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.     

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

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

Breast myeloma: a report of 3 cases with fine needle aspiration cytologic findings

BACKGROUND: Multiple myeloma of the breast is very rare, and the fine needle aspiration (FNA) findings have not been reported before. CASES: Two cases of multiple myeloma presented with bilateral breast nodules during treatment with chemotherapy. One case of multiple myeloma presented initially with a left breast mass. FNA smears of all 3 cases revealed numerous plasma cells, plasmablasts and multinucleated giant plasma cells. The smears were diagnosed as plasma cell tumors. Serum immunoelectrophoresis revealed IgG myeloma in 2 cases and IgA myeloma in 1. Marrow aspirates revealed > 30% plasma cells. Two patients died, and 1 was alive at this writing. CONCLUSION: The aspiration cytology findings of myeloma can be confuse, with primary and secondary tumors of the breast. The previous clinical history and ancillary studies, such as bone marrow study and serum immunoelectrophoresis, are essential to the correct diagnosis.     

Primary osteogenic sarcoma of the breast: cytomorphologic study of 3 cases with histologic correlation

BACKGROUND: Primary osteogenic sarcomas of the breast are extremely rare neoplasms. The histologic and cytologic features are comparable to those of their soft tissue and skeletal counterparts. To assess the utility of fine needle aspiration (FNA) in preoperative identification of osteogenic sarcomas, we retrospectively reviewed the FNA findings of 3 cases diagnosed in our hospital over 2 1/2 years. CASES: Three women, aged 48, 55 and 76 years, presented with a palpable lump of a few months' duration in their breasts. FNA was indicative of malignancy, and mastectomy with ipsilateral axillary lymph node dissection was performed. The cytologic features were of hypocellular or hypercellular smears with pleomorphic cells; scarce or abundant metachromatic amorphous material, suggestive of osteoid; osteoclast-like giant cells; and stromal fragments. CONCLUSION: Although cytologic features can be suggestive of osteosarcoma in the appropriate clinical setting, prompt preoperative diagnosis of malignancy in FNA samples of these tumors can avoid undertreatment, because mammographic and clinical findings are in many cases confused with the features of a benign lesion, more specifically calcified fibroadenoma.     

Fine needle aspiration cytology of lymph nodes in HIV-infected individuals

OBJECTIVE: To assess the role of fine needle aspiration cytology (FNAC) in lymphadenopathy in human immunodeficiency virus-infected individuals (HIVII). STUDY DESIGN: Thirty-nine HIVII presenting with lymphadenopathy at University Hospital, Kuala Lumpur, were subjected to FNAC. Cytologic smears were routinely stained with May-Grünwald-Giemsa stain. Special stains and immunostains were used when necessary. RESULTS: In nine cases, the cytologic appearance was compatible with HIV type A and in one case with HIV type C lymphadenopathy. In 21 cases, acid-fast bacilli (AFB) were demonstrated in the cytologic smears, enabling a diagnosis of mycobacterial lymphadenitis. In one of these cases there was a concomitant infection with Penicillium marneffei that was overlooked on initial cytologic examination. The cause of granulomatous lymphadenitis could not be ascertained in one case, where neither AFB nor any other organisms were demonstrable. Two cases of histoplasma and one of cryptococcal lymphadenitis were diagnosed, as was one high grade non-Hodgkin's lymphoma that could be immunophenotyped on cytologic material. In three cases the aspirates were inadequate for a cytologic diagnosis. CONCLUSION: Lymph node FNAC is a valuable investigative modality in HIVII. Most opportunistic infections (bacterial and fungal) can be correctly identified, and high grade lymphoma can be diagnosed and phenotyped.     

Multilobated large B-cell lymphoma diagnosed cytologically. A case report.

