Primary multilobated T-cell lymphoma of the breast diagnosed by fine needle aspiration cytology and immunocytochemistry

The fine needle aspiration (FNA) cytologic, immunocytochemical and ultrastructural findings of a primary multilobated T-cell lymphoma arising in the breast of a 61-year-old woman are described. Large pleomorphic multilobated malignant cells were primarily identified as lymphomatous in origin and phenotypically as T-cells by a selected panel of monoclonal antibodies applied to the original smears obtained by FNA biopsy. This appears to be the second report of a multilobated lymphoma arising in the breast and the first with a T-cell phenotype in this anatomic site.     

Burkitt-type lymphoma. Diagnosis by fine needle aspiration cytology

Forty cases of lymphoma were categorized as Burkitt-type lymphoma in a study of fine needle aspiration (FNA) smears. These constituted 14.3% of all cases of non-Hodgkin's lymphoma diagnosed between 1974 and 1982. The median age was 22 years in these cases, 81.8% of which had extranodal tumors. The majority of the cells in the smears (59.8% +/- 8.32%) were in the 11 micron to 15 micron size range and 60.3% +/- 10.3% had noncleaved nuclei. An average 71% of the cells contained cytoplasmic and/or nuclear vacuolizations. Nonneoplastic macrophages were present in the smears in 87.5% of the cases. A study of paraffin-embedded sections in 17 cases revealed the characteristic "starry-sky" appearance in 11; in 5 it was not clearly appreciated and in 1 the nonneoplastic macrophages were absent. FNA cytology was found to be quite reliable for arriving at a diagnosis of Burkitt-type lymphoma. More than 50% of the cases were managed without resort to subsequent surgical biopsy. Exploratory laparotomy was avoided in 69% of the cases having abdominal tumors.     

Peripheral T-cell lymphoma not otherwise specified vs. Hodgkin's lymphoma on fine needle aspiration cytology

OBJECTIVE: To study the morphologic features of peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) on fine needle aspiration cytology (FNAC) smears and to identify cytomorphologic features that would delineate them from features of cases of Hodgkin's lymphoma (HL). CONCLUSION: Fourteen cases each of PTCL, NOS, and HL with adequate FNAC smears were retrieved. These cases were analyzed for 12 cytomorphologic features: presence of atypical lymphoid cells, percentage of large lymphoid cells, lymphoid cells with cleaved/indented nuclei, typical Reed-Sternberg (RS) cells, mononuclear cells with prominent eosinophilic macronucleoli, mononuclear cells with prominent nucleoli, histiocytes, eosinophils, plasma cells, polymorphonuclear leukocytes, vessels and perivascular clustering of atypical mononuclear/atypical lymphoid cells. Each of these features was evaluated for its presence or absence and was semiquantitated on a scale from 0 to +3. RESULTS: The presence of atypical lymphoid cells with a spectrum ranging from small to intermediate and large was seen exclusively in cases of PTCL. Lymphoid cells with cleaved or indented nuclei, endothelium-lined vessels with perivascular clustering of tumor cells and absence of typical RS cells, and mononuclear cells with prominent eosinophilic macronucleoli emerged as the parameters significant in not only diagnosing cases of PTCL, NOS, but also in their delineation from cases of HL. CONCLUSION: A careful analysis of cytomorphologic features can be useful in at least suggesting a diagnosis of PTCL and help to distinguish that diagnosis from HL, which the features may mimic. Immunophenotyping and molecular studies are important in arriving at a definitive diagnosis.     

Multilobated large B-cell lymphoma diagnosed cytologically. A case report.

BACKGROUND: Fine needle aspiration (FNA) biopsy can be used to reliably classify most conditions involving lymph nodes or, at least, significantly reduce the differential diagnosis. CASE: A 70-year-old male presented with an ulcerated mass arising from the left tonsillar fossa and involving the anterior and posterior pillars. A biopsy of the tonsillar mass performed at an outside hospital was interpreted as a large cell undifferentiated carcinoma. Subsequently the patient developed systemic lymphadenopathy. A bone scan showed intense uptake within the medial tibial plateau of the left knee. FNA biopsy of the right axillary mass was interpreted at University of Cincinnati Medical College as a large cell lymphoma, multilobated type. Histologic and immunohistochemical studies of the lymph node confirmed the presence of multilobated B-cell lymphoma. Lymphoma chemotherapy was initially successful but was discontinued due to toxicity. The patient died two months after the initial cytologic diagnosis of lymphoma. CONCLUSION: Multilobated lymphomas are an unusual variant of non-Hodgkin's lymphomas (mostly B-cell type). Cytology and immunocytochemistry are useful diagnostic procedures that can help to diagnose this relatively uncommon type of lymphoma and significantly reduce the possibility of misdiagnosis.     

