Secondary tumors of the pancreas diagnosed by endoscopic ultrasound‐guided fine‐needle aspiration: A 10‐year experience

Determining whether a pancreatic mass is a primary or secondary neoplasm is necessary for appropriate treatment. We reviewed our experience using endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) for diagnosis of pancreatic tumors to identify clinical and cytopathologic characteristics of metastatic disease. We reviewed all cases of tumors metastatic to the pancreas evaluated at The University of Texas MD Anderson Cancer Center and The Methodist Hospital in Houston, Texas during the period from 2002 to 2012. The review included cytologic specimens, clinical history, radiologic findings, primary tumor type, and clinical follow‐up. We identified 66 patients with disease metastatic to the pancreas for which cytologic material was available: 38 (58%) men and 28 (42%) women, with an average age of 63 years (range, 40–89 years). Most metastases (98%) were single lesions, and nearly half were located in the head of the pancreas (30/66). The most common site of origin for these metastases was kidney (27 [41%] cases). Follow‐up information was available for 65 (98%) patients, and duration of follow‐up ranged from <1 to 10 years (mean, 2.3 years). Thirty‐three patients (50%) were alive at the time of the most recent follow‐up contact. Of the 25 patients with metastatic renal cell carcinoma, clear cell type, 19 (76%) were alive at the time of the most recent follow‐up. It was concluded that metastases may mimic primary pancreatic carcinomas both clinically and cytologically. Ancillary studies in conjunction with clinical history are necessary for the accurate diagnosis of FNAs of secondary pancreatic tumors. Diagn. Cytopathol. 2014;42:738–743. © 2014 Wiley Periodicals, Inc.     

Cytologic features of pancreatic adenocarcinoma with “vacuolated cell pattern.” report of a case diagnosed by endoscopic ultrasound‐guided fine‐needle aspiration

The “vacuolated cell pattern” has only been recently described as a distinct morphologic variant of pancreatobiliary adenocarcinoma. Herein, we report the endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) cytologic features of a case of pancreatic adenocarcinoma with “vacuolated cell pattern” occurring in a 60‐year‐old man. The aspirate smears and cell block sections from the EUS‐FNA of a 23.5 mm hypoechoic pancreatic head mass were highly cellular, showing variably‐sized crowded three‐dimensional cell clusters, flat sheets, and numerous highly atypical single cells. The background was bloody and showed necrotic debris, but no discernible mucus. The most striking feature of the aspirate was the presence of numerous very large (20–50 µm) vacuoles, occupying the entire cytoplasm, pushing the nuclei to the side and indenting them, that imparted a cribriform appearance to the sheets of neoplastic cells. The non‐vacuolated neoplastic cells were large, had abundant dense (squamoid) cytoplasm, irregularly contoured hyperchromatic nuclei, and prominent macronucleoli. Histologic evaluation of the pancreatectomy specimen showed a “vacuolated cell pattern” adenocarcinoma composed of poorly formed glands, solid sheets, and infiltrating single cells with pleomorphic nuclei and large cytoplasmic vacuoles. To our knowledge, this is the first report describing the cytologic features of this rather uncommon morphologic variant of pancreatic adenocarcinoma. Recognition of this morphologic variant of pancreatic adenocarcinoma in ESU‐FNA samples allows its differentiation from primary and metastatic signet‐ring cell carcinomas. Diagn. Cytopathol. 2014;42:302–307. © 2014 Wiley Periodicals, Inc.     

Ultrasound‐guided fine‐needle aspiration of a rectal submucosal nodule

Although endoscopic biopsy of a rectal submucosal nodule may be nondiagnostic, endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) can be an important tool to make diagnosis. We report a case of a female patient who had an EUS‐FNA of a submucosal nodule after a nondiagnostic rectal biopsy. The original diagnosis was erroneously rendered as concerning for necrotic neoplasm. The correct diagnosis of Solesta‐induced foreign body reaction was made on reviewing the slides once the history of remote Solesta injection was made available. This case illustrates the pathognomonic features of Solesta‐induced rectal nodule and underscores the importance of detailed history as well as inclusion of iatrogenic diseases in the differential to prevent erroneous diagnosis and management. Potential pitfalls in cytopathological diagnosis are discussed.     

