Stereotaxic fine needle aspiration cytology of clinically occult malignant and premalignant breast lesions

Stereotaxic fine needle aspiration (FNA) cytology was used to study clinically occult (nonpalpable) breast lesions in 114 consecutive patients with mammographically suspicious findings prior to excisional biopsy. The aspirate contained insufficient material for cytologic evaluation in 15 cases (13.2%), which were histologically diagnosed as benign (7 cases), atypical hyperplasia (7 cases) or carcinoma in situ (1 case). The cytologic findings indicated a benign lesion in 77 cases (67.5%), which were histologically diagnosed as benign (71 cases) or atypical ductal hyperplasia (6 cases). The cytologic sample showed atypia in eight cases (7.0%), which were histologically diagnosed as severe atypical ductal hyperplasia (three cases), carcinoma in situ (one case) or proliferative fibrocystic disease (four cases). In the eight cases (7.0%) cytologically interpreted as probably malignant, histology confirmed six invasive carcinomas, one carcinoma in situ and one fibrocystic disease. Of six cases (4.4%) cytologically reported as malignant, five were histologically diagnosed as invasive carcinoma and one as carcinoma in situ. Overall, stereotaxic FNA cytology reported as malignant or probably malignant 14 of the 15 cases with a histologic confirmation of malignancy, for a sensitivity of 93.3%. Cytology correctly identified 78 of the 83 histologically negative cases, for a specificity of 94.0%. The 16 cases histologically diagnosed as ductal hyperplasia, which carries a high risk for subsequent malignancy, were studied in detail in an effort to define histologic and cytologic criteria for this entity. Using selected histologic criteria, 11 of these cases were graded as showing mild-to-moderate atypical hyperplasia and 5 as showing severe atypical hyperplasia. Three of the latter cases were similarly identified by an analogous cytologic grading; the other two cases had insufficient cytologic samples. The total results in this series of 114 cases support the use of stereotaxic FNA cytology in the diagnosis of these nonpalpable breast lesions, examples of which are illustrated. In particular, it may help to raise the low specificity yielded by mammography alone, which would represent a significant advance for the patient in terms of the accuracy, expediency and reduced cost of diagnosing these lesions.     

Fine needle aspiration biopsy in uveal melanoma

Fine needle aspiration (FNA) biopsies were performed in a series of patients with uveal tumors. Cytopathologic examination established the correct diagnosis in 26 of 29 uveal melanomas. FNA biopsy was able to exclude the diagnosis of a malignant neoplasm in five nonmelanoma tumefactions. Histologic and FNA cytologic typing of melanomas as epithelioid or predominantly spindle cell showed good agreement, with the same classifications made in 14 of 18 cases. FNA biopsy specimens also proved to be adequate for DNA-content and cell-cycling studies. The cessation of cell cycling in successfully irradiated melanomas may be useful in establishing the postradiation status of tumors that have questionable growths after therapy, as was shown using FNA samples in three such cases in this study. The results of this study show that FNA biopsy is a useful diagnostic adjunct in patients with atypical lesions that require therapy.     

Fine needle aspiration cytology of pulmonary carcinoid tumors

Twenty-four cases coded as pulmonary carcinoid tumors initially sampled by fine needle aspiration (FNA) biopsy were reviewed in order to determine the cytologic features most useful in making the FNA diagnosis. The diagnosis of carcinoid tumor had been confirmed in 23 cases; the remaining case, though closely resembling a carcinoid tumor on the FNA specimen, proved to be a sclerosing hemangioma of the lung. Comparison of the original and review interpretations of the FNA specimens revealed that all typical spindle cell carcinoids and all atypical carcinoids were correctly diagnosed and classified. Of the 15 typical round cell carcinoids, the original cytologic diagnosis was lymphoma in 2 cases and benign bronchial lining cells in 2 cases. Thus, it appears that diagnostic errors are most likely in "typical" carcinoids. Review of the FNA findings suggests that the frequently stripped cytoplasm (with resulting non-cohesive bare nuclei), coupled with the almost universal plexiform vascularity (seen in 21 of 23 cases), should allow an accurate cytologic diagnosis in virtually all cases.     

