Fine-needle aspiration cytology of intraductal papillary mucinous tumors of the pancreas

BACKGROUND: Intraductal papillary mucinous tumors (IPMT) account for 5% of pancreatic neoplasms. Preoperative identification is important because of their frequent multifocal or diffuse involvement in pancreatic ducts, which makes extensive surgery necessary even in benign cases. To the authors' knowledge, the cytologic features of this entity in fine-needle aspiration biopsy (FNAB) specimens have seldom been described and are poorly standardized. METHODS: Eleven consecutive cases of surgically proven IPMT with previous endoscopic ultrasonography (EUS)-guided FNAB were collected for retrospective analysis. EUS-FNAB had been performed with on-site attendance of a cytopathologist in all cases. Macroscopic and microscopic appearance of mucin, cellular type and arrangement, presence of nuclear grooves, and degree of nuclear atypia were recorded. RESULTS: Final diagnosis was benign IPMT (B) in four cases, borderline IPMT (Bo) in two cases, malignant IPMT (M) in one case, and IPMT associated with invasive carcinoma (Ca) in four. Retrospective analysis found moderate to high levels of extracellular mucin in 10 of the 11 cases. The other case (one Ca) showed a small amount of thick mucin. In all cases, epithelial cells were identified, although cellularity was very low in four cases (three B and one Bo). Atypia was absent in two cases (two B) slight in two cases (two B), moderate in three cases (one Bo and two Ca), and severe in four cases (one Bo, one M, and two Ca). Mucinous epithelium was found in nine cases and nonmucinous epithelium in five cases (one Bo and four Ca). Papillary structures were observed in five cases (two Bo and three Ca), sheets in eight cases (four B, one Bo, one M, and two Ca), single atypical cells in five cases (one Bo and four Ca), irregular clusters in three cases (one Bo and two Ca), and nuclear grooves in two cases (one B and one Bo). CONCLUSIONS: The most common features of IPMT were extracellular mucin and sheets of mucinous epithelium. Papillae and nuclear grooves were not consistently found. Nonmucinous epithelium, severe atypia, single atypical cells, and irregular clusters indicated a high probability of malignant transformation. Even in the absence of atypia, a clinically significant diagnostic orientation can be established in most cases on the basis of the characteristic cytologic picture.     

Diagnostic accuracy and pitfalls in fine-needle aspiration interpretation of Warthin tumor

BACKGROUND: Despite its well-defined histologic appearance, the often variegated cytomorphologic appearance of Warthin tumor (WT) on fine-needle aspiration (FNA) may lead to an erroneous cytopathologic interpretation. In this study, the authors analyzed the potential sources of diagnostic errors and overall accuracy of FNA diagnosis of WT. METHODS: A retrospective search of The Johns Hopkins Hospital Surgical Pathology files (1985-2001) revealed 97 patients with WT, including 31 patients who underwent prior FNA. A comprehensive review of cytopathologic material was undertaken to calculate the overall accuracy of FNA and to identify sources of diagnostic error. RESULTS: All tumors presented in the parotid gland. Four tumors (13%) were deemed inadequate for interpretation due to insufficient material. The FNA diagnosis of WT was rendered in only 20 tumors (74%). The remaining 7 tumors (26%) were misdiagnosed on FNA as consistent with or suspicious for carcinoma or some other neoplastic process. A retrospective review of the tumors, which were over-called on FNA, showed a predominance of necrotic or cellular debris (n = 6 tumors; 22%), significant epithelial metaplasia with atypia (n = 4 tumors; 15%), background inflammation suspicious for tumor diathesis (n = 3 tumors; 11%), spindle cells (n = 1 tumor; 4%), and abundant mucin with keratinized squamous cells (n = 1 tumor; 4%). CONCLUSIONS: FNA is moderately accurate for diagnosing WT, with a 74% accuracy rate in the current series. Cytologic misinterpretation may occur due to a lack of characteristic cytomorphologic features of WT and overabundance of one or more of the following: squamous metaplasia/atypia, mucoid/mucinous background, spindle-shaped cells, and cystic/inflammatory debris. An adequate awareness of these potential sources of erroneous diagnoses, coupled with appropriate clinical findings, may result in a higher accuracy rate.     

