A cytologic perspective on meibomian gland carcinoma

OBJECTIVE: To reevaluate and reestablish the reproducible diagnostic cytomorphologic features of meibomian gland carcinoma (MGCA), demonstrating the importance of fine needle aspiration cytology (FNAC) in eyelid lesions and leading to better management of the tumor. STUDY DESIGN: Cytologic smears ofpreviously diagnosed cases of MGCA over a 3-year period were collected, along with their histopathology reports. The cytomorphology of the histopathologically proven cases were reevaluated in greater detail. The cytologic smears were stained with Leishman-Giemsa cocktail and Papanicolaou stain, and the histopathologic sections were stained with hematoxylin-eosin. Special stains and immunohistochemical stains were applied as required. RESULTS: Of the 19 cases, 3 diagnosed as MGCA on cytologic examination were reported as basal cell carcinoma on histopathology. On reevaluation of the cytologic smears, in addition to the regular characteristic features of MGCA, interesting findings such as an isolated dispersed cell population in a bubbly background, signet ring cells, pseudo-mucin cell balls, giant cell reaction and hyaline-like round bodies were observed. CONCLUSION: This study emphasizes the cytomorphologic features of MGCA in addition to those described in the literature, which could be of a great help in its diagnosis. Further, it emphasizes the importance of FNAC in the diagnosis of MGCA.     

Extradural spinal meningioma as a source of plasmacytoid cells. A case report

BACKGROUND: Meningiomas, tumors that often affect middle-aged and elderly people, occasionally arise in the spine, typically at the thoracic level. The cytologic findings in meningiomas include whorls and syncytial clusters of bland-looking cells with scattered, psammomatous calcifications and intranudclear cytoplasmic inclusions. However, in many cases, not all these findings are seen, and in rare cases, unusual cytomorphologic features are observed. CASE: A case of spinal meningioma was located in the extradural compartment and composed predominantly of singly scattered cells with a plasmacytoid appearance, demonstrated on fine needle aspiration biopsy smear preparations. The cell block showed more typical features of meningioma, and the diagnosis was supported by the results of immunohistochemical staining. CONCLUSION: The diagnosis of spinal meningioma is readily made by employing magnetic resonance imaging. The diagnosis can be difficult to confirm pathologically when atypical histologic findings are present, as in this case, with prominent plasmacytoid features. Sections from the cell block and immunohistochemical stains as well as clinical and radiologic findings were extremely helpful in arriving at the final diagnosis.     

Pheochromocytoma. Cytologic findings on intraoperative scrape smears in five cases

BACKGROUND: There have been few studies describing the cytology of adrenal pheochromocytoma (PC). Although fine needle aspiration (FNA) for a preoperative diagnosis of PC is generally considered a contraindication, this tumor can be an unsuspected finding in adrenal FNA performed for other reasons. STUDY DESIGN: Scrape cytology smears prepared in five cases of PC were examined for different cytomorphologic features. The results were correlated with the corresponding permanent histologic sections. RESULTS: Previously described features, like cellular smears showing cells with abundant, poorly defined fragile cytoplasm, bare nuclei, anisonucleosis, "salt and pepper" chromatin, variable nucleoli and few ganglion cell-like cells, were noted. In addition, several previously unreported cytologic features were observed: (1) loosely cohesive PC cells along a ramifying, delicate central core; (2) intracytoplasmic microvesicular (not hyaline/homogeneous) globules; and (3) different arrangements of capillary-stroma and PC cells (Zellballen pattern; empty capillary rings; stroma with adherent, intact PC cells or fragments of disrupted PC cell cytoplasm). CONCLUSION: The cytologic appearance of PC may resemble that of other neuroendocrine tumors; however, it can be diagnostic when combined with proper clinical data and ancillary tests.     

Fine needle aspiration cytology of sclerosing lobular hyperplasia of the breast: a case report

BACKGROUND: Sclerosing lobular hyperplasia presenting as a palpable, circumscribed nodular mass in a young female's breast is characterized histologically by prominent hyperplasia of the lobules and sclerosis of the intralobular connective tissue. The cytomorphologic features and differential diagnosis of the lesion are presented. CASE: A 14-year-old female presented with a painless, progressively increasing, nodular, firm, mobile lump measuring 5 x 5 cm in the right breast. The clinical and radiologic diagnosis was fibroadenoma. Fine needle aspiration smears showed a clean background with uniform, round to oval epithelial cells in flat sheets, round clusters and rosettelike (acinar) arrangements. A few naked nuclei were present, while stromal fragments were not seen. CONCLUSION: When analyzed in the context of the clinical findings, the cytologic features of sclerosing lobular hyperplasia help to differentiate it from other benign palpable nodular lesions of the juvenile breast.     

