Assessment of fine needle aspiration as a screening test for occult prostatic carcinoma

As part of an ongoing study of objective parameters of prognostic value in prostatic carcinoma, a routine procedure was developed to aspirate all prostates prior to surgery. These targets were different from those of other workers in the field of prostatic fine needle aspiration (FNA), who generally advocate that FNA be confined to suspicious nodules. The aspirations were performed by a large group of practicing urologists who had no special training in prostatic FNA except for guidelines provided by their peers and information available in the literature. This approach permitted an assessment of the performance of FNA as a screening test rather than as a diagnostic procedure. During the period from January 1983 to February 1987, 1,683 patients had prostatic FNAs performed (plus subsequent histologic study). The following diagnoses were rendered: "inadequate/scanty specimen" in 625 cases (37%), "negative/atypical" in 844 cases (50%) and "suspicious/positive" in 214 cases (13%). Histologic examination showed stage A1 prostatic adenocarcinoma in 18 patients. The cytologic diagnoses on these 18 patients were inadequate/scanty in 3 (17%), negative/atypical in 13 (72%) and suspicious/positive in 2 (11%). Of the 214 patients with a positive/suspicious diagnosis by FNA, the diagnosis of prostatic carcinoma was confirmed by tissue evidence in 200; the other 14 patients had either no evidence of prostatic carcinoma on surgical biopsy (needle biopsy/transurethral resection/suprapubic prostatectomy) or had no surgical biopsy. Eight of the 14 patients developed clinical evidence of carcinoma, 1 died of urinary bladder carcinoma and 1 was lost to follow-up. In the remaining four patients, there is still no evidence of prostatic carcinoma after about one-and-one-half years of follow-up. These results indicate that (1) specialized training is required in order to obtain adequate smears by prostatic FNA; (2) prostatic FNA is not a good screening technique for detecting stage A1 prostatic carcinoma; and (3) a positive diagnosis by prostatic FNA, even when not confirmed by tissue biopsy, is still an indication of disease.     

Primary squamous cell carcinoma of the thyroid diagnosed by fine needle aspiration cytology. A report of two cases.

BACKGROUND: Primary squamous cell carcinoma of the thyroid is a rare malignant tumor that needs to be distinguished from other neoplasms. CASES: Two males aged 65 and 68 years presented with an enlarged right lobe of the thyroid. Thyroid scintigraphy revealed a cold nodule. Clinically malignancy was suspected. Fine needle aspiration (FNA) revealed numerous clusters and isolated malignant cells, dyskeratotic cells and deposits of eosinophilic granular keratin material. Subtotal thyroidectomy was performed. Histologic findings confirmed the cytologic diagnosis of squamous cell carcinoma. CONCLUSION: Primary squamous cell carcinoma of the thyroid is a rare tumor. FNA findings of this tumor were not reported before. FNA study cannot help to differentiate primary from metastatic squamous cell carcinoma of the thyroid.     

Breast metastasis from uterine leiomyosarcoma diagnosed by fine needle aspiration: a case report

BACKGROUND: Leiomyosarcomas of the breast are a rare subgroup of primary breast sarcomas. Even more rare is breast metastasis of an extramammary leiomyosarcoma. To date, only 4 cases have been reported in the literature. CASE: We report a case of breast metastatic leiomyosarcoma in a 58-year-old woman with a prior history of uterine leiomyosarcoma, resected 18 months earlier. The breast mass was palpable and a fine needle aspiration (FNA) was performed. The microscopic examination showed cellular smears composed of loosely structured clusters and tissue fragments of spindle-shaped and polygonal or rounded malignant cells in disorderly arrangement. The tumor cells were medium- or large-sized, with basophilic cytoplasm and enlarged, irregular, hyperchromatic nuclei with nucleoli. Tumor giant cells and multinucleation were also present. The morphologic features along with immunocytochemical positivity for desmin, muscle-specific actin and vimentin indicated the diagnosis of a metastatic leiomyosarcoma. CONCLUSION: FNA cytology can be a reliable method for the diagnosis of leiomyosarcoma. The morphologic criteria in combination Swith the clinical history and the immunocytochemical findings can indicate a definitive diagnosis and avoid additional painful and time-consuming diagnostic procedures for the appropriate patient's further clinical management.     

