Cytologic patterns of metastatic thymoma: Diagnosis by fine-needle aspiration biopsy

Thymomas are the most frequent primary tumors of the anterior mediastinum. These lesions are slow growing and can be locally invasive, but extrathoracic metastases are rare, occurring in less than 2% of cases. Fine-needle aspiration biopsy (FNAB) may be helpful in making the diagnosis of metastatic thymoma, with or without a clinical history of primary mediastinal thymoma. We report three cases of metastatic thymoma diagnosed by FNAB. Each case illustrates a distinctive cytologic pattern. While two of the patients had a history of histologically confirmed thymoma 11 and 13 years previously, a third patient presented with an enlarged supraclavicular lymph node and pulmonary nodules, and no prior diagnosis of thymoma. These cases demonstrate that based on distinctive cytologic patterns and features, a diagnosis of metastatic thymoma can be made with FNAB. Ancillary studies will often confirm the diagnosis. Diagn Cytopathol 1994;11:182–187. © 1994 Wiley-Liss, Inc.     

Utilization of fine-needle aspiration biopsy in the diagnosis of metastatic tumors to the pancreas

There is relatively little information concerning the use of fine-needle aspiration biopsy (FNAB) to diagnose a mass in the pancreas that is secondary to metastatic tumor. This study reviews the incidence and types of neoplasms which metastasize to the pancreas and assesses the contribution FNAB can make in their diagnosis. of 117 radiologically guided FNABs of the pancreas, 11% (n = 13) showed metastatic malignancy. Nine patients had a previous history of malignancy while four patients presented with a pancreatic mass and were subsequently found to have widespread malignant disease. the majority of metastatic lesions were epithelial (77%, n = 10). Patient outcomes were generally poor (mean survival 2.8 mo). Metastases to the pancreas occur from a variety of primary sites and should be considered in patients with a pancreatic mass and a history of prior malignancy. FNAB is useful in diagnosing these metastases and this is clinically important because of their poor prognosis.     

Infantile myofibromatosis: diagnosis suggested by fine-needle aspiration biopsy

A newborn male infant presented with multiple subcutaneous and parenchymal lesions. These lesions, thought clinically to represent disseminated neuroblastoma, were assessed via fine-needle aspiration biopsy. The spindled cells and associated collagen were interpreted as a type of fibromatosis, most probably infantile myofibromatosis. This diagnosis was subsequently confirmed histologically, and the patient experienced spontaneous involution or regression of all lesions by 18 mo of age. To our knowledge, this is the first documented case of this entity initially suggested on the basis of a fine-needle aspiration biopsy specimen.     

Cytologic criteria for subclassification of Hodgkin's disease using fine-needle aspiration

Hodgkin's disease (HD) is increasingly being evaluated by fine-needle aspiration (FNA); however, criteria to subclassify HD into its four subtypes--nodular sclerosis (NS), mixed-cellularity (MC), lymphocyte-depleted (LD), and lymphocyte-predominant (LP)--has not been established. In order to evaluate criteria for subclassification, all FNA cases of HD obtained over a 5-yr period at Indiana University Medical Center that had confirmatory surgical biopsies were reviewed. The number of Reed-Sternberg (RS) cells was quantitated in each cytologic case and statistically analyzed by subgroup, using analysis of variance (ANOVA). LD had the highest mean (means) number of RS cells (means = 51) with NS and MC having similar means (means = 7 and 6, respectively). Only one case of LP was identified and therefore could not be analyzed statistically. Fibrosis and the presence of RS variants were qualitatively assessed and were not helpful in distinguishing the subtypes of HD. Although the quantitation of RS cells may be used to identify LD types of Hodgkin's disease, MC and NS cannot be separated reliably on this criterion alone. Although FNA can be used to diagnose HD, stage a patient, or assess efficacy of chemotherapy, subtyping of HD should still be done on histologic sections of excised lymph nodes.     

An approach to fine-needle aspiration biopsy diagnosis of hepatic masses

After reviewing collection techniques and the cytology of normal and reactive hepatocytes, a systematic approach to the evaluation of fine-needle aspiration biopsy smears of hepatic mass lesions is presented. One of the main problems facing the cytopathologist is the differentiation of cirrhosis from well-differentiated hepatocellular carcinoma. Smears from patients with cirrhosis often contain clusters of bile duct epithelial cells and chronic inflammatory cells, while properly sampled hepatocellular carcinoma smears should contain no bile duct epithelial cells and few inflammatory cells. Key criteria which favor the diagnosis of hepatocellular carcinoma over cirrhosis are: increased nuclear to cytoplasmic ratio, trabecular pattern, and atypical naked hepatocytic nuclei. Key criteria which favor the diagnosis of primary hepatocellular carcinoma over metastatic disease include polygonal cells with centrally placed nuclei, cells separated by sinusoidal capillaries, and bile. This systematic approach to the evaluation of hepatic fine-needle aspiration biopsies must be used with the realization that other uncommon mass lesions of the liver do exist (focal nodular hyperplasia, adenoma, hepatoblastoma, bile duct carcinoma, vascular tumors, mesenchymal tumors, and lymphomas).     