Cytology of leukemic lymphadenopathy

OBJECTIVE: To describe the cytomorphologic features of leukemic cells in lymph node aspiration material. STUDY DESIGN: We studied lymph node fine needle aspiration (FNA) smears of 36 leukemic patients. In 23 cases the lymphadenopathy was noticed simultaneously with marrow leukemia, and in the other 13 cases the lymphadenopathy was noticed during a relapse. Special stains, such as periodic acid Schiff, Sudan Black-B, Oil Red-O and nonspecific esterase, were used in special cases. RESULTS: Thirty-three cases were diagnosed as lymphoma, 1 as extramedullary hematopoiesis and 2 as leukemic involvement. CONCLUSION: Leukemic lymphadenopathy can be misdiagnosed as lymphoma on FNA smears. The clinical findings, previous history, hematologic studies and immunocytochemical studies are essential to the differentiation of leukemic smears from lymphoma. However, in some cases the leukemic infiltration can be diagnosed with certainty, provided that the smears show the characteristic findings, such as Auer rods and neoplastic promyelocytes with azurophilic granules.     

Fine needle aspiration of lymphadenopathy in visceral leishmaniasis

OBJECTIVE: To illustrate the cytomorphologic features of Leishmania lymphadenitis associated with visceral leishmaniasis (V/L) and post-kala-azar dermal leishmaniasis (PKDL) and to highlight the fact that Leishmania lymphadenitis must he included in the differential diagnosis of patients presenting with lymphadenopathy, particularly in areas endemic for the disease. STUDY DESIGN: Fine needle aspiration (FNA) was routinely done in 21 cases of lymphadenopathy in VL (18 cases) and PKDL (3 cases), and the detailed cytomorphologic features were correlated with the respective histopathologic findings. RESULTS: Amastigote forms of Leishman-Donovan (LD) bodies were seen in 19 cases both intracellularly, in histiocytes and multinucleate giant cells, and extracellularly. The FNA smears revealed a polymorphous population of cells composed of lymphocytes, histiocytes, plasma cells, giant cells and tingible body macrophages. In a few cases, epithelioid cell granulomas were also seen. The cytomorphologic features were confirmed and correlated on histopathology. CONCLUSION: Not all lymphadenopathy in VL and PKDL is due to Leishmania lymphadenitis. Demonstration of LD bodies on FNA smears helps with the early diagnosis of VL and PKDL with lymphadenopathy where the diseases are endemic.     

The role of fine needle aspiration cytology in the diagnosis of lymphoma

The accuracy of fine needle aspiration (FNA) cytology for the diagnosis of lymphoma and other hematolymphoid malignancies was investigated by a review of 158 FNA specimens from 143 patients. Patients included in the study had either a diagnosis of a hematolymphoid malignancy by FNA cytology or a biopsy diagnosis of lymphoma that was preceded by FNA cytology. Biopsy specimens were obtained from 85% of the patients. Of the 158 needle aspirates, 118 (75%) were diagnosed as lymphoma, 13 (8%) as suspicious of lymphoma, 8 (5%) as myelomas, 3 (2%) as leukemias, 12 (8%) as positive for malignancy and 4 (2%) as negative for malignancy. Two of the 118 needle aspirates diagnosed as lymphoma were false positives while 3 of 13 diagnosed as suspicious for lymphoma were found to be benign. Overall, there were four false negatives. Morphologic subclassification of the lymphomas, originally attempted for 60 needle aspirates, was identical to the histologic subclassification in 51 cases (85%). FNA cytology provided the initial diagnosis of a hematolymphoid malignancy in 51% of the cases and allowed the documentation of recurrent disease in 49%. The results demonstrate the usefulness of FNA cytology for the diagnosis and management of patients with lymphoma.     

