Worrisome histologic alterations following fine-needle aspiration of benign parotid lesions

OBJECTIVE: To describe the histologic changes associated with preoperative fine-needle aspiration biopsies of benign parotid lesions and the features that distinguish these changes from malignant neoplasms. MATERIALS AND METHODS: Ten benign parotid lesions with a recent history of preoperative fine-needle aspiration were selected, including pleomorphic adenoma (4 cases), oncocytic adenoma (3 cases), myoepithelioma (1 case), Warthin tumor (1 case), and lymphoepithelial cyst (1 case). RESULTS: A spectrum of histologic alterations were observed. Alterations included squamous cell metaplasia (8 cases), infarction and necrosis (4 cases), subepithelial stromal hyalinization (3 cases), acute and chronic hemorrhage and inflammation with multinucleated giant cells (all cases), granulation tissue with subsequent fibrosis (all cases), cholesterol cleft formation (1 case), pseudoxanthomatous reaction (1 case), pseudocapsular invasion (1 case), and microcystic degeneration (2 cases). In cases with exuberant squamous metaplasia, necrosis, or subepithelial stromal hyalinization, a diagnosis of squamous cell carcinoma or low-grade mucoepidermoid carcinoma was seriously considered. CONCLUSIONS: Knowledge of a previous fine-needle aspiration procedure and awareness of its effects on histology of the subsequent parotidectomy specimens are necessary to avoid potential misdiagnosis.     

Histological alterations following fine-needle aspiration for parathyroid adenoma: Incidence and diagnostic problems

This study aimed to clarify the histological alterations following fine-needle aspiration for parathyroid adenoma and discuss the occurrence of diagnostic problems. Among the 392 patients with parathyroid adenoma who underwent resection, fine-needle aspiration was performed for 21 (5.1%) parathyroid adenoma nodules. Histological findings that were significantly more frequent in cases that underwent fine-needle aspiration were considered histological alterations following fine-needle aspiration for parathyroid adenoma, including the following six findings: thick fibrous capsule (71.4%), multilayered fibrous capsules (14.3%), capsular pseudo-invasion (42.9%), fibrous bands (57.1%), hemosiderin deposition (14.3%), and tumor implantation (14.3%). Eighteen parathyroid adenoma nodules (85.7%) exhibited one or more of the six findings. Tumor cells and adipocytes entrapped within the thick fibrous capsule were occasionally observed. The fibrous bands were frequently connected to the thick fibrous capsule. The number of passes, duration between fine-needle aspiration and resection, tumor size, and purpose of fine-needle aspiration were not related to the incidence of histological findings. Because of the histological alterations following fine-needle aspiration for parathyroid adenoma that can be easily mistaken for signs of atypical adenoma or parathyroid carcinoma, we recommend that the six findings be excluded from pathological findings indicating atypical adenoma or parathyroid carcinoma in patients with preoperative fine-needle aspiration.     

Histologic alterations in the thyroid gland after fine-needle aspiration

To evaluate the histologic alterations due to the fine-needle aspiration (FNA), a comparative study between 20 aspirated and 20 nonaspirated thyroidectomy specimens was performed. The most common findings in the aspirated group were hemorrhage (80%) and vascular proliferation and/or vascular thrombosis (45%). In one of the aspirated cases with the cytologic diagnosis of follicular neoplasm, histologic sections revealed prominent vascular and endothelial proliferation. Fibrosis, cystic degeneration, and infarction were other histologic findings in the aspirated group. Hemorrhage was seen in 45% and cystic degeneration in 25% of the nonaspirated cases. Fifty percent of the nonaspirated cases did not have any additional findings. In conclusion, knowledge of previous FNA application and awareness of possible histologic alterations due to the needling is necessary while evaluating the histologic sections of the thyroidectomy specimens. Diagn. Cytopathol. 16:230–232, 1997. © 1997 Wiley-Liss, Inc.     

Thyroid microcarcinoma: fine-needle aspiration diagnosis and histologic follow-up

The increased sensitivity of many imaging modalities (ultrasound, computed tomography scan, magnetic resonance imaging) has resulted in the identification of thyroid nodules, measuring 1 cm or less. Usually these small lesions are regarded as incidental and are not sampled by fine-needle aspiration (FNA). However, some of these lesions undergo FNA because of suspicious radiology findings (multifocality, calcification, etc) or in patients with a history of radiation to the head and neck region. We present FNA findings and histologic follow-up of 39 thyroid nodules that measured 1.0 cm or less. All FNAs were performed under ultrasound guidance. The lesions ranged in size from 0.2 to 1.0 cm. Twenty-two lesions were diagnosed as papillary carcinoma (PTC), 4 as medullary carcinoma (MC), and 13 as suspicious for PTC on FNA. Histologic follow-up showed PTC in 35 and MC in 4 cases; 11 PTC were multifocal (31%) and lymph node metastases were present in 8 (16%) cases. Ultrasound-guided FNA is effective in the sampling of thyroid cancers that are 1.0 cm or less. The present study shows that some of these lesions can be clinically significant.     