Myoepithelial cell-rich neoplasms: cytologic features of benign and malignant lesions

BACKGROUND: Lesions that contain abundant myoepithelial cells may present as a diagnostic challenge in fine-needle aspiration (FNA) specimens. Potential diagnostic problems may arise due to morphologic heterogeneity of myoepithelial cell-rich lesions and difficulty in predicting malignancy in FNA specimens. An accurate diagnosis is important, because malignant myoepithelial cell-rich lesions require a wider local excision and lymph node dissection. The authors characterized the cytologic features of myoepithelial cell-rich lesions in an attempt to define the criteria that facilitate distinction between benign and malignant tumors. METHODS: FNA biopsies of myoepithelial cell-rich lesions with corresponding histologic specimens were selected. The cytology specimens were evaluated for the following criteria: cellularity, cell morphology, pleomorphism, chromatin pattern, presence of nucleoli, background material, necrotic debris, and presence of mitotic figures. A review of the histologic sections was performed for diagnostic confirmation. RESULTS: Seventeen specimens from 17 different patients were selected. The histologic diagnoses were myoepithelial carcinoma (n = 6 patients), malignant mixed tumor with predominant myoepithelial carcinoma (n = 2 patients), epithelial-myoepithelial carcinoma (n = 1 patient), and benign mixed tumor (n = 8 patients). The primary sites included the parotid gland (n = 10 patients), submandibular gland (n = 3 patients), minor salivary gland (n = 3 patients), and breast (n = 1 patient). Most specimens, whether they were benign or malignant, were very cellular. Pleomorphism, coarse chromatin, prominent nucleoli, mitotic figures, and necrosis were observed only in malignant specimens. Background material and ductal cells were seen in both benign and malignant specimens. CONCLUSIONS: The presence of pleomorphism, coarse chromatin, prominent nucleoli, mitotic figures, and/or necrosis should raise the possibility of myoepithelial carcinoma in FNA specimens from myoepithelial cell-rich lesions.     

Fine-needle aspiration of pancreatic serous cystadenoma: cytologic features and diagnostic pitfalls

BACKGROUND: The preoperative diagnosis of pancreatic serous cystadenoma (SCA) is important because as a typically benign tumor it can be treated expectantly, whereas many other cystic tumors require excision. This study examines the cytology, clinical and radiologic features, diagnostic accuracy of fine-needle aspiration (FNA), and potential pitfalls associated with this rare tumor. METHODS: Cytomorphologic features were retrospectively reviewed from 28 FNAs of SCA from 21 patients. FNA biopsies were guided by percutaneous computed tomographic or ultrasonographic imaging in 10 cases and by endoscopic ultrasonographic imaging in 18 cases. Corresponding histology (14 tumors) and clinical/imaging findings were also evaluated. RESULTS: Patients typically presented with upper abdominal discomfort or asymptomatically. Radiologically, a well-demarcated, multiloculated cystic mass involving the pancreatic head or uncinate process was common. Aspirates were sparsely cellular against a clean or granular, proteinaceous background. Tumor cells formed loose clusters or monolayered sheets composed of cuboidal cells with indistinct cell borders and granular or clear cytoplasm that was often stripped from the nucleus. Nuclei were small, round, with fine chromatin and indistinct nucleoli and devoid of mitotic activity. Seven (25%) of the aspirates were initially classified as "consistent with SCA," 6 (21%) as "no malignant cells," 3 (11%) as "nondiagnostic specimen," 3 (11%) as "suspicious for malignancy," 3 (11%) as "rare atypical cells," and 6 (21%) as "probably or consistent with mucinous cystic neoplasm." Features causing diagnostic difficulty were scant cellularity, papillary groups, nuclear atypia, and columnar cells mimicking those of mucinous neoplasms. Gastrointestinal (GI) epithelium and mucin also caused confusion. The detection of intracytoplasmic glycogen (3 of 6 cases) and cyst fluid analysis (2 of 2 cases) showing low viscosity and low or undetectable levels of carcinoembryonic antigen, CA 19.9, and amylase enhanced diagnostic confidence. CONCLUSIONS: Diagnosing SCA by FNA is challenging. Familiarity with its morphologic spectrum, use of ancillary studies, and correlation with clinical/radiologic findings greatly improves diagnostic accuracy. Contaminating GI epithelium and mucin should be distinguished from components of a mucinous neoplasm.     