Cytopathologist‐performed ultrasound‐guided fine‐needle aspiration of parathyroid lesions

The gold standard to determine the cause of primary hyperparathyroidism (PHPT) is bilateral neck exploration. As most cases are caused by parathyroid adenoma, there is a movement toward preoperative localization of the abnormal gland by ultrasound and/or Tc⁹⁹‐sestamibi scan and minimally invasive parathyroidectomy. Nonpalpable thyroid nodules are common and cannot be differentiated from parathyroid lesions by imaging alone. This study examines cytopathologist‐performed ultrasound‐guided fine‐needle aspiration (UG‐FNA) in diagnosis of parathyroid lesions. Between January 1, 2007 and December 31, 2008, seven patients with PHPT or other parathyroid lesions with one or more sonographically‐visible thyroid masses underwent cytopathologist‐performed UG‐FNA with immediate cytological evaluation (ICE). One mass was palpable and nine were nonpalpable. Three parathyroid adenomas, two benign colloid nodules, one papillary carcinoma, three parathyroid cysts, and one thyroid cyst were diagnosed. The nodules in three patients with parathyroid adenomas were identified as follicular lesion/neoplasm on ICE. Additional UG‐FNA passes were made to obtain tissue for immunohistochemistry stains, which confirmed parathyroid origin. Two of these patients had a separate benign colloid nodule and one had a thyroid cyst diagnosed by UG‐FNA. The PHPT patient with papillary carcinoma on UG‐FNA had the malignancy confirmed at surgery and a sonographically occult parathyroid adenoma. The three patients with thyroid cysts identified by radiology were suspected of being parathyroid cysts on the basis of real‐time sonographic features at the biopsy table. The clear cyst fluid obtained by UG‐FNA had markedly elevated PTH. Cytopathologist‐performed UG‐FNA can distinguish between parathyroid and thyroid nodules in patients with suspected parathyroid lesions. Diagn. Cytopathol. 2010. © 2009 Wiley‐Liss, Inc.     

Temporal mandibular joint chondrocalcinosis (tophaceous pseudogout) diagnosed by ultrasound‐guided fine‐needle aspiration

Tophaceous pseudogout is a calcium pyrophosphate dihydrate crystal (CPPD) deposition disease that frequently affects elderly patient in the temporomandibular joint (TMJ). A diagnosis of CPPD deposition disease in the TMJ is challenging due to its mimicking of other benign and malignant entities. Surgical exploration followed by histologic examination is by far the most frequently used diagnostic modality. We present a case of an 87‐year‐old female who presented with a right TMJ mass. A final diagnosis of tophaceous pseudogout was made on cellular material obtained by ultrasound‐guided fine‐needle aspiration (US‐guided FNA). Based on our case and current available literature, ultrasound‐guided FNA is a reliable tool for diagnosing tophaceous pseudogout of the TMJ.     

Value of cytopathologist‐performed ultrasound‐guided fine‐needle aspiration as a screening test for ultrasound‐guided core‐needle biopsy in nonpalpable breast masses

