Comparison of diagnostic results obtained by fine needle aspiration cytology and tru-cut or open biopsies

In seven cases fine needle aspiration (FNA) cytology provided a diagnosis of neoplasm when the Tru-Cut (TC) tissue biopsies (four cases) and open biopsies (three cases) were negative. The specimens consisted of two breast carcinomas, two metastatic neoplasms in the liver, one metastatic melanoma in inguinal lymph nodes, a retroperitoneal mass and a pelvic mass. In the two cases of mammary carcinoma, TC biopsies were negative and FNAs were diagnostic of carcinoma. TC biopsies in the two cases of questionable hepatic metastasis were negative, but FNAs demonstrated a malignant neoplasm. Open biopsy of a retroperitoneal mass failed to diagnose a neoplasm however, subsequent ultrasound-directed FNA demonstrated a neoplasm, possibly seminoma. FNA cytology of inguinal lymph nodes in one case was diagnostic of melanoma; open biopsy showed no neoplasm. Because of the FNA diagnosis, additional sections were made and the presence of melanoma was confirmed. This series demonstrates that FNA cytology should be considered the initial diagnostic procedure more often.     

Fine needle aspiration biopsy of a hepatic mass. An example of a near error

Material obtained by fine needle aspiration (FNA) from a hepatic mass showed conflicting features in Papanicolaou-stained smears and hematoxylin-and-eosin-stained cell block sections. A sarcomatous lesion (metastatic pleomorphic liposarcoma) was suggested by the smears while the cell block sections revealed the lesion to be a lipid-rich hepatocellular carcinoma. The nature of this apparent discrepancy is discussed.     

Fine needle aspiration cytology of a rhabdomyoma of the pharynx

The fine needle aspiration (FNA) cytology of an extracardiac adult rhabdomyoma of the pharynx is documented. The smear of the aspirate contained large cells with peripherally located, uniform, round nuclei and abundant granular eosinophilic cytoplasm. In addition to these features, peripheral vacuoles were seen in sections of a cell block prepared from the aspirate. Special stains of the cell block sections and of the surgical specimen showed cross striations in some cells while electron microscopy showed the typical features of adult rhabdomyoma. The findings in this case suggest that FNA can diagnose this rare, benign neoplasm when it presents as a solitary mass in the head and neck region. Its differential diagnosis from other neoplasms that occur in that area is discussed.     

Fine needle aspiration cytology of malignant melanoma of soft parts. Report of two cases

Two cases of malignant melanoma of soft parts were diagnosed by fine needle aspiration (FNA) biopsy. One case involved the right thumb of a 22-year-old woman; the other involved a submental mass in a 36-year-old man who had been previously diagnosed as having malignant melanoma of soft parts. The FNA smears showed discohesive polygonal or oval and fusiform cells with eccentric nuclei, irregular nuclear chromatin and prominent nucleoli. FNA cell block sections contained polygonal or fusiform cells with clear cytoplasm, eccentrically placed nuclei and prominent nucleoli. Ultrastructural and immunocytochemical studies on aspirated material supported the diagnosis of malignant melanoma.     

Paratesticular spindle cell rhabdomyosarcoma diagnosed by fine needle aspiration cytology: a case report

BACKGROUND: Spindle cell rhabdomyosarcoma is a rare, newly identified subtype ofembryonal rhabdomyosarcoma with improved behavior and a predilection for the paratesticular area. Fine needle aspiration (FNA) cytology findings of embryonal rhabdomyosarcoma have been described. However, there is no previous report on the cytologic findings of spindle cell rhabdomyosarcoma at testicular or extratesticular sites. CASE: A 13-year-old boy presented with a large, right sided scrotal mass. Fine needle aspiration (FNA) was performed for rapid diagnosis. The smears revealed numerous spindle cells and large fragments of cytoplasmic processes with cross-striations and were diagnosed as spindle cell rhabdomyosarcoma. The histologic sections were also diagnosed as spindle cell rhabdomyosarcoma. CONCLUSION: The cytologic findings of this rare tumor have not been reported before. The cross-striations were easily identified in FNA smears, so the diagnosis of spindle cell rhabdomyosarcoma was made confidently. The histologic sections showed only spindle cells with different patterns of arrangement, resembling leiomyosarcoma. The cross-striations were not identified in the histologic sections. In this case cytologic diagnosis aided the histologic diagnosis.     

