Fine needle aspiration cytology of granulomatous diseases of the lung, including nontuberculous Mycobacterium infection

The spectrum of cytomorphologic changes of pulmonary granulomas diagnosed by fine needle aspiration (FNA) biopsy is reported, with a review of the pertinent literature concerning the cytologic diagnosis of granulomatous disease. In our cases, organisms were not seen in the Papanicolaou-stained smears. Recognition of the granulomatous cellular pattern, however, resulted in a thorough search for organisms by special stains, and an etiologic diagnosis was made in each case. These cases emphasize the need for routine staining and culture of FNA material when an initial diagnosis of malignancy is not made. One of the cases appears to be the first report of a nontuberculous Mycobacterium infection diagnosed by fine needle aspiration biopsy.     

Idiopathic granulomatous mastitis. Report of a case diagnosed with fine needle aspiration cytology.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a benign, inflammatory breast disease of unknown etiology. Although it is rare, it frequently presents in a manner similar to that of breast carcinoma. CASE: A 41-year-old female developed unilateral idiopathic granulomatous mastitis, diagnosed by fine needle aspiration cytology. The clinical presentation and mammographic findings were suspicious for carcinoma. Fine needle aspiration cytology showed granulomatous inflammation. Histopathologic examination revealed a noncaseating, granulomatous lesion. Further clinical, radiologic and laboratory investigations disclosed no etiology. Therefore, we considered the case to be idiopathic granulomatous mastitis. CONCLUSION: Cytologically it may be difficult to distinguish IGM from carcinoma of the breast. Typical cytologic findings of the lesion are helpful to rule out cancer. In the differential diagnosis, all known causes of granulomatous changes have to be excluded before a diagnosis of idiopathic granulomatous mastitis is made.     

Fine needle aspiration cytology of cat scratch disease

The cytologic features of cat scratch disease diagnosed by fine needle aspiration cytology of a right inguinal lymph node in a 23-year-old woman are reported. Characteristic granulomas, with peripherally palisading epithelioid histiocytes and centrally located neutrophils, and an associated polymorphic cell population were observed. The cytologic pattern closely parallels the expected histopathologic findings and therefore can suggest the diagnosis in unsuspected cases or can confirm the clinical impression. The cytologic differential diagnosis and a discussion of other granulomatous lymphadenitis are presented.     

Malacoplakia of the pelvis. Report of a case with cytologic and ultrastructural findings obtained by fine needle aspiration.

Malacoplakia is a rare granulomatous, inflammatory disease usually diagnosed on a biopsy specimen. Only five cases have been diagnosed by FNA, most of them in the prostate. We report the cytologic and ultrastructural findings in fine needle aspirates of pelvic malacoplakia. The main characteristic of the smears was a richly inflammatory background with abundant, foamy histiocytes containing Michaelis-Gutmann bodies. The results indicate that fine needle aspiration is useful in diagnosing this disease, excluding a neoplastic process and performing follow-up.     

Fine needle aspiration cytology of granulomatous prostatitis induced by BCG immunotherapy of bladder cancer

Six patients treated with intravesical bacillus Calmette-Guérin (BCG) for superficial bladder cancer had granulomatous prostatitis demonstrated histologically by transperineal needle biopsy. Four of the six patients also underwent transrectal fine needle aspiration (FNA) for cytologic study. The diagnosis of granulomatous prostatitis was made cytologically in all four without knowledge of the histologic findings. Granulomatous prostatitis appears to be common following intravesical BCG treatment; these cases show that FNA cytology can be recommended as a method for diagnosing this complication.     

Fine needle aspiration cytologic findings and differential diagnosis of solitary pseudorheumatoid nodule

The cytologic findings in fine needle aspirates of two solitary pseudorheumatoid nodules are presented. The main characteristic of the smears was a necrotic granular and filamentous background accompanied by a granulomatous inflammatory infiltrate. The differential diagnosis is analyzed. The results in these cases indicate that the diagnosis of a solitary pseudorheumatoid nodule may be made by fine needle aspiration cytology after a critical evaluation of the cytologic and clinical data and with the help of special stains and microbial culture.     

Cytomorphology of tuberculous mastitis. A report of nine cases with fine needle aspiration cytology

Nine cases of tuberculosis of the breast were diagnosed by fine needle aspiration (FNA) cytology over a six-month period. All cases presented with a breast lump, three of which clinically simulated carcinoma. FNA cytology showed a picture of suppurating granulomatous mastitis; the diagnosis of tuberculosis was established after the demonstration of acid-fast bacilli in the aspirated material.     