Detection of Epstein-Barr virus-associated antigen in fine needle aspiration smears from cervical lymph nodes in the diagnosis of nasopharyngeal carcinoma

Epstein-Barr virus (EBV) has consistently been shown to be associated with undifferentiated nasopharyngeal carcinoma, and an EBV-associated nuclear antigen (EBNA) has been detected in the cells of nasopharyngeal carcinoma. A study on the applicability of EBNA detection in fine needle aspiration (FNA) smears from cervical lymph nodes in the diagnosis of metastatic nasopharyngeal carcinoma was performed. All 11 cases (100%) with metastatic nasopharyngeal carcinoma showed EBNA-positive tumor cells, characterized by bright, granulated nuclear fluorescence. Three (50%) of six cases with other metastatic head and neck carcinomas also showed EBNA-positive tumor cells. These findings suggest that the presence of EBNA-positive tumor cells in FNA smears from cervical lymph nodes is not specific for metastatic nasopharyngeal carcinoma. On the other hand, a negative result in the presence of tumor cells may help to exclude it. A larger study is required to verify these preliminary findings.     

Fine needle aspiration cytology of neoplasms metastatic to the breast

The fine needle aspiration (FNA) cytologic findings in 18 cases of metastatic neoplasms of the breast are reported. The cases were encountered in a combined series of 2,529 FNA breast biopsies, of which 666 were malignant; the metastatic neoplasms of the breast thus constituted 2.7% of all the malignant breast tumors. The series consists of 15 women and 3 men, with a mean age of 48 years (range of 11 to 73 years). Sixteen biopsies confirmed metastatic malignancy in patients with known extramammary primaries; the prebiopsy clinical diagnoses in six of the patients were benign breast lesions. In eight patients, the clinical differential diagnosis was either a benign or malignant primary breast lesion versus a metastatic malignancy. In two additional patients, the FNA biopsy identified metastatic neoplasms from unsuspected extramammary primaries. The metastatic neoplasms included three small-cell carcinomas of the lung, one squamous-cell carcinoma of the lung, two malignant melanomas, three ovarian malignancies, including a dysgerminoma, and one each of carcinoma of the fallopian tube, endometrial carcinoma, transitional-cell carcinoma of the urinary bladder, prostatic carcinoma, acute granulocytic leukemia, lymphoma, mycosis fungoides, hepatoma and neuroblastoma of the retroperitoneum. Recognition of unusual cytologic patterns raised the suspicion of, or confirmed the diagnosis of, malignancy in all cases, with no false-negative diagnoses. None of the cases were cytologically interpreted as a primary breast malignancy. Ancillary studies performed on the FNA material, including immunocytochemistry, contributed to a definitive diagnosis in three cases. FNA diagnosis of metastatic malignancy of the breast is essential in order to avoid unnecessary mastectomy and to ensure appropriate chemotherapy and/or irradiation treatment.     

Cytologic features of ovarian granulosa cell tumor metastatic to the lung. A case report