Invasive cervical thymoma masquerading as a solitary thyroid nodule. Report of a case studied by fine needle aspiration

A 49-year-old woman underwent fine needle aspiration (FNA) biopsy of a presumed thyroid nodule. The initial cytopathologic interpretation suggested a chronic lymphocytic thyroiditis or a malignant lymphoma. The examination of frozen sections during surgery also suggested the presence of a lymphoma. However, histopathologic examination of permanent sections showed the lesion to be an invasive ectopic lymphocyte-predominant thymoma adjacent to the thyroid. Immunoperoxidase staining of FNA cell block sections and permanent sections showed positivity for keratin, proving the epithelial nature of the elongated and spindle-shaped tumor cells. This case high-lights the need to be aware of unusual lesions that may occur in the area of the thyroid; recognizing the potential diversity of "thyroid" masses that ultimately prove to be of nonthyroid origin should aid in making the correct cytologic differential diagnosis and interpretation of FNA samples obtained from such masses.     

Hodgkin's disease presenting as an enlarged thyroid gland. Report of a case diagnosed by fine needle aspiration

An unusual case of Hodgkin's disease (HD) in a 36-year-old woman that was diagnosed by fine needle aspiration (FNA) biopsy of a neck mass believed clinically to be diffuse goiter is reported. The aspirate was composed mainly of dispersed lymphocytes; admixed with these were occasional large mononuclear cells with round-to-oval nuclei and prominent nucleoli. Binucleated variants of the large cells were interpreted as Reed-Sternberg cells, suggesting the diagnosis of HD. Subsequent to the FNA biopsy, radiologic examinations demonstrated an enlarged mediastinum, and incisional biopsy of the neck mass confirmed the diagnosis of HD. This case emphasizes the value of FNA biopsy as a rapid and reliable procedure, even in the unusual but established clinical presentation of HD as a diffuse neck mass.     

Fine needle aspiration cytologic diagnosis of focal intrahepatic extramedullary hematopoiesis

A computed tomographic scan in an 80-year-old man with a urinary obstruction demonstrated a solitary space-occupying liver lesion, which was clinically suspected to be a metastatic carcinoma. Fine needle aspiration (FNA) of the mass produced a smear containing atypical, possibly malignant, cells. Correlation of the FNA findings with the patient's history resulted in a cytologic diagnosis of an intrahepatic focus of extramedullary hematopoiesis (EMH). This case shows FNA biopsy to be a reliable method of diagnosing foci of EMH, but also demonstrates the potential pitfall of diagnosing atypical megakaryocytes as malignant in FNA smears. EMH should be considered in the differential diagnosis of patients with bone marrow disorders and mass lesions in extramedullary sites.     

Chondroblastoma of the rib presenting as an intrathoracic mass. Report of a case with fine needle aspiration biopsy, immunocytochemistry and electron microscopy.

We describe an unusual case of chondroblastoma of the rib, initially presenting as a mediastinal mass eroding a vertebra, in which the preoperative diagnosis was made by fine needle aspiration (FNA) cytology and confirmed by histology and electron microscopy of the surgical specimen. Cytologic study of the smears revealed osteoclastlike giant cells and dishesive, mononucleate tumor cells; sections of the paraffin-embedded, aspirated material showed the chondroid matrix and typical chicken wire calcific deposits. Supporting diagnostic evidence was provided by immunohistochemical demonstration of S-100 protein. Unusual features were the presence of intranuclear pseudoinclusions and cytoplasmic granular deposits, which proved to contain iron on histochemical staining, ultrastructural morphology and x-ray analysis. This case emphasizes the value of FNA cytology in providing a correct diagnosis of chondroblastoma as well as the utility of embedding the aspirated material for histologic, immunohistochemical and ultrastructural studies.     