Fine needle aspiration biopsy diagnosis of giant-cell tumor of bone. An experience with nine cases

The cytologic findings in nine cases of giant-cell tumor (osteoclastoma) of bone diagnosed by fine needle aspiration (FNA) biopsy are described. The aspirates contained a dual population of cells, consisting of mononucleated tumor cells and multinucleated giant cells (osteoclasts). The tumor cells were usually evident in the FNA smears as cohesive perivascular clusters; some were present as sheets or single cells. The most striking feature, which may best suggest the diagnosis of giant-cell tumor in an FNA smear, was the attachment of the osteoclasts to the cohesive groups of tumor cells. Even when the cells were more dissociated, there was a rather regular distribution of the two types of cells. This series further demonstrates that FNA biopsy permits an accurate cytopathologic diagnosis of giant-cell tumor and that its use can clarify the clinical and radiologic impressions of these bony lesions preoperatively. The differential diagnosis between osteoclastoma and other giant-cell containing bone lesions is discussed in detail.     

Fine needle aspiration cytology of parotid sarcoidosis

Granulomatous lesions of the salivary gland are rare; as such, there have been few reports of the cytologic features of granulomatous sialadenitis in general, and salivary gland sarcoidosis in particular. A case of systemic sarcoidosis involving both parotid glands, diagnosed initially by fine needle aspiration (FNA) cytology, is presented. The specific cytologic features included histiocytes of both epithelioid and giant multinucleated types, without background necrosis. The FNA cytologic differential diagnosis of bilateral parotitis is discussed.     

Cytodiagnosis of bone tumors by fine needle aspiration

A retrospective study was undertaken of bone lesions examined by preoperative fine needle aspiration (FNA) cytology in our hospital during the ten-year period from 1970 to 1979. The 430 cytologically examined lesions were classified into three groups: inflammatory lesions, tumorlike lesions and tumors. A total of 54 patients had undergone surgery, with most of the lesions in those cases proven to be tumors or tumorlike by histologic study. Correlation between the histologic and FNA cytologic findings showed complete compatibility in 76% of the cases, partial compatibility in 13% and incompatibility in 11%. It is concluded that FNA biopsy is appropriate for identifying bone tumors and tumorlike lesions if sufficient numbers of tumor cells are obtained for morphologic examination. Although aspiration cytodiagnosis can be of considerable value in the recognition of certain bone lesions, it cannot replace formal tissue biopsy in the diagnosis of primary bone neoplasms. The morphology of several common bone tumors is described in detail and their differential diagnosis is discussed.     

Positive predictive value of fine needle aspiration cytology of breast lesions

The predictive value of fine needle aspiration (FNA) was assessed in 1,181 consecutive cases of breast lesions in which cytologic abnormalities were reported. The positive predictive value (PPV) of an FNA cytologic report of atypia, suspicious or positive was 0.49, 0.95 or 0.996, respectively. In the presence of a suspicious/positive report by both physical examination and mammography, the PPV of a cytologic report of suspicious was 0.99. The PPV was directly correlated with age, partly due to the incidence of fibroadenomas among younger patients; fibroadenomas were present in 53 of 146 cases with a false FNA report of atypia, in 10 of 19 cases with a false FNA report of suspicious and in 2 of 2 cases with a false FNA report of positive. Overall, 93 cases reported as benign by physical examination and mammography were biopsied on the basis of the FNA cytologic report; cancers were diagnosed in 33 of these 93 cases (6 cancers among 42 women less than 40 years old and 27 cancers among 51 women greater than 39 years old). The widespread use of FNA cytology to study breast lesions is thus recommended, without regard to patient age and even in the presence of clinically benign findings, since the increase in the rate of cancer detection is worth the excess of unnecessary biopsies. The predictive value of a positive report of FNA cytology, or even of a suspicious report in the presence of clinical suspicion, is so high that an intraoperative frozen section biopsy might be spared in such cases.     

