Fine‐needle aspiration cytology of endometriosis

Endometriosis commonly involves the pelvis, but may also present as a palpable mass in extrapelvic sites, such as the abdominal wall or inguinal region, where it can be evaluated by fine needle aspiration (FNA). In this report, we illustrate the findings seen in seven cases of endometriosis diagnosed by FNA in patients with a chief complaint of pain associated with an abdominal wall or pelvic mass, occurring in a setting of prior pelvic surgery. The most common previous surgery was Cesarean section (n = 6), followed by hysterectomy (n = 2), and hernia repair (n = 1). In all cases, cytologic examination revealed a glandular component composed largely of orderly fragments of cohesive epithelial cells, a spindle cell stromal component presenting either as loosely organized tissue fragments or single cells, and rare hemosiderin‐laden macrophages. Four cases showed focal cytologic atypia in the glandular component with extreme nuclear atypia identified in two of these cases. Atypical features included nuclear crowding and disorganization, nuclear enlargement, hyperchromasia with irregular chromatin distribution and anisonucleosis, raising the possibility of a coexistent malignancy and recommendation for excision. Although malignancy was not identified in follow‐up surgical excision specimens, the wide range of cytomorphologic changes that can be seen in FNA specimens of endometriosis should be recognized. Diagn. Cytopathol. 2017;45:359–363. © 2016 Wiley Periodicals, Inc.     

Spontaneous Cutaneous Endometriosis in the Mons Pubis Region

Most cutaneous endometriosis develops at the site of an abdominal surgical scar. Spontaneous cutaneous endometriosis is extremely rare. We report a case of spontaneous cutaneous endometriosis in the mons pubis region. A 41‐year‐old woman presented with a mass in the right mons pubis, causing cyclic pain associated with menses. Fine‐needle aspiration (FNA) biopsy was performed. The smears contained three cellular components: honeycombed sheets of glandular epithelial cells, fragments of ovoid‐to‐spindle shaped stromal cells, and background inflammatory cells, including hemosiderin‐laden macrophages, histiocytes, and neutrophils. Biphasic clusters of glandular epithelial cells and stromal cells were identified. FNA cytology is a safe and useful adjunctive tool for diagnosing cutaneous endometriosis. Diagn. Cytopathol. 2014;42:615–618. © 2013 Wiley Periodicals, Inc.     

Fine‐needle aspiration cytology of abdominal wall endometriosis

While about 15% of menstruating women develop endometriosis, abdominal wall endometriosis is relatively rare. We present 10 cases of abdominal wall endometriosis diagnosed by fine‐needle aspiration (FNA) cytology and confirmed by subsequent surgical excision. A palpable abdominal wall mass was the most common symptom, followed by pain. Nine cases were associated with previous surgery. The smear showed glandular epithelial cells and spindle or ovoid stromal cells accompanied by macrophages in eight cases. The nucleus was round‐to‐oval and the nucleolus was inconspicuous. Mitosis was not observed in any case. In two cases, which were suspicious of malignancy on FNA, the epithelial cells showed anisonucleosis, hyperchromasia, and small conspicuous nucleoli. The stromal cells were spindle or ovoid in shape, without metaplastic changes. Histiocytes were noted in nine cases and hemosiderin‐laden histiocytes were noted in two cases. The proportion of inflammatory cells varied. FNA diagnosis of abdominal wall endometriosis is possible when the cytological features are interpreted cautiously, together with the patient's clinical history. An accurate diagnosis on FNA will prevent unnecessary surgery. Diagn. Cytopathol. 2013. © 2011 Wiley Periodicals, Inc.     

