Case of chondroid syringoma mimicking a nodular hidradenoma: A diagnostic pitfall on cytopathology

Limited literature is available on the use of fine needle aspiration (FNA) for skin tumors. Awareness of cytological features of these lesions is important to prevent misdiagnosis. A 45‐year‐old male, presented with slowly growing swelling over the thigh since 4 years. FNA from multiple sites yielded highly cellular smears with a dual cell population consisting of cells with small round nucleus scanty cytoplasm and polygonal cells with moderate to abundant cytoplasm. Extracellular basement membrane like material was also noted. A diagnosis of benign adnexal neoplasm, suggestive of nodular hidradenoma was made. Paraffin sections showed an encapsulated dermal tumor composed of ductal and myoepithelial cells in ducts, sheets, strands with chondromyxoid stroma. A final diagnosis of chondroid syringoma was given following evaluation of histopathology slides and Immunohistochemistry. FNA interpretation of skin tumors can be challenging since literature is limited. The placement of tumors into benign or malignant category is realistic and can direct management guidelines. Greater awareness of these lesions and following stringent diagnostic criteria can help in establishing a more accurate diagnosis.     

Fine‐needle aspiration cytology in the diagnosis of malignant proliferating trichilemmal tumor: Report of a case and review of the literature

Malignant proliferating trichilemmal tumor is a rare cutaneous neoplasm derived from the outer root sheath of the hair follicle. Fine‐needle aspiration cytology is being increasingly used in the investigation of primary and metastatic cutaneous tumors. However, there are few reports on the cytology of trichilemmal tumors in the literature. We describe the cytological features of this uncommon adnexal tumor presenting as a scalp mass in a 58‐year‐old woman. In view of its aggressive biological behavior, it is crucial for cytologists to be aware of this rare lesion and distinguish it from primary cutaneous squamous‐cell carcinoma. The differences on fine‐needle aspiration cytology can be subtle and pose problems in diagnosis. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Cutaneous metastasis of hepatocellular carcinoma diagnosed by fine needle aspiration cytology and Hep Par 1 immunopositivity

Cutaneous metastasis of hepatocellular carcinoma (HCC) is very rare, accounting for less than 0.8% of all known cutaneous metastases and occurring in 2.7–3.4% of HCCs. With less than 50 such cases reported worldwide, most of which were diagnosed histologically on excised lesions, it can only be expected that diagnosis made on cytological features alone would be challenging. We report a case of cutaneous metastasis of HCC diagnosed based on cytological features and confirmed by Hep Par 1 immunopositivity of the cell block material. An 81‐year‐old man, who was known to have unresectable HCC, presented with a 1‐month history of painless, left nasal alae mass. The mass measured 1.5 cm in diameter, and was multilobulated with a central necrosis. Fine needle aspiration of the mass was done. Smears were cellular, comprising of malignant cells in loose clusters and aggregates as well as singly dispersed. The malignant cells displayed moderate nuclear pleomorphism, occasional prominent nucleoli, and intranuclear pseudoinclusion. Cell block material demonstrated the trabeculae pattern of the malignant cells and Hep Par 1 immunopositivity. The final diagnosis of a metastatic cutaneous HCC was made. In conclusion, cutaneous HCC metastasis is rare and should be considered in the differential diagnosis in patients with a history of HCC presenting with suspicious skin lesion. In the right clinical setting, a confident diagnosis can be made in such cases by using the fine needle aspiration technique aided with immunopositivity for Hep Par 1 antibody of the aspirated material. Diagn. Cytopathol. 2012. © 2011 Wiley Periodicals, Inc.     

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.     

Cytological diagnostic clues in fine needle aspiration of breast myofibroblastoma: A case report

Myofibroblastoma of the breast is a rare, benign mesenchymal tumor derived from the stroma and tends to occur mainly in middle‐aged to elderly men. There are a few cases reported in the literature describing its cytological features. We report the cytological and histological findings of a breast myofibroblastoma in a 68‐year‐old man. He presented with a palpable nodule of 2‐months duration in his left breast. The cytological smears obtained by fine needle aspiration showed less cohesive cellularity in a fascicular arrangement consisting of spindle cells with elongated cytoplasm, occasional nuclear grooves, and intranuclear cytoplasmic inclusions associated to fragments of stromal collagen. The cytological diagnosis was a mesenchymal proliferation suggesting the possibility of myofibroblastoma which was confirmed on histopathological examination. The breast myofibroblastoma has distinctive cytological features that in conjunction with the clinical and radiological data allow a specific diagnosis. Diagn. Cytopathol. 2012. © 2011 Wiley Periodicals, Inc.     

