Fine-needle aspiration cytology of lymphoproliferative lesions involving the major salivary glands

Fine-needle aspiration biopsy (FNA) is an accurate and cost-effective procedure for evaluating salivary gland lesions. Lymphoproliferative lesions may manifest as salivary gland enlargement. We report our experience with 43 cases of reactive and neoplastic lymphoproliferative lesions of the salivary glands evaluated by FNA, including 23 cases of reactive lymphoid hyperplasia and 20 neoplastic lymphoproliferative processes. The latter included 2 multiple myelomas and 18 non-Hodgkin lymphomas (small lymphocytic lymphoma/chronic lymphocytic leukemia, 1; small cleaved cell lymphoma, 1; lympho-plasmacytoid lymphoma, 1; mucosa-associated lymphoid tissue lymphoma, 2; mixed cell lymphoma, 4; lymphoblastic lymphoma, 1; and large cell lymphoma, 8). There were no false-negative diagnoses. Aspiration smears from 3 patients with reactive lymphoid hyperplasia and 4 patients with malignant lymphoma initially were interpreted as atypical lymphoid proliferations or as suggestive of malignant lymphoma. Thus, FNA had a sensitivity of 100% and a specificity of 87%. The majority of patients were treated medically without surgical intervention. Among the patients who underwent surgical resection of the salivary gland, 7 had an equivocal cytologic diagnosis and 2 had a benign cytologic diagnosis, but their parotid swelling failed to regress despite medical treatment. In most instances, FNA provides useful information for subsequent disease management and obviates surgical intervention.     

Fine needle aspiration cytology of a myoepithelioma presenting as a thyroid nodule

Myoepitheliomas are rare neoplasms that are typically found in the major and minor salivary glands and represent approximately 1.5% of all salivary gland neoplasms. We present a patient with an exophytic anterior midline neck mass, which was initially believed to be a thyroid isthmus nodule that underwent fine needle aspiration (FNA) biopsy. FNA cytologic evaluation reveals numerous plump spindle cells and a myxoid background, thus raising the possibility of rare benign mixed tumor of the thyroid. However, the resected specimen consists of predominately spindle cells with a minor component of chondromyxoid matrix, and no ductal epithelial cells, favoring a diagnosis of myoepithelioma. Although this lesion clinically and radiologically appeared to arise from the thyroid gland, at the time of resection, it was found to be adjacent to the thyroid isthmus and was ultimately diagnosed as a soft tissue myoepithelioma of the midneck. Diagn. Cytopathol. 2015;43:153–157. © 2014 Wiley Periodicals, Inc.     

Evaluation of fine needle aspiration cytology of salivary glands: an analysis of 141 cases

141 salivary gland lesions that were subjected to fine needle aspiration (FNA) cytology at the University Hospital, Kuala Lumpur, from January 1993 to October 2000 were reviewed with a view to assess the sensitivity and utility of cytological diagnosis in diseases of salivary glands. The highest number of cases was seen in the sixth decade of life. There was no gender preponderance in salivary gland neoplasms except in Warthin's tumours that occurred predominantly in males. The parotid gland was the most frequent salivary gland needled. Seven cases (5%) presented with bilateral salivary gland enlargement. Cytological study yielded a neoplastic diagnosis in 74.5% cases. Of the neoplastic lesions, 71.4% could be definitely designated as benign and 25.7% as clearly malignant. Pleomorphic adenoma and acinic cell carcinoma were the most common benign and malignant neoplasms diagnosed respectively. 53 cases had histological correlation; of these, 49 (92.5%) were neoplastic. The overall diagnostic accuracy of FNA cytological diagnosis in salivary gland lesions was found to be 73.6%.     

