Salivary duct carcinoma metastatic to inguinal lymph node: a case report of salivary duct carcinoma with distant metastasis diagnosed by fine-needle aspiration

Salivary duct carcinoma (SDC) is a high-grade malignant tumor exhibiting aggressive growth with early regional and distant metastasis. We report a case of SDC in a 53-yr-old male with distant metastasis to an inguinal lymph node. The diagnosis of the primary tumor as well as the metastatic lesion was accomplished by fine-needle aspiration (FNA). Aggressive clinical management appears to be the main therapeutic option for long-term survival. Therefore, establishing an accurate preoperative diagnosis by FNA can have both clinical and prognostic relevance.     

Diagnostic clues for differentiating Merkel cell carcinoma from lymphoma in fine-needle aspiration cytology

Nodal fine needle aspiration (FNA) is usually the first procedure in the work-up of malignancy of unknown primary. Merkel cell carcinoma (MCC) is an aggressive cutaneous cancer more common in Caucasians but rare among Asians. It is a diagnostic challenge in evaluating FNA from a metastatic MCC without the knowledge of a current or prior history of skin cancer. We report the case of a Taiwanese male with cervical and axillary masses. The diagnosis of the FNA from the axillary lymph node was lymphoproliferative lesion suspicious for lymphoma. The histopathological evaluation of nodal biopsy revealed a metastatic neuroendocrine carcinoma and the subsequent excision of the right palm tumor confirmed MCC. Retrospective review of the FNA and imprint cytology smears of the nodal biopsy showed nuclear molding, Indian filing and rare cytoplasmic pale bodies, but no lymphoglandular bodies. Cytologically metastatic MCC may mimic small round cell tumor including lymphoma, we consider these three cytological features as additional diagnostic clues for metastatic MCC. In this report, we present the cytologic and pathological features of this metastatic MCC and discuss the differential diagnosis of the cytologic mimickers.     

Fine-needle aspiration cytology of amyloid associated with nonneoplastic and malignant lesions

To assess the value of fine-needle aspiration (FNA) cytology for the diagnosis of amyloid, we retrospectively studied all FNA cases diagnosed as having amyloid during a 6-yr period (1990–1996). FNA was performed on both superficial and deep locations. A total of 6 cases containing amyloid was studied, including primary medullary thyroid carcinoma, metastatic medullary thyroid carcinoma to a vertebrae, multiple myeloma, squamous-cell carcinoma of the lung metastatic to a hilar lymph node, primary pulmonary amyloid, and amyloid tumor in a vertebral body in a patient with primary systemic amyloidosis. Despite the location or disease association, the cytologic appearance of amyloid in all cases was similar. On Diff-Quik stain, amyloid appeared as amorphous, irregular, waxy, basophilic to metachromatic clumps of material. Papanicolaou stain revealed cyanophilic to organophilic clumps of material with occasional prominent fissures. In all 6 cases, amyloid was confirmed by Congo red stain and in 3 cases by a thioflavin T stain. In 4 of the 6 cases (67%), amyloid was associated with an underlying malignancy. In 3 cases malignant cells were admixed with the amyloid, and in another case malignancy was present at a distant site. We conclude that FNA biopsy is a helpful initial procedure for the evaluation of patients with amyloid deposits. The clinical implications of amyloid found in any particular body site include both benign and malignant conditions. The presence of an associated neoplasm must be especially considered in the differential diagnosis of amyloid deposits. Diagn. Cytopathol. 1998;18:270–275. © 1998 Wiley-Liss, Inc.     

Rhabdomyosarcoma in an adult presenting with nodal metastasis: a pitfall in fine-needle aspiration cytology of lymph nodes

A 40-yr-old woman with an asymptomatic sinonasal rhabdomyosarcoma (RMS) initially presented with submental nodal metastasis. The fine-needle aspiration (FNA) and the subsequent biopsy of the nodal metastasis were misinterpreted as metastatic carcinoma because the primary tumor was occult, the tumor cells were exclusively round cells with a nested arrangement, and rhabdomyoblasts were absent. The correct diagnosis of metastatic RMS became apparent when the primary sinonasal tumor, detected in a CT, was biopsy proven to be an alveolar RMS. Retrospectively, there were helpful clues to the correct diagnosis in the nodal FNA and biopsy. When FNA cytology or biopsy histology of a lymph node suggests metastatic carcinoma but the tumor cells are nonimmunoreactive to carcinoma markers, the differential diagnosis should be expanded to include not only metastatic melanoma but also metastatic sarcoma and lymphoma. Cytologically, the presence of multinucleated giant tumor cells, including the rosette forms, in the FNA smears should alert the cytopathologist to the possibilities of sarcoma and anaplastic large cell lymphoma.     