The role of peritoneal washings in the diagnosis of endometriosis

Endometriosis, the presence of endometrial tissue outside the uterine corpus, is a common finding in reproductive age women. It is classically diagnosed based on the presence of at least two of the following elements: endometrial glands, endometrial stroma, and hemosiderin‐laden macrophages (HLMs). Although a common finding in surgical pathology specimens at the time of gynecologic surgery, there is little literature on the role of pelvic washings in diagnosing endometriosis. Our study aimed to examine the characteristics of endometriosis in pelvic washings at the time of gynecologic surgery. We report nine cases of endometriosis diagnosed on pelvic washing. Two had a reported history of endometriosis. Four had endometriosis on the concurrent surgical pathology specimen. Liquid‐based cytology was diagnostic of endometriosis in seven patients, including five with glandular cells and HLMs and two with glandular cells, HLMs, and endometrial stromal cells. Cell block was diagnostic of endometriosis in eight patients, including four cases with intact fragments of endometrial glands and stroma. Three cases showed glandular cells and HLMs, while one showed separate fragments of glandular cells and stromal cells. Pelvic washings increased the diagnostic yield for endometriosis at the time of gynecologic surgery, as only four out of nine cases had endometriosis diagnosed on surgical pathology. Cell block in particular aids in the diagnosis, since intact glandular and stromal fragments frequently can be identified.     

Diagnosis of endometriosis by fine-needle aspiration cytology.

Endometriosis is a fairly common disease found in a variety of extrauterine locations. It primarily affects reproductive age women and has symptoms varying from occult to more specific complaints. Occasionally the lesions produce solid nodules and/or cysts that are clinically palpable and easily evaluated by fine needle aspiration (FNA). We describe three cases of endometriosis diagnosed by FNA. The patients ranged in age from 32 to 38 and reported cyclic symptoms of pain, bleeding, or change in mass size. Two patients presented with subcutaneous masses (one along the upper pubic ramus, the other in the lower abdomen) and had ultrasonically guided FNA. The third patient had a vaginal cuff mass sampled by transvaginal FNA. All cytologic smears contained characteristic sheets of epithelial cells and fragments of loosely arranged spindled stroma. One case also showed mild epithelial atypia and plump stromal cells. Hemosiderin-laden macrophages were found in only one case. The cytologic diagnoses were confirmed by tissue in all patients. Endometriotic nodules must be evaluated for possible malignant transformation and differentiated from other benign and malignant masses, especially when clinical symptoms are vague. FNA offers a safe and effective tool for identification of endometriosis and obviates the need for diagnostic surgical procedures in some patients.     

Malignant Leydig‐cell tumor of the testis diagnosed by fine‐needle aspiration using ThinPrep technique

Leydig cell tumors (LCT) are rare sex cord‐stromal tumors that account for 2–3% of all testicular tumors. Approximately 10% of LCTs shows evidence of malignant behavior. We present a case of LCT with severe atypia diagnosed by fine‐needle aspiration (FNA) in a 49‐year‐old man who presented with gynecomastia and right testis enlargement. The FNA material on conventional and ThinPrep smears revealed a hemorrhagic and necrotic background with high cellularity, consisting of large cells, isolated or in small cohesive clusters, abundant, eosinophilic cytoplasm, round nuclei, fine chromatin, and variably conspicuous nucleoli. Occasionally, pleomorphic cells with hyperchromatic nuclei and prominent nucleoli were seen. Immunocytochemistry was positive against vimentin, inhibin, and calretinin. Histological examination of the surgical specimen was in accordance with the FNA findings. The cytologic diagnosis of LCT of the testis, using FNA, is achievable in a preoperative setting to vitiate the need for more invasive biopsy procedures; malignancy could be considered on cytology when necrosis and marked atypia are evident. Diagn. Cytopathol. 2011. © 2010 Wiley‐Liss, Inc.     

Fine-needle aspiration cytology of papillary renal cell carcinoma: the association with concomitant secondary malignancies

Papillary renal cell carcinoma is a rare type of renal malignancy. Cytogenetic findings characteristic for this tumor have been described as well as mutations of the proto-oncogene c-met. Secondary malignancies occurring together with papillary renal cell carcinomas are rare, and are often of genitourinary tract origin. We describe two cases of papillary renal cell carcinoma occurring in association with two other visceral malignancies, gastrointestinal stromal tumor and colon adenocarcinoma.Two cases of papillary renal cell carcinoma diagnosed by fine-needle aspiration (FNA), occurring in association with gastrointestinal malignancies were reviewed.Both aspirates showed cytologic features characteristic for papillary renal cell carcinoma, namely papillary structures, foamy histiocytes, intracytoplasmic hemosiderin, and nuclear grooves. Subsequent histology and immunohistochemical stains supported the cytologic diagnosis. The histologic diagnosis of gastrointestinal stromal tumor and colon adenocarcinoma were confirmed.Papillary renal cell carcinoma is a type of renal carcinoma that can be often accurately diagnosed by FNA. The occurrence of associated visceral malignancies has never been reported. The possible role of the protooncogene c-met in the development of these tumors was explored.     