The significance of cutaneous metastasis from visceral tumors diagnosed by fine-needle aspiration biopsy

Cutaneous metastases from various visceral organs were studied in 43 patients. The morphologic diagnosis in each case was established by fine-needle aspiration cytodiagnosis. There were 28 males and 15 females, with median ages of 62 and 61 yr, respectively. The most common primary tumor in men was carcinoma of the lung (35%), followed by malignant melanoma (21%) and carcinoma of the oropharynx (14%). In women, the most frequent primary cancers were carcinoma of the colon (59%) and lung (20%). Metastatic cutaneous lesions were more frequent in the back (23%), upper extremities (21%), and scalp (12%). Median survival from onset of cutaneous metastasis was shortest in primary lung cancer at 3 mo followed by colon at 5 mo and oropharynx at 5.5 mo. Our study confirms that cutaneous metastasis represents a terminal manifestation of the disease due to either hematogenous or lymphatic spread. This study also reiterates the clinical usefulness of needle aspiration biopsy as an alternative diagnostic tool in establishing the presence of cutaneous metastasis.     

Extragonadal germ cell tumors: A fine-needle aspiration biopsy study

Germ cell tumors (GCT) are neoplasms that originate predominately in the ovary and testis. Tumors of germ cell origin only very uncommonly arise in extragonadal sites. We have diagnosed ten primary malignant extragonadal GCT arising in the mediastinum, retroperitoneum, liver, and sacrococcygeal region by fine-needle aspiration biopsy (FNAB). Patient ages ranged from 1 to 54 years; the majority were males. Our series included three seminomas, three yolk sac tumors (YST), one choriocarcinoma, one embryonal carcinoma, and two mixed, poorly differentiated GCT. in aspirates, seminomatous elements are dissociated with uniform mononucleate cells having large vesicular nuclei and prominent nucleoli. A tigroid background is produced with Diff-Quik—stained smears. YST yields cohesive clusters of cells with large nuclei, vacuolated cytoplasm, and extracellular hyaline matrix (spheres or hyaline globules). Giant multinucleate tumor cells are seen in choriocarcinoma. Embryonal carcinoma yields cellular smears of hyperchromatic cells with scant cytoplasm arranged predominantly in glandular or papillary formations. Ultrastructural (four cases) and immunocytochemical (seven cases) studies of aspirated material corroborated our cytologic interpretations. Aneuploid tumor cells were found by flow cytometry in aspirated material from a YST. Subsequent histologic examinations were performed on eight, and all were confirmatory. Although extragonadal GCT are relatively uncommon, they need to be considered in FNAB material from midline mass lesions. Ancillary studies were useful in confirming their diagnosis. © Wiley-Liss, Inc.     

Percutaneous fine-needle aspiration biopsy of the pancreas

Percutaneous fine needle aspiration biopsy of the pancreas allows to obtain without surgery a tissue proven diagnosis of focal lesions of the pancreas. Ultrasound (US), computed tomography (CT), or fluoroscopy are used to guide the positioning of the needle in the lesion. Various benign and malignant lesions can be diagnosed and the cytologic features of them are presented. The average sensitivity of the technique in the diagnosis of pancreatic carcinoma is 80.5% in the literature. The use of percutaneous fine needle biopsy of the pancreas decreases the number of investigations to be done in a patient with pancreatic disease.     

Cytologic interpretation of fine-needle aspiration biopsies from clinically occult breast masses

Fine-needle aspiration biopsy (FNAB) was performed on 39 occult breast masses of soft tissue density using standard mammographic guidance. All malignant tumors were diagnosed as either positive or suspicious for carcinoma, and there were no false-positive or false-suspicious diagnoses. These excellent results can be attributed to accurate cytologic interpretation based on consideration of problems unique to these lesions and the sampling method, such as scantier cellularity, potentially less confidence in needle placement, and the nature of the occult mass itself. The team approach between pathologist, radiologist, and clinician is emphasized.     