Fine‐needle aspiration (FNA) of breast masses in the United States has been on the decline for the last decade and has been largely replaced by ultrasound‐guided core‐needle biopsy (UG‐CNB). Some studies show core‐needle biopsy (CNB) is superior to FNA in terms of absolute sensitivity, specificity, and inadequate rate. However, the importance of a skilled aspirator, experienced cytopathologist, and immediate cytological evaluation (ICE) in FNA is often not considered. CNB is more expensive, invasive, risky, and painful than FNA. This prospective study examines the value of cytopathologist‐performed ultrasound‐guided FNA (UG‐FNA) with ICE as a screening test for cytopathologist‐performed UG‐CNB on nonpalpable or difficult‐to‐palpate solid breast masses visible on ultrasound. One hundred twenty consecutive nonpalpable or difficult‐to‐palpate presumably solid breast masses in 109 female patients from January2, 2008 to June 30, 2008 underwent cytopathologist‐performed UG‐FNA with ICE. Twenty cases were converted to cytopathologist‐performed UG‐CNB because ICE was inadequate, hypocellular, atypical, suspicious, or malignant. Patients with clearly benign cytology did not undergo UG‐CNB. UG‐FNA with ICE reduced the percentage of patients undergoing UG‐CNB by 87%. A new role for cytopathologist‐performed UG‐FNA of nonpalpable breast masses has been identified. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Large platelet aggregates in endoscopic ultrasound‐guided fine‐needle aspiration of the pancreas and peripancreatic region: A clue for the diagnosis of intrapancreatic or accessory spleen

Intrapancreatic and intraabdominal accessory spleens (IPIASs) are rarely encountered in endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) biopsies. However, as incidentally discovered IPIAS can mimic a benign or malignant pancreatic neoplasm on imaging studies, a definitive diagnosis made by EUS‐FNA can avert an unnecessary surgical intervention or additional radiologic follow‐up. We report five cases of intrapancreatic splenules and one case of accessory spleen (AS) in which a definitive diagnosis was made on EUS‐FNA. Previously recognized FNA cytomorphologic features of splenic tissue, including ASs and splenosis, are endothelial cells and polymorphous lymphocytes admixed with neutrophils, eosinophils, plasma cells, histiocytes, and lymphoglandular bodies. We describe the additional finding of abundant large platelet aggregates as another distinguishing feature of splenic tissue on FNA. In all six cases, large platelet aggregates were identified along with polymorphous lymphoid cells, lymphoglandular bodies, loose aggregates of endothelial cells and scattered or aggregated bland spindle cells. A review of 10 consecutive cases of EUS‐FNA‐sampled benign intraabdominal lymph nodes showed that the presence of large platelet aggregates, three‐dimensional aggregates of lymphoid cells and of bland slender spindle cells and the absence of follicular germinal cell components (tingible body macrophages and lymphohistiocytic aggregates) are useful in differentiating IPIASs from reactive lymph nodes. Immunoperoxidase stains were useful to confirm a suspected IPIASs by showing CD31‐positive acellular flocculent material, consistent with large platelet aggregates and a rich CD8‐positive endothelial cell network between CD45‐positive lymphoid cells and CD68‐positive histiocytes in all six cases. Diagn. Cytopathol. 2013;41:661–672. © 2013 Wiley Periodicals, Inc.     

Endoscopic ultrasound‐guided fine‐needle aspiration biopsy of gastric schwannoma: Cytomorphologic features and diagnostic pitfalls

Schwannoma rarely occurs in the stomach. We present a case of gastric schwannoma, which was initially evaluated by endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) biopsy and confirmed by surgical resection. The patient was a 57‐years‐old woman with history of dyspepsia, who was found to have a large submucosal mass in the stomach. EUS‐FNA showed scant spindle cells with abundant lymphocytes. The spindle cells were immunoreactive with S100, while negative for CD117, desmin, and CD34. The lymphocytes were mixed B‐cells and T‐cells. Immunostaining, flow cytometry, and molecular testing showed no evidence of B‐cell lymphoma. The diagnosis of gastric schwannoma was confirmed by histopathological evaluation of the resected tumor. Gastric schwannoma has unique features of mixed spindle cells and lymphocytes. The tumor should be differentiated from other gastric mesenchymal tumors, and lymphoproliferative disorder is a pitfall.     

