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.     

Papillary thyroid carcinoma with exuberant nodular fasciitis-like stroma in a fine needle aspirate. A case report

BACKGROUND: Papillary thyroid carcinoma (PTC) with exuberant nodular fasciitis-like stroma (PTC-ES) is a new morphologic variant of conventional PTC. It is characterized by extensive reactive stromal proliferation, which may occupy 60-80% of the tumor. CASE: A 42-year-old female developed a tender, left-sided thyroid mass. The fine needle aspiration biopsy specimen contained, besides diagnostic epithelial features of PTC, many cohesive tissue fragments of cellular stroma. CONCLUSION: A correct cytopathologic diagnosis of PTC-ES can be established if both epithelial and stromal components are present in needle aspirates.     

Papillary carcinoma of the breast. Cytologic study of nine cases.

OBJECTIVE: To study the cytologic findings of papillary breast carcinoma by fine needle aspiration. STUDY DESIGN: The study group consisted of fine needle aspiration (FNA) specimens of breast tumors from nine patients performed during the period 1988-1997. Eight were female, and one was male. The FNA results were compared with the final histologic diagnosis. RESULTS: The tumor sizes were 4-6.5 cm. The aspirations yielded a good amount of bloody material. The smears revealed high cellularity, papillary clusters, isolated low-to-tall columnar cells, mild to moderate atypia, hemorrhagic background, foam and hemosiderin-laden macrophages, calcification, rare mitoses, palisading row of cells and bipolar cytoplasmic eosinophilic granules. The smears were diagnosed as either suspicious or suggestive of papillary carcinoma. The histologic examination revealed invasive papillary carcinoma. CONCLUSION: Papillary carcinoma of the breast can be diagnosed by using a panel of cytologic findings that includes hypercellularity, papillary clusters, hemorrhagic background, palisading rows of tall columnar cells, cellular atypia and calcification. The interesting finding in this study was the presence of eosinophilic bipolar cytoplasmic granules, which has not been reported before.     

Fine needle aspiration biopsy of primary renal synovial sarcoma. A case report

BACKGROUND: Primary renal synovial sarcoma is a relatively recently described and characterized neoplasm, formerly designated embryonal sarcoma of the kidney, and has not been diagnosed before by fine needle aspiration biopsy cytology. We describe the cytologic features of a malignant biphasic neoplasm of the kidney that was subsequently diagnosed at nephrectomy and confirmed with molecular genetic analysis as a biphasic renal synovial sarcoma. CASE: A 38-year-old male presented with acute abdominal pain. Computed tomography (CT) demonstrated a 4.7-cm mass in the left kidney. No soft tissue or extrarenal masses were identified. A CT-guided fine needle aspiration biopsy revealed a malignant biphasic tumor characterized by minimally atypical tubular epithelium, immature spindle cells and foci of coagulative tumor necrosis. At nephrectomy, a necrotic, pseudo-encapsulated synovial sarcoma of the upper pole of the left kidney was identified and was additionally evaluated with immunohistochemistry and molecular genetic studies. The case is unique since biphasic synovial sarcomas have yet to be reported to occur in the kidney and fine needle aspiration biopsy findings of this renal neoplasm have never been reported to our knowledge. CONCLUSION: Synovial sarcoma should be a diagnostic consideration particularly in a young adult with a malignant spindle cell neoplasm of the kidney. The list of differential diagnoses should include sarcomatoid renal cell carcinoma, sarcomatoid transitional cell carcinoma of the renal pelvis, angiomyolipoma and monophasic or biphasic synovial sarcoma.     

Fine needle aspiration cytology of papillary endothelial hyperplasia. A case report.

BACKGROUND: Papillary endothelial hyperplasia is an intravascular or rarely extravascular proliferation of endothelial cells. It is considered an unusual form of thrombus organization. CASE: A 41-year-old, healthy male presented with a neck mass, which was aspirated. The cytomorphologic features were interpreted as consistent with squamous cell carcinoma. Subsequent workup failed to reveal a primary lesion, and the mass was surgically excised. Histopathology showed papillary endothelial hyperplasia associated with a hematoma. Immunocytochemical staining for factor VIII-related antigen on a destained, alcohol-fixed smear from the fine needle aspirate confirmed the endothelial nature of the cells. CONCLUSION: A vascular lesion should be considered in a fine needle aspiration biopsy of a head and neck mass, in particular when the clinical features are not consistent with a metastatic malignancy. The absence of cytoplasmic orangeophilia and immunoreactivity for factor VIII-related antigen may be helpful in establishing the diagnosis.     