BACKGROUND: Fine needle aspiration (FNA) biopsy can be used to reliably classify most conditions involving lymph nodes or, at least, significantly reduce the differential diagnosis. CASE: A 70-year-old male presented with an ulcerated mass arising from the left tonsillar fossa and involving the anterior and posterior pillars. A biopsy of the tonsillar mass performed at an outside hospital was interpreted as a large cell undifferentiated carcinoma. Subsequently the patient developed systemic lymphadenopathy. A bone scan showed intense uptake within the medial tibial plateau of the left knee. FNA biopsy of the right axillary mass was interpreted at University of Cincinnati Medical College as a large cell lymphoma, multilobated type. Histologic and immunohistochemical studies of the lymph node confirmed the presence of multilobated B-cell lymphoma. Lymphoma chemotherapy was initially successful but was discontinued due to toxicity. The patient died two months after the initial cytologic diagnosis of lymphoma. CONCLUSION: Multilobated lymphomas are an unusual variant of non-Hodgkin's lymphomas (mostly B-cell type). Cytology and immunocytochemistry are useful diagnostic procedures that can help to diagnose this relatively uncommon type of lymphoma and significantly reduce the possibility of misdiagnosis.     

Fine needle aspiration cytology and immunocytochemical characterization of the histiocytes in sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman syndrome)

A fine needle aspiration (FNA) biopsy of an enlarged lymph node in a three-year-old boy who had asymptomatic cervical and submandibular lymphadenopathy showed large histiocytes with abundant pale, eosinophilic cytoplasm containing well-preserved lymphocytes and occasional plasma cells and granulocytes. These features were consistent with a diagnosis of sinus histiocytosis with massive lymphadenopathy (SHML). Immunophenotypic study of the histiocytes, performed on the FNA smears and on paraffin-embedded sections, showed reactivity for S-100 protein and alpha-1-antichymotrypsin and negativity for lysozyme. These features, which are characteristic of SHML, demonstrate the reliability of FNA cytology in making the diagnosis of this disorder.     

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.     

Lymphoepithelioid cell lymphoma (Lennert's lymphoma). Report of a case with fine needle aspiration cytology

BACKGROUND: Lymphoepithelioid cell lymphoma (LCL) is a rare morphologic variant of peripheral T-cell lymphoma. Although their histopathologic and immunohistochemical findings are well known, the cytopathologic features have not been well documented. This report describes the fine needle aspiration cytology (FNAC) findings of a case of LCL. CASE: A 75-year-old woman presented with cervical, supraclavicular, axillary and mediastinal lymphadenopathy. FNAC of a cervical lymph node was performed. The smears contained a polymorphous infiltrate formed by abundant histiocytes disposed singly or in clusters, small and medium-sized to large atypical lymphoid cells and reactive cells, including eosinophils and plasma cells. Isolated capillary-sized vessels also were observed. Histopathologic and immunohistochemical examination confirmed the diagnosis of Lennert's lymphoma. CONCLUSION: Although histopathologic and immunohistochemical studies were required for a definitive diagnosis, the findings of FNAC in this case appeared distinctive and suggested the possibility of LCL.     

Diagnosing Kikuchi disease on fine needle aspiration biopsy: a retrospective study of 44 cases diagnosed by cytology and 8 by histopathology.

OBJECTIVE: To study the accuracy of fine needle aspiration (FNA) diagnosis of Kikuchi lymphadenitis (KL). STUDY DESIGN: Retrospective review of all cases of FNA biopsy of lymph nodes in which KL was diagnosed or suggested. False positive cases were studied. Cases of KL diagnosed by histopathology were examined for the false negative rate of FNA diagnosis. RESULTS: Forty-four cases of KL diagnosed or suggested by FNA were found. Five of eight cases were confirmed on lymph node excision. The false positive rate was 37.5%. One case was nonspecific reactive changes. Two cases were proven to be tuberculous lymphadenitis by culture. Eight cases of KL diagnosed by lymph node excisional biopsy had prior FNA. Four were diagnosed as or suspected to be KL. The false negative rate was 50%. CONCLUSION: The overall accuracy of FNA diagnosis of KL was 56.25%. Detailed study offalse positive cases and knowledge of other conditions suggested that overreliance on certain cytologic features and the morphologic erlap between KL and tuberculous lymphadenitis could have been the reasons for the inaccuracies.     