Pleomorphic adenoma of the breast: Cytology of fine-needle aspiration and its differential diagnosis

The cytologic findings of a case of pleomorphic adenoma of the breast are presented. This rare tumor appeared identical to pleomorphic adenoma of salivary glands. It presented diagnostic difficulties, however, because of its rarity and the fact that its associated clinical findings suggested a malignancy. The cytologic differential diagnosis includes a phyllodes tumor, fibroadenoma, and metaplastic carcinoma. Awareness of this entity should permit a definitive diagnosis by aspiration biopsy.     

Role of fine-needle aspiration biopsy in the assessment of renal masses

Clinical and histological control of fine-needle aspiration biopsy (FNAB) diagnosis of 72 kidney masses observed between 1981 and 1988 confirmed 34 benign and 33 malignant lesions, but did not confirm four malignant and one benign lesions, giving a total diagnostic accuracy of 93.05%. The role of FNAB in selecting cases to be sent to surgery was investigated by comparing the incidence of useful surgery (for benign and primary malignant neoplasias) and the incidence of useless surgery (for nonneoplastic lesions and secondary malignant neoplasias) in nephrectomized patients who either had (group A, 27 patients) or didn't have (group B, 198 patients) preoperative FNAB. The differences were highly significant (P less than 0.001). Furthermore, patients operated for malignant neoplasias (20 in group A; 117 in group B) displayed highly significant differences (P less than 0.001) with respect to renal vein infiltration (1 in group A versus 22 in group B) and local-regional lymph node metastases (1 in group A versus 15 in group B). In conclusion, FNAB is a reliable method for selecting cases for surgery and for aiding in the diagnosis of malignant neoplasias.     

Cytological diagnosis of endocrine tumors of the pancreas by endoscopic ultrasound-guided fine-needle aspiration biopsy

The aim of this study was to evaluate the efficacy and accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) in the diagnosis of pancreatic endocrine tumors and to analyze their cytomorphology. Between March 1999 and June 2004, a total of 30 patients with a cytological diagnosis of pancreatic endocrine tumors were found. Their records were retrieved and the cytological materials were analyzed. The mean size of the tumors assessed by EUS was 3.0 cm. Immediate preliminary interpretation was rendered after an average of 1.5 passes. Based on the cellular patterns, cases were divided into three categories: loosely cohesive aggregates, discohesive single cells, and cohesive flat sheets. Most tumor cells had abundant cytoplasm and eccentric nuclei. Chromatin was fine or coarse but was evenly distributed in all cases. Nuclear pleomorphism, multinucleation, intranuclear inclusions, mitotic figures, and necrosis were seen. Immunohistochemical (IHC) studies on cell blocks confirmed the diagnosis in all cases. EUS-guided FNA is efficient and accurate in establishing the diagnosis of pancreatic endocrine tumors. The variety of cellular patterns presents several differential diagnostic issues that should be considered to avoid erroneous interpretation.     

Objective comparison of cellular yield in fine-needle biopsy of lymph nodes with and without aspiration

Recent reports have indicated that needle biopsy without aspiration obtained adequate material for diagnosis. To determine objectively the adequacy of cell yield both for diagnosis and for special studies (e.g., flow cytometry, markers), we prospectively studied 20 superficial lymph nodes in 20 patients with a history of lymphoma. In each case, the cytology materials were obtained by fine-needle biopsy techniques with (FNAB) and without (FNB) aspiration. Two needle passes for each method were placed in separate tubes of RPMI medium. With FNAB, the cell counts (determined by a Coulter counter) ranged from 1,55 to 70 million (M) per tube, mean = 19.12 M, whereas with FNB, the cell counts ranged from 1.58 M to 40 M, mean = 15.48 M (P=0.4555). Although FNAB provided more cells in 12 cases (60%), FNB provided more cells in the remaining 8 cases (40%) (P=0.9392). Both techniques provided adequate numbers of cells for special studies in all cases. We conclude that FNB can provide an adequate number of cells both for diagnosis and for special studies.     

Extramedullary plasma cell tumors: diagnosis by fine-needle aspiration cytology

Nine cases of plasma cell tumors were diagnosed by fine-needle aspiration cytology, the sites of aspiration being soft-tissue swellings in five cases, lymph nodes in three cases, and both soft-tissue swelling and lymph node in one case. The age of the patients ranged from 33 to 74 yrs, with a median of 52 yrs. Only three of these nine cases were clinically diagnosed as multiple myeloma. Unequivocal demonstration of myeloma cells was possible in eight cases. The smear in ninth case showed mostly undifferentiated blast cells with a few cells showing plasmacytoid differentiation. Giant myeloma cells with monstrous segmented nuclei were encountered in two cases. M-component could be demonstrated in serum and/or urine samples in all seven cases in which it was sought.     