Prominent oncocytic metaplasia in pleomorphic adenoma: A potential diagnostic pitfall

Pleomorphic adenoma (PA) is the most common salivary gland tumor. The cytological features of PA are well recognized, and its diagnosis is straightforward in most cases. Some metaplastic changes in PA are well known; however, occurrence of oncocytic metaplasia in PA is very rare. In this report, we describe the first cytological case of prominent oncocytic metaplasia in PA identified based on immunocytochemical analysis. We report the case of a 62‐year‐old Japanese female who presented with swelling of the left neck region. A fine‐needle aspiration cytologic examination was performed followed by surgical resection. The Papanicolaou smear revealed the presence of discohesive neoplastic cells in a myxoid background. These neoplastic cells had a relatively rich, granular cytoplasm, and round nuclei with moderate pleomorphism. Initial cytodiagnosis revealed carcinoma ex PA (CXPA). Immunocytochemical analysis showed that abundant mitochondria were present in the cytoplasm of these neoplastic cells. Histopathological examination of the resected tumor demonstrated proliferation of oncocytic neoplastic cells within a myxoid material and the presence of conventional PA components. A final diagnosis of prominent oncocytic metaplasia in PA was made. Oncocytic metaplasia showed nuclear atypia and pleomorphism; therefore, CXPA, which presents with severe nuclear atypia and necrotic background, must be differentiated from oncocytic metaplastic PA. Recognition of oncocytic metaplasia in PA is important for correct diagnosis.     

Mediastinal seminoma: A case report with special emphasis on SALL4 as a new immunocytochemical marker

Cytological diagnosis is a valuable method for detection of mediastinal tumors, and recent reports have shown the usefulness of fine‐needle aspiration cytology for diagnosis of mediastinal tumors, including germ cell tumors. We report a case of mediastinal seminoma diagnosed intraoperatively by cytological examination of cystic fluid containing tumor cells. An anterior mediastinal tumor with cystic component was incidentally found in a 28‐year‐old Japanese male. Cytological examination of the cystic fluid at the time of tumor resection showed single and loose aggregates of large round to polygonal cells with large round nuclei, vesicular chromatin and nucleoli, and mild to moderate amounts of PAS‐positive cytoplasm admixed with mature lymphocytes. A diagnosis of seminoma was made intraoperatively. On subsequent immunostaining, the tumor cells showed nuclear positivity for SALL4, a recently recognized germ cell marker that, in the appropriate setting, can be helpful to distinguish germ cell tumors from other mediastinal neoplasms, such as malignant lymphoma, thymoma, and thymic carcinoma. Diagn. Cytopathol. 2013;41:821–824. © 2012 Wiley Periodicals, Inc.     

Atypical granular cell tumor of the thyroid: cytomorphologic features on fine needle aspiration

Granular cell tumors are uncommon soft tissue neoplasms of nerve sheath origin, which are predominately benign and are characterized by abundant granular cytoplasm, uniform nuclei, and indistinct cell borders. Features of malignancy include spindle cell morphology, necrosis, prominent nucleoli, increased nuclear to cytoplasmic ratio, nuclear pleomorphism, and increased mitotic rate. Granular cell tumors are most common in the soft tissues of the head and neck, but have only been rarely described in the thyroid gland. Here we report a case of an atypical granular cell tumor of the thyroid seen on fine needle aspiration, which displayed focal atypical cells with spindle cell morphology, increased nuclear to cytoplasmic ratio, and prominent nucleoli. The differential diagnosis of such findings is also presented.     

Moderately differentiated neuroendocrine carcinoma (atypical carcinoid) of the supraglottic larynx. A report of two cases including immunohistochemistry and aspiration cytology.

Moderately differentiated neuroendocrine carcinoma of the larynx is morphologically distinct from the classic carcinoid and small-cell carcinoma. It is composed of medium to large polyhedral cells with an insular, trabecular, or acinar growth pattern, variable pleomorphism, and a tendency to metastasize to skin and bone. We describe the clinicopathological features of the tumor in two patients in whom tumor dissemination resulted in death 13 and 33 months after diagnosis. Both tumors occurred above the glottis and metastasized to bone but not to regional tissues. In one case, the diagnosis was confirmed when the aspiration cytological specimen from a rib lesion suggested a neuroendocrine carcinoma resembling medullary thyroid cancer (triangular cytoplasm, double nuclei, and fine red cytoplasmic granules on May-Grünwald-Giemsa staining). Both tumors were originally misdiagnosed as squamous cell carcinoma, as acinic cell cancer, or as suggesting metastasis of melanoma. Immunohistochemistry gave strong reactivity in both for chromogranin A and calcitonin, although the serum level of calcitonin, determined in one case, was normal.     