BACKGROUND: Granulosa cell tumor (GCT) of the ovary is an uncommon but not rare tumor, and the adult type usually affects postmenopausal women. The adult type of GCT has several characteristic clinicopathologic features, including a composition of small, uniform cells with Call-Exner bodies and an ability to metastasize to extrapelvic organs, even several decades after the initial operation. CASE: A 62-year-old female was incidentally found to have multiple shadows in the peripheral portions of both lung fields on roentgenography. She had a past history of oophorectomy for an ovarian carcinoma more than 20 years earlier. A transbronchial lung biopsy series was nondiagnostic. An aspirate obtained by transthoracic fine needle aspiration (FNA) biopsy revealed clusters of rather uniform, small cells with nuclear grooves, suggestive of a metastatic lung tumor. Histologic examination of the lung tissue in comparison with the previous oophorectomy specimen confirmed the impression of GCT metastatic to the lung. CONCLUSION: A preoperative diagnosis of metastatic lung tumor was established by transthoracic FNA cytology. The important cytologic criteria for the differential diagnosis are uniformity of tumor cells, coffee bean-like nuclear grooves and Call-Exner bodies. The possibility of late recurrence of this kind of tumor, even two or three decades after surgical resection, should be kept in mind.     

Adenoid cystic carcinoma metastatic to the kidney: a case report

BACKGROUND: Fine needle aspiration (FNA) of kidney lesions under image control is widespread and well documented. This technique is essential in preoperative differential diagnosis of solid and cystic benign or malignant lesions of the kidney. Kidney metastases are not frequent and are usually described in terminally ill patients, by which time the illness is extended, or in autopsy findings. A small percentage of kidney lesions are metastatic tumors from a known primary location and are found in oncologic controls. CASE: We present a case of metastasis to the kidney from a palate adenoid cystic carcinoma (ACC) diagnosed 14 years previously. The patient presented with a kidney cystic lesion. FNA revealed the characteristic features of an ACC. CONCLUSION: We emphasize the usefulness of FNA in the differential diagnosis of renal metastatic tumors. The characteristic cytologic morphology of ACC permits differentiation between a primary renal tumor and a metastatic process.     

Fine needle aspiration cytology of follicular dendritic cell sarcoma. Report of a case with cytologic detection in an extranodal site

BACKGROUND: Follicular dendritic cell sarcoma (FDCS) is a rare malignancy of accessory immune cells that can present in both nodal and extranodal sites. Previous cytologic case reports of FDCS have focused on fine needle aspiration (FNA) findings in nodal sites with low grade morphology and indolent clinical courses. CASE: A 33-year-old female presented with a three-month history of abdominal distention, early satiety and nausea. Initial imaging studies showed a large abdominal mass, with subsequent studies showing lung, liver and lymph node metastases. Examination of primary and metastatic tumors by a combination of conventional histology, immunohistochemistry and FNA demonstrated an extranodal intraabdominal follicular dendritic cell sarcoma. CONCLUSION: FDCS demonstrates a characteristic cytologic picture on FNA, with important cytologic features, including both syncytial and discohesive large epithelioid to spindled malignant cells with intranuclear inclusions, nuclear grooves and a prominent, mature, lymphocytic inflammatory component. No evidence of morphologic tumor progression was noted in comparison of primary and metastatic tumors. To aid in the cytologic distinction of FDCS from other similar-appearing neoplasms, we recommend acquisition of material for immunohistochemical studies, recognition of diverse clinical presentations (including extranodal and aggressive) and acknowledgment of the range of tumor morphologic grades.     

Fine needle aspiration of pleomorphic giant-cell carcinoma of the pancreas. Case report with ultrastructural observations

The fine needle aspirate in a case of pleomorphic giant-cell carcinoma of the pancreas, an unusual but highly malignant variant of ductal carcinoma of the pancreas, was characterized by bizarre tumor giant cells, "osteoclastlike" giant cells and abundant mitoses. The differential diagnostic possibilities include sarcoma (rhabdomyosarcoma, malignant fibrous histiocytoma and liposarcoma), melanoma, choriocarcinoma, metastatic giant-cell carcinoma of the lung and giant-cell tumor of the pancreas. A combination of clinical history, imaging findings and fine needle aspiration biopsy with transmission electron microscopy could lead to the appropriate diagnosis and help differentiate this entity from the other possible considerations.     