Primary papillary serous carcinoma of the peritoneum: report of a case with diagnosis by fine needle aspiration and immunocytochemistry

BACKGROUND: Primary papillary serous carcinoma (PPSC) of the peritoneum is a rare neoplasm, histologically indistinguishable from papillary serous carcinoma of the ovary, which diffusely involves the peritoneum but spares or minimally invades the ovaries. To the best of our knowledge, the preoperative and the fine needle aspiration diagnosis of this disorder have not been reported before. CASE: A woman developed an extensive peritoneal neoplasm 4 years after hysterectomy and bilateral salpingo-oophorectomy for benign disease. Fine needle aspiration of the tumor was performed, and the cytologic and immunocytochemical findings were consistent with papillary serous carcinoma. A diagnosis of PPSC of the peritoneum was rendered because review of all slides from previous surgical specimens showed no evidence of carcinoma and no other primary tumors were found elsewhere. CONCLUSION: Fine needle aspiration cytology coupled with immunocytochemical and clinical data allows an unequivocal preoperative diagnosis of papillary serous carcinoma (primary peritoneal or with an ovarian origin). The sole limitation to establish a primary peritoneal origin before surgery is the requirement to histologically study the ovaries. Based on this fact, the preoperative fine needle aspiration cytology diagnosis of PSCP should be restricted to oophorectomized patients.     

Transcutaneous fine needle aspiration biopsy of the preepiglottic space

OBJECTIVE: To evaluate transcutaneous fine needle aspiration biopsy of the preepiglottic space for staging supraglottic squamous cell carcinoma. STUDY DESIGN: We studied 28 patients who underwent total or horizontal supraglottic laryngectomy as their main therapy modality due to supraglottic squamous cell carcinoma, followed in some cases by adjuvant radiation therapy. All the patients underwent transcutaneous fine needle aspiration. RESULTS: The cytopathologic examination of the material obtained by aspiration was compared to the histopathologic analysis of the laryngectomy specimens; the efficiency was 96.4%. The method did not cause any morbidity. CONCLUSION: Transcutaneous fine needle aspiration biopsy of the preepiglottic space is useful for preepiglottic space evaluation, with a high correlation with histopathologic results and no morbidity.     

Tall cell variant of papillary carcinoma arising from a thyroglossal cyst: report of a case with diagnosis by fine needle aspiration cytology

BACKGROUND: Papillary carcinoma arising from a thyroglossal duct cyst (TDC) is the most frequent malignancy arising from this embryologic remnant of the thyroglossal duct. The preoperative fine needle aspiration cytology (FNAC) of such neoplasms has rarely been cited. Approximately 170 TDC cases have been reported in the literature worldwide, diagnosed solely on histopathology. CASE: A 63-year-old woman presented with an anterior midline neck mass of years' duration. A hypodense cyst was located at the level of the hyoid bone. FNAC of the midline neck mass showed bloody, mucoid material and numerous atypical, elongated cells. The aspirated material was reported as "papillary carcinoma possibly arising from the thyroglossal duct," and the diagnosis was confirmed by histopathologic investigation on resection material. CONCLUSION: Tall cell variant is a rare variant of papillary carcinoma and has a poor prognosis. The differential diagnosis includes Hürthle cell lesions, oncocytic papillary thyroid carcinoma and Warthin-like papillary carcinoma.     

Cytologic and histologic findings in multiple renal hybrid oncocytic tumors in a patient with Birt-Hogg-Dubé syndrome: a case report

BACKGROUND: Birt-Hogg-Dubé (BHD) syndrome is a rare autosomal dominant neoplastic syndrome characterized by multiple skin lesions, lung cysts and renal tumors. A variety of histologic types of renal tumors have been reported, including clear cell renal cell carcinoma (RCC), papillary RCC, chromophobe RCC, oncocytoma and a recently described hybrid oncocytic tumor, which is thought to be highly associated with BHD. CASE: We report a case of a 48-year-old woman with BHD who initially presented to our institution with spontaneous pneumothorax and was found to have multiple lung cysts and renal tumors on computed tomography. We describe the fine needle aspiration findings of one of the renal tumors, which was suggestive of so-called hybrid oncocytic tumor. We also describe the gross and histologic findings of the multiple kidney tumors that the patient subsequently had excised. CONCLUSION: When multiple kidney tumors from a single patient appear oncycytic on fine needle aspiration, especially when focal clear cells are present, the possibility of oncocytomas and hybrid tumors associated with BHD must be entertained.     