Cytologic findings in calcifying epithelial odontogenic tumor: a case report

BACKGROUND: Calcifying epithelial odontogenic tumor (CEOT), or Pindborg's tumor, is a rare, benign, odontogenic neoplasm first described by Pindborg in 1955. It is most commonly seen in the fourth and fifth decades of life, usually arises in the mandibular premolar-molar areas and accounts for approximately 1% of all intraosseous odontogenic tumors. This report describes the cytologic findings in a case of CEOT. CASE: A 62-year-old woman was referred to the ear, nose and throat clinic with a right maxillary mass. The fine needle aspiration (FNA) smears showed numerous calcifications; amorphous, eosinophilic material; and clusters of round epithelial cells embedded in a bloody background. The smears were diagnosed as suspicious for malignancy. Maxillectomy was done. The histologic sections were diagnosed as CEOT. CONCLUSION: FNA findings of calcifying epithelial odontogenic tumor have been described rarely. The clusters of epithelial cells with prominent nucleoli are mistaken for features of a malignant tumor.     

Dirofilaria repens diagnosed by the presence of microfilariae in fine needle aspirates: a case report

BACKGROUND: Dirofilariasis due to Dirofilaria repens with viable microfilariae outside the worm have not been reported before. CASE: A 40-year-old truck driver from rural Shiraz, Iran, had a firm mass, 2.5 x 2.5 cm, at the dorsolateral aspect of the right forearm. Fine needle aspiration (FNA) was performed on 2 occasions. Several microfilariae with blunt heads, pointed posterior ends and empty caudal spaces resembling microfilariae of Wuchereria bancrofti but longer were seen. Since Iran is a nonendemic area for lymphatic filariae and the patient had a history of contact with a dog, with the impression of dirofilariasis, the mass was excised, and the presence of adult worms in tissue sections confirmed the diagnosis. CONCLUSION: This case ofsubcutaneous dirofilariasis was diagnosed by detecting microfilariae in FNA smears and was confirmed on histopathology.     

Application of the immunoperoxidase technique to cell block preparations from fine needle aspirates

Immunocytochemistry on fine needle aspiration (FNA) material has been mainly performed on cytologic preparations; there have been few reports on the use of FNA cell blocks. This study compared the intensity scores of immunoperoxidase staining on FNA cell block preparations from 21 breast, 12 thyroid and 10 lymph node aspirates with the scores on the corresponding surgically excised specimens. FNA materials for cell blocks were fixed in formalin and embedded in agar. Ten commercially available antibodies forming three panels were studied using standard peroxidase-antiperoxidase and avidin-biotin complex techniques. In general, the staining results on the FNA cell block sections agreed with those on the surgical specimens; in addition, there were fewer aberrant positive staining results and much less background staining in the cell block sections. These phenomena were most striking with the cytokeratin antibodies. It is concluded that immunoperoxidase staining on FNA cell block preparations is reliable; the advantages of the use of cell block sections as opposed to smears are discussed.     

Neuroblastoma with concomitant giardiasis: report of a case with diagnosis by fine needle aspiration cytology

BACKGROUND: Diagnosis of two pathologies, including a neoplasm and infectious condition, by fine needle aspiration (FNA) cytology in the same patient is rare. CASE: A 2-year-old, male child presented with fever, abdominal pain and abdominal mass. Imaging findings were strongly in favor of a neuroblastoma. FNA smears from the mass revealed fecal material containing numerous trophozoites of Giardia lamblia. FNA was repeated in view of the imaging findings. Repeat smears showed a small round cell tumor with rosettes and background filamentous/fibrillar material consistent with a neuroblastoma. Chemotherapy reduced the mass considerably. Histopathology of the resected residual mass revealed a ganglioneuroma in addition to remnants of neuroblastoma. The patient was free of disease two years after the initiation of chemotherapy. CONCLUSION: When FNA cytology shows an infectious pathology in the clinical and imaging setting of a tumor, FNA should be repeated so that an important component of the diagnosis is not missed.     