The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects

Although the histologic diagnosis of endometriosis is usually straightforward, many diagnostic problems can arise as a result of alterations or absence of its glandular or stromal components. The diagnostic difficulty in such cases can be compounded by tissue that is limited to a small biopsy specimen. The appearance of the glandular component can be altered by hormonal and metaplastic changes, as well as cytologic atypia and hyperplasia. Although the last 2 findings are often referred to collectively as "atypical endometriosis," they should be separately recognized as their premalignant potential likely differs. In some cases, the endometriotic glands are sparse or even absent (stromal endometriosis). The stromal component can be obscured or effaced by infiltrates of foamy and pigmented histiocytes, fibrosis, elastosis, smooth muscle metaplasia, myxoid change, and decidual change. Occasional findings in endometriosis that may raise concern for a neoplasm include necrotic pseudoxanthomatous nodules, polypoid growth (polypoid endometriosis), bulky disease, and venous, lymphatic, or perineural invasion. Inflammatory and reactive changes within, adjacent to, or at a distance from foci of endometriosis can complicate the histologic findings and include infection within endometriotic cysts, pseudoxanthomatous salpingitis, florid mesothelial hyperplasia, peritoneal inclusion cysts, and Liesegang rings. The histologic diagnosis of endometriosis can also be challenging when it involves an unusual or unexpected site. Five such site-specific problematic areas considered are endometriosis on or near the ovarian surface, superficial cervical endometriosis, vaginal endometriosis, tubal endometriosis, and intestinal endometriosis, including the important distinction of an endometrioid carcinoma arising from colonic endometriosis from a primary colonic adenocarcinoma. Finally, endometriotic foci can occasionally be intimately admixed with another process, such as peritoneal leiomyomatosis or gliomatosis, resulting in a potentially confusing histologic appearance.     

Cribriform‐morular variant of papillary thyroid carcinoma—Cytological and immunocytochemical findings of 18 cases

The purpose of this article was to describe cytologic findings of cribriform‐morular variant of papillary thyroid carcinoma (CMV‐PTC) in detail, to review previously reported cases, and to emphasize the diagnostic significance of this subtype. We examined 19 ultrasound‐guided fine needle aspiration (FNA) specimens from 18 CMV‐PTC patients. Cytologic features of CMV‐PTC were as follows, (1) hypercellularity, (2) papillary arrangement composed of tall columnar cells, (3) cribriform pattern, (4) morules, (5) spindle cells, (6) obscure ground‐glass nuclei, (7) peculiar nuclear clearing (PNC), (8) foamy or hemosiderin‐laden histiocytes, (9) hyaline materials, (10) absence of colloid in the background. The nuclear and cytoplasmic immunoreactivity of beta‐catenin and biotin‐positive PNC can indicate CMV‐PTC. We believe that cytologic diagnosis of CMV‐PTC is possible and it may lead to the early detection of polyposis coli. Diagn. Cytopathol. 2010;38:890–896. © 2010 Wiley‐Liss, Inc.     

Hepatic endometriosis diagnosed by liquid‐based cytology: A Case Report

A 44‐year‐old woman presented to Emergency Department with sudden onset of severe upper abdominal pain. T2‐weighted MRI image showed a large cystic mass with a thickened wall measuring 9.5 × 9.1 × 11.2 cm in the right hepatic lobe. It was radiologically interpreted as a cystic mass with differential diagnosis including echinococcal cyst, biliary cystadenoma, and malignant neoplasm. The cystic mass was intraoperatively aspirated and a liquid‐based cytology preparation (ThinPrep) and a cell block were made. The ThinPrep slides showed three dimensional clusters of epithelioid cells with scant delicate cytoplasm and tissue fragments composed of small stromal cells with round to oval shaped nuclei and a small amount of dense cytoplasm lined by the cuboidal epithelial cells. Occasional ciliated cells and abundant hemosiderin laden macrophages were also present. The cell block showed many tissue fragments containing glands and stroma with associated hemorrhage and hemosiderin laden macrophages, typical of endometrial tissue. Although it is uncommon, hepatic endometriosis should be considered in the differential diagnosis of cystic liver mass in women, especially those with a history of endometriosis or obstetric/gynecologic surgery. Diagn. Cytopathol. 2014;42:441–444. © 2013 Wiley Periodicals, Inc.     