Cytologic features of pilocytic astrocytoma in cerebrospinal fluid specimens

OBJECTIVE: To illustrate the cytomorphologic features of pilocytic astrocytoma (PA) in cerebrospinal fluid (CSF) samples. STUDY DESIGN: A search of records from 1965 to 2001 was performed to identify all patients with a diagnosis of PA in whom CSF samples were examined. Slides from CSF samples originally reported as atypical, suspicious or positive were reviewed and the cytomorphologic features assessed. RESULTS: Two hundred ninety-three patients with a diagnosis of PA were identified. Of these, 44 had a total of 65 cytologic preparations of CSF. In 34 patients (77.2%) the CSF cytology was negative, in 5 (11.4%) either atypical or suspicious, and in 5 (11.4%) positive for neoplastic cells. The tumors in the 5 positive cases arose in the cerebellar hemispheres (2), cerebellar vermis (1), thalamus (1) and tectum with extension into the fourth ventricle (1). All positive samples were hypercellular, with an average of 5 cell clusters per case (range, 3-11). The clusters were composed of cohesive epithelioid cells with a mean of 8 cells per cluster. In addition, some cases had scattered, isolated, single cells. These single neoplastic cells had prominent, hairlike cytoplasmic processes. The cells in clusters appeared epithelioid, with oval nuclei, mild nuclear pleomorphism, finely or slightly coarsely granular chromatin and cobweblike cytoplasm. CONCLUSION: The cytomorphologic features of PAs recapitulate their histologic characteristics. The tumor cells are recognizable in CSF samples and readily distinguishable from histiocytes and ependymal cells.     

Criteria for the diagnosis of fibroepithelial lesions of the breast with liquid-based cytology

OBJECTIVE: To establish diagnostic criteria for diagnosing and differentiating fibroepithelial lesions of the breast on ThinPrep (Cytyc Corp., Boxborough, Massachusetts, U.S.A.). STUDY DESIGN: Eighty-four fibroepithelial lesions were sampled by ultrasound-guided aspiration biopsy. Based on smears and histologic correlates, there were 55 fibroadenomas, 26 papillary neoplasms and 3 phyllodes tumors. The ThinPrep slides for each sample were reviewed retrospectively and evaluated for specific morphologic and cytologic features. RESULTS: On ThinPrep slides, 95% of the fibroadenomas had a predominance of single myoepithelial nuclei, 89% had staghorn clusters, and 47% had myxoid stroma. Among the papillary neoplasms, 8% had a predominance of single columnar ductal cells, 31% had papillary groups, 23% had vessels, and 27% had collagenous spherulosis. The ThinPrep preparations of the phyllodes tumors showed that 67% had single myoepithelial nuclei, 33% had a predominance of single ductal cells, 67% had staghorn clusters, and 0% had myxoid stroma. A majority of the fibroadenomas and the papillary neoplasms showed mild to moderate ductal epithelial hyperplasia. A majority of the phyllodes tumors showed moderate ductal epithelial hyperplasia. CONCLUSION: Fibroepithelial lesions of the breast can be accurately differentiated using ThinPrep samples based on the evaluation of specific cytologic and morphologic features, including the presence of staghorn clusters, fibromyxoid stroma, vessels, collagenous spherulosis, papillary clusters and predominance of myoepithelial nuclei or columnar cells in the background. However, the degree of ductal epithelial hyperplasia does not aid in the diagnosis.     

Fine needle aspiration cytology of a low grade myxoid renal epithelial neoplasm: a case report

BACKGROUND: Recently, several case reports have described a rare but distinct subtype of renal tumor, referred to as a "low grade renal epithelial neoplasm," that appears to have a better prognosis than conventional renal cell carcinoma does. This report describes the cytologic features of this tumor as determined by fine needle aspiration (FNA) biopsy. CASE: A 53-year-old woman with a history of lymphoma had a renal mass incidentally discovered on an abdominal computed tomographic scan performed for lymphoma restaging. Results of an FNA biopsy showed relatively uniform, medium-sized tumor cells with moderate amounts of finely vacuolated or wispy cytoplasm and indistinct cell borders. The nuclei were primarily round with coarse chromatin and had prominent nucleoli. In the cell block preparation, the tumor cells showed a tubular architecture and an abundant myxoid matrix. The patient underwent a partial nephrectomy. The tumor was classified as a low grade myxoid renal epithelial tumor. CONCLUSION: This unusual kidney tumor appears to have distinctive cytomorphologic features, including a uniform population of epithelial cells with round nuclei, an abundant myxoid matrix and tubular architecture.     

