Clinical utility of fine needle aspiration biopsy in the diagnosis of Wegener's granulomatosis. A report of two cases.

In two patients, pulmonary lesions of Wegener's granulomatosis (WG) were sampled by fine needle aspiration biopsy: one with the clinical diagnosis of primary pulmonary malignancy and the other with a clinical suspicion of WG. In the latter case the smears showed distinctive eosinophilic, collagen necrosis (pathergic necrosis), poorly formed granulomata composed of loose aggregates of elongated, often palisading epithelioid histiocytes, and multinucleate histiocytes. A cell block preparation in this case contained minute tissue fragments illustrating the distinctive, pathergic-type necrosis. In the former case, many of these features were present, but additionally there were several groups, atypical bronchial epithelial cells that, in light of the clinical impression, initially led to an incorrect diagnosis of bronchoalveolar carcinoma. Subsequent review of this case led to the diagnosis of WG. Antineutrophil cytoplasmic antibody (ANCA) serology was later obtained, confirming the diagnosis of WG in both cases. In our experience, the cytomorphologic findings of granular collagen necrosis, granulomata and multinucleate cells, although not specific, should alert the cytopathologist to consider the diagnosis of WG, especially when special stains for microorganisms are negative. A recommendation for ANCA serology testing early in the disease process, particularly in the limited forms of the disease, may lead to early recognition of WG, resulting in prompt institution of immunosuppressive therapy, greatly improving the patient's prognosis.     

Diagnosis of xanthogranulomatous cholecystitis by fine needle aspiration biopsy. A case report

Xanthogranulomatous cholecystitis is an uncommon benign thickening of the gallbladder wall characterized histopathologically by extensive histiocytic infiltration. A case is presented in which a 62-year-old woman with clinical cholecystitis was found at surgery to have a markedly thick-walled, adherent gallbladder, raising the differential diagnosis of an inflammatory versus an infiltrating neoplastic process. Intraoperative fine needle aspiration (FNA) biopsy revealed abundant foamy histiocytes ("xanthoma cells"), both dispersed and in clusters associated with capillaries suggestive of organization. Occasional multinucleated giant cells and columnar epithelial cells were also present. The differential diagnosis of histiocytic processes sampled by FNA biopsy is reviewed.     

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.     

Pitfalls in the diagnosis of Wegener''s granulomatosis on fine needle aspiration cytology

OBJECTIVE: To review the clinical and pathological findings in six suspected cases of Wegener's granulomatosis (WG) and highlight the diagnostic difficulties faced by the cytopathologist. METHODS: Retrospective review of records of the Cytopathology Department to identify patients who underwent image-guided transthoracic pulmonary fine needle aspiration cytology (FNAC) for pulmonary lesions of suspected WG and those who were subsequently confirmed to have WG. Detailed evaluation of cytomorphological features was carried out. RESULTS: A total of six cases were identified in whom the initial procedure to obtain a pathological diagnosis was transthoracic FNAC. In one case, atypical squamous cells on cytology initially suggested a diagnosis of squamous cell carcinoma while in another a diagnosis of WG was made on cytology; however, a subsequent lung biopsy revealed silicosis. CONCLUSION: Acute inflammation and necrosis are the most consistent cytopathological findings in WG. In selected cases FNAC can provide supportive pathological evidence to establish a diagnosis of WG.     

Fine needle aspiration diagnosis of lymphomatoid granulomatosis. A case report.

The diagnosis of lymphomatoid granulomatosis (LG) of the lung depends on obtaining adequate histologic material to demonstrate the characteristic angioinvasive, polymorphous, lymphoid infiltrate and normally requires an open lung biopsy. Fine needle aspiration biopsy (FNAB), if only smeared directly, does not allow an assessment of the lymphoid infiltrate in relation to blood vessels. However, we report a case diagnosed by FNAB in which the specimen was processed by an alternative method that allows cell blocks to be made from all visible particles. Percutaneous FNAB of a nodular pulmonary infiltrate was performed after bronchoscopy and transbronchial needle biopsy failed to yield a diagnosis. The FNAB specimen was placed in 50% alcohol and submitted for processing. The specimen was then filtered through a fine sieve, and all visible tissue was embedded in bacteriologic agar and processed as a standard surgical specimen. The filtrate was processed as standard fluid cytology. The atypical, angioinvasive, lymphoid infiltrate was clearly demonstrated on the cell blocks, and the diagnosis of LG was made. This diagnosis was confirmed by subsequent open lung and skin biopsies.     

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.     