Intraductal papillary mucinous neoplasm of the pancreas: cytologic features predict histologic grade

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is an increasingly recognized cystic neoplasm of the pancreas, histologically classified by the degree of epithelial atypia and by the presence or absence of invasion of the cyst wall. To the authors' knowledge, the cytologic features of this neoplasm are poorly characterized, especially with respect to tumor grade. METHODS: Thirty-three endoscopic ultrasound (EUS)-guided pancreatic fine-needle aspiration biopsy (FNAB) samples and 1 pancreatic duct brush specimen from 25 patients with a histologically confirmed IPMN were retrospectively reviewed. Blinded to tumor grade, background mucin, inflammation, necrosis, overall cellularity, the presence of gastrointestinal-contaminating epithelium, architecture of cell clusters, and nuclear and cellular morphology were evaluated. In cases in which special stains for mucin were performed, the diagnostic utility of these stains was assessed. These cytologic features were subsequently correlated with the histologic diagnosis. RESULTS: The 34 cytology samples represented 4 adenomas, 15 IPMN-moderate dysplasias, 7 intraductal carcinomas, and 8 IPMNs with invasive carcinoma. Extracellular mucin was present in 97% of all cases; 53% had thick, viscous, "colloid-like" mucin. Special stains for mucin were positive in 6 of 11 cases (54%), helping to identify thin mucin in only 2 cases. Gastrointestinal contamination did not appear to create diagnostic difficulty due to an apparent dual (dysplastic-nondysplastic) epithelial population, but only 4 adenomas were evaluated in this study. Necrosis distinguished IPMN with carcinoma from IPMN-adenomas and IPMN with moderate dysplasia (P < .00001), and was more often observed with invasion than IPMN-carcinoma in situ (P < .05). Tight epithelial cell clusters with hyperchromatic nuclei and a high nuclear to cytoplasmic ratio was more significant in IPMN of at least moderate dysplasia (P = .03). Pale nuclei with parachromatin clearing was found to be a nuclear feature that was suspicious for at least carcinoma in situ (P < .001). In addition, significant background inflammation (neutrophils and histiocytes) was found to be more characteristic of IPMN with at least carcinoma in situ (P = .002). CONCLUSIONS: The presence of thick, "colloid-like" mucin is noted in half of the IPMN cases, but was not found to be specific to grade. The absence of such mucin does not exclude an IPMN. The presence of tight epithelial cell clusters is consistent with a neoplasm of at least moderate dysplasia, and abundant background inflammation and parachromatin clearing correlated with the presence of at least carcinoma in situ. Necrosis was the only feature found to be strongly suggestive of invasion.     

Fine-needle aspiration cytology of breast carcinoma with endocrine differentiation

BACKGROUND: The value of fine-needle aspiration (FNA) in atypical proliferative to in situ to low grade invasive breast lesions remains limited due to the overlapping cytologic features of these entities. In the current study the authors review the FNA cytology of endocrine carcinoma and identify common cytologic features that allow for the diagnosis of this uncommon, low grade subtype of mammary malignancy. METHODS: The histopathology files from the medical practices of both authors were searched between January 1996 and May 1999 and yielded six cases of endocrine carcinoma. The clinical history and all previous FNA smears were reviewed. RESULTS: All six patients were elderly women (mean age of 72 years). Four patients presented with breast masses, one patient presented with nipple discharge, and one patient presented with both a breast mass and nipple discharge. All six surgical specimens showed endocrine ductal carcinoma in situ (E-DCIS), with four specimens showing invasive endocrine carcinoma, two of which were labeled as mucinous carcinoma. All invasive components showed the same histomorphologic and immunohistochemical profiles as the in situ components. Cytology demonstrated common features of the cellular smears with clusters and single, monomorphic plasmacytoid tumor cells that possessed moderate amounts of eosinophilic, granular cytoplasm and eccentric nuclei with fine chromatin and inconspicuous nucleoli. In four cases, additional fragments of fine and elaborate papillary fronds also were present. CONCLUSIONS: The cytologic smear diagnosis of endocrine carcinoma is assisted by the presence of plasmacytoid tumor cells and arborizing papillary fronds.     