Aspiration cytology of glomus tumor: a case report.

BACKGROUND: Glomus tumor is a relatively uncommon soft tissue tumor that can occur at any age and anatomic site, with a predilection for the subungual region. CASE: A 24-year-old female presented with a gradually enlarging, painful swelling in the subungual region of the right index finger. Fine needle aspiration was performed under a ring block and yielded hemorrhagic material. The smears revealed clusters of uniform, round to oval cells admixed with wisps of magenta intercellular myxoid material and a few spindle-shaped cells crossing clusters of tumor cells. A diagnosis of benign vascular tumor consistent with glomus tumor was given. Subsequent histopathologic examination confirmed the diagnosis and showed alpha-SMA positivity on immunohistochemistry. CONCLUSION: This case report is the second on the cytologic features of glomus tumor in the English-language literature. Although the cytomorphologic features of glomus tumor are quite distinctive, an appropriate clinical history and immunohistochemical stains (e.g., alpha-SMA and vimentin positivity) can further help to ascertain the diagnosis.     

Nodular fasciitis and proliferative myositis as variants of one disease entity

The concept of nodular fasciitis and proliferative myositis as variants of the same fibroblastic disorder is supported by intermediary cases, showing simultaneous features thought to be typical of either nodular fasciitis or proliferative myositis. Various other anatomical, pathological and clinical similarities found in this study of 100 cases support such conclusions. 'Ganglion-like' cells were a distinct, but not exclusive, feature of all cases with sole, or only partial, muscle involvement.     

Cytologic features of malignant peripheral nerve sheath tumor

OBJECTIVE: To study the cytomorphologic features of malignant peripheral nerve sheath tumor (MPNST), including the epithelioid cell variant, and to establish differential diagnostic features with benign neurogenic tumors and other sarcomas. STUDY DESIGN: Cytologic smears from primary, recurrent and metastatic tumors in 10 patients with MPNST were reviewed. Three patients had neurofibromatosis 1 (NF1), and in two others the tumor arose from a preexisting neurofibroma. Immunocytochemical evaluation of S-100 protein was performed in four cases. A complete pathologic study was available in all cases. To assess the validity of morphologic recognition, a blinded study, including eight cases of spindle MPNST among smears from histologically proven schwannomas, synovial sarcomas, leiomyosarcomas, malignant fibrous histiocytomas and liposarcomas, was performed. RESULTS: Neurogenic differentiation was recognizable in four cases (differentiated), while the other four (anaplastic) were indistinguishable from other pleomorphic sarcomas. The presence of elongated, slender, often wavy nuclei and less commonly a delicate, fibrillary metachromatic stroma were features suggestive of nerve sheath differentiation. Other cytologic, as well as clinical, features permitted their identification as malignant. Two cases of epithelioid MPNST disclosed large, polygonal to plasmocytoid tumor cells without specific cytologic features. S-100 immunoexpression was positive in two of the four cytologic samples tested. CONCLUSION: Although no morphologic findings are specific to MPNST, the above-mentioned cytologic features may suggest, in differentiated cases, its neurogenic differentiation. On the basis of morphologic features alone, the diagnosis of anaplastic and epithelioid MPNST is not possible, and immunocytochemical and ultrastructural studies are necessary. A specific cytodiagnosis is possible in recurrences, metastases and cases of NF1 or a preexisting neurofibroma.     

Myoepithelioma within the carpal tunnel: a case report and review of the literature

Myoepitheliomas of the extremity are rare and usually benign, while a minority display malignant features. This case demonstrates the diagnosis and management of myoepithelioma within the carpal tunnel. Clinical and radiological tumour features were evaluated. Hematoxylin and eosin stained tumour sections were examined, and immunohistochemistry was performed. Histology revealed a nodular mass of epithelioid cells in clusters within a myxoid/chondroid stroma. No mitoses were noted. Cytokeratins, neuron-specific enolase, synaptophysin, glial fibrillary acidic protein, and S100 were positive on immunohistochemistry. A literature review revealed very few prior reports of myoepithelioma in the wrist, and limited data concerning any relationship between recurrence and quality of surgical margins. In this case, wide local excision would have significantly compromised dominant hand function, and therefore a marginal excision was deemed appropriate in the context of bland histological features. Surgical margins noted in future case reports will aid clinical decision making.     