Anaplastic large cell lymphoma presenting as a pleural effusion and mimicking primary effusion lymphoma. A report of 2 cases

BACKGROUND: Systemic anaplastic large cell lymphoma (ALCL) is predominantly a nodal disease, but extranodal involvement can occur during the disease course or as the primary presentation. We report two rare cases of ALCL presenting with a pleural effusion, mimicking primary effusion lymphoma (PEL). CASES: Two patients, a 47-year-old woman and an 81-year-old man, presented with a pleural effusion for investigation. The pleural fluid contained abundant, large, lymphoid cells with marked nuclear atypia. These neoplastic cells strongly expressed CD30 and EMA and showed a T-cell phenotype (CD3+CD45RO+ for case 1 and CD4+ for case 2). Case 1, in addition, showed ALK1 expression. The tumor cells in both cases were negative for human herpes virus type 8 (HHV8) and Epstein-Barr virus (EBV). ALCL shows overlapping cytologic features with PEL, but the T-cell phenotype, ALK1 expression in case 1, lack of association with HHV8 and EBV, HIV seronegativity and subsequent discovery of nodal disease in case 2 were all in favor of ALCL over PEL. CONCLUSION: In rare cases a pleural effusion is the presenting feature of ALCL, and distinction from PEL depends on correlation with clinical findings, detailed immunophenotyping and study of the status of HHV8 and EBV.     

Fine needle aspiration of lymphoblastic lymphoma. A multiparameter diagnostic approach.

Sixteen fine needle aspiration (FNA) biopsies of lymphoblastic lymphoma (LBL) that were used to either initially diagnose disease (12) or document relapse (4) were reviewed. Cellular aspirates (2 x 10(7) cells) were readily obtained for immunologic, DNA/RNA flow cytometric and immunoglobulin and/or T-cell receptor gene rearrangement studies. Cytologically, aspirates were characterized by intermediate-sized cells (9.5-18.5 microns) with fine nuclear chromatin, small, inconspicuous nucleoli, irregular nuclear contours and scant basophilic cytoplasm. Frequent mitotic figures were seen (1-14 figures per 1,000 cells). Fourteen cases demonstrated a T-cell phenotype with considerable phenotypic variability. One case demonstrated a precursor B-cell phenotype, and another demonstrated biphenotypic expression with both T-cell and myeloid differentiation. Eleven of 14 cases (79%) were positive for terminal deoxynucleotidyl transferase. Thirteen of 15 cases (87%) manifested diploid DNA content by flow cytometric analysis and were characterized by intermediate proliferative activity (S+G2M 12.7 +/- 8.7% SD) and intermediate mean RNA index (1.3 +/- .5 SD). T beta gene rearrangements were demonstrated in four of five phenotypic T-cell LBL cases analyzed, with concomitant JH gene rearrangements observed in three cases, confirming that bigenotypic rearrangements characterize some T-cell LBLs. We conclude that FNA samples are adequate for accurate characterization of LBL and may obviate the need for surgical biopsy.     

FNA of breast fibroadenoma: observer variability and review of cytomorphology with cytohistological correlation

OBJECTIVE: To determine the observer variability in reporting fibroadenoma of the breast by fine needle aspiration (FNA) and to review the cytomorphological features of the lesion with cytohistological correlation. METHODS: Retrospective analysis of FNA smears from 110 cases diagnosed as fibroadenoma of which surgical pathology follow-up was available in 33. Two pathologists were asked to categorize smears from 67 cases of breast lesions while blinded to the clinical finding as fibroadenoma, epithelial hyperplasia (usual and atypical) and malignant. All fibroadenoma (33) and cancer (15) cases were biopsy-proven. The same set of slides was re-circulated to one of the pathologists, and his first and second round results were compared. RESULTS: Pre-review cytohistological correlation was attained in 32 of 33 cases of fibroadenoma (97%). The overall agreement between the two observers was 87% [Kappa = 0.74, 95% confidence interval (CI) 0.72-0.76]. Cytohistological correlation was achieved in 26 of 33 (79%) cases. Intra-observer agreement was 91% (Kappa = 0.82, 95% CI 0.89-0.93) with cytohistological correlation in 29 of 33 (87%) cases. Causes of diagnostic errors included marked dissociation, pleomorphism, poorly cellular smears from hyalinized fibrodenoma, lacational changes and apocrine metaplasia with cystic changes. Multinucleated giant cells were frequently encountered in FNA smears from fibroadenoma (31.8%), but in none of the lumpectomy specimens. Their histiocytic nature was suggested by immunohistochemistry. CONCLUSION: FNA was a highly sensitive method for the diagnosis of fibroadenoma. Current cytological criteria were reliable and gave high inter- and intra-observer reproducibility.     