Atypical hemangioma of the breast: a diagnostic pitfall in breast fine-needle aspiration

We report on the fine-needle aspiration (FNA) cytology of atypical hemangioma of the breast in a 52-yr-old female. The patient presented with a 2-cm palpable left breast mass. An FNA of the mass was performed following a mammogram, corresponding to the palpable breast mass. The FNA demonstrated the presence of numerous atypical single spindle cells scattered throughout a hemorrhagic background. An unequivocal diagnosis of malignancy was not rendered in this case. However, the degree of cytologic atypia suggested a malignant process, and a recommendation for an excisional biopsy was made. Atypical hemangioma should therefore be included in the differential diagnosis of angiosarcoma and other benign and malignant spindle-cell lesions of the breast encountered on cytologic samples.     

Acinic-cell carcinoma,papillary-cystic variant: a diagnostic dilemma in salivary gland aspiration

Fine-needle aspiration (FNA) plays a pivotal role as the initial diagnostic modality of choice when dealing with salivary gland (SG) lesions. Due to the heterogeneous nature of most SG neoplasms, cytologic interpretation on FNA can be quite challenging. This is particularly valid when dealing with rare tumor types, such as the papillary-cystic variant of acinic-cell carcinoma (ACC-PCV), resulting in a high rate of false-negative cytologic diagnoses. Seven cases of ACC-PCV diagnosed on tissue resection with a prior FNA performed in cytology were studied. Material consisted of Diff-Quik and Papanicolaou stained cytologic smears, as well as hematoxylin-eosin stained cell block and histopathologic sections. In no case did the FNA performed prior to the surgical resection eventuate in a cytopathologic diagnosis of cancer. A retrospective morphologic review of the smears disclosed several characteristics common to all 7 cases, i.e., mostly tightly cohesive fragments of neoplastic epithelium seen as monolayered sheets or with a prominent papillary architecture, high nuclear:cytoplasmic ratio ductal-type epithelium, cystic material and degenerated cellular debris, histiocytes, cells with squamoid and metaplastic oncocytic changes, vacuolated and pigmented histiocyte-like tumor cells, and lack of a predominant single-cell component or naked neoplastic cell nuclei. ACC-PCV represents a rare yet significant cause of false-negative results for cancer on SG aspirations. An erroneous interpretation may occur due to lack of experience in dealing with this tumor type, the rarity of published literature on ACC-PCV, and a predominantly cystic, somewhat variegated appearance of the tumor mimicking other benign and malignant SG lesions.     

Osteosarcoma metastatic to adrenal gland diagnosed by fine-needle aspiration

Osteosarcoma, a primary malignant tumor of the long bones, frequently metastasizes to the lungs. We report an unusual case of osteosarcoma metastatic to the right adrenal gland in a 37-yr-old male who presented 8 yr after remission with an adrenal mass. A preoperative diagnosis was made by fine-needle aspiration (FNA) biopsy. FNA biopsy revealed pleomorphic oval cells with prominent nucleoli, spindle cells, and giant tumor cells. Diagnostic osteoid was readily seen on smears and was also detected by polarization of cell-block section. Immunocytochemical stains revealed positivity of tumor cells for vimentin and osteonectin. Cytokeratin stains were negative. The cytologic diagnosis of metastatic Osteosarcoma was made, which was later confirmed upon resection of tumor by histology. Although the role of FNA in the diagnosis of primary bone tumors, including osteogenic sarcoma (OGS), remains controversial, this case, however, demonstrates the value of FNA biopsy combined with immunocytochemistry performed on the aspirated material in diagnosing osteosarcoma from an unusual location such as the adrenal gland.     

Diagnosis of recurrent uterine carcinosarcoma by fine-needle aspiration cytology: report of a case

Uterine carcinosarcomas are uncommon, aggressive neoplasms usually afflicting postmenopausal women. Histologically, they are characterized by the presence of both malignant epithelial and stromal cells. The latter may be either homologous or heterologous in nature. The cytologic diagnosis of carcinosarcoma via fine-needle aspiration (FNA) was previously described for primary tumors arising in the parotid gland, breast, lung, and ovary. Although the diagnosis of uterine carcinosarcoma via cervicovaginal, endometrial, and peritoneal fluid cytology has been described, the FNA cytology diagnosis of recurrent uterine carcinosarcoma has only been rarely described. We present a case of recurrent uterine carcinosarcoma in a 59-yr-old woman, diagnosed by ultrasound-guided FNA cytology. Cytologic smears showed a biphasic neoplasm consisting of both malignant columnar epithelial and spindle cells, in a background of tumor diathesis. This case illustrates the diagnostic utility of aspiration cytology in the investigation of recurrent carcinosarcoma in clinically suspicious lesions arising postsurgery.     