Incidence of pelvic and extrapelvic endometriosis in Eastern region of Nepal

Endometriosis is described as the presence of endometrial glands or stroma in abnormal locations outside the uterus. It afflicts 10% women of childbearing age. A 5-year retrospective analysis of histopathologically proven cases of endometriosis was done. Haematoxylin and Eosin stained slides were reviewed for type of lining epithelium, endometrial glands, stroma, fresh and old hemorrhage & inflammatory cells. Clinical details were analyzed. Age of the patient ranged from 22 - 48 years. The most common site of endometriosis was ovaries (69.23%) followed by scars (11.43%), cervix (7.69%), fallopian tube (3.84%), vagina (3.84%) and appendix (3.84%) in descending order of frequency. Most common symptom was pain. On ultrasound and X-ray diagnosis could not be made in any case. Clinically endometriosis was diagnosed in 9 (34.62%) cases. On histopathological examination majority of the cases (42.3%) had endometrial glands, stroma and hemosiderin laden macrophages. 3 cases (11.43%) had endometrial lining epithelium and stroma only, which on laproscopy also were diagnosed to have endometriosis. It was concluded that high rate of surgical excision of organs were done because of misdiagnosis.     

Aspiration biopsy of nodular pseudoangiomatous stromal hyperplasia of the breast: clinicopathologic correlates in 10 cases

Nodular pseudoangiomatous stromal hyperplasia (PASH) of the breast is rare and often indistinguishable from fibroadenoma, clinically and on aspiration biopsy smears. We report our observations in 10 patients with PASH, evaluated by fine-needle aspiration (FNA) biopsy and core biopsy. We retrospectively reviewed the clinical, radiographic, cytologic, and histologic findings in 10 cases of pure nodular PASH. Ten patients with a presumed clinical and radiologic diagnosis of fibroadenoma underwent aspiration biopsy. The aspiration smears were diagnosed as fibroadenoma (4 cases), cellular fibroadenoma (1 case), schwannoma versus neurofibroma (1 case), fibrocystic change (3 cases; 2 with atypia), and "not specific for a lesion" (1 case). A diagnosis of PASH was not suspected in any case. A discrepant or imprecise cytologic diagnosis and/or the presence of dissociated spindle or epithelial cells, or cellular stromal fragments prompted a surgical excision in 7 of 10 patients (70%). The remaining 3 patients exhibited cytologic features of fibroadenoma and were diagnosed as such; however, surgical excision was recommended. Three patients underwent a subsequent core biopsy, with a diagnosis of PASH being made in 1 patient. FNA biopsy could not discriminate PASH from fibroadenoma in 4 of 10 patients (40%) or suggest a diagnosis of PASH in any case. On retrospective review, the finding of plump, spindle-shaped mesenchymal cells may be a cytologic clue to suggest a diagnosis of PASH.     

Fine needle aspiration cytology of nodular fasciitis of the breast

We report a case of nodular fasciitis (NF) of the breast, which was cytologically diagnosed as a spindle cell proliferation with undetermined malignant potential. Owing to small size of the lesion (5.9 × 3.7 × 4.1 mm), only fine needle aspiration (FNA) cytology was performed under ultrasound guidance. The FNA smears were cellular, rich in single/clustered spindle cells but mammary ductal epithelial/myoepithelial cells were absent. These cytologic findings suggested spindle cell growth of mesenchymal origin. Pattern‐less arrangement of spindle cells, heterogeneous composition of the stromal matrix, lack of nuclear/cellular atypia, occasional mitosis but no aberrant mitotic figures, and lymphocyte infiltration indicated reactive rather than neoplastic nature of the lesion. Nonetheless, lumpectomy was conducted because the possibility of neoplasm was not completely ruled out. The histologic diagnosis of the resected nodule was NF. FNA specimens were reviewed thoroughly in an attempt to define the key cytomorphologic features of NF that are important for the correct diagnosis. Differential diagnoses from the lesions that show similar cytologic pictures are discussed in detail. Although NF arising from the breast is rare, cytopathologists should be aware of its clinical and cytopathologic characteristics. Knowledge of the possibility of NF in the breast and its cytologic findings may help cytopathologists to discern its reactive, not neoplastic, characteristics of the lesion. If the referring surgeon is alerted NF as a possibility along with other differential diagnoses, close observation would become a management option. In‐depth discussion of cytologic features and a review of the pertinent literature are also included. Diagn. Cytopathol. 2015;43:222–229. © 2014 Wiley Periodicals, Inc.     