Nevus-cell aggregates in lymph nodes: fine-needle aspiration cytologic findings and resulting diagnostic difficulties

We report a case of nodal nevus present in enlarged lymph nodes with changes of dermatopathic lymphadenopathy sampled by fine-needle aspiration (FNA) cytology prior to clinical evaluation of the patient. This lymph node pathology was established later by lymph node excisional biopsy, by which along with a skin biopsy the dermatopathic lymphadenopathy was tentatively attributed to early mycosis fungoides. The FNA revealed fairly atypical melanotic tissue from the dermatopathic lymphadenopathy along with nodules of uniform melanocytic nevoid cells, the presence of which in combination with the dermatopathic atypical tissue provided a tentative diagnosis of metastatic melanoma of unknown primary, with the diagnosis of nodal nevus presented as a less likely possibility. This is to our knowledge the first cytologic report on FNA of nodal nevus, which besides presenting cytologic findings of this entity highlights some of the problems related to providing an accurate diagnosis, if this exceptionally unusual pathologic entity is encountered in lymph nodes sampled for enlargement from pathologies unrelated to this entity. The subject of nevus changes in lymph nodes is briefly discussed.     

Epithelial inclusion cyst arising in an intramammary lymph node: Case report with cytologic findings

The occurrence of epithelial inclusion cysts (EIC) in axillary lymph nodes is a rare but well recognized entity, arising either from direct implantation or from embryonal rests. Theoretically, EIC can occur in intramammary lymph nodes, but there has been only one prior report of such a lesion. Here, we describe a case of an EIC arising in an intramammary lymph node of a 37‐year‐old woman. This report focuses on the FNA cytologic features of this lesion and its differential diagnoses. On FNA, the EIC arising in an intramammary lymph node was characterized by mature lymphocytes, squamous epithelial cells, and keratinizing material. The presence of squamous cells can lead to the erroneous diagnosis of more common breast lesions, such as squamous cell carcinoma or metaplastic carcinoma. Contrary to these more sinister diagnoses, EIC arising in an intramammary lymph node is a benign condition. As this rare lesion sometimes mimics a neoplasm both clinically and radiographically, awareness of this entity is important to prevent over treatment. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

A case of amelanotic spindle-cell melanoma presenting as metastases to breast and axillary lymph node: diagnosis by FNA cytology

Metastatic neoplasms to the breast are relatively rare. Spindle-cell lesions of the breast are also uncommon. Here we present a case of fine-needle aspiration (FNA) of an amelanotic, spindle-cell melanoma metastatic to the breast and axillary lymph node. The patient was a 47-yr-old female who presented with a right breast mass, left axillary adenopathy, and a pigmented skin lesion on the back. FNA of the right breast and left axilla showed malignant, nonpigmented spindle cells that were weakly positive for HMB-45 on immunocytochemistry. The skin biopsy showed a pigmented malignant melanoma with epithelioid features, and also weak positivity for HMB-45. Although malignant melanoma is one of the more common tumors to metastasize to the breast, this is the first known case that showed exclusive spindle-cell morphology. History and physical examination were crucial in making the correct FNA diagnosis. The cytologic differential diagnosis of spindle-cell tumors of breast and the discordant morphology between the primary and metastatic melanotic lesions observed in this case are discussed.     

Ovarian carcinoma presenting with axillary lymph node metastasis: a case diagnosed by fine-needle aspiration and brief review of the literature

Ovarian carcinoma is a lethal disease and a main cause of morbidity and mortality among gynecological malignancies. Metastatic ovarian carcinoma to the axillary node is an exceptionally infrequent pathological entity. We report a case of ovarian carcinoma, which presented with axillary lymph node metastasis and review the previously documented cases. A 63-year-old woman with a medical history of stage IIIb ovarian carcinoma was admitted to our hospital complaining of a mass in her right axilla. Fine-needle aspiration (FNA) biopsy was performed. Cytological examination revealed a poorly differentiated carcinoma with immunocytochemical features consistent with metastatic ovarian carcinoma. This case illustrates a rare presentation of ovarian carcinoma and underlines the need to consider it in the differential diagnosis of axillary lesions.     