Cutaneous granular cell tumor clinically mimicking ectopic breast diagnosed on fine needle aspiration cytology

Granular cell tumor (GCT) is a rare benign neoplasm of Schwannian origin which accounts of 0.5% of soft tissue tumors. Although the most common site for GCT is tongue, it can occur at any site. GCT presenting as cutaneous nodule is rare, however cases have been reported in literature. We hereby document a case of 30 year female with a hyper‐pigmented cutaneous nodule of anterior chest wall on the milk‐line mimicking as an ectopic breast, diagnosed as GCT on fine needle aspiration cytology. We also add a note on the differential diagnoses of GCT with differentiating cytological features to emphasize on the correct diagnosis of GCT pre‐operatively.     

Pitfalls in the diagnosis of adult rhabdomyoma by fine needle aspiration: Report of a case and a brief literature review

Fine needle aspiration (FNA) is a valuable, noninvasive, commonly used technique in the diagnoses of head and neck tumors. Adult rhabdomyoma is a rare benign tumor of striate muscle tissue usually located in the head and neck region. Cytomorphologically, the tumor cells have eosinophilic finely granular cytoplasm, which sometimes can mimic other tumors. We report a case of adult rhabdomyoma, which was initially misinterpreted as granular cell tumor on FNA biopsy due to lacking of typical cytological features of adult rhabdomyoma. We recommend that adult rhabdomyoma should be included in differential diagnoses when the cytological features are suggestive of granular cell tumor. A panel of immunohistochemical stains including S100, desmin, and myoglobulin may also be helpful in making correct diagnosis. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Fine‐needle aspiration of the diffuse sclerosing variant of papillary thyroid carcinoma masked by florid lymphocytic thyroiditis; A potential pitfall: A case report and review of the literature

The diffuse sclerosing variant of papillary thyroid carcinoma (DSV–PTC) is a rare tumor with aggressive behavior that requires aggressive treatment. Despite characteristic clinical and histological features that easily permit diagnosis, pre‐operative fine‐needle aspiration cytology (FNAC) diagnosis is often challenging and thus delays diagnosis. We describe the cytological features of a case of DSV–PTC diagnosed by FNAC in a 30‐year‐old woman presenting with an ill‐defined mass in her neck lasting for 2 months. Ultrasonograpy revealed a heterogeneous enlargement of both thyroid lobes suspicious for a lymphoproliferative syndrome. Flow cytometry showed a suspect B‐lymphocyte population. FNAC showed in five out of six slides an overwhelming presence of slightly atypical monomorphic small lymphocytes. The remaining slide showed syncytial tissue fragments of follicular cells with nuclear enlargement and pleomorphism, irregular nuclear membrane, grooves with scattered intranuclear inclusions, squamous metaplastic epithelium, and abundant psammoma bodies. A diagnosis of DSV–PTC was rendered and confirmed by total thyroidectomy and lymph node dissection. Our report supports the possibility of obtaining a preoperative diagnosis of DSV–PTC by FNAC. In the case of diffuse thyroid enlargement, adequate sampling of the thyroid and the presence of the combination of features described in our case permitted the diagnosis of this PTC variant. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Fine‐needle aspiration of cystic pancreatic mucinous tumor: Oncotic cell as an aiding diagnostic feature in paucicellular specimens