Fine needle aspiration cytology of localized Leishmania lymphadenitis

Leishmania lymphadenitis, an uncommon cause of lymphadenopathy, is usually diagnosed by surgical biopsy performed because of suspicion of lymphoma. The cytopathologic features of this disease do not appear to have been previously described. This paper describes the findings in seven cases of Leishmania lymphadenitis diagnosed by fine needle aspiration (FNA) cytology. The identification of Leishman-Donovan bodies in epithelioid cells in the aspirates led to the cytologic diagnosis of Leishmania lymphadenitis, which was histologically confirmed in all cases. Since this disease is self-limiting and requires no treatment, FNA diagnosis is especially useful in that the patient can be spared more invasive diagnostic techniques.     

Fine needle aspiration biopsy of Ki-1-positive large-cell "anaplastic" lymphoma.

The cytopathologic, immunohistochemical and ultrastructural features of a case of Ki-1-positive lymphoma are presented and discussed. On fine needle aspiration (FNA) biopsy smears, the Ki-1-positive lymphoma was characterized by large isolated cells with abundant dense/vacuolated cytoplasm and large nuclei with irregular profiles. Although most cells contained one nucleus, binucleated and multilobed/multinucleated cells were also seen. The cohesion of the malignant cells in histologic sections of a biopsied lymph node suggested an anaplastic carcinoma. The discrepancy was resolved by ultrastructural and immunologic analyses. The main differential diagnoses on FNA material include Hodgkin's disease, malignant melanoma and undifferentiated carcinoma; the cytologic suspicion should be confirmed by immunocytochemical studies.     

Pediatric acute leukemia presenting as bilateral renal enlargement. Report of a case with fine needle aspiration cytologic features suggestive of megakaryocytic differentiation

BACKGROUND: Fine needle aspiration (FNA) cytologic diagnosis of acute myeloid leukemia involving the kidney has rarely been reported, but acute leukemia with cytologic features suggestive of megakaryocytic differentiation has not been described before. CASE: An 8-month-old male presented with an abdominal swelling, bilateral cervical and inguinal lymphadenopathy and enlarged left epididymis. Ultrasonography of the abdomen revealed a space-occupying lesion in the liver and bilateral enlargement of the kidneys. FNA smears from the right kidney and right submandibular lymph node showed numerous blast cells. Since rare blast cells were positive for myeloperoxidase, a cytodiagnosis of involvement by acute myeloid leukemia (AML) was made. However, following the hematologic diagnosis of acute megakaryoblastic leukemia (M7) from peripheral blood and bone marrow smear examination, FNA smears were reviewed. There were cytoplasmic blebs or protrusions in the blast cells and cytologic features suggestive of their differentiation toward micro-megakaryocytes and megakaryocytes. There was also evidence of shedding of platelets, including numerous giant platelets. The reviewed FNA cytodiagnosis was suggestive of AML (M7). CONCLUSION: Extramedullary involvement by acute megakaryoblastic leukemia (M7) can be suspected based on cytomorphologic features in FNA smears.     

T-cell/histiocyte-rich diffuse large B-cell lymphoma. Report of a case diagnosed by fine needle aspiration biopsy with immunohistochemical and molecular pathologic correlation

BACKGROUND: T-cell-rich B-cell lymphoma (TCRBL) is a lymphoma of B-cell type associated with a prominent component of T cells (constituting > 50% of the cellular population). We report the first case of TCRBL diagnosed by fine needle aspiration (FNA). It was confirmed by subsequent lymph node excision biopsy. CASE: A 37-year-old woman presented with a short history of chest wall pain. Examination revealed induration, warmth and armorlike swelling of the right anterior chest wall, axilla and upper arm, with matted lymph nodes in the ipsilateral axilla and supraclavicular fossa. FNA showed a polymorphic, lymphoid aspirate, among which were many small lymphocytes, significant numbers of centroblastlike cells and a few markedly atypical lymphoid cells with convoluted nuclei. Histiocytes, freely lying karyorrhectic debris and mitotic figures were readily identified. Plasma cells, eosinophils and Reed-Sternberg cells were not seen. The cell block contained similar cells, with larger lymphoid cells scattered among smaller lymphocytes. Immunohistochemical studies showed that the larger cells were B cells. Molecular studies on the cell block confirmed an immunoglobulin gene rearrangement. CONCLUSION: TCRBL is a distinct type of lymphoma that can be accurately diagnosed by FNA.     