Common epithelial tumors of the ovary: proliferating and of low malignant potential

Ovarian tumors of low malignant potential (LMP) must be distinguished from benign, "proliferating" ovarian tumors and from frank ovarian carcinoma. Serous and mucinous tumors of LMP demonstrate epithelial stratification, the formation of epithelial tufts, cytologic atypia, and mitotic activity, but they do not demonstrate stromal invasion by epithelial cells, which is a feature of frank carcinoma. Mucinous carcinoma may also be recognized by epithelial stratification exceeding three cell layers and the formation of true cribriform glandular patterns. Although controversial, we do not at present recognize a LMP tumor of endometrioid type but prefer to classify those endometrioid neoplasms with a prominent fibrous stroma and glandular complexity similar to adenomatous endometrial hyperplasia as proliferating endometrioid adenofibromatous and cystadenofibromatous tumors. There is only mild cytologic atypia in such tumors. Because of the moderate to marked cytologic atypia that occurs in some clear cell neoplasms with a prominent fibrous stroma, we believe those tumors do merit a designation of LMP tumors. In both the proliferating endometrioid and LMP clear cell adenofibromatous and cystadenofibromatous tumors, carcinoma must be excluded by an absence of stromal invasion, which is frequently recognized by a confluent glandular pattern. The histologic features of proliferating Brenner tumors are similar to those of low grade, papillary, noninvasive, urothelial carcinoma, whereas we propose that Brenner tumors of LMP show high grade cytologic atypia but remain noninvasive in the ovary.     

Endometriosis of sigmoid colon mimicking malignant tumor diagnosed by intraoperative imprint cytology

A case of endometriosis of the sigmoid colon on imprint cytology from an intraoperative biopsy is discussed. Cytologic specimens showed sheets or tubular epithelial clusters and stromal fragments. The epithelial cell nuclei were small and round to ovoid with finely granular chromatin and inconspicuous nucleoli. The background showed a few scattered spindle-type stromal cells without pigment-laden histiocytes. A definitive diagnosis of endometriosis can be based on cytology, provided that the cytologic findings are interpreted in the appropriate clinical context.     

Cytologic features of pancreatic intraepithelial neoplasia and pancreatitis: Potential pitfalls in the diagnosis of pancreatic ductal carcinoma

Fine‐needle aspiration (FNA) has played a significant role in the diagnosis of pancreatic masses but false‐positive diagnoses occur. The Anatomic Pathology files were searched for FNAs of pancreas with subsequent resections. FNAs with a diagnosis of positive for or suspicious for adenocarcinoma followed by a benign resection specimen were reviewed and the surgical pathology and cytology findings correlated. Six cases had a cytologic diagnosis of adenocarcinoma or suspicious for adenocarcinoma but resection specimens were benign. In two cases, a non‐invasive intraductal papillary mucinous neoplasm (IPMN) without significant dysplasia was present surrounded by foci of pancreatic intraepithelial neoplasia (PanIN). In both cases, the degree of atypia within the IPMN was less than that seen cytologically. The nuclear features of the PanIN overlapped those seen in the smears. In two cases, a neuroendocrine neoplasm was present accompanied by multifocal PanIN. The cytologic features of the neuroendocrine neoplasm did not correlate with the material cytologically diagnosed as adenocarcinoma. The cytologically atypical epithelium was similar to the PanIN. Two diagnoses of adenocarcinoma were made cytologically but the pancreatectomy specimens revealed pancreatitis with reactive atypia. Cytologic diagnosis of pancreatic adenocarcinoma has high specificity. Six cytologic misdiagnoses of adenocarcinoma occurred in 105 patients. The cytologic features of these misdiagnoses correlated with histopathologic changes of intermediate to high‐grade PanIN or marked reactive atypia in severe pancreatitis. PanIN may be an under recognized, but significant source of false‐positive results. Diagn. Cytopathol. 2011. © 2010 Wiley‐Liss, Inc.     