Fine needle aspiration cytology of localized Leishmania lymphadenitis

Leishmania lymphadenitis, an uncommon cause of lymphadenopathy, is usually diagnosed by surgical biopsy performed because of suspicion of lymphoma. The cytopathologic features of this disease do not appear to have been previously described. This paper describes the findings in seven cases of Leishmania lymphadenitis diagnosed by fine needle aspiration (FNA) cytology. The identification of Leishman-Donovan bodies in epithelioid cells in the aspirates led to the cytologic diagnosis of Leishmania lymphadenitis, which was histologically confirmed in all cases. Since this disease is self-limiting and requires no treatment, FNA diagnosis is especially useful in that the patient can be spared more invasive diagnostic techniques.     

Fine needle aspiration cytology of granulomatous prostatitis

The fine needle aspiration (FNA) cytologic findings are presented for 18 cases of granulomatous prostatitis (12 nonspecific, 5 tuberculous and 1 eosinophilic cases). These cases represented 19% of all prostatitis cases and 2% of all prostatic aspirates examined from January 1986 to December 1987. The cytomorphologic differences between the three types of granulomatous prostatitis are described, with emphasis on the differentiation between the nonspecific and specific varieties. The differential diagnostic features between reactive changes and well-differentiated adenocarcinomas of the prostate are also presented. The findings in these cases indicate that FNA cytology is a reliable procedure for the morphologic diagnosis of granulomatous prostatitis, which can clinically mimic prostatic carcinoma when it presents as a diffuse or nodular enlargement with increased consistency.     

Disseminated rhinosporidiosis masquerading as soft tissue round cell tumour diagnosed by fine needle aspiration cytology

Rhinosporidium seeberi belongs to the eukaryotic class Mesomycetozoea and causes chronic granulomatous lesions known as rhinosporidiosis. Rhinosporidiosis frequently involves the nasal cavity and nasopharynx through transepithelial invasion. Atypical presentations of this disease at other body sites have been reported, including the subcutis, visceral organs, bones, and genitals. Only a few cases of cutaneous and subcutaneous involvement have been reported to date. This chronic granulomatous condition is known for its recurrence following autoinoculation unless the correct diagnosis and appropriate treatment are given. We describe a case of an immunocompetent adult who had undergone fine needle aspiration cytology (FNAC) of mass-like swellings in the right thigh and right calf at another healthcare centre and had been diagnosed with a small round blue cell tumour. FNAC at our centre confirmed a rare case of rhinosporidiosis that was clinically mimicking a soft tissue neoplasm of the lower extremity, and the erroneous interpretation of the prior cytology studies had resulted in misinterpretation of the individually dispersed pathogenic organisms as individual malignant cells. FNAC of rhinosporidiosis can lead to early diagnosis and prompt treatment of this pathogen when it presents at unanticipated body sites.     

Cytopathology of the tall cell variant of thyroid papillary carcinoma.

The tall cell variant of thyroid papillary carcinoma differs from classic papillary carcinoma in its more aggressive clinical behavior, cell type (columnar amphophilic to oxyphilic) and higher frequency of stromal lymphoid infiltrate. A retrospective study of three such cases was made, with an emphasis given to the utility of fine needle aspiration cytology in their identification. Aspirates revealed papillary fronds and cyanophilic and oxyphilic neoplastic cells with a high proportion of nuclear grooves and cytoplasmic inclusions. These nuclear details allowed a specific diagnosis of papillary carcinoma with oxyphil cells as compared to oxyphilic cell follicular tumors. Smears from two cases showed, in addition, lymphoid cells and multinucleate giant cells. In them a diagnosis of coexisting Hashimoto's disease, granulomatous thyroiditis or inflammatory tumor stroma could not be excluded cytologically.     

Cytopathologic features of pituitary carcinoma with cervical vertebral bone metastasis: a case report

BACKGROUND: Pituitary carcinomas are extremely rare tumors of the adenohypophysis. The presence of craniospinal and/or systemic extracranial metastases is the only reliable criterion for the diagnosis of pituitary carcinoma. To date, only 2 cases have been reported correctly by fine needle aspiration biopsy (FNAB). We present an additional case of pituitary carcinoma with FNAB features. CASE: A 60-year-old woman presented with clinical features of Cushing's disease and a pituitary tumor. She underwent transsphenoidal resection of the tumor. The initial diagnosis was an adrenocorticotrophic hormone (ACTH)-producing invasive pituitary adenoma. The patient presented again with neck pain 6 years after the operation. Magnetic resonance imaging revealed metastatic tumor masses at the level of C5-C6 of the cervical vertebrae. Intraoperative fine needle aspiration and incomplete excision of metastatic tumors were performed. Cytologically, tumor cells were composed of a combination of loose groups and single cells. Neoplastic cells had a relatively monotonous appearance and displayed characteristic neuroendocrine tumor features. Immunocytochemistry from cell block sections revealed AE1/ AE3, synaptophysin chromogranin A and ACTH positivity in the tumor cells. CONCLUSION: Pituitary carcinoma with extracranial systemic metastases demonstrates typical neuroendocrine features on fine needle aspiration. In the differential diagnosis, metastatic neuroendocrine carcinomas should be kept in mind. In the absence of sufficient clinical data, these 2 entities cannot be distinguished correctly through the cytologic features.     