Adenoid cystic carcinoma metastatic to the lung. Report of a case diagnosed by fine needle aspiration biopsy cytology

Cytologic examination of a fine needle aspiration (FNA) biopsy specimen served to diagnose a lung metastasis in a patient with an adenoid cystic carcinoma primary in a minor salivary gland of the hard palate. The aspiration cytologic features of the metastatic adenoid cystic carcinoma were similar to those of primary adenoid cystic carcinoma, including uniform tumor cells with scant cytoplasm surrounding transparent, mucoid spherical bodies. FNA biopsy cytologic diagnosis of metastatic adenoid cystic carcinoma is accurate, particularly if mucoid spherical bodies are present.     

Fine needle aspiration cytology of a thyroid metastasis of metaplastic breast carcinoma: a case report

BACKGROUND: Metaplastic breast carcinoma is defined as mesenchymal and/or squamous cell components associated with ductal carcinoma. Because of the heterogeneous nature of this tumor, cytologic interpretation on fine needle aspirates can be quite challenging. This is especially true of metastatic lesions of this rare tumor type. Metastasis to the thyroid has not been previously reported. CASE: A 57-year-old woman with a history of metaplastic breast carcinoma for which she underwent mastectomy, chemotherapy and radiation therapy 2 years earlier presented with a fast-growing left thyroid mass with progressive hoarseness and dysphasia. Clinical presentation and findings from a neck computed tomographic scan were strongly suggestive of a primary thyroid malignancy. The aspirate specimen was composed of scant, highly atypical epithelial cells in a background of an abundant chondromyxoid matrix and scattered, benign follicular cells. A literature review confirmed the novelty of this case. CONCLUSION: This case emphasizes the value of clinical information and the importance of generous sampling in achieving a correct diagnosis of metastatic metaplastic carcinoma.     

Diagnosis of icteric-type hepatocellular carcinoma by fine needle aspiration: a case report

BACKGROUND: Bile duct invasion is very rare in patients with hepatocellular carcinoma (HCC). It usually presents difficult problems with the clinical differential diagnosis. Moreover, another difficulty might arise when an obstructive jaundice patient is found to have past history of 2 separate malignancies. Fine needle aspiration (FNA) becomes the method of choice for clarification of the bile duct tumor thrombus. CASE: A 72-year-old man presented with progressive obstructive jaundice for 1 month. Past history revealed the occurrence of 2 distinct malignancies during the previous 3 years; they had been resected successfully. Initial imaging studies, including abdominal sonography and computed tomography, were negative for the liver. However, FNA demonstrated clusters of pleomorphic and hyperchromatic cancer cells with an increased nuclear/cytoplasmic ratio proliferating in a vague trabecular pattern with some appearance of sinusoids. Multinucleated giant cells were seen. No bile duct epithelial cells were seen. The diagnosis of the third separate malignancy, moderately differentiated HCC, was made. CONCLUSION: To our knowledge, this is the first report of icteric-type HCC diagnosed by FNA although the primary lesion was undetectable on routine, noninvasive examinations. FNA cytology is an accurate and minimally invasive method for early confirmation of biliary HCC thrombi.     

Diagnosis of malignant granular cell tumor by fine needle aspiration cytology:.

BACKGROUND: Malignant granular cell tumors (GCT) are the rarest of all sarcomas, and the histologic differentiation from their benign counterpart may be extremely difficult or impossible unless metastatic disease is demonstrated. To our knowledge, this is the first report of a malignant GCT diagnosed by fine needle aspiration (FNA) cytology. CASE: A 70-year-old, Caucasian female presented with a progressively enlarging left supraclavicular mass. FNA of the mass revealed a metastatic tumor cytologically consistent with GCT. With this diagnosis, a search for other metastatic sites was initiated. Computed tomography (CT) scan revealed several tumor nodules in the lungs and liver. CT-guided FNA and tru-cut needle biopsy of a liver mass confirmed the diagnosis of metastatic GCT. In searching for a primary site, the patient revealed a clinical history of having had a tumor removed from her back two months before; it was reported to be an atypical GCT. Comparison of the three tumors revealed similar histologic, cytologic and immunohistochemical features. CONCLUSION: Evidence of mild to moderate cytologic atypia; increased mitotic activity; locally aggressive growth; increased proliferative activity as demonstrated by immunohistochemical evaluation of proliferation markers; and DNA ploidy analysis, as reported for this case, may be helpful in predicting malignant behavior of GCTs.     