Fine needle aspiration of urethral recurrence of urothelial carcinoma after radical cystectomy presenting as a perineal mass: a case report

BACKGROUND: Recurrence of urothelial (transitional cell) carcinoma in the urethra after cystectomy for invasive urothelial carcinoma is relatively uncommon. It is also uncommon for the recurring urethral tumor to present as a painful perineal mass. Fine needle aspiration (FNA) can be used to evaluate such perineal lesions and confirm tumor recurrence. CASE: A 5-cm-diameter mass was found in the perineum of a 63-year-old man 1 year after radical cystoprostatectomy for invasive urothelial carcinoma of the urinary bladder. The mass was detected on pelvic computed tomographic scanning. FNA cytology showed numerous urothelial carcinoma cells of high grade displaying squamous cell differentiation mimicking the histopathologic findings of the primary tumor found on cystectomy. Diagnosis of recurrent urothelial carcinoma was rendered. The FNA in this case spared the patient an open biopsy. CONCLUSION: Mass lesions arising in the perineum of patients who underwent cystectomy for urothelial carcinoma should raise the suspicion of urothelial carcinoma recurrence. Evaluation of perineal masses for recurrence of urothelial carcinoma can be made on FNA without the need for open biopsy.     

Utility of repeat fine needle aspiration in acute suppurative lesions. Follow-up of 263 cases

OBJECTIVE: To determine the clinical value of repeat fine needle aspiration (FNA) as a follow-up strategy in the management of patients in India, clinically suspected of having tuberculosis (TB) but showing a cytologic picture of acute suppuration. STUDY DESIGN: Repeat aspirates from 263 patients presenting with lymph node or soft tissue masses were analyzed. The previous FNA of these cases had shown acute inflammatory exudate but no epithelioid granuloma or acid-fast bacilli (AFB). RESULTS: The repeat FNA helped to detect 55% additional cases of TB within a period of 8 weeks; 67% of them were diagnosed in the second and third weeks. Diagnostic yield rose to 59% after the third FNA. AFB were detected in 34 (13.3%) cases that showed a low bacterial load. In addition, nontubercular lesions, such as epidermal inclusion cyst (4), cysticercosis (3), sialadenitis (2) and metastatic carcinoma (8), were diagnosed. CONCLUSION: All cases showing acute suppuration without granulomas or AFB on the first FNA should be reevaluated by follow-up FNA and staining for AFB. This will enhance the diagnostic yield of tuberculosis in developing countries, where molecular diagnostics are too costly or unavailable. This procedure is cost effective as compared to biopsy and culture. In addition to tuberculosis, many unexpected nontubercular lesions may also be unmasked. Repeat FNA reduces sampling and screening errors, improves sensitivity and helps to study the evolution of epithelioid granulomas.     

Kikuchi's histiocytic necrotizing lymphadenitis. Diagnosis by fine needle aspiration

Two cases of Kikuchi's histiocytic necrotizing lymphadenitis diagnosed by fine needle aspiration (FNA) of enlarged lymph nodes are reported. The FNA smears contained randomly activated lymphoid cells, necrotic debris, karyorrhectic cells and prominent histiocytes, suggesting the presence of reactive lymph nodes. The true nature of the lesions was evident from the examination of cell block sections prepared from tissue fragments in the aspirates, which preserved the architectural relationships of the different cell types. The same patterns were found in retrospectively and subsequently examined excised lymph nodes from these cases. The differential diagnosis of this entity, which may simulate a malignant lymphoma because of the presence of large numbers of activated lymphoid cells, is discussed and the value of preparing FNA cell blocks is emphasized. Though this rare benign disease may be suspected clinically in the more typical cases, such as young women with cervical lymphadenopathy, fever, neutropenia and otherwise excellent condition, the diagnosis cannot be made without a lymph node biopsy, which FNA may be able to provide in some instances.     

Lymphoepithelial cyst with crystalloid formation. Cytologic features of two cases

BACKGROUND: The presence of amylase crystalloids (AC) in cystic lesions of the parotid gland is a rare occurrence and has been diagnosed to date as sialadenitis. We report the first two cases of parotid lymphoepithelial cyst (LC) containing this type of crystalloid. CASES: Case 1, a 56-year-old male, presented with a 3-cm parotid cyst. Fine needle aspiration (FNA) was performed on the mass. Smears showed numerous crystalloids identical to those described as crystallized amylase. Case 2, a 36-year-old female, had a 2-cm parotid mass. FNA smears exhibited the same features as did case 1. The two patients were treated with superficial parotidectomy, and an LC containing AC was diagnosed in both cases. CONCLUSION: When the above findings are present on FNA of parotid gland, the diagnosis of LC must be considered.     

