastic and pleomorphic tumor giant cells occasionally arranged in small fragments. Rare atypical spindle cells could be observed. Some reactive lymphocytes were observed intermingled with tumor cells. Immunohistochemistry displayed vimentin reactivity and negativity for keratins and leukocytic common antigen. The specimen removed showed a well-circumscribed, 30-mm, yellowish solid tumor. Touch imprints displayed pleomorphic tumor cells showing intense anisonucleosis; a moderate amount of clear, sometimes microvacuolated cytoplasm; and tissue fragments with a storiform pattern. Histologic examination revealed microscopic and immunohistochemical features of malignant fibrous histiocytoma (MFH) arising in soft tissues of the spermatic cord. CONCLUSION: FNA of a spermatic cord lesion may reveal a pleomorphic sarcoma. A pleomorphic appearance together with some spindle elements and compatible immunocytochemistry could help diagnose spermatic cord MFH. This is one of the few reports dealing with FNA cytology of paratesticular tumors and the first report, to the best of our knowledge, showing the cytologic characteristics of a case of spermatic cord MFH.     

FNAC in the diagnosis of recurrent dermatofibrosarcoma protuberans of the forehead. A case report

BACKGROUND: Dermatofibrosarcoma protuberans is a rare cutaneous soft tissue tumor of intermediate malignant potential with a characteristic tendency for recurrence. Metastases are unusual. This tumor usually occurs in the trunk and extremities and, infrequently, on the face and scalp. Its cytologic appearance on fine needle aspiration has only been rarely reported. It is characterized by numerous fibroblastlike cells that arrange as single cells or in clusters of spindle cells arrayed in a storiform pattern. CASE: A 42-year-old male presented with a one-year history of an enlarging left forehead mass (lateral brow) that was adjacent to an old surgical scar. Fine needle aspiration revealed a low grade spindle cell neoplasm morphologically identical to a dermatofibrosarcoma protuberans excised 15 years earlier, indicating tumor recurrence. CONCLUSION: Distinguishing dermatofibrosarcoma protuberans from other spindle cell tumors and fibrohistiocytic lesions may pose significant challenges to the pathologist. However, in the appropriate clinical setting and applying strict diagnostic criteria, fine needle aspiration cytology is a reliable tool in establishing the diagnosis of this neoplasm.     

Aspiration cytology of fibrosarcomatous variant of dermatofibrosarcoma protuberans with osteoclastlike giant cells in the chest wall: a case report

BACKGROUND: A case of fibrosarcomatous variant of dermatofibrosarcoma protuberans (FS-DFSP) with osteoclastlike giant cells involved the dermis and subcutaneous tissue of the chest wall. This case was misdiagnosed as primary breast tumor clinically and had cytologic features similar to those of the metaplastic breast carcinoma (MRBC). CASE: A 53-year-old female presented with a nodular breast mass enlarging slowly over a long period of time and growing rapidly for about 3 months. The aspirates showed high cellularity with both individually scattered and fascicular arrays of spindle cells. A few multinucleated giant cells without nuclear atypia were intermixed with dissociated spindle cells. There was no epithelial component in the smear. Cytologic evaluation suggested the possibility of a low grade spindle cell sarcoma as well as MBC. Subsequently, the patient underwent modified radical mastectomy, and the diagnosis of FS-DFSP was made. CONCLUSION: Distinguishing FS-DFSP with osteoclastlike giant cells from other spindle cell tumors of the breast, especially MBC showing predominantly spindle cell components, may pose significant challenges to the pathologist. However, clinical and radiologic findings and a meticulous search for other components raised the possibility of FS-DFSP on aspiration cytology.     

Giant lamellar bodies in pulmonary MALT lymphoma. A case report

BACKGROUND: Giant lamellar bodies are laminated, scroll-like whorls seen within alveolar spaces and have been occasionally observed in sclerosing hemangioma of the lung. However, to the best of our knowledge, the cytologic findings of giant lamellar bodies have not been reported. We describe cytologic findings of giant lamellar bodies associated with pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma. CASE: A 72-year-old male had a pulmonary mass measuring 2.0 x 1.4 x 1.5 cm. Cytologic smears imprinted from a cut surface of the resected mass revealed a large number of concentrically laminated structures, giant lamellar bodies, measuring 15-40 microns in diameter. Necrotic cellular remnants were occasionally observed in the center of the structures. In the background, small to medium-sized lymphoid cells and plasmacytoid cells were observed. Histologic diagnosis of the tumor was IgG, kappa type, MALT lymphoma. An aggregate of giant lamellar bodies was observed within entrapped, dilated alveolar spaces lined with hypertrophied, type II pneumocytes. Immunohistochemically, the giant lamellar bodies were positive for KL-6. CONCLUSION: Giant lamellar bodies may be derived from surfactant and necrotic type II pneumocytes and may be observed cytologically in cases of pulmonary MALT lymphoma.