Cytologic findings of breast ductal lavage and concurrent fine needle aspiration in pleomorphic lobular carcinoma in situ: a case report

BACKGROUND: Breast ductal lavage (DL) is a noninvasive procedure for sampling ductal epithelial cells. Patients at risk for breast cancer or with prior history can be monitored by DL. This report compares cytomorphology in concurrent DL, fine needle aspiration (FNA) and histology in a case of pleomorphic lobular carcinoma in situ (PLCIS) with signet ring features. CASE: A 57-year-old woman had DL and FNA performed after quadrantectomy for lobular carcinoma in situ with signet ring cell features. DL and FNA were diagnosed as suspicious and positive for malignancy, respectively. Subsequent biopsy showed PLCIS. Cytomorphologic features of DL, FNA and histology were compared. DL showed epithelial cells in small clusters or single-file arrangement and single-lying; in FNA, single cells predominated. DL and FNA showed nuclear atypia and cytoplasmic vacuoles, the latter more prevalent in FNA. Both samples showed cells with signet ring features. The atypical epithelial cells present in DL and FNA were identical to those seen in the histologic material. CONCLUSION: Cytomorphologic findings in DL, although less striking, are comparable to those seen in FNA. Architecture, nuclear atypia and intracytoplasmic vacuoles are helpful features in DL for establishing a diagnosis of suspicious if not positive for malignancy in LCIS.     

Inflammatory myofibroblastic tumor of the breast. A case report

BACKGROUND: Inflammatory myofibroblastic tumor (IMT) of the breast is a very rare tumor like lesion with only 6 previously reported cases. Very little is known about the cytology of IMT. We present the fine needle aspiration (FNA) cytology of a case of recurrent, bilateral IMT of the breast and detail the clinical course, radiologic findings, morphologic appearances and immunohistochemical profile of the lesion. CASE: A 79-year-old female was initially seen in 1991 because of a suspicious mammographic abnormality in her right breast. Ultrasound-guided FNA cytology showed an unusual "inflammatory" lesion with occasional aggregates of cellular connective tissue fragments, sheets of uniform ductal epithelial cells with myoepithelial cells, spindle cells, lymphocytes and histiocytelike cells. The lesion was excised, and histology confirmed a benign process with spindle cells, lymphocytes and histiocytes. No malignant features were noted. During follow-up many new lesions appeared in both breasts, and after several FNA procedures and local excisions, bilateral mastectomy was performed at the patient's urging. She remained disease free. CONCLUSION: Although IMT of the breast has benign cytology and histology, clinically and on imaging, it resembles carcinoma. Awareness of the condition may help prevent a false diagnosis of carcinoma.     

Masson's vegetant intravascular hemangioendothelioma. Fine needle aspiration cytology, histology and immunohistochemistry of a case

Masson's vegetant hemangioendothelioma is a benign intravascular tumor, sometimes confused with such malignant vascular tumors as angiosarcoma, whose clinical appearance is nonspecific and whose diagnosis can only be established through microscopic examination. The fine needle aspiration (FNA) cytologic findings together with the histologic and immunohistochemical findings of such a tumor in a 22-year-old man are presented. Cytologically, the material obtained by FNA consisted of two distinct populations of cells. One type of cell had large nuclei (sometimes displaced towards the periphery), finely granular chromatin, prominent nucleoli and abundant globular cytoplasm. The second type of cell had spindle-shaped or oval nuclei, granular chromatin and scanty eosinophilic cytoplasm. Although these findings may permit the cytologic recognition of this entity, the aspirate in this case was interpreted as showing a vascular mesenchymal tumor of probable malignancy. Histologic examination of the excised tumor, aided by immunoperoxidase studies for factor VIII antigen that revealed the endothelial nature of the proliferating cells, established the correct diagnosis.     