The gray zone in breast fine needle aspiration cytology. How to report on it?

OBJECTIVE: To study the "gray zone" in breast fine needle aspiration cytology in which an unequivocal diagnosis cannot be reached with fine needle aspiration cytology findings. STUDY DESIGN: This study compared cytology and histopathology of 72 breast lesions in which an initial cytologic diagnosis of atypia was given. RESULTS: There were 36 benign (50%) and 36 malignant (50%) histologic biopsy cases in the cytologic atypia group. Anisonucleosis, chromatin and nuclear membrane irregularity, and presence of myoepithelial cells were significantly different in benign and malignant cases. CONCLUSION: The gray zone in breast fine needle aspiration cytology is a broad spectrum that changes from proliferative fibrocystic disease to sclerosing adenosis to malignancy. Diagnosing gray zone pathology as atypical in fine needle aspiration cytology causes no delay in treatment as excisional biopsy is recommended for all equivocal cases.     

Fine needle aspiration cytology in HIV‐related lymphadenopathy: experience at a single centre in north India

P. K. Sarma, A. K. Chowhan, V. Agrawal and V. Agarwal
Fine needle aspiration cytology in HIV‐related lymphadenopathy: experience at a single centre in north India Objective: Fine needle aspiration (FNA) is emerging as a rapid and minimally invasive tool in evaluating lymphadenopathy associated with human immunodeficiency virus (HIV). We evaluated the role of FNA in differentiating various causes of lymphadenopathy in patients with HIV and correlated the cytological diagnosis with CD4 counts. Methods: Seventy‐nine HIV‐positive patients (median age 35 years, 68 male) underwent ultrasound‐guided (n = 16) and unguided (n = 63) FNA from 1999 to 2006. Smears were stained with May–Grünwald–Giemsa, haematoxylin & eosin and Papanicolaou stains. Ziehl–Neelsen (ZN) staining for acid‐fast bacilli (AFB) was performed in all cases. Staining for fungus was performed whenever required. Results: The aspirates were adequate in 75 cases (95%). Non‐specific reactive hyperplasia was the most common FNA diagnosis (39, 52%) followed by granulomatous necrotizing lymphadenitis (15, 20%), necrotizing lymphadenitis (13, 17.3%) and granulomatous lymphadenitis (4, 5.2%). Fungal infection and non‐Hodgkin lymphoma (NHL) were seen in two patients each. ZN staining was positive for AFB in 25 (33.3%) cases. One of these was morphologically interpreted as reactive hyperplasia, 12 as necrotizing lymphadenitis and 12 as granulomatous necrotizing lymphadenitis. Both patients with NHL had CD4 counts below 100/dl. Necrotizing lymphadenitis and granulomatous lymphadenitis were significantly associated with CD4 counts below and above 200/dl, respectively (P = 0.0002). Conclusions: FNA is an important tool for assessing the cause of lymphadenopathy in HIV patients. Necrotizing inflammation is more often seen in patients with low CD4 counts. AFB are commonly found in necrotic aspirates with or without granulomas. However, a stain for AFB should be performed in all aspirates from HIV‐related lymphadenopathy including reactive hyperplasia.     

Fine needle aspiration cytology of granulomatous mastitis. Report of a case and review of the literature

A case of granulomatous mastitis diagnosed by fine needle aspiration (FNA) cytology alone is reported. A 24-year-old pregnant woman presented with a six-week history of a rapidly enlarging breast mass, considered clinically to be malignant. The FNA smears contained numerous aggregates of epithelioid histiocytes admixed with Langhans' and foreign-body giant cells, lymphocytes, neutrophilic leukocytes and apoptotic debris, leading to a diagnosis of granulomatous mastitis. The features of granulomatous mastitis and its differential diagnoses are discussed.     

Granulomatous angiopanniculitis of the breast. A case report

BACKGROUND: Granulomatous angiopanniculitis (GAP) is a rare benign condition of the breast of unknown etiology. Clinically and by fine needle examination, GAP may simulate breast carcinoma. The cytologic characteristics have not been described before. CASE: A 63-year-old female exhibited a palpable mass in her left breast. The fine needle aspirate contained both epithelioid and stromal elements. The epithelioid component consisted of dissociated individual cells and small groups and clusters of atypical cells. The stromal component showed a uniform, not-atypical pattern. The lumpectomy specimen showed nonnecrotizing granulomatous panniculitis and lymphoid angiitis without involvement of ducts or lobules. CONCLUSION: Granulomatous lesions should be borne in mind in the differential diagnosis of breast cancer in fine needle aspiration cytology. GAP must be histopathologically distinguished from granulomatous inflammation in the breast of autoimmune or infectious origin as specific medical therapy may be available for these latter diseases.     