In juxtaposition with imaging studies, endoscopic ultrasound‐guided fine‐needle aspiration has gained popularity in the initial evaluation of pancreatic masses, especially cystic lesions of pancreas. Cystic pancreatic mucinous tumors include mucinous cystic neoplasm and intraductal papillary mucinous tumor, both of which have been known to have a low malignant potential and a high rate of association with invasive adenocarcinoma. As such, preoperative diagnosis is of great significance in guiding patient management. Although fine‐needle aspiration cytological diagnosis of pancreatic tumor in cellular specimens has been well described, as with other cystic lesions, the yield of diagnostic cells from needle aspiration of cystic pancreatic mucinous tumors is typically low. Cytological diagnosis from these paucicellular specimens remains challenging. An additional compounding problem is the high frequency of gastrointestinal mucin and epithelial contamination. The diagnostic morphology and criteria in these paucicellular specimens have not been well addressed in the literature. The cytopathologists' ongoing efforts tend to improve the diagnostic accuracy. In this current study, oncotic cells, characterized by cytoplasmic swelling and karyolysis, were analyzed from 17 cases of cystic pancreatic mucinous tumor, of which the diagnosis was either confirmed by surgical resection or supported by cell block and/or increased CEA. Oncotic cells were found in variable amounts in almost all the cystic pancreatic mucinous tumors in this series. None of the five fine‐needle aspirations intended for aspirations of hypoechoic nonlesional pancreas, which yielded either gastrointestinal tract material only or admixture of gastrointestinal and normal pancreatic components, was found to contain oncotic cells, evidencing the utility of oncotic cell as a surrogate morphologic marker in aiding the diagnosis of cystic pancreatic mucinous tumor as well as its differentiation from gastrointestinal contaminant, particularly in paucicellular specimens. Diagn. Cytopathol. 2009. © 2008 Wiley‐Liss, Inc.     

Clear cell hidradenoma: a mimic of metastatic clear cell tumors

Clear cell hidradenoma is a benign skin appendage tumor that may mimic conventional-type renal cell carcinoma. Histologically, clear cell hidradenoma contains small ductular lumens, focal apocrine and squamoid change, and a less prominent vascular pattern than renal cell carcinoma. Furthermore, immunohistochemical studies can aid in distinguishing the 2 tumors. Knowing the cytologic features of primary skin adnexal neoplasms helps distinguish them from cutaneous metastases, which are more commonly referred for fine-needle aspiration biopsy evaluation. Detailed clinical history, physical findings, and ancillary studies are essential for correct diagnosis and categorization of these tumors. We report the rare case of a patient with renal cell carcinoma who underwent excision of an axillary clear cell hidradenoma, which was clinically suggestive of cutaneous metastatic disease.     

Is fine needle aspiration cytology (FNAC) useful in skin adnexal masses? A study on 5 cases of pilomatixoma

Superficial cutaneous/subcutaneous nodules, caused by a variety of inflammatory, benign and malignant pathology of diverse origin, are tempting lesion for fine needle aspiration cytology (FNAC). Amongst these, adnexal tumor show considerable overlap, both in clinical manifestation as well as in histopathology. Archieval records of clinical findings, FNAC smears and reports pertaining to 5 histologically proved cases of pilomatricoma (PMX) were analyzed. Different cytological findings were graded + to +++. Pre FNAC clinical diagnoses were sebaceous cyst, tuberculous lymphadenopathy, dermatofibroma, reactive lymphadenopathy and lipoma. PMX was diagnosed on FNAC in 3 cases on finding groups of basaloid cells, ghost epithelial cells, pink fibrillary material and calcium deposits. Other cases were diagnosed as epidermal inclusion cyst with the differential diagnosis of well differentiated squamous cell carcinoma and skin appendageal tumor of undetermined origin in one case each. In all the cases, FNAC established epithelial nature of the lesion, excluding clinically mimicking inflammatory/neoplastic lesions of other origin. FNAC should be followed by excision biopsy to accurately type the epithelial neoplasm.     

Chondroblastic osteosarcoma of the temporal region: A diagnostic dilemma

Chondroblastic osteosarcoma (OS) accounts for about 25% of all cases of OS. It can pose diagnostic difficulty on cytology, as the tumor cells may resemble the carcinomatous cells. We present a case of a 35‐year‐old female patient who presented with a firm swelling in the left temporal region. On fine‐needle aspiration, the smears revealed abundant cellularity with tumor cells showing significant nuclear pleomorphism and multinucleation. The tumor cells had abundant foamy to vacuolated cytoplasm, thereby indicating sebaceous differentiation and it was cytologically interpreted as sebaceous carcinoma. However, on subsequent histopathology, similar tumor cells were seen lying down abundant amount of osteoid material along with foci of chondroid differentiation and was diagnosed as chondroblastic OS. Pitfalls in the cytodiagnosis of this case along with differential diagnosis on cytology are discussed. Diagn. Cytopathol. 2011. © 2010 Wiley‐Liss, Inc.     