Fine-needle aspiration of rheumatoid nodule: a case report with review of diagnostic features and difficulties

Patients with rheumatoid arthritis may develop extra-articular subcutaneous nodules as part of the systemic disease or as initial manifestation. These lesions may represent significant diagnostic dilemmas in patients with clinical suspicion of malignancy. In this setting, fine-needle aspiration (FNA) of the nodules may be the simplest and most appropriate diagnostic approach. In the literature, however, there are only sporadic reports describing FNA cytology of a rheumatoid nodule. In this report, we present a case of a 67-year-old male with a history of rheumatoid arthritis and squamous-cell carcinoma of the larynx who developed a subcutaneous neck nodule in the immediate proximity of the surgical scar. Clinically, because of the history of squamous-cell carcinoma and location of the lesion, the nodule was suspected to be metastatic cancer, but was proven by FNA biopsy to represent rheumatoid disease. Cytological criteria of rheumatoid nodule and diagnostic difficulties are discussed.     

Fine-needle aspiration cytology of metastatic small cell carcinoma of the colon: A report of three cases

Small cell carcinoma of the large intestine is a rare, extremely aggressive malignancy often associated with an overlying adenoma. We report three cases of metastatic small cell carcinoma of the colon diagnosed by fine-needle aspiration (FNA) biopsy. Two of the patients were women (ages 33 and 46 yr old) and one was a man (69 yr old). FNA biopsy established the diagnosis of metastatic small cell carcinoma involving the liver (2 cases) and soft tissue of the scapular region (1 case). In one patient, the FNA diagnosis of hepatic metastases preceded identification of the primary site. Subsequently, the patient was found to have a small cell carcinoma subadjacent to a colonic villous adenoma, illustrating the importance of investigating villous lesions of the colon in patients with metastatic small cell carcinoma of unknown primary origin (especially in non-smokers). All three cases showed the characteristic cytologic features of small cell carcinoma. Ancillary studies performed on aspirated material confirmed the diagnosis of small cell carcinoma in one case. Immunocytochemical studies revealed punctate cytokeratin and diffuse neuron-specific enolase (NSE) positivity of the malignant cells. Ultrastructurally neurosecretory granules were evident. To the best of our knowledge, this is the first FNA cytologic report of metastatic small cell carcinoma of the large intestine. This FNA report also demonstrates when a small cell carcinoma is detected in a metastatic site in a patient lacking a lung primary, a likely primary site could be adjacent or beneath a polypoid lesion of the colon. Diagn Cytopathol 1996;15:54–59. © 1996 Wiley-Liss, Inc.     

Aspiration biopsy of osseous metastasis of occult hepatocellular carcinoma: Case report, literature review, and differential diagnosis

Fine-needle aspiration (FNA) cytology is a reliable technique for rapid diagnosis in virtually every organ of the body, including bone lesions. We report on the FNA findings in a 61-yr-old male of an osteolytic sacral lesion, which determined the diagnosis of an unsuspected metastatic hepatocellular carcinoma. In this case, the diagnosis was confirmed by FNA biopsy without resorting to surgical biopsy.     

Unusual small bone metastases from epithelial malignancies: Diagnosis by fine-needle aspiration cytology with histologic confirmation

Although epithelial malignancies can have bone metastases, involvement of small bones is exceedingly rare, representing either first manifestation of an occult carcinoma or late disseminated disease. Small bone metastases may mimic primary skeletal diseases leading to misdiagnosis and delayed treatment. We report three cases of metastatic epithelial malignancies diagnosed by computed tomography (CT)-guided fine-needle aspiration (FNA) biopsy in two patients with lytic calcaneal lesions and a patellar lesion in a third patient; all with histologic confirmation. Case 1, a 63-yr-old female, presented with heel pain. FNA and tissue biopsy of the calcaneus revealed a clear cell malignancy consistent with a renal primary. Follow-up abdominal CT scan revealed a renal lesion consistent with renal cell carcinoma. Case 2, a 37-yr-old male with squamous cell carcinoma of the esophagus, presented with foot pain. FNA and tissue biopsy of the calcaneus revealed metastatic squamous cell carcinoma. Case 3, a 52-yr-old male with a history of squamous cell carcinoma of floor of mouth, presented with knee pain and swelling. FNA and tissue biopsy of the patella revealed metastatic squamous cell carcinoma. To the best of our knowledge, this is the first complete FNA cytology report with histologic confirmation of unusual small bone metastases of the feet and patella from epithelial malignancies and shows the value of FNA cytology in establishing a correct diagnosis, and excluding primary skeletal diseases. © 1995 Wiley-Liss, Inc.     