Fine needle aspiration cytologic findings in a case of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman syndrome)

The clinical, fine needle aspiration (FNA) cytologic and histologic findings in a case of sinus histiocytosis with massive lymphadenopathy (SHML) in a five-year-old boy are presented. The FNA smears showed a proliferation of plasma cells, lymphoid cells and histiocytes demonstrating emperipolesis that is characteristic of this benign disorder; these cytologic findings were reported as a reactive lymphoid infiltrate with a high content of benign histiocytes. The diagnosis was made on a subsequent open biopsy performed on the persistent lymphadenopathy. The differential diagnosis of lymph nodes containing a prominent component of histiocytes is discussed.     

Fine needle aspiration cytology of tuberculosis of the lumbar vertebrae (Pott's disease)

The cytomorphologic features of tuberculosis of the lumbar vertebra having a granulomatous pattern diagnosed by fine needle aspiration (FNA) biopsy are reported in a 72-year-old woman with a prior history of malignant lymphoma treated by chemotherapy. Cytologic examination revealed microtissue fragments of cohesive cells, including epithelioid histiocytes and scattered, multinucleated Langhans-type giant cells. This is believed to be the first reported case of vertebral tuberculosis (Pott's disease) diagnosed by FNA cytology and confirmed by culture of the aspirate material. This case illustrates the value of FNA cytology in the diagnosis of nonneoplastic skeletal lesions and confirms the value of FNA biopsy the early detection of infectious processes in patients with malignancy.     

Semi-quantitative analysis of soft-tissue reactions in fine needle aspirates from tissue cysticercosis

Fine needle aspiration cytology (FNA) has a well-documented role in the diagnosis of cysticercosis. However, little is discussed about the associated inflammatory response in the host tissues. Aspirates from 182 cases of subcutaneous cysticercosis were semiquantitated for the type and degree of inflammatory response, and the amount and preservation of the parasite. Tissue sections were reviewed where available. In the FNA where no parasite was observed but a confirmatory tissue diagnosis was available, it was found that eosinophils (52%), epithelioid cell granulomas (30%), palisading histiocytes (33%) and giant cells (28%) were seen less frequently than in those where larval fragments were identified in the aspirated material in varying quantities, the response being 88-92% eosinophils, 50-70% palisading histiocytes, 68-80% epithelioid cell granulomas and 46-74% giant cells. Repair cells were maximally seen when readily identifiable larval fragments were seen in the aspirate. Bizarre cells were equally distributed in these aspirates. The tissue response in FNA from subcutaneous cysticercosis can be varied and eosinophils are found to increase with the presence of the degenerating parasite. In soft-tissue aspirates, palisading histiocytes with epithelioid cell granulomas with or without giant cells and an inflammatory exudate with predominantly eosinophils alerts one to search diligently for a parasite.     

Pulmonary tumorlet: a case report of a diagnostic pitfall in cytology

BACKGROUND: Pulmonary tumorlets are usually an incidental pathologic curiosity of no clinical importance, but may be mistaken for epithelial and nonepithelial neoplasms. Fine needle aspiration (FNA) of this cell proliferation has rarely been reported. We describe a pulmonary tumorlet associated with bronchocentric granulomatosis presenting as a tumorous consolidation on chest radiograph. CASE: In a hitherto healthy 70-year-old man admitted for acute respiratory infection, a solid consolidation was found on chest radiograph. Medical history was uneventful except right-sided pleurisy in 1949. Computed tomography-guided FNA sample was composed of loose clusters of small columnar cells with cyanophilic cytoplasm and centrally located round to oval nuclei. With a tentative diagnosis of well-differentiated adenocarcinoma, lumpectomy was performed. Intraoperative cytology demonstrated lymphocytes, epithelioid cells, giant cells of Langerhans type and clusters of columnar cells. Definitive histologic examination confirmed the intraoperative diagnosis of necrotizing granulomatosis and tumorlet. Neuroendocrine origin of the cells was confirmed by immunocytochemical and immunohistochemical studies resulting in strong reactivity of the cells to synaptophysin, NSE, chromogranin A and N-Cam. CONCLUSION: Knowledge of the cytomorphologic presentation of tumorlets in FNA and consideration of the appropriate differential diagnoses combined with ancillary studies might have prevented lung resection.     

Subclassification of localized Leishmania lymphadenitis in fine needle aspiration smears

OBJECTIVE: To describe the cytologic findings of localized Leishmania lymphadenitis and discuss the differential diagnosis. STUDY DESIGN: The study group consisted of 133 cases. All of them were diagnosed by fine needle aspiration (FNA) study. The ages ranged between 3 and 80 years, 102 were male and 31 female. Seventy lymph nodes were excised. RESULTS: The FNA smears revealed a polymorphic population of cells composed of lymphocytes, histiocytes, giant cells, abnormal plasma cells and tingible body macrophages. Leishman-Donovan (LD) bodies were identified in all cases, but their number differed from case to case. Granulomas, dendritic cells, mast cells and lymphoglandular bodies were identified in a substantial number of cases. Depending upon the presence of characteristic cytologic findings, the cases were divided into five major groups: acute inflammation with giant cells, histiocytic granulomas, epithelioid cell granulomas, plasma cell type and mixed histioplasmacytic type. CONCLUSION: Leishmaniasis is an uncommon cause of cervical lymphadenitis but should be considered in the differential diagnosis of unexplained lymphadenopathy in endemic countries. Demonstration of LD bodies is necessary for the diagnosis of this self-limited condition, for which no treatment is required.     