Osteoclastomalike giant cell tumor of the parotid gland: report of a case with fine needle aspiration diagnosis

BACKGROUND: Osteoclastomalike giant cell tumor of the parotid gland has been reported rarely. The tumor has occurred rarely at many sites, such as thyroid, pancreas, soft tissue, breast, skin, heart, colon, lung, kidney, ovary and bladder. The exact origin of the tumor is unclear. However, osteoclastlike giant cells have been considered either part of a stromal process reactive to a neoplasm or a component of a primary neoplasm. CASE: A 35-year-old female presented with a mass in the left parotid gland clinically diagnosed as a pleomorphic adenoma. Fine needle aspiration (FNA) was advised before surgical excision. FNA smears revealed numerous osteoclastlike, multinucleated giant cells and many malignant-looking mononuclear cells. The smears were diagnosed as positive for malignancy, suggestive of osteoclastomalike giant cell tumor. The tumor was excised, and histopathologic study confirmed the cytologic diagnosis. CONCLUSION: The cytologic findings of osteoclastomalike giant cell tumor of the parotid gland have not been previously reported. FNA aided the diagnosis and planning of treatment. FNA is important in the diagnosis of parotid tumors.     

Fine needle aspiration cytologic findings in four cases of pilomatrixoma (calcifying epithelioma of Malherbe).

Four cases of pilomatrixoma studied by fine needle aspiration (FNA) biopsy prior to resection and histologic diagnosis were reviewed to identify the cytologic features useful in making the FNA cytodiagnosis. Cytopathology had initially correctly diagnosed two cases while misdiagnosing one as a carcinoma and one as a suspected carcinoma. The aspirates from all cases contained either clustered or isolated basaloid cells, with variably sized nuclei and prominent nucleoli. "Ghost cells" were also present in most smears stained with the Giemsa stain and could thus be very helpful for making the FNA diagnosis of pilomatrixoma. The occurrence of either foreign-body giant cells or calcium deposits in the aspirates could also contribute to suggesting the correct diagnosis of pilomatrixoma in some cases.     

Fine needle aspiration biopsy diagnosis of mucoepidermoid carcinoma. Statistical analysis

Fine needle aspiration (FNA) biopsy is an increasingly popular method for the evaluation of salivary gland tumors. Of the common salivary gland tumors, mucoepidermoid carcinoma is probably the most difficult to diagnose accurately by this means. A series of 96 FNA biopsy specimens of salivary gland masses, including 34 mucoepidermoid carcinomas, 51 other benign and malignant neoplasms, 7 nonneoplastic lesions and 4 normal salivary glands, were analyzed in order to identify the most useful criteria for diagnosing mucoepidermoid carcinoma. Thirteen cytologic criteria were evaluated in the FNA specimens, and a stepwise logistic regression analysis was performed. The three cytologic features selected as most predictive of mucoepidermoid carcinoma were intermediate cells, squamous cells and overlapping epithelial groups. Using these three features together, the sensitivity and specificity of accurately diagnosing mucoepidermoid carcinoma were 97% and 100%, respectively.     

The application of fine needle aspiration cytology in the diagnosis of multiple primary malignant tumors

Four cases with multiple primary malignant tumors are presented. In all cases, fine needle aspiration (FNA) cytologic findings indicated the presence of more than one primary malignancy. In one case, the cytologic examination simultaneously diagnosed two separate primaries. Since FNA cytology can often be used to identify the tumor type, it can be utilized in the identification of many multiple primary malignancies, as these cases show.     

Diagnostic pitfalls in the fine needle aspiration of thyroid nodules. A study of 555 cases in Chinese patients

The diagnostic value and limitations of fine needle aspiration (FNA) were determined by examining 555 palpable thyroid nodules in Chinese patients who had a definitive diagnosis established by thyroidectomy (529 cases) or large-needle biopsy (26 cases). Of the aspirates, 97.8% were satisfactory for cytologic examination. The overall malignancy rate was 20%. FNA detected 73 (74.5%) of 98 primary malignant tumors and 9 (90%) of 10 metastatic tumors. Diagnostic errors were most commonly due to inadequate specimens and cystic lesions. Cystic fluid, present in one-third of all lesions, was associated with a malignant nodule in 13% of the cases. FNA was most valuable for detecting papillary carcinomas; it may at times suggest the likelihood of a follicular carcinoma.     