Transthoracic needle aspiration biopsy in Wegener's granulomatosis. Morphologic findings in five cases

Percutaneous needle aspiration biopsies of the lung from five patients with Wegener's granulomatosis were reviewed. Three of the patients presented with the generalized form of the disease while two presented with the limited pulmonary form; one of the latter subsequently developed disseminated disease. The morphologic findings in the pulmonary aspirates were similar in all cases. The cytologic preparations contained neutrophils entrapped within necrotic debris plus scattered but prominent histiocytic giant cells, which often had nuclei arranged in rings or horseshoes, in a background of lymphocytes, epithelioid histiocytes and reactive pneumocytes. Cell block preparations showed discrete areas of necrosis containing a neutrophilic infiltrate and focally palisaded by epithelioid histiocytes. The intervening viable tissue contained prominent histiocytic giant cells and chronic inflammatory cells enmeshed in a fibrous matrix. One cell block contained a small artery with a small focus of possible granulomatous arteritis. While an open lung biopsy is generally required for a definitive diagnosis, the pathologist may encounter unsuspected Wegener's granulomatosis in a needle aspirate. Recognition of the findings observed in these cases should alert the pathologist to the possibility of Wegener's granulomatosis so that an open lung biopsy can be performed if clinically indicated and cytotoxic therapy can be promptly instituted if the diagnosis of this entity is confirmed.     

Fine needle aspiration biopsy of mastitis secondary to empyema necessitatis. A report of two cases.

BACKGROUND: Empyema necessitatis is a relatively rare entity. Two instances of mastitis secondary to empyema necessitatis, diagnosed by fine needle aspiration biopsy are reported. CASES: One case was tuberculous in etiology and was initially recognized by cytologic findings of epithelioid and granulomatous cellular reactions and the presence of acid-fast bacilli, which were subsequently cultured and speciated as Mycobacterium tuberculosis. The other case was due to coexisting Actinomyces and Actinobacillus. These organisms were cytologically suggested by "sulfur" granules of filamentous, gram-positive bacilli, admixed gram-negative coccobacilli and Splendore-Hoeppli phenomenon in an exudative cell background and were confirmed by microbiologic culture as Actinomyces israelii and Astinomyces actinomycetemcomitans, respectively. CONCLUSION: The usefulness of fine needle aspiration cytology in the diagnosis of empyema necessitatis, supported by ancillary microbial culture, histochemistry, and radiographic imaging, is well illustrated by these two cases.     

Fibromatosis colli in infants. A cytologic study of eight cases

OBJECTIVE: To review eight cases of fibromatosis colli and assess their cytomorphologic features. STUDY DESIGN: Cytologic smears from eight patients diagnosed as having fibromatosis colli on fine needle aspiration cytology were reviewed. RESULTS: Cytologic features of fibromatosis colli are bland-appearing fibroblasts and degenerative atrophic skeletal muscle in a clean background. Besides these, we found a large number of muscle giant cells; numerous bland, bare nuclei; and parallel clusters of fibroblasts. Collagen was seen in all cases. CONCLUSION: A confirmatory, noninvasive diagnosis of fibromatosis colli can be made by fine needle aspiration cytology alone; invasive diagnostic and therapeutic measures are best avoided. Excision biopsy may not be necessary and should be reserved for cases with a strong clinicopathologic suspicion of malignancy.     

Granulomatous inflammation of the breast in a pregnant woman: report of a case with fine needle aspiration diagnosis

BACKGROUND: Granulomatous inflammation of the breast is an inflammatory process with multiple etiologies. It can accompany breast carcinoma or be idiopathic. It often presents clinically in a fashion mimicking carcinoma. Idiopathic granulomatous mastitis is strongly associated with lactation and is reported to occur in postpartum patients. This is the second fine needle aspiration (FNA) report of idiopathic granulomatous inflammation in the breast of a pregnant woman. CASE: A 27-year-old, 7-month-pregnant woman presented with a hard nodule in her right breast; on ultrasound examination it showed mixed echogenicity, suspicious for carcinoma. FNA showed granulomatous inflammation. The smears were highly cellular, with many clusters of and single epithelioid cells displaying moderate pleomorphism and prominent nucleoli in a background composed of neutrophils, plasma cells, lymphocytes and multinucleated cells. Core needle biopsy revealed a nonnecrotizing, granulomatous lesion. CONCLUSION: The diagnosis of granulomatous inflammation can be challenging, and the cytologic features can be difficult to separate from those of carcinoma. The relatively rare occurrence of this lesion and its cytologic features make it a potentially difficult diagnosis and diagnostic pitfall.