Metastatic medullary thyroid carcinoma to the breast in a patient with combined medullary and papillary carcinoma of thyroid—A case report

We report the fine‐needle aspiration cytology of a case of medullary thyroid carcinoma (MTC) metastatic to the breast in a 66‐year old female within two years of diagnosis of the thyroid tumor. The aspirate of the breast metastases revealed a plasmacytoid population of cells in loose clusters and singly with mild to moderate pleomorphism. Nuclear groves and occasional intranuclear cytoplasmic inclusions were seen. The cells stained positive for calcitonin and negative for thyroglobulin. Use of immunocytochemical methods proved useful to diagnose metastasis which was essential in planning treatment. Cases of metastatic MTC to the breast diagnosed on fine‐needle aspirates reported in the literature are reviewed. Diagn. Cytopathol. 2015;43:343–348. © 2014 Wiley Periodicals, Inc.     

Cytological features of cystadenocarcinoma in cyst fluid of the parotid gland: Diagnostic pitfalls and literature review

Cystadenocarcinoma is a rare malignant tumor, with an estimated incidence of 2% of malignant salivary gland tumors. Cytological diagnosis of cystadenocarcinoma is important for differential diagnosis between benign lesions and malignant tumors with cystic growth. We report a case of cystadenocarcinoma causing difficulty in cytological diagnosis. A 23‐year‐old man presented with an asymptomatic mass in the left parotid gland that had been present for 2 years. The mass was elastic hard, measuring 30 × 35 mm in diameter. Preoperative fine‐needle aspiration cytology (FNAC) showed a small number of tumor cell clusters in the cystic fluid. The cluster was arranged in a ball‐like structure and was cohesive with overlapping. Tumor cells had a small vacuolated, soap‐bubble appearance in the cytoplasm. The papillary‐cystic variant of acinic cell carcinoma (ACC‐PCV) was suggested from these findings on FNAC. Histologically, the tumor was not encapsulated, but formed large cystic spaces against a background of fibrous connective tissue. The tumor cells in the cystic dilated duct showed papillary structures, which were continuous with the lining cuboidal cells. There was neither a definite double‐layered arrangement in cystic ducts and solid islands nor histological findings characteristic of the papillary‐cystic or follicular pattern of ACC‐PCV. As tumor cells with a small vacuolated, soap‐bubble appearance of the cytoplasm are common findings of both cystadenocarcinoma and ACC‐PCV, they are of little use for differentiation; however, they are so characteristic that the majority of benign salivary gland lesions with cystic structures can be excluded, if enough attention is paid. Diagn. Cytopathol. 2010. © 2009 Wiley‐Liss, Inc.     

Chondroid syringoma diagnosed by fine needle aspiration cytology

Chondroid syringoma is a rare benign skin adnexal tumor of eccrine/apocrine origin affecting commonly the head and neck region. It used to be previously called as mixed tumor of skin because of the presence of both the epithelial and mesenchymal components. There are only few case reports describing the fine needle aspiration cytologic features of chondroid syringoma for diagnosis. We studied a 20‐year‐old male case from Taplejung district of Nepal came to Otorhinolaryngology out patient department with the complaints of painless, progressively enlarging swelling on the dorsum of nose. On examination, 2.0 × 2.0 cm, firm, non‐tender swelling was seen on the right side of dorsum of nose. Overlying skin was normal, and the swelling was fixed to the skin but freely mobile over underlying structure. A clinical diagnosis of dermoid cyst was entertained, and the case was subjected to FNAC. FNA yielded mucoid material which on microscopy showed clusters of round cells with moderate to abundant cytoplasm embedded in chondromyxoid ground substance. The nuclei were monomorphic, centrally to eccentrically located and had fine chromatin. On the basis of these cytologic features, a diagnosis of chondroid syringoma was made. We concluded that Chondroid syringoma may be considered as a rare differential diagnosis in the swelling of head and neck region and the diagnosis can be easily confirmed or ruled out by means of fine needle aspiration cytology. Diagn. Cytopathol. 2010. © 2009 Wiley‐Liss, Inc.     

Fine needle aspiration of metastatic malignant Leydig cell tumor of testis: a case report

A 53-year-old male presented with a right inguinal mass of one-year duration. The fine needle aspiration of the inguinal mass showed a highly cellular tumor composed of sheets and isolated, large round to polygonal cells with moderate pleomorphism. Many bare nuclei were seen with occasional intranuclear inclusions. A provisional diagnosis of metastasis probably of testicular tumour was made. The orchidectomy showed a brown tumor replacing the entire testis and infiltrating the epididymis. The histological features showed Leydig cell tumor without Reinke crystalloids.