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 diagnosis in HIV-related lymphadenopathy in Mangalore, India

OBJECTIVE: To evaluate the usefulness of fine needle aspiration (FNA) study of lymph nodes in HIV-positive patients. STUDY DESIGN: The study was conducted at Kasturba Medical College, Mangalore, India. Samples from lymph nodes of 48 HIV-positive patients were taken and air dried, and wet smears were made. After staining with routine cytologic stains and special stains, detailed cytomorphologic study was conducted. RESULTS: Tuberculosis accounted for nearly half (48%) the cases,followed by HIV lymphadenitis (36%), lymphoma (10%), suppurative lymphadenitis (2%), Mycobacterium avium-intracellulare lymphadenitis (2%) and metastases (2%), in descending order of their frequency. A suppurative picture, which was found in 13% of cases of tuberculous lymphadenitis in AIDS patients, occasionally was misleading without the help of acid fast bacilli stain. CONCLUSION: FNA is a useful tool in the diagnosis of lymphadenopathy in HIV-positive patients provided that proper safety measures are taken to avoid contracting the infection.     

Diagnostic value of needle aspiration cytology in the assessment of palpable axillary lymph nodes. A study of 336 cases

OBJECTIVE: To evaluate the diagnostic value of needle aspiration cytology (NAC) in the assessment of palpable axillary lymph nodes and determine whether ancillary procedures can be useful in enhancing the diagnosis. STUDY DESIGN: The material was analyzed in 336 cases with enlarged axillary lymph nodes in which NAC were performed by the conventional method. In all cases cytologic examination was done on site after staining the smears with the Papanicolaou method. In addition, air-dried smears, fixed smears, filter preparations from needle washings and cell blocks were studied. The NAC diagnosis was supported by examining cell blocks, which showed the reliability of histologic architecture; further support was obtained with tissue biopsy and/or comparison with the primary tumor in some of the cases. RESULTS: Twelve cases were diagnosed as inflammatory lesions, and 64 were unsatisfactory due to scanty/acellular samples (despite 2-3 repeat samplings). However, in 6 of these, malignant tumors were later found on a biopsy done due to persistent and continued enlargement of an axillary lymph node or nodes. One hundred twenty-two cases were regarded as negative (normal cellular elements, n = 52; reactive elements, n = 70), and 4 cases were suspicious for malignancy. In 124 cases a variety of metastatic tumors were diagnosed (breast, n = 63; melanoma, n = 22; others, n = 39), and in 10 cases a diagnosis of lymphoma was made. CONCLUSION: NAC of palpable axillary lymph nodes as a first-line of investigation is a cost-effective procedure and is not only useful in the diagnosis of various lesions but can also help in deciding on management. Also, histologic architecture from cell blocks can be correlated with cytology, and such material can be used for histochemical and immunomarker studies.     

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.     

Diagnosis of intestinal malakoplakia by fine needle aspiration cytology

Two cases of intestinal malakoplakia were diagnosed by fine needle aspiration (FNA) cytology. Clinically, these cases were mistaken for a lymphoma and a tuberculosis. Percutaneous abdominal FNA material showed numerous macrophages with the characteristic Michaelis-Gutmann bodies. These bodies were easily identified both inside and outside the macrophages in the smears.     

Chronic wuchereriasis presenting as a vaginoperineal fistula: report of a case with aspiration cytologic diagnosis

BACKGROUND: Filariasis is often an occult disease with myriad presentations. Cytology has an established role in diagnosing clinically unsuspected cases. CASE: A 20-year-old female presented with recurring perineal ulcers, vaginal discharge and inguinal lymphadenopathy. Radiology revealed a vaginoperineal fistula. Fine needle aspiration (FNA) of the ulcer bed and smears prepared from the ulcer discharge showed an adult, gravid, female filarial worm and unsheathed larvae. Similar microfilariae were also seen in FNA smears from inguinal lymph nodes. The atypical clinical presentation and unusual parasite morphology posed initial difficulties in characterization of the microfilarial species. CONCLUSION: This case report highlights the morphologic clues to the dif ferential diagnosis offilarial species on cytologic specimens. Chronic wuchereriasis presenting as a vaginoperineal fistula has not been reported previously.