Fine needle aspiration cytology of metastatic hepatic adrenocortical carcinoma mimicking hepatocellular carcinoma: a case report

BACKGROUND: Adrenocortical carcinoma (AC) is a rare neoplasm, usually considered one of the most morbid and lethal human tumors. It occurs primarily in children and young adults and often presents with advanced and/or metastatic disease. CASE: A 9-year-old boy with a previous diagnosis of adrenocortical carcinoma underwent computed tomography (CT)-guided fine needle aspiration (FNA) for preoperative investigation of a hepatic mass. All smears revealed abundant groups of cells surrounding an interconnective, thin-walled, central vascular core. These cells showed finely vacuolated, large cytoplasm with eccentrically placed nuclei. Occasionally, cells underwent a sudden, marked increase in size, with prominent atypia. Multinucleated, atypical giant cells and high mitotic rate were also evident. The cytologic findings resembled the previous histologic adrenocortical carcinoma features. CONCLUSION: The cytologic features of metastatic hepatic adrenocortical carcinoma may mimic those of hepatocellular carcinoma. However, the presence of atypical multinucleated and pleomorphic cells with microvacuolated cytoplasm and eccentric nuclei as well as the absence of naked nuclei and endothelial linings yield the diagnosis of adrenocortical carcinoma. Nevertheless, other space-occupying liver lesions in children must also be considered. This case demonstrates the usefulness of CT-localized FNA biopsy in hepatic masses in children, and discusses the possible cytologic differential diagnosis.     

Meningioma presenting as a parapharyngeal tumor: report of a case with fine needle aspiration cytology

BACKGROUND: Meningiomas rarely extend out of their intracranial confines through skull foramina to present as cervical tumors, where they would be accessible to fine needle aspiration (FNA) and thereby create difficulties in cytodiagnosis by mimicking other, more commonly aspirated head and neck tumors. CASE: A psammomatous meningioma arising intracranially and extending through the jugular foramen presented as a mass at the angle of the jaw clinically. On FNA cytology the diagnosis was suggested, but the cytomorphologic features overlapped with those of more commonly aspirated head and neck tumors, such as acinic cell carcinoma arising primarily in a salivary gland, metastatic papillary thyroid carcinoma and paraganglioma (glomus jugulare tumor). These possibilities had to be excluded through correlation with radiologic and intraoperative findings, which showed a dural-based tumor extending through the jugular foramen to assume a parapharyngeal location. Histology of the final excision specimen confirmed a psammomatous meningioma. CONCLUSION: The possibility of meningioma should be considered in the cytologic differential diagnosis of parapharyngeal tumors, particularly since its cytomorphologic features may mimic those of some of the more commonly encountered and aspirated head and neck tumors.     

Aspiration cytology of renal-cell carcinoma metastatic to the thyroid

Fine needle aspiration (FNA) of a thyroid mass clinically suspected of being acute thyroiditis led to a cytologic diagnosis of hypernephroma metastatic to the thyroid and to the subsequent detection of the occult primary tumor. The FNA cytomorphologic findings were substantiated by cytochemical staining of FNA samples and confirmed by subsequent histopathologic examination of the resected thyroid. Postoperative studies revealed an expansive growth in the left kidney; analysis of the nephrectomy specimen showed an invasive renal-cell carcinoma. This case emphasizes the considerable value of FNA biopsy in making the frequently difficult preoperative differential diagnosis of primary and metastatic thyroid tumor and the importance of cytochemical analyses in making that distinction and in suggesting the site of the primary tumor.