融合基因阳性肺腺癌的病理组织学特征及与砂粒体的相关性研究

背景与目的：间变性淋巴瘤激酶(anaplastic lymphoma kinase,ALK)、c-ros原癌基因1酪氨酸激酶(c-ros oncogene 1 receptor tyrosine kinase,ROS1)和RET融合基因被陆续证实为肺腺癌的驱动基因突变,并可在靶向治疗中获益。该研究旨在阐述融合基因阳性肺腺癌病理组织学特征,并探讨砂粒体与融合基因阳性肺腺癌的相关性。方法：收集复旦大学附属肿瘤医院原发肺腺癌患者手术切除新鲜标本和石蜡固定标本,检测肺腺癌标本中表皮生长因子受体(epidermal growth factor receptor,EGFR)、鼠类肉瘤病毒癌基因(Kirsten rat sarcoma viral oncogene,K-ras)、ALK、RET和ROS1基因突变状态。选取融合基因阳性肺腺癌病例44例(9例ROS1阳性,20例K-ras阳性,15例RET阳性)和融合基因阴性肺腺癌111例(20例EGFR突变,20例K-ras突变,71例未检测出基因突变)用于本项研究。根据2015年世界卫生组织(World Health Organization,WHO)肺腺癌新分类评估融合基因组与无融合基因组的病理组织学形态特征,并观察肺腺癌组织中砂粒体的数量及其分布的特征,并探讨砂粒体与融合基因阳性肺腺癌的相关性。结果：融合基因组中主要组织学亚型为腺泡状亚型(19/44,43.2%)和实体亚型(13/44,29.5%),无融合基因组主要组织学亚型为腺泡状亚型(50/111,45.0%)。实体亚型更多见于融合基因组,但两组间主要组织学亚型差异无统计学意义(P=0.060)。含印戒细胞成分、微乳头结构、黏液筛状结构及细胞外黏液分泌在融合基因组中阳性率均显著高于无融合基因组(P=0.000,P=0.044,P=0.000,P=0.010)。砂粒体在融合基因组阳性率显著高于无融合基因组(P=0.000),并且砂粒体与微乳头及黏液筛状结构具有显著相关性(P=0.000)。结论：实体亚型及腺泡状亚型常见于融合基因阳性肺腺癌。砂粒体、微乳头、细胞外黏液分泌、黏液筛状结构及含印戒细胞成分等特征性组织学形态与融合基因阳性肺腺癌密切相关,并且砂粒体与微乳头结构和(或)黏液筛状结构往往同时存在。通过对肺腺癌的特征性形态学观察对肺腺癌基因检测的优先性筛选具有指导意义。     

胰腺导管内黏蛋白性乳头状瘤CT、MRI诊断及鉴别诊断（附6例报告)

目的:探讨胰腺导管内黏蛋白性乳头状瘤CT、MRI表现特点及诊断价值。方法:6例经手术和病理证实的胰腺导管内黏蛋白性乳头状瘤均行CT平扫及增强检查。4例行MRI检查,其中2例行MRI增强扫描。结合文献,回顾性分析其临床表现及CT、MRI征象表现。结果:本组患者主胰管型5例,混合型1例。CT表现:主要表现为胰腺主胰管或分支胰管不规则扩张,呈分叶状囊性表现,其中4例显示壁结节。增强扫描肿瘤实性部分轻度强化。MRI扫描:胰腺导管不规则扩张,T1WI扩张胰管呈均匀低信号,2例扩张囊壁上见结节样隆起呈等信号。T2WI扩张胰管呈高信号,壁结节显示不清。压脂T1WI扫描肿瘤结节显示清楚。增强扫描肿瘤结节中度强化。结论:CT、MRI对胰腺导管内黏蛋白性乳头状瘤的诊断具有重要价值。     

Parathyroid proliferations: a source of diagnostic pitfalls in FNA of thyroid

BACKGROUND: With wide use of fine-needle aspirates (FNA) for investigation of thyroid nodules, a growing number of parathyroid glands are being inadvertently aspirated for cytologic study. Aiming to determine the effectiveness of FNA to differentiate between parathyroid and thyroid lesions, all cases aspirated initially as thyroid nodules and that had a final histologic diagnosis of parathyroid lesion were retrieved from the authors' files and were systematically reviewed to delineate possible specific diagnostic criteria. METHODS: From a total of 90,000 FNA diagnoses of thyroid nodules, 4740 cases were isolated for which a final histologic diagnosis was available. Among these, 29 cases with a final histologic diagnosis of a parathyroid lesion were identified and reanalyzed according to the initial cytologic diagnoses. Furthermore, the FNA smears were reviewed, and specific features were recorded. RESULTS: FNA failed to recognize the parathyroid origin of the lesions in all but 2 cases with known hyperparathyroidism. Most aspirates were misinterpreted either as suspicious for or as thyroid neoplasms because of high cellularity and absence of colloid. Histologically, the lesions proved to be parathyroid hyperplasia, adenoma, or carcinoma. Specific cytologic features are discussed. CONCLUSION: A safe differential diagnosis between thyroid and parathyroid disease on morphological ground in cytologic smears is difficult due to overlapping features of these lesions. To avoid surgical mismanagement, it is essential, in every highly cellular lesion seen in the context of a colloid-free background, to consider and report the possibility of a parathyroid lesion, thus enabling the clinician to proceed to a more detailed preoperative evaluation in this direction.     