Fine needle aspiration biopsy of epithelioid angiomyolipoma. A case report

BACKGROUND: Epithelioid angiomyolipoma (AMYL) is a variant of angiomyolipoma characterized by sheets of epithelioid cells that may mimic renal cell carcinoma. This is the first report describing the fine needle aspiration biopsy features of this lesion. CASE: A 47-year-old man with a history of epithelioid angiomyolipoma of the kidney treated with nephrectomy nine months previously presented with a recurrent retroperitoneal mass and multiple nodular liver lesions. Fine needle aspiration biopsy of one of the liver lesions showed fragments and sheets of noncohesive epithelioid cells with thin cytoplasm, markedly atypical nuclei, and scattered bizarre and multinucleated forms. The epithelioid cells focally expressed HMB-45 and were nonimmunoreactive, with epithelial markers. CONCLUSION: Epithelioid AMYL may pose differential diagnostic problems with high grade carcinoma, especially renal cell, hepatocellular and metastatic carcinoma. An awareness of this entity and its characteristic cytologic features and immunoreactivity with HMB-45 is helpful in its identification.     

Histologic analysis and comparison of techniques in fine needle aspiration-induced alterations in thyroid

OBJECTIVE: To assess histologic alterations following fine needle aspiration (FNA) of the thyroid and differentiate these from ominous lesions, such as papillary carcinoma thyroid, as well as assess and compare the degree of tissue trauma from the techniques: needle only vs. needle with syringe, size of needle and number of aspirations. STUDY DESIGN: Thyroidectomy specimens of 100 cases with prior FNA biopsy were selected. The changes called "worrisome histologic alteration following fine needle aspiration of the thyroid" (WHAFFT) were studied. Number of FNAs, needle size and technique were tabulated for 73 of 100 cases. RESULTS: Worrisome changes were confined to areas near the needle tract and hence could be differentiated from ominous lesions. Control cases did not show WHAFFT lesions. Non-aspiration FNA cytology (FNAC) technique results in fewer, less frequent WHAFFT changes. The increasing number of FNAs leads to statistically significant increase in infarction, necrosis and vascular changes. A gradation in the WHAFFT changes, directly proportional to the increasing diameter of the needle, was observed. CONCLUSION: The pathologist should be aware of WHAFFT to avoid misinterpretation. The technique of non-aspiration FNAC is significantly less traumatic. An increase in FNAs or size of needle results in more severe WHAFFT changes.     

Fine needle aspiration cytology diagnosis of renal medullary carcinoma: a case report

BACKGROUND: Renal medullary carcinoma is a recently described, highly aggressive neoplasm that affects predominantly young African American males with a history of sickle cell trait. To the best of our knowledge, this is the first report of fine needle aspirate cytology (FNAC) findings of renal medullary carcinoma. CASE: A 14-year-old, African American male with a history of sickle cell trait presented with the sudden onset of third cranial nerve palsy. Radiographic examination demonstrated possible tumor masses in the brain, thorax and left kidney. Ultrasound-guided fine needle aspiration was performed on the left kidney, and a cytologic diagnosis of "suspect renal medullary carcinoma" was rendered. The cytologic diagnosis was confirmed by tissue examination. CONCLUSION: The cytologic features of renal medullary carcinoma include loosely cohesive clusters and single epithelioid cells with cytologic atypia, including high nuclear/cytoplasmic ratios, hyperchromasia, prominent nucleoli and cytoplasmic vacuolation. These cytologic findings, coupled with clinical findings (young black male with sickle cell trait), allow recognition of this rare renal neoplasm.     