Fine needle aspiration cytology of fibroadenoma with multinucleated stromal giant cells. A review of cases in a six-year period

OBJECTIVE: To describe the fine needle aspiration cytology findings of fibroadenoma with multinucleated stromal giant cells, with histologic correlation. STUDY DESIGN: The author reviewed the cytologic findings of two cases of fibroadenoma with multinucleated stromal giant cells from the file of Pamela Youde Nethersole Eastern Hospital in a six-year period from 1995 to the end of 2000. The diagnosis was confirmed by histologic examination of the lumpectomy specimens. RESULTS: The two cases had similar cytologic findings. The direct smears contained cohesive clusters of bland-looking ductal cells arranged in a "staghorn" pattern. Numerous naked nuclei were also seen in the background. Also, there were occasional multinucleated giant cells in isolation. These giant cells contained 5-10 randomly arranged, round to oval nuclei, fine chromatin and sometimes distinct nucleoli. The cytoplasm was abundant and pale staining, and the cell border was ill defined. Associated epithelioid histiocytes and foamy macrophages were not seen. Histologic examination of the lumpectomy specimens showed architectural features of fibroadenoma with pericanalicular and intracanalicular patterns. In addition, scattered multinucleated giant cells with focal degenerative change were noted in the tumor stroma. Their stromal nature was confirmed by immunohistochemical study. CONCLUSION: Multinucleated stromal giant cells are rarely identified in fine needle aspiration biopsies of fibroadenoma. Recognition of this peculiar finding may help to avoid misdiagnosis of other, more sinister conditions, such as phyllodes tumor and metaplastic carcinoma.     

Atypical squamous cells as a diagnostic pitfall in pulmonary Wegener's granulomatosis. A case report

BACKGROUND: Wegener's granulomatosis (WG) is characterized by systemic, necrotizing, granulomatous inflammation accompanied by vasculitis. It classically involves the triad of the upper respiratory tract, lungs and kidneys. Isolated pulmonary lesions of WG may present in some patients as pulmonary masses, simulating neoplasms. The features of WG can be suggested by cytologic study. Atypical epithelial cells associated with WG have previously been reported as a cause of a false positive diagnosis of bronchoalveolar carcinoma. CASE: In this case the cytologic findings included atypical squamous cells in a background of acute, chronic and granulomatous inflammation. In several respiratory specimens the atypical squamous cells were incorrectly interpreted as diagnostic of squamous cell carcinoma. The correct diagnosis of WG was confirmed with open lung biopsy, which demonstrated necrotizing granulomatous inflammation with geographic necrosis and associated vasculitis. CONCLUSION: Markedly atypical squamous cells mimicking squamous cell carcinoma can be found accompanying the inflammatory process associated with WG and are a possible diagnostic pitfall. The possibility of WG as well as other inflammatory processes should always be considered in the differential diagnosis of squamous cell carcinoma of the lung. This case is the only reported case of WG in which atypical squamous cells were a diagnostic pitfall, initially suggesting a diagnosis of squamous cell carcinoma.     

Sputum cytodiagnosis of disseminated histiocytic lymphoma. A case report

Cytohistologic evidence of pulmonary involvement with histiocytic lymphoma was discovered in a patient nine years after the original clinical diagnosis was made. The positive sputum cytologic diagnosis confirmed the radiologic impression of pulmonary involvement, which was substantiated by an open lung biopsy. This case report demonstrates the value of periodic sputum cytology in the diagnosis and management of histiocytic lymphoma. Sputum cytology should be utilized more frequently in the monitoring of pulmonary histiocytic lymphoma.     