Differential diagnosis of malignant intrahepatic tumors by ultrasonically guided fine needle aspiration biopsy and by laparoscopic/intraoperative biopsy. A comparative study

Thirty-six cases of ultrasonographically detected liver tumors (28 malignant and 8 benign lesions) were investigated by both fine needle aspiration (FNA) biopsy and laparoscopic or intraoperative tissue biopsy. The sensitivity of FNA biopsy in detecting a neoplasm was 85.7% while that of tissue biopsy was 82.1%. Specificity was 100% in both methods. A correct histologic diagnosis of the neoplasm could be made on the cytologic smear in only 14 cases (50.0%) due to technical and methodologic difficulties. Endoscopic and intraoperative tissue biopsy yielded sufficient material to make a definite histologic tumor diagnosis in 23 of 28 cases. Additional information on tumor spread and sequelae of liver infiltration was obtained by macroscopic tissue observations in nine cases. These results indicate that FNA biopsy is less sensitive in the classification of primary or secondary liver tumors and that tissue biopsies obtained during laparoscopy or laparotomy are required if a suspected hepatic neoplasm needs to be classified exactly to plan therapy and to establish a prognosis.     

Fine needle aspiration of breast lesions in women aged 30 and under

Fine needle aspiration (FNA) biopsies of 1,598 breast masses were performed between 1983 and 1989, and of them, 48 were from women aged 30 and under for whom a cytologic diagnosis was made by FNA and histologic follow-up was available. In 37 (77%) of the cases, both the cytologic and histologic diagnoses were benign. Fibroadenoma (20/37) and fibrocystic changes (14/37) were the most common benign lesions aspirated. Eight (17%) FNAs showed cytologic atypia. Four of these atypical lesions proved to be benign (two fibroadenomas, two fibrocystic changes). Epithelial proliferation in fibroadenomas and fibrocystic changes and cellular stroma in a fibroadenoma mimicking phylloides tumor were the causes of atypia in these biopsies. Four of the eight atypical lesions were shown to be carcinoma at biopsy (three infiltrating duct, one atypical medullary). Low cellularity, epithelial cohesiveness mimicking a fibroadenoma and background lactational changes in a pregnant patient were the causes of the atypical, rather than unequivocally malignant, diagnoses in these cases. In three patients (6%), a diagnosis of carcinoma was made by FNA and confirmed histologically (all were infiltrating duct carcinoma). Although most breast masses in women aged 30 and under are benign, cytologic atypia in a breast fine needle aspirate in this age group warrants a surgical biopsy. Clinical follow-up alone may be appropriate for young women with clinically nonsuspicious breast masses without cytologic atypia.     

Conventional respiratory cytology versus fine needle aspiration cytology in the diagnosis of lung cancer

The results of 184 fine needle aspiration (FNA) cytologic examinations were compared with the findings of "conventional" respiratory cytology (on sputums, bronchial brushings and bronchial washings) and histology (on biopsy and autopsy samples) and with the medical records. Positive cytologic results were obtained in 6 (10%) of 60 sputums, 17 (21%) of 80 brushings, 16 (19%) of 84 washings and 82 (44%) of 184 aspirates. These positive results were confirmed by biopsy for 6 of 6 sputums, 16 of 17 brushings and 15 of 16 washings. Among the 82 patients with a positive FNA cytology, malignancy was confirmed by lung biopsy in 39 and by autopsy in 2; the cytologic diagnosis was supported by clinical and radiographic findings in all but 1 of the remaining 41 patients. Using transbronchial lung biopsy, autopsy and medical records as final standards, the positive predictive values were 100% for sputum, 94.1% for brushings, 93.0% for washings and 98.6% for FNA samples. The high positive predictive values of FNA and the other cytologic procedures indicate that these diagnostic modalities provide simple, rapid and reliable methods for the diagnosis of lung cancer.     

Fine needle aspiration biopsy in the diagnosis of intrathoracic masses.