Secondary infection and ischemic necrosis after fine needle aspiration for a painful papillary thyroid carcinoma: a case report

BACKGROUND: Papillary thyroid carcinoma (PTC) is often asymptomatic and rarely presents as a painful goiter. Further, the thyroid gland is not easily infected. Therefore, acute suppurative thyroiditis (AST) is unusual. PTC is also seldom combined with AST. We report a case of painful PTC with secondary infection after fine needle aspiration (FNA). CASE: A 19-year-old girl complained of a painful goiter without skin change after an episode of upper airway infection. PTC was diagnosed according to the FNA cytology (FNAC) at another hospital. The goiter became more painful after FNA. The patient's second FNAC at our hospital revealed only many polymorphonuclear leukocytes (PMNs). Antibiotic treatment ameliorated the pain, but the goiter persisted. The third FNAC revealed some PMNs and papillary carcinomatous cells. After total thyroidectomy, pathology revealed ischemic necrosis with a focal PMN aggregation around the needle track and papillary carcinomatous cells nearby. According to the time sequence, secondary infection after FNA was suspected. CONCLUSION: A painful goiter is an unusual presentation of PTC. Although FNAC is feasible for studying a thyroid lesion, malignant cells might be missed when secoandary injection and ischemic necrosis occur after FNA. Therefore, aseptic procedures are necessary to prevent bacteria from seeding into the thyroid.     

Fine needle aspiration cytology of invasive cribriform carcinoma of the breast with osteoclastlike giant cells: a case report

BACKGROUND: Nonneoplastic osteoclastlike giant cells are occasionally associated with carcinoma of the breast, pancreatobiliary and gastrointestinal systems. In the breast, this uncommon stromal response is seen mainly in invasive carcinoma with low grade cytology, among which invasive cribriform carcinoma is the classic example. Details of the fine needle aspiration cytology of this phenomenon, especially in thin-layer preparations, have been described rarely. CASE: The fine needle aspiration cytology of an invasive cribriform carcinoma of the breast occurred in a 66-year-old woman. Cytology showed cohesive sheets and three-dimensional cribriform clusters of bland-looking and mitotically inactive ductal cells in a blood-stained background. Scattered multinucleated, osteoclastlike giant cells, some containing hemosiderin granules, were also seen. Myoepithelial cells and naked nuclei were not obvious. The cellular composition was more discernible in liquid-based cytologic preparations. Histologic examination of the excisional biopsy showed an invasive cribriform carcinoma associated with many osteoclastlike giant cells in a hypervascular stroma. CONCLUSION: In view of the extremely low grade cytology of the malignant ductal cells, invasive cribriform carcinoma may closely mimic benign proliferative breast diseases on fine needle aspiration biopsy. Recognition of this special relationship with osteoclastlike giant cells, which are rarely present in certain subtypes of breast cancer but not benign lesions, can help to arrive at a correct cytologic diagnosis.     

Fine needle aspiration cytology of collecting duct carcinoma of the kidney: report of a case with distinctive features and differential diagnosis

BACKGROUND: The relative rarity of collecting duct carcinoma (CDC) of the kidney in conjunction with a lack of distinctive cytologic features is a diagnostic challenge for any cytopathologist when dealing with such a tumor on fine needle aspiration cytology. In previous cytologic reports, CDC is not well characterized, and the features overlapped with those of high grade renal cell carcinoma (RCC). Because of the differences in behavior and treatment from conventional RCC, it is important to attempt to diagnose this tumor correctly. CASE: The cytologic findings of CDC in a 56-year-old woman were distinctive and not emphasized previously. Ductal/tubular differentiation, prominent desmoplastic stromal component, neutrophilic infiltration and the presence of numerous tubules ranging from benign to dysplastic and frankly malignant were notable features of this tumor. The expression of high-molecular-weight cytokeratin and Ulex europaeus agglutinin helped to confirm the diagnosis. CONCLUSION: The present case highlights several characteristic cytologic features that were useful in suggesting the diagnosis of CDC on fine needle aspiration cytology. Immunohistochemical stains, such as high-molecular-weight cytokeratin and lectin, helped to confirm the diagnosis.     