Morphologic and immunocytochemical evaluation of 220 fine needle aspirates of malignant lymphoma and lymphoid hyperplasia

A total of 220 fine needle aspiration (FNA) specimens from 212 patients with clinically suspected or previously histologically confirmed lymphoma were evaluated by cytology in conjunction with immunophenotyping analysis of the aspirate; the results were compared with the histologic diagnosis made on previous or current accessions of lymph node or extranodal tissue. Smears of the aspirates were stained with the Diff-Quik and Papanicolaou stains while immunoperoxidase staining using antibodies against kappa and lambda immunoglobulin light chains and Leu-4 was routinely performed on Cytospin preparations. Where indicated, additional marker studies (including T-200, Leu-1, Leu-2a, Leu-3a + 3b, Leu-M1, B1, Leu-12, IgM, CALLA and TdT) were performed. For the non-Hodgkin's lymphomas, specimens were classified by the cytologic characteristics of the neoplastic cells according to the International Working Formulation scheme. The combination of cytologic smears and immunoperoxidase studies resulted in a diagnosis of lymphoma in 173 cases (79%). The remaining aspirates were interpreted as suspicious for lymphoma (7%), benign (10%) or inadequate for diagnosis (4%). Of the 15 suspicious aspirates, 5 proved to be Hodgkin's disease and 2 to be T-cell lymphoma by subsequent biopsy. The cause of failure in the nine inadequate aspirates were necrosis (3 cases), sclerosis (2 cases) and faulty technique (4 cases). In the cases that had concurrent tissue biopsies, no false-positive diagnoses were rendered. These results indicate that FNA used in association with immunocytochemistry is a reliable tool for establishing the diagnosis and classification of the majority of cases of lymphoma. Optimal immunoglobulin light-chain ratios for defining monoclonality in FNA specimens of B-cell lymphomas are proposed.     

Fine needle aspiration cytology of Hodgkin's lymphoma: A cytohistologic correlation study from a cancer center in Kuwait

OBJECTIVE: To assess the diagnostic accuracy offine needle aspiration cytology (FNAC) in the diagnosis of Hodgkin's lymphoma (HL). STUDY DESIGN: We selected all the cases in which a cytologic diagnosis of HL, suggestive of or suspicious for HL, or HL as the prime differential diagnosis was offered on FNAC. These cases were correlated with histopathologic follow-up. Cases of primary HL diagnosed on cytology but without histopathology were excluded from the study. RESULTS: Histopathologic follow-up was available in 46 cases. Of these, 42 were correctly diagnosed as HL, and there was a discorrelation in 4 cases, comprising 3 cases of non-HL (T-cell-rich B-cell lymphoma [TCRBCL]-2, anaplastic large cell lymphoma-1) and 1 case of metastatic carcinoma. Overall accuracy was 91.3%. In 14 cases, the cytologic features were diagnostic ofrecurrence; hence, no histopathologic examination was done. No follow-up was available for the remaining 19 cases, which were excluded from the study. CONCLUSION: FNAC is very useful for rapid and accurate approach to the diagnosis of recurrent and most cases of primary HL. Because of morphologic similarities, it is difficult to differentiate HL from anaplastic large cell lymphoma and TCRBCL on FNAC. It is advisable to request a histopathologic examination in all cases of primary HL.     

Lymphoepithelioid cell lymphoma (Lennert's lymphoma). Report of a case with fine needle aspiration cytology

BACKGROUND: Lymphoepithelioid cell lymphoma (LCL) is a rare morphologic variant of peripheral T-cell lymphoma. Although their histopathologic and immunohistochemical findings are well known, the cytopathologic features have not been well documented. This report describes the fine needle aspiration cytology (FNAC) findings of a case of LCL. CASE: A 75-year-old woman presented with cervical, supraclavicular, axillary and mediastinal lymphadenopathy. FNAC of a cervical lymph node was performed. The smears contained a polymorphous infiltrate formed by abundant histiocytes disposed singly or in clusters, small and medium-sized to large atypical lymphoid cells and reactive cells, including eosinophils and plasma cells. Isolated capillary-sized vessels also were observed. Histopathologic and immunohistochemical examination confirmed the diagnosis of Lennert's lymphoma. CONCLUSION: Although histopathologic and immunohistochemical studies were required for a definitive diagnosis, the findings of FNAC in this case appeared distinctive and suggested the possibility of LCL.     