During a 3.5-year period (January 1, 1987, to June 30, 1990) 420 percutaneous fine needle aspiration (FNA) biopsies were performed on 390 patients (309 males, 81 females) suffering from one or more intrathoracic, radiologically visible lesions. Aspirations were carried out using 21- or 23-gauge Chiba needles under fluoroscopic or computed tomographic control. The aspirates were used to make minibiopsies and cytologic smears. Diagnosis was possible in 373 cases (95.64%): on the first pass in 344 cases, on the second in 28 cases and on the third in 1. In 17 cases (4.36%) the aspirate was inadequate for diagnosis. There were complications in 10 cases (2.56%) (9 pneumothorax and 1 hemophtysis) requiring intensive care. The 373 percutaneous FNA biopsy diagnoses included 256 malignant tumors (68.63%), of which 234 were primary and 22 were secondary, and 117 benign lesions (31.37%), 5 of them neoplastic and 112 nonneoplastic. Three hundred two of 373 percutaneous FNA biopsy diagnoses were followed (80.96%). One hundred twenty-three follow-ups were histologic (40.73%), including secondary tumors, which could be compared with the primary histotype. Twenty-eight follow-ups were cytologic (9.27%), and 151 were clinical (50.00%), using progression of the disease or the beginning of chemoradiotherapy as a criterion for malignancy and a stable condition or regression of the lesion with nononcologic medical treatment as a criterion for benignity. Percutaneous FNA biopsy diagnoses were confirmed in 288 cases (221 true positives and 67 true negatives) and unconfirmed in 14 (1 false positive and 13 false negatives). Specificity, sensitivity, negative predictive value, positive predictive value and total diagnostic accuracy were, respectively, 98.52, 94.44, 83.75, 99.54 and 95.36%. The histologic typing accuracy of percutaneous FNA biopsy on 70 specimens of surgically removed malignant epithelial neoplasias was 70.00%. These results confirm that percutaneous FNA biopsy is a reliable method of diagnosing intrathoracic masses and reduces the need for diagnostic thoracotomy.     

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.     

Metastatic tumors in fine needle aspiration biopsy of the thyroid

A series of almost 25,000 thyroids examined by fine needle aspiration (FNA) biopsy was reviewed to ascertain the incidence and presentation of metastatic cancers in thyroid FNA samples. Metastatic cancers in FNA samples from the thyroid were identified in 25 cases (0.1%); the primary tumors were carcinomas of the kidney (8 cases), lung (7 cases), breast (5 cases), cervix uteri (1 case) and colon (1 case) and 1 case each of malignant melanoma, malignant pleural mesothelioma and rhabdomyosarcoma. FNA cytology was positive in all 25 cases. In 11 cases, the primary tumor was clinically known at the time of FNA biopsy; of the other 14 cases, cytology suggested that the malignancy was metastatic in only 5. Metastases of renal and mammary adenocarcinomas were almost indistinguishable from follicular and papillary thyroid carcinomas on cytologic grounds. The results demonstrate the rarity of this finding and the difficulty of diagnosing a metastatic tumor in the thyroid by FNA biopsy, in the absence of a clinical history of a prior primary neoplasm.     

Testicular germ cell tumors. Classification based on fine needle aspiration biopsy

Fine needle aspiration (FNA) biopsy was performed preoperatively on 13 patients with testicular germ cell tumors. The cytologic typing of the tumors was based on the presence or absence of seminoma, embryonal carcinoma, yolk-sac tumor, choriocarcinoma and teratoma in the aspirate. The cytologic findings showed good agreement with the histologic findings. Only four cases showed a single type of tumor; the other nine cases showed as many as four different tumor components. A few characteristic cytologic features proved to be sufficient for tumor typing; this suggests that FNA biopsy cytology can also be useful in identifying metastatic germ cell tumors in extra-gonadal sites.     

Fine needle aspiration in a malignant lymphoepithelial lesion: a case report

BACKGROUND: A primary malignant lymphoepithelial lesion (MLEL) of the salivary gland is a rare tumor. Though histologic morphology of this lesion is well documented, the cytologic findings regarding fine needle aspiration (FNA) are not yet well described. CASE: A 56-year-old Thai woman from Udonthanee was admitted to Srinagarind Hospital with a 2-year history of a painless mass in the left parotid gland. FNA of the left parotid mass was performed, and findings suggestive of malignancy were discovered. A wide local excision was performed 1 year later, and MLEL with metastasis to the regional lymph nodes was diagnosed by histopathology. CONCLUSION: We report our first experience of cytologic findings from FNA of histologically diagnosed MLEL. The aspirate comprised groups of cohesive and isolated malignant epithelials with a background of numerous lymphocytes. Cytotechnologists should be reminded of this rare lesion when confronted with a lymphocytic background from either benign or malignant lesions.