Cytopathology of insular carcinoma of the thyroid.

BACKGROUND: Insular carcinoma of the thyroid (ICT) first was reported in 1984. To the authors' knowledge, few cytology reports have been published since that time. The authors describe the cytologic features of six tissue-proven ICTs and propose criteria that suggest its diagnosis. METHODS: Four cases were thyroid fine-needle aspiration (FNA) samples. Two cases were FNAs of metastases. All cases were found to be classic ICT on examination of primary or metastatic surgical specimens. RESULTS: Three cases originally were diagnosed as carcinoma, including two FNAs of metastatic sites and one thyroid FNA. Two additional thyroid FNAs were diagnosed as suspicious for malignancy, favor follicular neoplasm. One case was termed a neoplasm, favor follicular type. Smears showed high cellularity and scanty colloid. Three cases were found to contain some microfollicles. One case showed a few papillae. Necrosis and mitosis were rare. Cells were round with pale, poorly defined cytoplasm. Nuclei were round and monomorphic with finely granular chromatin, mild hyperchromasia, smooth nuclear membranes, and small nucleoli. Nuclear grooves and inclusions were rare. CONCLUSIONS: Three cases were diagnosed as suspicious for follicular neoplasm, the main differential diagnosis of ICT. Both tumors exhibited high cellularity and scanty colloid. However, ICT showed a predominance of single cells whereas follicular neoplasms reveal microfollicles with more nuclear atypia. There is cytologic overlap between these two neoplasms. Papillary thyroid carcinoma should be distinguished from ICT easily because the latter usually does not reveal the classic cytologic features associated with the former. ICT should be considered in the differential diagnosis of follicular neoplasms. Features favoring ICT are predominance of single cells, small loose nests of cells with few microfollicles, and little nuclear atypia. Cancer (Cancer Cytopathol) Copyright 1999 American Cancer Society.     

Intraductal papillary-mucinous neoplasms of the pancreas: an analysis of in situ and invasive carcinomas in 28 patients

BACKGROUND: Intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas are intraductal tumors with variable amounts of papilla formation, mucin production, and cytoarchitectural atypia. Associated invasive carcinomas, reported to occur in up to 30% of patients, often are mucinous and clinically indolent. METHODS: The clinical and pathologic features of 28 IPMNs resected at Memorial Sloan-Kettering Cancer Center between 1983 and 1997 were reviewed. RESULTS: There were 16 females and 12 males with a mean age of 68 years (range, 44-79 years) and a mean tumor size of 4.5 cm (range, 1.5-11.0 cm). The head of the gland was the predominant tumor site (89%). Abdominal pain, weight loss, and acholic stool were the most common symptoms at presentation. According to histology, two types of papillae were identified: intestinal (22 patients) and pancreatobiliary (6 patients). In the intraductal component, cytologic atypia was minimal (i.e., intraductal papillary-mucinous [IPM] adenoma) in 2 patients and moderate (IPM borderline tumor) in 5 patients, and severe atypia (IPM carcinoma in situ) was seen at least focally in 21 patients. In addition, invasive carcinoma was identified in 15 patients (53%), 4 of whom had only microscopic foci. Invasive carcinoma was of the mucinous type (colloid) in six patients and of the tubular type (conventional ductal adenocarcinoma) in nine patients. At a median follow-up of 35 months, four patients died of disease; two of these patients had only borderline atypia with no identified in situ or invasive carcinoma in the sections submitted. Eighteen patients had no evidence of disease, 1 patient was alive with recurrent disease, and 5 patients died of other causes. The actuarial 5-year disease free survival rate was 78%. Of the 14 patients with invasive carcinoma, 5 of 6 patients with colloid type tumors were free of tumor at a mean of 55 months. Of the patients with tubular type invasive carcinoma, two patients died of their disease (at 4 years and 7 years), three patients died of other causes, and four patients were alive (three were free of disease, and one experienced disease recurrence) at an average follow-up of 7.5 years. CONCLUSIONS: Two distinct patterns of intraductal papillae are seen in patients with IPMNs: intestinal and pancreatobiliary. Both in situ and invasive carcinoma may be encountered more commonly than previously recognized. Tubular type invasive carcinomas occur as well as mucinous type (colloid) carcinomas. Although the neoplasms are less aggressive as a group than conventional pancreatic ductal adenocarcinoma, patients with IPMNs may pursue a deadly course, even in the absence of identifiable invasive carcinoma. Conversely, patients with tubular type invasive carcinoma arising in the background of IPMN may follow a more favorable course than patients with conventional ductal adenocarcinoma without IPMN, emphasizing the importance of recognizing the IPMN component in patients with pancreatic adenocarcinoma.     