Fine needle aspiration cytology of pseudosarcomatous reactive proliferative lesions of soft tissue

OBJECTIVE: To summarize the diagnostic features of fine needle aspiration cytology (FNAC) of pseudosarcomatous reactive proliferative lesions of soft tissue and to establish the criteria for differentiating these lesions from true sarcoma, thus allowing conservative management. STUDY DESIGN: FNA of 17 cases (13 nodular fasciitis, 2 proliferative fasciitis, 2 proliferative myositis), from 1994 to 2001, were reviewed in correlation with the clinical course or results of biopsy. RESULTS: The FNAC features of pseudosarcomatous reactive proliferative soft tissue lesions were characterized by a pleomorphic pattern of proliferative cells and the presence of ganglion cell-like cells. The proliferative cells varied widely from spindle shaped, with long cytoplasmic processes, to more plump cells, with round to oval nuclei. In spite of the large nuclei and prominent nucleoli in ganglion cell-like cells, the nuclei were cytologically benign, with thin and smooth nuclear membranes and fine chromatin. Clinically, all lesions appeared as small, superficially located, rapidly growing nodules with a short duration of symptoms. Ten cases of nodular fasciitis, one case of proliferative fasciitis and two cases of proliferative myositis had a spontaneous resolution in 1-12 weeks (mean, 4.7) following diagnosis by FNAC. All patients were well and devoid of any symptoms or signs of recurrence or metastasis in a follow-up period of 1-64 months after FNAC or biopsies. CONCLUSION: It is possible to differentiate pseudosarcomatous reactive proliferative soft tissue lesions from true sarcoma based on cytologic criteria in FNAC together with clinical correlation. All such lesions diagnosed by FNAC should be managed nonsurgically first, with follow-up. If regression does not occur within four to eight weeks, surgery should be performed.     

Cytomorphologic patterns in papillary cystic variant of acinic cell carcinoma of the salivary gland

OBJECTIVE: To study the cytomorphologic profile of the papillary and cystic variant of acinic cell carcinoma (ACC-PCV) of the salivary glands. STUDY DESIGN: We studied 6 aspirates from 5 cases of ACC-PCV. RESULTS: All the cases had varied cytomorphologic features depending upon the degree of vacuolation of cells. However, common to all was a papillary pattern and a cystic fluid background with or without mucin blobs; that led to misdiagnosing the tumor as mucoepidermoid carcinoma on 2 occasions. The smears showed papillary fragments, sheets or clusters of vacuolated/histiocyte like cells and granular cells. The histiocytelike cells resembled macrophages, with finely vacuolated cytoplasm and an eccentrically placed nucleus with frequent binucleation. Vascular cores were seen in a few aspirates. The granular cells were similar to those seen in the usual acinic cell carcinoma but were smaller. The tumor did not show any acinar pattern and lacked naked nuclei in the background. In 4 aspirates finely distributed, brown hemosiderin pigment was detected in the vacuolated cells. CONCLUSION: ACC-PCV is papillary and cystic and hence is often not recognized as acinic cell carcinoma. However, papillary fragments of vacuolated cells or histiocytelike cells and granular cells are clues to the diagnosis.     

Cytopathology of exocrine pancreatic carcinoma in effusions.

The cytomorphologic features were analyzed in 26 fluid samples (18 peritoneal and 8 pleural fluids) obtained in vivo from 20 patients with pancreatic carcinoma. All tumors were ductal adenocarcinomas, as proven histologically on autopsy samples. The basic cytomorphologic pattern in the smears was that of a malignant glandular tumor, consisting of cell groups with various degrees of cohesiveness. The most prominent feature was a linear arrangement (the so-called "Indian file") of tumor cells showing nuclear molding; these aggregates were frequently closely associated with the flat round clusters of cells. Other nonspecific features of adenocarcinoma included eccentric hyperchromatic nuclei, abundant, often well-preserved vacuolated cytoplasm, a variable amount of fibrin and a reactive background. Review of the autopsy specimens also revealed the presence of an "Indian-file" pattern in most cases, especially when a conspicuous desmoplastic reaction was present. These findings suggest that pancreatic carcinoma should be included in the differential diagnosis of positive serous effusions showing these cytomorphologic features.     