Infarcted myxoid fibroadenoma following fine-needle aspiration

Infarction of breast fibroadenomas is very rare and is frequently associated with physiologic changes, such as pregnancy and lactation. We report a case of an infarcted fibroadenoma following fine-needle aspiration. The patient presented with an asymptomatic breast mass, which was clinically difficult to evaluate. Excisional biopsy was performed 7 days after a nondiagnostic fine-needle aspiration of the mass. Microscopically, the nodule showed features of a classic fibroadenoma of the intracanalicular type with myxoid or mucinous stromal changes, as well as extensive areas of acute infarction. This report provides another example of the changes that may be observed in biopsy specimens obtained after fine-needle aspiration of the breast.     

Spindle cell lipoma of the parotid: fine-needle aspiration and histologic findings

A 47-year-old man presented to the otolaryngologist with a 7-year history of a mass of the cheek. Fine-needle aspiration revealed foci of spindled cells admixed with abundant fat and myxoid material. A diagnosis of spindle cell lipoma was rendered on the resected specimen. The cytologic findings of spindle cell lipoma of the parotid gland as seen by fine-needle aspiration are presented along with the histologic correlates.     

Papillary endothelial hyperplasia in the thyroid following fine-needle aspiration

A 74-year-old woman was found to have exuberant papillary endothelial hyperplasia within her thyroid gland subsequent to multiple fine-needle aspiration biopsies of a Hürthle cell neoplasm. To our knowledge, this histologic alteration in the thyroid has not been previously reported. We describe this unusual complication following fine-needle aspiration, and we delineate the clinicopathologic and differential diagnostic features.     

Specimen fine-needle aspiration cytology of littoral cell angioma with histologic and immunohistochemical confirmation

We performed a specimen fine-needle aspiration biopsy (FNAB) of a littoral cell angioma (LCA) from a 33-yr-old male who underwent elective splenectomy due to thrombocytopenia secondary to Wiscott-Aldrich syndrome. Gross examination revealed a 420-g, diffusely enlarged spleen which contained two moderately well-circumscribed, soft brown lesions measuring 0.3 and 1.0 cm, respectively. Benchtop aspiration of the lesions following splenectomy yielded a cellular sample composed predominantly of dispersed single cells, which ranged from columnar to spindle to circariform in shape. Nuclei were round to oval with even chromatin, and many contained single longitudinal grooves. A majority of the cells contained abundant, granular hemosiderin pigment, a key cytologic feature. Immunohistochemical staining revealed reactivity for antibodies to CD68 and factor VIII-related antigen with no reactivity for S-100 protein and CD8. Littoral cell angioma must be differentiated from splenic hamartoma, hemangioma, angiosarcoma, littoral cell angiosarcoma, and epithelioid and spindle cell hemangioendothelioma. A combination of cytologic features and immunohistochemical results should enable an accurate diagnosis.     

Liesegang rings in a submental mass: fine-needle aspiration with histologic correlation.

Liesegang rings are lamellated concretions commonly found in chronic cystic lesions that are inflamed, necrotic, fibrotic, or hemorrhagic. We report on an unusual case of a 14-yr-old girl with an acute, rapidly enlarging solid submental mass in which Liesegang rings were identified on aspirate smears.     

Atypia in fine-needle aspiration cytology of the breast: a histologic follow-up study of 301 cases

A gray area of uncertainty exists in fine-needle aspiration (FNA) cytology of the breast in which common criteria to distinguish benign from malignant lesions overlap. Aims of this study were to define this area and to evaluate statistically cytomorphologic criteria in a semiquantitative analysis. In a test set of specimens from well-differentiated carcinomas and benign proliferative lesions, signs of malignancy were cell dissociation, arrangement in small clusters, nuclei greater than 16 microns, anisonucleosis, irregular nuclear borders, nucleoli, and necrosis. Features in favor of benignancy were large monolayers, nuclei less than 16 microns without variation in size, smooth nuclear borders, and bipolar nuclei in the monolayers. Originally the term "atypia" had been applied to 956 (12%) of all FNAs of the breast performed at our institute from 1974 to 1985. Using these criteria in a review of all 301 cases in which histologic follow-up and cellular smears were available, much better results were obtained than originally; specificity increased from 80% to 95%, and sensitivity increased from 60% to 90%. The number of overdiagnoses decreased from 24 to seven, and underdiagnoses decreased from 57 to nine. In this selected series, the area of uncertainty was restricted to 16% of the cases; the number of these cases that proved to be malignant and benign was equal. In such cases of indistinct cytomorphologic criteria, a surgical biopsy is indicated for histologic studies.     