Fine-needle aspiration cytology findings of an uncommon micropapillary variant of pure mucinous carcinoma of the breast: review of patients over an 8-year period

BACKGROUND: Previous attempts at subclassifying pure mucinous carcinomas of the breast based on architectural patterns and other associated features are on record. A distinctive micropapillary variant with most tumor cells arranged in micropapillae/pseudoacini has not been described previously. METHODS: The author reviewed the histologic slides from all 556 patients who underwent wide excision/mastectomy for mammary ductal carcinoma, either in situ or invasive, at Pamela Youde Nethersole Eastern Hospital, Hong Kong, during an 8-year period from early 1994 to the end of 2001. Five patients with pure mucinous carcinoma with diffuse micropapillary architecture were noted. The cytologic features (if available) were correlated with clinical, radiologic, and pathologic findings. RESULTS: Among the five patients with pure mammary mucinous carcinoma (micropapillary variant), three patients underwent preoperative fine-needle aspiration biopsies and had specimens available for review. The direct smears and cytospin preparations were of moderate cellularity and showed cohesive clusters and micropapillae of mildly pleomorphic tumor cells among a mucoid background. True tumor papillae with fibrovascular cores were not present. Nuclear hobnailing was observed commonly, and occasional psammoma bodies were found. There were also scanty isolated tumor cells scattered around. The pseudoacinar pattern was appreciated more readily in the cell block sections. Histologic examination of the surgical specimens showed features of pure mucinous carcinoma with diffuse micropapillary architecture. The micropapillary arrangement was confirmed further by the demonstration of a reverse polarity immunostaining pattern for epithelial membrane antigen and the identification of microvilli rimming the periphery of tumor cell clusters under the electron microscope. Peritumoral lymphovascular permeation and ipsilateral axillary lymph node metastasis was found in one of the patients. CONCLUSIONS: The micropapillary variant of mammary mucinous carcinoma demonstrates characteristic cytologic and histologic features that warrant special attention. It may represent the mucinous counterpart of invasive micropapillary carcinoma. Further analysis of a larger series of patients, however, will be required to delineate its prognostic significance, especially its propensity for lymph node metastasis.     

Distinction of phyllodes tumor from fibroadenoma: a reappraisal of an old problem

BACKGROUND: Using fine-needle aspiration (FNA) smears, it is difficult to distinguish low grade phyllodes tumor (PT) from fibroadenoma (FA) due to overlapping cytologic features between the two lesions. The authors retrospectively studied 45 histologically proven fibroepithelial breast tumors of which 33 were FA and 12 were PT (1 malignant, 8 borderline, and 3 benign) to define cytologic features that can help in the accurate categorization of these lesions by using FNA samples. METHODS: The cytologic features analyzed included: 1) epithelial component for number (<5 or >5), architecture, apocrine metaplasia, squamous metaplasia, nuclear pleomorphism, and mitosis; 2) stromal fragments for number (<5 or >5), cellularity (on a scale of 1+ to 3+), borders, cell characteristics, nuclear pleomorphism, and mitosis; 3) individual dispersed stromal cells in the background for cellularity (on a scale of 1+ to 3+), and cellular shape (short/round/oval or long spindle) based on whether they were smaller or larger than 2 times the size of a small round lymphocyte. RESULTS: The mean age of patients with FA was 34 years and of those with PT 44 years. The average size of FA was 2.0 cm, and the average size of PT was 4.0 cm. The characteristics of the epithelial fragments of PT and FA were not significantly different. Stromal fragments were noted in 60% of FA and 83% of PT samples examined. Fifty-six percent of PT and 30% of FA exhibited hypercellular stromal fragments (3+ cellularity), and the difference was not statistically significant. Large club-shaped hypercellular stromal fragments were present only in FA (in 21% of the samples). There was no difference in the overall cellularity of the background stromal nuclei in the two types of lesions. Long spindle nuclei averaging greater than 30% of the dispersed stromal cell population in the background were found only in cases of PT (in 57% of the samples; P < 0.001). Short/round/oval nuclei characterized most FAs. Long spindle nuclei constituting 10-30% of the dispersed stromal cells, however, occurred in both PT and FA to the extent of 43% and 21%, respectively. CONCLUSIONS: Hypercellular stromal fragments occur not only in PT, but also in FA, and hence they cannot be used as the sole criterion for making a diagnosis of PT on FNA. The proportion of individual long spindle nuclei (>30%) amid the dispersed stromal cells in the background is the most reliable discriminator between the two lesions. Lesions in which long spindle nuclei constitute between 10% and 30% may represent either PT or FA, and therefore such lesions should be categorized as indeterminate on FNA.     