Aspiration cytology of a case of tumoral calcinosis

The fine-needle aspiration (FNA) cytologic findings in a case of non-familial tumoral calcinosis are described. These include abundant calcific amorphous deposits, mononuclear histiocytes, osteoclast-type multinucleated giant cells, and fragments of tissue consisting of osteoblast-type cells with atypical epithelial-like features mimicking an epithelial malignancy. This is the first reported case describing the cellular morphology of tumoral calcinosis in an FNA specimen. A previously reported case described the evacuation of acellular calcific fluid only. In the present case, vigorous aspiration of the solid portions of the lesion yielded cellular material representative of the histology of the lesion. Points of caution for a correct interpretation of the cytologic findings are discussed. © 1995 Wiley-Liss, Inc.     

Superficial endometriosis of the cervix: A source of abnormal glandular cells on cervicovaginal smears

Superficial endometriosis of the cervix, a benign process which may be associated with atypical glandular cells of undetermined significance (AGUS) on cervicovaginal (CV) smears, is becoming increasingly recognized on colposcopic examination. This study details the clinical, cytologic, and histology features of six cases of superficial cervical endometriosis. All CV smears featured atypical endocervical-like columnar cells in sheets and strips as well as cells with endometrial characteristics including solid cohesive, crowded, overlapping glandular groups, loss of cellular polarity, and a frequent ragged "feathered" edge appearance with protruding nuclei, occasional rosette formations, and endometrial stroma. Recognition of endometrial stroma in continuity with groups of cells with these features on CV smears may suggest the diagnosis of this benign condition. However, the cytologic features of endometriosis show sufficient overlap with those of precancerous and cancerous glandular lesions that many of these cases will continue to be diagnosed as "atypical glandular cells."     

Fine-needle aspiration diagnosis of ectopic thyroid: Report of one case

Fine-needle aspiration (FNA) of a mass of the floor of the mouth in a teenage woman showed many foamy and pigmented histiocytes. cholesterol crystals, and few sheets of follicular cells with paravacuolar granules and cytoplasmic flares. The cytologic findings were consistent with adenomatous thyroid tissue. This was confirmed by subsequent surgical excision and histologic diagnosis of the surgical specimen. The differential diagnosis and value of preoperative diagnosis by FNA of lesions of the floor of the mouth in general and ectopic thyroid in particular, are briefly discussed.     

Cytologic features of lymphoepithelial cyst of the pancreas: two preoperatively diagnosed cases based on fine-needle aspiration.

We describe the cytologic features seen in fine-needle aspiration (FNA) specimens from two cases of preoperatively diagnosed lymphoepithelial cyst (LEC) of the pancreas. Pancreatic LEC is a rare, true cyst of uncertain histogenesis that may clinically and radiologically mimic a pseudocyst or cystic neoplasm. Both our patients were middle-aged men who presented with vague abdominal pain. Computed tomography (CT) of the abdomen revealed a mass in or around the pancreas, and CT-guided percutaneous FNA (patient 1) and endoscopic ultrasound-guided FNA (patient 2) yielded paste-like yellow-gray material. Cytologic smears showed numerous anucleated squamous cells in a background of keratinous and amorphous debris. A few benign nucleated squamous cells and plate-like cholesterol crystals were also seen. Unlike LEC of the head and neck region, only rare lymphocytes and histiocytes were present. Pancreatic LEC was diagnosed based on these cytologic findings and was histologically confirmed following cyst enucleation (patient 1) and partial pancreatectomy (patient 2). We conclude that preoperative FNA and recognition of the characteristic cytologic pattern will enable conservative surgical management of pancreatic LEC. Diagn. Cytopathol. 1999;21:346-350.