Nodular fasciitis: Spontaneous resolution following diagnosis by fine-needle aspiration

Nodular fasciitis can be histologically mistaken for a sarcoma. Typical cases are less than 5 cm and enlarge rapidly over days or weeks before diagnosis. The natural history of nodular fasciitis is unknown, since the diagnosis is usually based on excised lesions. Fine-needle aspiration of nodular fasciitis has been described, and features benign-appearing spindle cells (singly and in groups), collagen, and myxoid material. We describe 11 cases in which nonsurgical observation led spontaneously to complete resolution. Our study includes 7 males and 4 females (24 to 73 years of age; median = 42). Lesions were located in the arm (4), thigh (3), temporal area (2), breast (1) and the parotid (1) and ranged from 0.5 to 5.0 cm. (median = 1.5). They had been present for from less than 1 to 4 weeks (median = 2). In 9 cases, spontaneous resolution occurred in from 3 to 8 weeks (median = 4). Two other patients were lost to follow-up for up to 11 months, after which resolution was noted. Small palpable masses in the subcutaneous soft tissues which evolve over a short period of time and show the cytologic features of nodular fasciitis should be managed nonsurgically. If resolution does not occur within a few weeks, surgery can then be performed. Diagn Cytopathol 1993;9:322-324.     

Parathyroid hormone (PTH) assay of parathyroid cysts examined by fine-needle aspiration biopsy

The authors report three cases of parathyroid cysts examined by the fine-needle aspiration biopsy technic. A presumptive diagnosis of parathyroid cyst was made when characteristic water-clear fluid was aspirated. The diagnosis was then confirmed by parathyroid hormone (PTH) assay. The authors believe that the C-terminal/midmolecule determination should be the assay of choice, because the N-terminal-specific assay gave normal or slightly elevated results in all the cases studied. If only an N-terminal-specific PTH assay is obtained, potential for a false negative diagnosis exists. With a correct PTH assay, a specific diagnosis of parathyroid cyst can be rendered, which enables appropriate treatment of total fluid aspiration, which thereby eliminates the need for thyroid hormone treatment or surgery in most cases. A discussion of PTH assays is presented along with speculations concerning the secretion of PTH by the parathyroid gland. The previous literature detailing cytologic findings and the PTH assays of parathyroid cysts diagnosed by the fine-needle aspiration biopsy are reviewed.     

Role of testicular fine-needle aspiration biopsy in the evaluation of male infertility: cytologic and histologic correlation

A series of testicular fine-needle aspiration biopsy specimens from 272 infertile men with azoospermia were reviewed and categorized according to morphologic patterns. These included active spermatogenesis, 14 (5%); hypospermatogenesis, 106 (39%); Sertoli cells only, 70 (26%); atrophic pattern, 52 (19%); and maturation arrest, 1 (0.36%). In 29 cases (11%) the amount of material was insufficient for evaluation. The histologic and cytologic findings in 52 cases showing spermatogenesis correlated very well in 52 cases for which open testicular biopsy specimens were also available. These findings indicate that fine-needle aspiration biopsy of the testis is a reliable and useful technique for the investigation of patients with azospermia.     

Cytomorphology of cystic parathyroid lesions: Report of four cases evaluated preoperatively by fine-needle aspiration

Cystic parathyroid lesions (CPL) account for 1–5% of neck cysts. They are seldom palpable; however, they may present as neck swellings that are mistaken both clinically and cytologically for thyroid nodules and subsequently referred for evaluation by fine-needle aspiration. We present 4 cases of histologically confirmed CPL (one simple cyst, one hyperplasia, and two adenomas), 2 of which were misdiagnosed as adenomatoid thyroid nodules by fine-needle aspiration. Aspirated fluid from one patient was clear and colorless, a classic finding for parathyroid cysts, and contained high levels of C-terminal/midmolecule parathyroid hormone (CMPH). Fluids obtained from the remaining 3 patients were bloody to brown, resembling thyroid cyst fluid. In only 1 of the 3 patients, the fluid was analyzed and contained high levels of CMPH. Though cytologic features of parathyroid epithelium overlap with those of thyroid epithelium, distinguishing features such as unusual cytoplasmic vacuolization and granularity, and the absence of colloid, should raise suspicions of a parathyroid lesion. Fluid from CPL may not possess the classic appearance; however, identification of the subtler cytologic features with knowledge of relevant clinical data should prompt analysis of cyst fluid for CMPH, thus confirming the diagnosis and avoiding inappropriate therapy. Diagn Cytopathol 1996;15:306–311. © 1996 Wiley-Liss, Inc.     