Epithelioid hemangioendothelioma of the lung diagnosed by transesophageal endoscopic ultrasound-guided fine needle aspiration: a case report

BACKGROUND: Epithelioid hemangioendothelioma is a rare vascular tumor of the lung and is also known as intravascular sclerosing bronchoalveolar tumor. Although it has relatively low malignant potential, extensive pulmonary involvement and systemic metastasis have been described. The cytologic features of these tumors are not very well defined, with only few case reports describing the cytologic findings of epithelioid hemangioendothelioma of the lung on fine needle aspiration. CASE: Endoscopic ultrasound-guided fine needle aspiration of a hilar mass was performed on a 25-year-old female. The cytology showed loosely cohesive sheets and clusters of epithelioid cells. The cellular features included large, irregular nuclei with nucleoli and a moderate amount of vacuolated cytoplasm. Rare cells had a suggestion of cytoplasmic lumen formation. Histologic examination of tissue fragments on the cell block revealed a tumor composed of rounded to spindled epithelioid cells in a background of light blue stroma. The endothelial differentiation was evidenced by cytoplasmic vacuoles and lumens, some of which contained erythrocytes. The endothelial nature of these cells was confirmed by positive staining with factor VIII and CD34. CONCLUSION: The cytomorphologic features of epithelioid hemangioendothelioma described in the literature and observed in our case are distinctive and can help with the interpretation of cytologic smears and prevent misdiagnosis.     

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.     

Pseudotumoral tuberculosis of the uterine cervix. Cytologic presentation

The cytologic presentation of a case of pseudotumoral tuberculosis of the uterine cervix is described. The presence in cervicovaginal smears of epithelioid cells arranged in clusters mixed with Langhans' giant cells was highly suggestive of tuberculosis. This diagnosis was confirmed by the detection of acid-fast bacilli in histologic preparations and cultures from biopsy specimens.     

Fine needle aspiration cytology of clear cell sarcoma. Report of a case with immunocytochemical, immunohistochemical and ultrastructural studies.

Cytologic findings of clear cell sarcoma obtained by fine needle aspiration (FNA) of a tumor are described. The tumor probably originated in the retroperitoneal tissue, and the diagnosis was confirmed histologically by open biopsy. Percutaneous needle aspirates of the intraabdominal tumor and touch preparations obtained from the open biopsy specimen revealed numerous atypical cells with an extremely hyperchromatic nucleus, prominent nucleoli and clear cytoplasm. The cytoplasm was rich in glycogen. The immunocytochemical technique demonstrated S-100 protein and neuron-specific enolase in the cytoplasm, both of which were exhibited also in the histologic specimen. Clear cell sarcoma is a rare tumor of soft tissue, and to our knowledge, detailed cytologic appearances of this tumor obtained by FNA have not been reported. In addition, the present tumor was unique in location. It is possible to diagnose clear cell sarcoma accurately on an FNA cytologic specimen if the periodic acid-Schiff stain and immunocytochemical technique are utilized in addition to the routine Papanicolaou method.     

Fine needle aspiration cytology of subareolar abscess of the breast. Spectrum of cytomorphologic findings and potential diagnostic pitfalls

The cytomorphologic findings of eight cases of subareolar abscess of the breast diagnosed by fine needle aspiration (FNA) biopsy are presented. A spectrum of cytologic findings was appreciated, including diagnostic anucleated squames associated with numerous neutrophils, keratinous debris, cholesterol crystals, parakeratosis and strips of squamous epithelium. A foreign-body reaction, with sheets of histiocytes and multinucleated foreign-body-type giant cells, was noted in some of the cases. Potential pitfalls for a false-positive diagnosis of malignancy included the presence of groups of atypical ductal cells, squamous atypia and fragments of exuberant granulation tissue. Seven of the eight cases had complete surgical excision of the lesion, which demonstrated the characteristic findings of dilated lactiferous ducts undergoing squamous metaplasia with rupture and surrounding extensive acute and chronic inflammation with foreign-body reaction. With recognition of the FNA cytologic findings of subareolar abscess of the breast, a specific diagnosis can be rendered, which then allows different treatment modalities depending on the stage of the lesion. Appreciation of the spectrum of cytologic features will enable the pathologist to make the correct diagnosis and thereby avoid potential pitfalls that can possibly lead to a false-positive diagnosis of malignancy.     

Critical appraisal of fine needle aspiration cytology in tuberculous lymphadenitis.

A cytomorphologic diagnosis of tuberculous lymphadenitis by examination of needle aspirates was made in 560 of 1,471 cases of lymphadenopathy studied over two years. Cytologic features were categorized into four groups: epithelioid clusters with or without Langhans's giant cells without necrosis (32.14%), epithelioid clusters with or without Langhans's giant cells with necrosis (50.35%), occasional epithelioid cells without characteristic necrosis/giant cells (2.85%) and necrosis without epithelioid clusters or Langhans's giant cells (14.64%). While a diagnosis of tuberculous lymphadenitis was offered with confidence in the first two groups, constituting about 82.49% cases, aspirates from the third- and fourth-group patients were subjected to Ziehl-Neelsen staining for acid-fast bacilli, which was positive in 12.5% and 75.6% of cases, respectively.