Anaplastic large cell lymphoma of the mediastinum diagnosed by transbronchial scratch cytology. A case report

BACKGROUND: Anaplastic large cell lymphoma (ALCL) is a subtype of non-Hodgkin's lymphoma characterized by CD30 antigen-positive, large neoplastic cells. We describe a case of ALCL suggested by cytologic examination of the tumor cells obtained from bronchial scratch preparations. CASE: A 26-year-old woman had had a dry cough since November 1996. Chest radiography in May 1997 revealed an abnormal shadow in the mediastinum extending to the pulmonary hilar region. The patient was hospitalized in June 1997. Computed tomography revealed a neoplastic lesion in the anterior mediastinum invading the right lung. Transbronchial scratch cytology revealed large, atypical lymphoid cells expressing CD30 and CD3 on immunocytochemical examination. A transcutaneous mediastinal biopsy was performed and a diagnosis of ALCL made. CONCLUSION: Differentiation from Hodgkin's disease was the most difficult point in this case. Detailed cytologic observation and CD3-positive immunocytology led to the correct diagnosis. The cell transfer technique of Sherman et al was very useful for immunocytologic staining. Thus, transbronchial scratch cytology was an especially valuable and effective procedure in this case.     

Cytomorphology of hyaline-vascular Castleman''s disease: a diagnostic challenge

OBJECTIVE: Hyaline-vascular Castleman's disease (CD) is difficult to diagnose on fine needle aspiration and may be mistaken to be a lymphoreticular malignancy because of the presence of large cells having nuclei showing atypical features. The cytomorphological findings in three histopathologically documented cases of hyaline-vascular CD were evaluated to a set of cytomorphological criteria which could help in the identification of this condition on aspirate smears. METHODS: The Papanicolaou and Diff-Quik stained smears from three cases of histologically documented hyaline-vascular CD were reviewed by one author. After review the following cytomorphological criteria were suggested to be indicators of the lesion. (i) The presence of large oval to round cells having ill-defined cytoplasmic margins and large nuclei with irregular nuclear outlines having fine or coarse chromatin giving a crumpled tissue paper appearance. (ii) A polymorphous population of lymphoid cells predominantly of small lymphocytes in the background. The smears from these three cases were then mixed with smears from four cases of reactive lymphoid hyperplasia and three cases of Hodgkin's lymphoma. These ten cases were blindly evaluated by two other cytopathologists in order to evaluate the utility of the proposed criteria in identifying CD. RESULTS: The cytomorphological criteria seen in the methodology section were present in all the cases. These features were helpful in distinguishing CD from reactive lymphoid hyperplasias and Hodgkin's Lymphomas in all cases except one case. CONCLUSION: Although hyaline-vascular CD is a difficult diagnostic entity on aspirate material the presence of large histiocytic cells with a crumpled tissue paper appearance of the nuclei in a background of small lymphocytes are useful indicators for suspecting this lesion. However, these findings should be analysed in larger studies to determine if they could in anyway reduce the diagnostic dilemma in cases of CD.     

Signet-ring cell lymphoma. Report of a case diagnosed by fine needle aspiration cytology

A case of signet-ring cell lymphoma initially diagnosed by fine needle aspiration (FNA) cytology is described. Immediate evaluation of air-dried smears showed a mixture of large and small lymphoid cells, including some signet-ring forms. Immunocytochemical studies of Cytospin preparations of the remaining aspirate yielded a diagnosis of a large-cell-type B-cell signet-ring lymphoma. Subsequent bone marrow biopsies confirmed the diagnosis of a low-grade lymphoma. The advantages of on-site evaluation in aspiration cytology are discussed.     

Fine needle aspiration biopsy in the diagnosis of tuberculosis

Bacteriologic data and aspiration smears obtained by fine needle aspiration (FNA) biopsy for a series of 39 cases of tuberculosis were reviewed. Based on the morphologic features of the aspiration smears, the cases were divided into two groups: 18 cases in which distinct epithelioid granulomas were present and 21 in which no granulomas were found but large amounts of necrotic debris with variable numbers of polymorphonuclear cells, histiocytes and lymphocytes were present. Material from the FNA biopsy specimen was submitted for culture and fluorescence studies in 34 cases (15 with and 19 without granulomas). In the first group, auramine-rhodamine staining of smears was positive in 4 of 15 cases and Mycobacterium tuberculosis was isolated in 12 of 15 cases. In the second group, auramine-rhodamine staining was positive in 9 of 19 cases and culture was positive for M. tuberculosis in 16 of 19 cases. The results indicate that studying FNA smears by light microscopy and bacteriologic culture is an effective way of diagnosing tuberculosis.