Circulating thyroglobulin and antithyroglobulin antibodies after fine needle aspiration of thyroid nodules

Circulating thyroglobulin and antithyroglobulin antibodies were assayed in fifteen patients affected by solitary "cold" nodules of the thyroid who had undergone fine needle aspiration for cytologic diagnosis. The aim of the study was to investigate whether a minor insult to thyroid tissue such as fine needle aspiration is able to release thyroglobulin into the circulation and to induce the formation of antithyroglobulin antibodies. The results obtained are as follows: 1. Circulating thyroglobulin increased substantially after fine needle aspiration in 11 out of 15 patients. 2. Antithyroglobulin antibodies did not appear in any patient during a follow-up period of two months. 3. The magnitude of basal thyroglobulin and thyroglobulin increase after needle aspiration were unrelated to cytologic diagnosis.     

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.     

Metaplastic carcinoma of the breast in an HIV-positive patient: a case report

BACKGROUND: Metaplastic carcinoma of the breast is a rare neoplasm that causes diagnostic difficulty on fine needle aspiration smears. Breast carcinoma in HIV-infected patients occurs at a relatively early age, with increased bilateral disease, unusual histology, and early metastatic spread with a poor outcome. CASE: A case of metaplastic carcinoma of the breast arose in a 36-year-old woman who was seropositive for HIV. In the absence of a sarcomatous component and presence of obvious ductal differentiation on aspirates, a diagnosis of high grade infiltrating duct carcinoma, not otherwise specified, was made on fine needle aspiration cytology (FNAC). CONCLUSION: This case underlines the limitations of FNAC in the diagnosis of metaplastic carcinoma of the breast. It also shows that it is imperative to maintain a high index of suspicion for rare pathologies in immunocompromised patients.     

Fine needle aspiration biopsy of the thyroid. Differential diagnosis by videoplan image analysis

Fine needle aspiration biopsy of cold thyroid nodules has become increasingly popular in determining neoplastic versus nonneoplastic conditions. The differential diagnosis between follicular adenoma and low-grade follicular carcinoma has not been consistently attainable, however; adenomatous goiter also may present problems in diagnosis, while papillary carcinoma seldom proves to be a difficult diagnosis. Image analysis, utilizing the Videoplan image analysis system, was performed on fine needle aspiration biopsy smears from these four types of nodules. The nuclear area, maximum diameter, minimal diameter and approximation to a circle were determined for 25 randomly selected cells with intact nuclei in each smear. These values were calculated with a range and standard deviation and were graphed for each parameter by case category. Cytoplasmic measurements could not be performed due to the absence of definite cytoplasmic boundaries. There was no significant difference in mean nuclear area between follicular adenoma, follicular carcinoma and adenomatous goiter. Papillary carcinoma was the only lesion to show any difference with this single parameter. The mean of maximum and minimum diameter and approximation to a circle were similar for all the types of thyroid masses examined in this study. The Videoplan image analysis system provided an efficient and accurate means of obtaining the nuclear measurements and calculating the statistics. These data illustrate that a differential diagnosis between follicular adenoma, follicular carcinoma and adenomatous goiter, while difficult by light microscopy, is not aided by image analysis of individual cell nuclei.     

Fine needle aspiration cytology of epithelial-myoepithelial carcinoma of salivary glands. A report of three cases.

BACKGROUND: Epithelial-myoepithelial carcinoma is a rare, low grade malignant tumor of the salivary glands. Histologically, it has a biphasic cellular composition and exhibits a high degree of differentiation. The fine needle aspiration cytology of this rare tumor is rarely described in the literature. CASES: We report the fine needle aspiration cytology of three epithelial-myoepithelial carcinomas, arising in the right parotid, left parotid and minor salivary gland of the hard palate. Cytology showed a biphasic population consisting of cells of ductal epithelial and myoepithelial origin arranged in small clusters and sheets. The myoepithelial cells had small, uniform nuclei; ample, clear cytoplasm and distinct cell borders, while the ductal epithelial cells had larger, mildly pleomorphic nuclei and scanty cytoplasm. These ductal cells tended to form tubules among background sheets of clear myoepithelial cells. This feature, if present, was an important diagnostic clue. Hyaline material surrounding cell clusters and focal adenoid cystic carcinoma-like areas with orangeophilic globules were also not uncommon. CONCLUSION: While the cytologic appearance of epithelial-myoepithelial carcinoma may closely mimic that of other salivary gland tumors, such as adenoid cystic carcinoma, pleomorphic adenoma and basal cell adenoma, certain peculiar cytologic features may allow a distinction to be made on fine needle aspiration biopsy.