Chordoma: diagnosis by fine-needle aspiration biopsy with histologic, immunocytochemical, and ultrastructural confirmation

Five cases of chordoma, diagnosed by fine-needle aspiration (FNA) biopsy, are presented. Four cases were histologically confirmed, and in one, immunocytochemical and ultrastructural studies were performed on both the aspirate and tissue specimen. Four cases presented as sacral masses, while in the fifth case, a destructive lesion of the clivus extended into the soft tissues of the lateral neck. A spectrum of cytomorphologic features was encountered including the presence of abundant microtissue fragments and cells in a dissociate pattern, often with abundant metachromatic extracellular matrix. Stellate and cuboidal cells often contained intracytoplasmic vacuoles of varying sizes. Intranuclear inclusions, mitotic figures, and anisonucleosis were prominent features of several cases. Immunoperoxidase studies on a single case demonstrated cytoplasmic staining for low- and high-molecular-weight cytokeratins, vimentin, and epithelial membrane antigen, while glial fibrillary acidic protein and carcinoembryonic antigen were negative. Ultrastructural features included the presence of mitochondrial endoplasmic reticulum complexes, occasional desmosome-like junctions, and abundant extracellular matrix adherent to the tumor cells. We believe the cytomorphologic findings are characteristic and, when taken in concert with immunocytochemical and ultrastructural studies, allow differentiation of chordoma from other primary or metastatic neoplasms occurring in bone. As demonstrated in our series, chordoma is often an unsuspected diagnosis. We believe that FNA biopsy of these lesions can lead to a correct preoperative diagnosis and may also be utilized to document recurrence and thus facilitate the evaluation and management of patients with these lesions.     

Unsuspected intrathyroidal parathyroid adenoma: mimic of lymphocytic thyroiditis in fine-needle aspiration specimens-a case report.

Fine-needle aspirations (FNAs) of parathyroid adenomas (PA) are infrequently encountered, but the scant literature on this topic emphasizes the difficulties in distinguishing them from thyroid neoplasms. We report on a case of an unsuspected intrathyroidal PA whose two FNA specimens mimicked almost perfectly the features of lymphocytic thyroiditis (LT). The smears from two FNAs of a "thyroid nodule" in a 22-yr-old woman were received with a clinical diagnosis of "LT." The cytological features of both specimens were similar and consisted of groups of epithelial cells in a background of numerous "naked" nuclei, interpreted as Hurthle cells and lymphocytes respectively, and leading to a cytological diagnosis of LT. Subsequent surgical excision of the "nodule" revealed a large intrathyroidal PA. The oxyphil cells and chief cells (the latter devoid of cytoplasm) present in the PA resembled Hurthle cells and lymphocytes respectively, in the FNA specimens. In conclusion, PA can give a cytological picture almost identical to that of LT in FNA material. Important clues to the diagnosis of PA in FNA specimens include the presence of prominent capillaries and the knowledge of a clinical history of hyperparathyroidism. Diagn. Cytopathol. 1999;21:276-279.     

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

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

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.     

Pediatric fine-needle aspiration biopsy.

A total of 135 fine-needle aspiration (FNA) biopsies from varying sites were performed in 123 children (mean, 10.5 years; range, one day to 18 years) over a five-year period. One hundred thirty (96.3%) biopsy specimens were satisfactory for evaluation. Seventy-nine cases were nonneoplastic (60.8%); among these cases, a specific diagnosis of infectious disease was made in 17 (13.1%). A diagnosis of neoplastic disease was made in 50 (38.5%) cases, of which 14 (10.8%) were benign, 28 (21.5%) were malignant, and 8 (6.2%) were neoplasms of uncertain biologic potential. The sensitivity of pediatric FNA biopsies was 90.6%, specificity 100%, positive predictive value 100%, negative predictive value 94.7%, and efficiency of the test 96.5%. There were no false-positive diagnoses and there were four false-negative diagnoses, three of which involved aspirates of the central nervous system (CNS). Ancillary studies, including immunocytochemistry (20 cases), electron microscopic examination (18 cases), microbiologic culture (8 cases), cytogenetic studies (7 cases), and flow cytometry (3 cases), were performed on the aspirated material, enabling a more specific diagnosis or supplying additional information in many cases. Definitive diagnosis by FNA biopsy enabled radiation therapy and/or chemotherapy to be administered for unresectable malignant neoplasms, provided material for culture of infectious lesions, identified benign lesions not needing surgery, and aided the surgeon in planning the extent of surgery in resectable malignant neoplasms. These results support the greater use of FNA biopsy in the pediatric population.