Cytopathology of fine-needle aspiration biopsy of the brain and spinal cord

The cytomorphologic findings of 37 intraoperative fine-needle aspiration (FNA) biopsies are presented. Thirty-two of the biopsies were performed at the time of craniotomy, and five were performed through a burr-hole. All cases used direct smear preparations stained with Papanicolaou and modified Wright stain (Diff-Quik). Immediate evaluation of the Diff-Quik-stained smears was performed for assessment of the adequacy of the specimen, and in most cases, a rapid preliminary diagnosis (similar to a frozen-section report) was rendered in the operating room. Cytopathologic features of anaplastic astrocytomas, glioblastoma multiforme, pituitary adenoma, meningioma, metastatic carcinoma, epidermoid cyst, herniated disc, hemangioblastoma, cerebral hemorrhage, and malignant lymphoma are described and illustrated. The cytologic preparation demonstrated superior cellular detail, which served as a considerable aid for diagnosis, and lacked the artifactural distortion often seen in the frozen-section preparations. Reliance on the fine-needle aspiration biopsy specimen enabled better triage of the small amount of tissue often available for permanent sections and special studies including electron microscopy and immunohistochemistry. Although not meant to replace tissue biopsy, FNA of the central nervous system though burr holes under radiologic guidance can be advantageous in selective cases.     

Value of ancillary studies in fine-needle aspiration biopsy

With growing interest in the application of fine-needle aspiration biopsy (FNAB) in primary diagnosis of benign and malignant lesions, there has been a significant increase in the use of ancillary studies in the aspirated material. To assess the value of such studies, we reviewed 254 morphologically difficult aspiration biopsy cases obtained from different sites that underwent ancillary studies which included microbiology (MC), special stains (SS), immunocytochemistry (ICC), electron microscopy (EM) and flow cytometry (FC). Correlation with available histologic material and/or pertinent clinical information was used as a “gold” standard. In some cases, more than one ancillary study was performed on a single aspirate. According to the impact of the ancillary studies on the final diagnosis, these studies were divided into three categories: confirmatory/ diagnostic (22%), helpful (41%), and non-helpful (37%). Overall, more studies had positive contributory effect to the diagnosis (63%) than those with non-helpful results (37%). Among these adjunct testings, ICC were the most commonly used tests (135/296, 46%), while the EM studies had more positive impact in establishing the diagnosis. These findings emphasize the usefulness of ancillary testings in FNAB and justify the more selective use of these studies in the aspirated material. © 1995 Wiley-Liss, Inc.     

Epithelioid hemangioendothelioma: Report of a case diagnosed by fine-needle aspiration

A case of epithelioid hemangioendothelioma suggested by fine-needle aspiration biopsy is reported. The clinical, cytological, histopathological, and postmortem findings are described. The diagnosis was confirmed by cyto-histoimmunochemical studies.     

Cytologic study of renal angiomyolipoma by fine-needle aspiration biopsy: Report of four cases

Four cases of renal angiomyolipoma (AML) diagnosed by fineneedle aspiration biopsy (FNAB) are reported. One case was associated with the clinical complex of tuberous sclerosis. The tumors were solitary in two cases and multiple and bilateral in the fourth. The cytologic features of the four cases were similar to those described in the literature: smooth muscle cells intermingled with mature fat cells and blood vessels, together with a lipoidic background. These tumors are currently considered benign although they may present characteristics accepted as criteria of malignancy in other tumors: pleomorphism and atypical smooth muscle cells, vascular invasion, capsular rupture, and lymphatic involvement. We conclude that it is important and possible to establish preoperative cytologic diagnosis, since treatment of these tumors is conservative and obviates aggressive nephrectomy. © 1994 Wiley-Liss, Inc.     

Fine-needle aspiration biopsy of abdominal and retroperitoneal tumors in infants and children

Fine-needle aspiration biopsy has been employed to establish morphologic diagnoses in abdominal and retroperitoneal tumors in 54 infants and children. A 0.4-0.7-mm gauge needle was used; the puncture was performed through the anterior abdominal wall in the abdominal tumors and by the lateral approach in the retroperitoneal tumors. Malignant tumors were discovered in 51 cases (94.4%). The nature of the lesion was recognized in 96.2%, and correct cell typing was achieved in 90.2%. The most frequent lesion was non-Hodgkin's malignant lymphoma, followed by neuroblastoma, nephroblastoma, and individual cases of other epithelial and mesenchymal tumors. Using parallel bone marrow examination, half of the neuroblastoma cases and five of 28 lymphoma cases showed bone marrow involvement. We observed no complications caused by the fine-needle aspiration technique. Due to the safety and efficacy of this technique, it can often be used instead of explorative laparatomy.