Oncocytoma of the lacrimal gland diagnosed initially by fine‐needle aspiration cytology

Oncocytomas are benign tumors that infrequently involve ocular adnexa. We describe a case of oncocytoma of the lacrimal gland which was initially diagnosed by fine‐needle aspiration cytology. An 83‐year‐old patient presented to the cytology laboratory with a peripunctal mass in the right eye. The tumor was aspirated. The cytoplasm of the tumor cells was rich in eosinophilic granules. The initial cytological diagnosis was oncocytoma. The tumor was then completely excised and the histological diagnosis confirmed the initial cytological one. Oncocytoma is a rare entity which must be considered in differential diagnosis of a peripunctal mass in elderly patients. The literature was reviewed confirming the rarity of such a presentation and the novelty of this case. Cytological criteria of malignancy are not yet established. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Endoscopic ultrasound guided fine‐needle aspiration of a splenic hemangioma with extramedullary hematopoiesis

Extramedullary hematopoiesis (EMH) is the production of mature blood elements outside of the bone marrow and can occur as a compensatory result of a marrow replacing process or from marrow space occupying lesions such as tumor or marrow fibrosis. EMH can also be induced by factors elicited by neoplasms, such as vascular endothelial growth factor (VEGF). Usually, EMH is a diffuse process most commonly observed in lymph nodes, liver, and spleen. Rarely, EMH can form a mass lesion. Although the spleen is a common site for diffuse EMH, it is a rare location for a mass forming EMH. Hemangiomas are the most common benign tumors of the spleen. A case of a discrete, 8 cm lesion was noted incidentally on CT scan in a 59‐year‐old man with no significant past medical history. Endoscopic ultrasound guided fine‐needle aspiration (EUS FNA) biopsy was performed and cytologic examination revealed trilinear hematopoiesis, with the most distinctive elements being megakaryocytes and erythroid precursors. A diagnosis of EMH was made. On resection, the mass was a hemangioma with EMH. EUS guided FNA is a useful tool for diagnosing splenic masses. Awareness of EMH, both as a mass forming lesion and a feature associated with benign and malignant vascular lesions is important, especially in patients with hematologic malignancies or marrow replacing processes. Diagn. Cytopathol. 2013;41:1086–1090. © 2011 Wiley Periodicals, Inc.     

Primary pancreatic leiomyosarcoma with metastasis to the liver diagnosed by endoscopic ultrasound‐guided fine needle aspiration and fine needle biopsy

Primary pancreatic leiomyosarcomas are rare tumors of the pancreas that are usually diagnosed after resection or by biopsy. One case in the literature has utilized endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) cytology. We report a second case of a primary pancreatic leiomyosarcoma that yielded diagnostic material on EUS‐FNA cytology. A 72‐year‐old female presented with 3–4 months of abdominal pain. A CT scan showed a large heterogeneous, lobulated pancreatic head and uncinate mass and multiple hypoattenuating liver lesions. An EUS‐FNA was performed on one of the liver lesions with a 25‐gauge needle, yielding an adequate sample with lesional cells. The initial read was a spindle cell neoplasm. A subsequent endoscopic ultrasound‐guided fine needle biopsy with a 22‐gauge needle was performed on the pancreatic head mass to rule out two primaries and to provide tissue for a mitotic index in the case of gastrointestinal tumor. Both the cell block of the EUS‐FNA and the core biopsy were equally cellular and showed interlacing spindle cells that stained positive for SMA and negative for DOG‐1, CD 117, and CD34. In addition, the core biopsy of the pancreas stained positive for Desmin. A diagnosis of a primary pancreatic leiomyosarcoma was made and the patient was started on systemic chemotherapy. Primary pancreatic leiomyosarcomas are rare pancreatic tumors that may yield diagnostic material by EUS‐FNA with a 25‐gauge needle. Diagn. Cytopathol. 2016;44:1070–1073. © 2016 Wiley Periodicals, Inc.