Cytomorphologic features of a polymorphous low grade adenocarcinoma of the palate. A report of 2 cases with immunocytochemistry

BACKGROUND: Polymorphous low grade adenocarcinoma (PLGA) is a histologically low grade tumor of minor salivary gland origin. It is important to differentiate PLGA from other salivary gland tumors with myoepithelial differentiation, such as pleomorphic adenoma, adenoid cystic carcinoma and epithelial myoepithelial carcinoma. Here we report 2 cases of PLGA originating in the palate and describe the cytomorphologic and immunocytochemical features. CASES: The patients were a 55-year-old woman and a 63-year-old man. Both presented with a mass in the palate. Clinically the mass appeared malignant, and resection was performed. Cytologically the tumor cells were composed of sheet clusters, pseudopapillary epithelial clusters, naked cells and stromal components. Immunocytochemically the tumor cells showed strong expression of carcinoembryonic antigen (CEA) and vimentin. CONCLUSION: PLGA may be difficult to distinguish from other salivary gland tumors with myoepithelial differentiation. However, the cytopathologist should be aware of the distinctive cytomorphologic features of PLGA, demonstrating immunopositivity to CEA and vimentin.     

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.     

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.     

Cytologic features of a primary myxoid malignant fibrous histiocytoma arising in the uterus: a case report.

BACKGROUND: Primary malignant fibrous histiocytoma (MFH) of the uterus is extremely rare. The 10 cases reported in the literature all involved the pleomorphic variant, and to the best of our knowledge, the myxoid variant has not been reported before. We describe the cytologic findings of primary uterine myxoid MFH in relation to the myxoid component, potentially leading to an incorrect diagnosis. CASE: A 68-year-old woman presented with a primary uterine tumor. Endometrial cytology showed numerous loosely arranged, spindle-shaped fibroblastlike cells; atypical histiocytelike cells; and giant cells with a necrotic background. The overall cytologic picture was of a degenerated pleomorphic leiomyosarcoma with an inconclusive diagnosis. A diagnosis of myxoid MFH was established after electron microscopic and immunohistochemical studies of the primary tumor and tumor transplanted, as primary cultured cells, in nude mice. The patient underwent an exploratory laparotomy and died of tumor progression 38 days after the initial consultation, without treatment. CONCLUSION: Because of overlapping cytologic features among uterine sarcomas with myxoid stroma, it is important to recognize the histiocytic lineage of tumor cells by immunohistochemistry and electron microscopy in various presentations of fresh samples.     

Nodular fasciitis of the breast: report of a case initially diagnosed by fine needle aspiration cytology

BACKGROUND: Nodular fasciitis is a rare benign pseudosarcomatous proliferation of fibroblasts in the breast, in which the clinical examination and mammographic findings may closely mimic mammary carcinoma. CASE: A case of nodular fasciitis was diagnosed by fine needle aspiration. A 15-year-old girl was admitted to our hospital with a recently noticed, rapidly growing mass in the right breast. The aspirate contained cohesive groups of fusiform cells with elongated and oval nuclei, regular nuclear membranes and inconspicuous nucleoli, intermingled with scattered lymphocytes, red blood cells and characteristic granular background substance. A cytologic diagnosis of nodular fasciitis was made and confirmed histologically. CONCLUSION: Mammary nodular fasciitis is often clinically suspicious for carcinoma and rarely diagnosed by fine needle aspiration cytology. A literature search yielded only five reported cases. The cytologic diagnosis of this entity helps to choose the correct surgical procedure, preventing psychological trauma to the patient.     

Malignant mesothelioma. Cytopathology of 75 cases seen in a New Jersey community hospital

Seventy-five cases of diffuse pleural and/or peritoneal malignant mesothelioma (73 of body cavity fluids and 2 of fine needle aspirates) were studied by cytologic methods. Of the three major histologic varieties of mesothelioma (epithelioid, fibrous and mixed, or biphasic), the epithelioid and biphasic types were associated with four cytomorphologic features useful in the diagnostic evaluation: (1) the presence of abnormal cells, apparently mesothelial, (2) nuclei with subtle malignant features, (3) the presence of cells showing transitional forms from normal to abnormal in the same sample and (4) the presence of large tissue fragments. The fibrous mesotheliomas presented cytologically as sarcomatous neoplasms. Three histochemical reactions were found to be valuable adjuncts to diagnosis in the differentiation of the primary malignancies of the serous membranes from metastatic cancers. These stains were the periodic acid-Schiff, with and without diastase digestion, the Alcian blue, with and without hyaluronidase digestion, and the Van Gieson. The histochemistry was diagnostically useful in 42% of the cases in which the cytomorphologic impression was uncertain or equivocal; it served as an added confirmatory finding in 64% of the cytologically diagnosable mesotheliomas.