Value of EUS‐FNA cytological preparations compared with cell block sections in the diagnosis of pancreatic solid tumours

Y. Kopelman, S. Marmor, I. Ashkenazi and Z. Fireman
Value of EUS‐FNA cytological preparations compared with cell block sections in the diagnosis of pancreatic solid tumours Objective: Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) is performed in order to achieve a definite tissue diagnosis of pancreatic lesions. This in turn is a guide to the appropriate treatment for the patient. Tissue samples collected by the same needle for cytological preparations and cell block histological sections (often referred to as FNA‐cytology and FNA–biopsy, respectively) are handled differently. The specific contribution of each of these tests was evaluated. Methods: One hundred and two consecutive patients underwent EUS‐FNA while being investigated for pancreatic solid lesions. Diagnosis was made by cytology, cell block sections or both. The diagnosis was confirmed by clinical outcome. Results: Male/female ratio was 61/41. Mean age was 65 ± 12 years (range, 22–94). Mean lesion size was 3.1 ± 1.8 cm (range, 0.6–10 cm); 68% were >2 cm and 75% were located in the pancreatic head. The average number of needle passes was two (range, 1–4 passes). Final tissue diagnosis was malignant in 66 (65%) patients. Sensitivity, specificity and accuracy were 73%, 94% and 81%, respectively, for cytology alone, and 63%, 100% and 78%, for cell blocks alone. Eighty‐two patients (80%) had cytology and cell blocks, which matched in 64 (78%) patients. EUS‐FNA results that relied on both techniques had 84% sensitivity, 94% specificity and 88% accuracy. Cytology revealed 13 malignancies not diagnosed on cell blocks, while cell blocks revealed five malignancies not diagnosed by cytology. Malignant lesions were more common in men; they were larger in size and located in the pancreatic head. Conclusion: EUS‐FNA cytology was more sensitive than cell blocks but less specific for the diagnosis of solid pancreatic lesions. The two methods are complementary and implementing both improves the diagnostic value of EUS‐FNA.     

Carcinoid tumor metastatic to breast diagnosed by fine needle aspiration. Case report and literature review

Fine needle aspiration (FNA) biopsy was used to study a mass in the left breast in a patient with a previous history of an ileal carcinoid tumor and later lymph node metastases who presented with bilateral palpable breast masses. The FNA specimens showed the lesion to be a carcinoid tumor. The metastatic nature of the lesion was proven by positive restaining of FNA smears by both the Sevier-Munger technique (demonstrating abundant argyrophilic cytoplasmic granules) and the Fontana-Masson method (showing argentaffin cytoplasmic granules). The distinction between primary and metastatic carcinoid tumors of the breast is discussed, as is their origin and their differentiation from other malignancies of the breast.     

Fine needle aspiration cytology of metastatic olfactory neuroblastoma: a case report

BACKGROUND: Olfactory neuroblastoma (ONB) is an uncommon tumor, presenting as a polypoid mass arising from the upper nasal cavity. This tumor has been seldom diagnosed by direct fine needle aspiration (FNA). CASE: Metastatic ONB was diagnosed by FNA. The patient was a 40-year-old female with a polypoid mass in the nasal cavity and ipsilateral cervical lymphadenopathy. The punch biopsy of the nasal tumor revealed a smudged small round cell neoplasm with neuroendocrine differentiation, consistent with ONB. In FNA smears from the cervical lymph node, there were well-preserved, small, monotonous cells with hyperchromatic nuclei, fibrillary cytoplasm and indistinct cell borders. Also noteworthy were occasional pseudorosettes as well as rare true rosettes. By immunocytochemistry, tumor cells were positive for cytokeratin, chromogranin and synaptophysin. CONCLUSION: ONB, like adrenal neuroblastoma, shows distinctive cytologic features, including a rosette or pseudorosette and fibrillary network. FNA can accurately demonstrate these characteristic findings, and in some cases it may be a better diagnostic modality than incisional biopsy.