Detection method and breast carcinoma histology

BACKGROUND: The association between method of detection and breast carcinoma histopathology has not been assessed adequately in a population-based setting. METHODS: Among women who were included in a population-based, case-control study of breast cancer, patients who were newly diagnosed with invasive breast carcinoma were identified from Wisconsin's statewide tumor registry. Only women age > or = 50 years were analyzed, because screening by mammography was not recommended before age 50 years at the time of the study. The breast tumors among these women (n = 2341 tumors) included the following histopathologies: lobular carcinoma (n = 206 tumors); ductal carcinoma, not otherwise specified (n = 1920 tumors); papillary carcinoma (n = 15 tumors); medullary carcinoma (n = 36 tumors); mucinous adenocarcinoma (n = 56 tumors); tubular adenocarcinoma (n = 41 tumors); invasive comedocarcinoma (n = 24 tumors); scirrhous adenocarcinoma (n = 15 tumors); and mixed ductal/lobular carcinoma (n = 28 tumors). RESULTS: Overall, women reported that 41% of tumors were detected by mammography, 48% of tumors were self detected, and 11% of tumors were detected by clinical breast examination (CBE). Detection by mammography was significantly more likely for women who had tubular carcinoma (83%; P < 0.001) and invasive comedocarcinoma (67%; P = 0.23) compared with women who had ductal carcinoma (40%). Mammography was significantly less likely to detect medullary carcinoma (17%) than ductal carcinoma (40%; P = 0.01). Lobular carcinoma was the only histopathology that, compared with ductal carcinoma, was detected significantly more often by CBE than by self detection. Mammography detected lobular carcinoma (42%) as frequently as ductal carcinoma (40%). However, the use of postmenopausal hormones may have modified these detection patterns: Among current users, mammography discovered a greater percentage of ductal carcinomas (51%) and fewer lobular carcinomas (36%) than nonusers. CONCLUSIONS: Among women age > or = 50 years, breast cancer detection by mammography, self detection, and CBE varied according to tumor histopathology.     

Fine-needle aspiration findings in patients with polymorphous low grade adenocarcinoma of the salivary glands

BACKGROUND: Polymorphous low grade adenocarcinoma of the salivary glands (PLAC) is a low grade neoplasm that predominantly occurs in the minor salivary glands. In this site it is amenable to biopsy and histologic diagnosis. However, experience with fine-needle aspiration (FNA) biopsy findings in these tumors is limited. The authors describe the FNA cytology of this entity. METHODS: Fine-needle aspirates from two primary parotid and three metastatic PLACs were reviewed and correlated with their histology. RESULTS: All aspirates showed similar cytologic features, with hypercellular smears showing branching papillae, sheets and clusters composed of bland uniform cells with round-to-oval nuclei, dispersed chromatin, and absent or inconspicuous nucleoli. The cells generally had a scant-to-moderate amount of eosinophilic cytoplasm. Mitoses and nuclear pleomorphism were absent. These cells formed tubular structures containing hyaline globules in all cases and often a dispersed myxohyaline stroma. Bare nuclei also frequently appeared in the background. Two cases, which had prior histologic diagnoses, were diagnosed on FNA as metastatic PLAC. One metastatic case was diagnosed as benign metastasizing pleomorphic adenoma. One primary case was diagnosed as adenoid cystic carcinoma and one case as PLAC on FNA. CONCLUSIONS: The cytologic differential diagnosis of PLAC includes adenoid cystic carcinoma, pleomorphic adenoma, and monomorphic adenoma. PLAC should be considered in the differential diagnosis of head and neck masses, where the cytology suggests one of these tumors, even when the clinical context (involvement of a major salivary gland, lymph node metastasis) is not typical of PLAC.     