Fine‐needle aspiration diagnosis of a metastatic adult sclerosing rhabdomyosarcoma in a lymph node

Adult sclerosing rhabdomyosarcoma (ASRMS) is a rare variant of rhabdomyosarcoma with a characteristic histological appearance of small, round cells in a dense, hyalinized stroma. Although nodal metastases of soft‐tissue sarcomas are considered uncommon, up to 5% overall are associated with lymph node metastases. Nonetheless, there is little literature on the cytologic characteristics of metastatic soft‐tissue sarcomas in lymph nodes, and to our knowledge, there are no reports of nodal metastasis of ASRMS diagnosed by fine‐needle aspiration (FNA) cytology. We report here a 55‐year‐old woman who presented with a right thigh mass and associated ipsilateral inguinal lymphadenopathy. Biopsy of the mass revealed a uniform population of small, round cells in a dense, sclerotic background. A diagnosis of ASRMS was rendered. Subsequently, the patient underwent FNA of an enlarged inguinal lymph node, which revealed an identical population of small, round cells in a dense, myxoid background. This case highlights the cytologic features of a rare form of rhabdomyosarcoma, and emphasizes the utility of FNA in the assessment of lymphadenopathy in the setting of a soft‐tissue sarcoma. Diagn. Cytopathol. 2010;38:761–764. © 2010 Wiley‐Liss, Inc.     

Barrett's esophagus with high-grade dysplasia simulating metastatic adenocarcinoma in a fine needle aspiration biopsy

An endoscopic ultrasound examination, performed to rule out invasive esophageal carcinoma in a patient with a history of Barrett's esophagus with high-grade dysplasia, disclosed an enlarged paraesophageal lymph node which was aspirated. The aspirate contained markedly atypical clustered large cells that displayed prominent nucleoli and mitoses, as well as lymphoid cells, suggestive of adenocarcinoma metastatic to a lymph node. The neoplastic-appearing cells were, in fact, dysplastic glandular cells that the needle traversed en route to a reactive lymph node. The case represents a rare instance in which Barrett's esophagus with high-grade dysplasia was discerned on fine needle aspiration (FNA) biopsy and highlights a potential pitfall in FNA.     

Metastatic extraocular sebaceous carcinoma with an occult primary

The cytological diagnosis of sebaceous carcinoma is based on the aspiration of tumor lobules with extensive sebaceous differentiation. However, these tumors may show a spectrum of cells ranging from basaloid to well-differentiated sebaceous. Extraocular sebaceous carcinoma is an uncommon tumor. An occult primary at initial presentation has not been described previously. A 60-yr old woman was referred to the fine-needle aspiration (FNA) clinic with a submandibular mass. The cytological diagnosis was mucoepidermoid carcinoma. Histopathologically, it was a sebaceous carcinoma metastatic to the submandibular lymph node. No primary tumor was identified. Six months later, she presented with a nodule at the angle of her mouth and a recurrence of the submandibular swelling. FNA cytology (FNAC) and histopathologic examination revealed a primary cutaneous sebaceous carcinoma with submandibular lymph node metastasis. A metastatic sebaceous carcinoma in the submandibular region with limited sebaceous differentiation and occult primary is another pitfall in the cytomorphological diagnosis of mucoepidermoid carcinoma.     