Fine-needle aspiration cytology of spindle cell lesions of the breast

BACKGROUND: Fine-needle aspiration biopsy (FNA) has been successful in diagnosing epithelial lesions of the breast. Its role in the evaluation of spindle cell and mesenchymal lesions of the breast, which include a variety of benign and malignant conditions, is less clear. This article discusses the cytologic features and differential diagnosis of these lesions, as well as the potential diagnostic pitfalls associated with them. METHODS: FNAs of the breast, in which a spindle cell or mesenchymal component was a key or dominant feature, were retrieved. Fibroadenomas without cellular stroma and typical lipomas were excluded. RESULTS: Forty-six aspirates (0.87%) in a series of 5306 breast FNAs contained a significant spindle cell or mesenchymal component. The aspirates were classified into 4 categories: 1) reactive conditions, including 2 diabetic mastopathies, 3 granulation tissue specimens, and 7 granulomatous lesions; 2) benign neoplastic conditions, including 1 mammary hamartoma, 1 dermatofibroma, 1 fibromatosis, 2 granular cell tumors, 2 angiolipomas, and 7 cellular fibroadenomas; 3) low grade malignant neoplastic lesions, including 10 low grade phyllodes tumors; and 4) high grade malignant neoplastic lesions, including 1 metaplastic carcinoma with chondroid stroma, 1 pleomorphic liposarcoma, 2 malignant fibrous histiocytomas, 2 osteosarcomas, and 4 metastatic melanomas. A specific diagnosis was rendered in 38 cases (82.6%). The mammary hamartoma was diagnosed as fibrocystic changes; the dermatofibroma as benign spindle cell lesion, not otherwise specified (NOS); and the primary osteosarcoma as an atypical spindle cell proliferation, NOS. The reactive ductal epithelial cells in one of the granulomatous mastitis specimens, as well as the hyperplastic ductal epithelial cells in one of the phyllodes tumors, were interpreted as atypical ductal proliferation. The marked cytologic atypia displayed by one granular cell tumor was interpreted as low grade adenocarcinoma and the primary liposarcoma as poorly differentiated carcinoma. CONCLUSIONS: Breast lesions with a significant spindle cell or mesenchymal component are rarely encountered in FNA and constitute a heterogeneous group that may pose a diagnostic dilemma. FNA should be the initial diagnostic procedure for investigating these lesions, as a specific diagnosis was rendered in the majority of cases. Cancer (Cancer Cytopathol) Copyright 1999 American Cancer Society.     

Fine-needle aspiration features of pilomatrixoma

BACKGROUND: Pilomatrixoma (PMX) is a benign skin neoplasm of hair matrix origin. The fine-needle aspiration (FNA) features of PMX frequently lead to a misdiagnosis of carcinoma. METHODS: Nine cases of PMX in which a preoperative FNA was performed were reviewed. The cytologic features were compared with the histologic appearance of corresponding surgical specimens as well as with cytologic features of tumors that arose in the differential diagnosis. RESULTS: Unequivocal benign diagnoses were rendered in three cases; the correct preoperative diagnosis of PMX was rendered in two of these cases and considered in an additional case. In four additional cases, carcinoma was diagnosed or could not be excluded. A noncommittal diagnosis of epithelial tumor, most likely of skin adnexal origin, was rendered in an additional single case. Retrospective review of the FNA smears in all nine instances disclosed cytologic features that corresponded well with the histologic components of PMX. Diagnostic cytologic features included cellular aspirates; clusters of small, primitive-appearing basaloid epithelial cells; a high nuclear-cytoplasmic ratio; evenly dispersed chromatin; prominent nucleoli; pink, fibrillary material enveloping clusters of basaloid cells; multinucleated giant cells; and sheets of ghost cells. CONCLUSIONS: The FNA cytologic diagnosis of PMX may be extremely difficult; its distinction from various primary cutaneous carcinomas is most problematic. Recognition of a unique constellation of cytologic features in FNA smears in the appropriate clinical context is most helpful in making this distinction.