Fine-needle aspiration biopsy and intraoperative cytologic smear findings in a case of benign mesothelial-cell inclusions involving a lymph node: case report and review of the literature

Although first described over a decade ago, the rare entity of mesothelial lymph node inclusions (nonneoplastic mesothelial cells involving lymph node sinuses) is not well-known among pathologists. Unlike most lymph node inclusions such as Müllerian inclusions or nevus cells, which usually occur in the capsule of the lymph node, mesothelial cells involve the lymph node sinus, mimicking metastatic carcinoma or metastatic mesothelioma. The spectrum of histologic findings ranges from a few mesothelial cells, perhaps only detectable by immunohistochemical stains, to a massive distention of the lymph node sinus with abundant mesothelial cells. Mesothelial-cell inclusions in lymph nodes are usually found in mediastinal lymph nodes of patients with pleural and/or pericardial effusions. It is hypothesized that the effusion, due to whatever cause, allows for mesothelial-cell migration into the submesothelial lymphatics and regional lymph nodes. To our knowledge, cytologic findings on aspiration biopsy and intraoperative smear preparations of a lymph node with mesothelial-cell inclusions have never been described. Familiarity with this entity is important in preventing misdiagnosis of malignancy.     

Clinical implications and value of immunohistochemical staining in the evaluation of lymph node infarction after fine-needle aspiration

We report on a series of 3 patients who underwent fine-needle aspiration (FNA) for clinically apparent lymphadenopathy. In all 3 cases, a diagnosis of malignancy was rendered based on cytologic findings (two metastatic squamous-cell carcinomas and one melanoma). However, initial follow-up surgical pathology reported only "extensive coagulative necrosis, no viable tumor seen." Subsequent immunohistochemical stains (cytokeratins (AE1/AE3), HMB45, S100, and Melan A) demonstrated the presence of metastatic tumor in the area of infarction in each case, thus establishing the presence of metastatic tumor and correct interpretation of the initial FNA. We conclude, based on our own experience and a few previously reported cases, that total infarction of the lymph nodes following FNA can occur, and immunohistochemistry can be helpful in clinical management.     

Endoscopic ultrasound-guided fine-needle aspiration of lymph nodes: the Hennepin County Medical Center experience

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) allows for the sampling and diagnosis of lesions of the gastrointestinal system and adjacent tissues. It has also proved helpful with the sampling of lymphadenopathy both for the staging of malignancy and for the diagnosis of lymphadenopathy of other causes. We review our experience with EUS-guided FNA of lymph nodes. The cytology files were searched at Hennepin County Medical Center (HCMC) for all cases of lymph nodes sampled by EUS. Clinical history, biopsy site, diagnosis, and follow-up information (including ancillary testing) were reviewed. Between January 1, 2000 and December 5, 2002, 217 lymph nodes from 185 different patients were sampled by EUS at HCMC. Biopsy sites included 62 mediastinal, 9 paraesophageal, and 146 intra-abdominal lymph nodes. Diagnoses were as follows: metastatic non-small cell carcinoma (n = 69); benign, reactive lymph node (n = 76); granulomatous lymphadenopathy (n = 18); malignant lymphoma (n = 7); atypical-suspicious for malignancy (n = 5); metastatic small cell carcinoma (n = 2); necrotic debris (n = 4), and foreign material (n = 1); 35 cases were nondiagnostic (16.1%) in 22 of 185 patients (11.9%). Ancillary tests including flow cytometry, cytogenetics, and cultures were performed. EUS-guided FNA of mediastinal and intra-abdominal lymph nodes provides diagnostic material from which ancillary testing may be performed.     

Intraoperative evaluation of sentinel lymph nodes for breast carcinoma: current methodologies

Sentinel lymph node biopsy is an important new addition to the surgical management of patients with breast carcinoma. Sentinel nodes have a higher chance of containing metastases than do nonsentinel nodes. Sentinel lymph node biopsy provides an opportunity to stage breast carcinoma patients more accurately and to modify subsequent treatment. One of the most exciting current roles of sentinel lymph node biopsy is the ability to stage patients intraoperatively, allowing a one-step axillary lymph node dissection if the sentinel lymph node contains metastatic carcinoma. Currently, intraoperative evaluation of sentinel lymph nodes is performed using imprint cytology with or without rapid cytokeratin staining, frozen sectioning with or without rapid cytokeratin staining, scrape preparations, or some combination of these techniques. We review the relative strengths and weaknesses of these different methodologies. A great deal of controversy exists regarding the management of patients with metastatic breast carcinoma, particularly those patients with occult and micrometastatic disease. These issues are beyond the scope of this article.