Selected problems in fine needle aspiration of head and neck masses.

A wide variety of masses in the head and neck, including those in the major salivary glands, can be approached by fine needle aspiration. In many instances, a correct definitive diagnosis con be rendered after examination of smears or cell block material. However, several significant but uncommon areas can lead to diagnostic difficulties, with the potential for clinically important diagnostic errors. Many of these occur in salivary gland lesions. The most frequent problems involve variations in the expected cytology of pleomorphic adenoma. Then, there are several benign-malignant "look-alike" pairs of lesions. The first of these is related to small-cell epithelial neoplasms of low nuclear grade; the most frequent problem is between basal cell adenomas and adenoid cystic carcinoma, particularly the solid (anaplastic) type. The next area contrasts mucoepidermoid carcinoma with its cytologic mimic, benign salivary gland duct obstruction. The final difficulty in salivary gland aspiration contrasts large-cell epithelial lesions of low nuclear grade: oncocytic proliferations and acinic cell carcinoma. The clinical implications of cytologically benign squamous cell-containing cyst aspirates from the lateral neck will be discussed. Finally, a brief consideration of methodological optimization for thyroid aspirations will be offered.     

Cytologic diagnosis of adenoid cystic carcinoma of salivary glands.

The cytomorphologic features in fine-needle aspiration (FNA) biopsies from 31 primary and 33 recurrent adenoid cystic carcinomas (ACC) were investigated. The correct FNA diagnosis was established in 24 of 31 primary ACC (77%). The diagnostic clue in aspirates from ACC are large globules of extracellular matrix, partially surrounded by basaloid tumor cells. In FNAs with predominance of basaloid tumor cells, but lacking characteristic globules, all other benign and malignant salivary gland tumors of epithelial-myoepithelial differentiation should be considered in the cytologic diagnosis. Pleomorphic adenoma is most frequently confused with ACC, and therefore, the cytologic findings in FNAs from 50 pleomorphic adenomas were compared with those diagnosed as ACC. Furthermore, rare neoplasms of salivary glands with epithelial-myoepithelial cell differentiation, including basal-cell adenoma and carcinoma, epithelial-myoepithelial carcinoma, and polymorphous low-grade adenocarcinoma, as well as some nonsalivary gland neoplasms presenting an adenoid cystic pattern, must be considered. The cytologic features of these entities are discussed in detail with respect to the cytologic diagnostic criteria of ACC.     

A case of amelanotic spindle-cell melanoma presenting as metastases to breast and axillary lymph node: diagnosis by FNA cytology

Metastatic neoplasms to the breast are relatively rare. Spindle-cell lesions of the breast are also uncommon. Here we present a case of fine-needle aspiration (FNA) of an amelanotic, spindle-cell melanoma metastatic to the breast and axillary lymph node. The patient was a 47-yr-old female who presented with a right breast mass, left axillary adenopathy, and a pigmented skin lesion on the back. FNA of the right breast and left axilla showed malignant, nonpigmented spindle cells that were weakly positive for HMB-45 on immunocytochemistry. The skin biopsy showed a pigmented malignant melanoma with epithelioid features, and also weak positivity for HMB-45. Although malignant melanoma is one of the more common tumors to metastasize to the breast, this is the first known case that showed exclusive spindle-cell morphology. History and physical examination were crucial in making the correct FNA diagnosis. The cytologic differential diagnosis of spindle-cell tumors of breast and the discordant morphology between the primary and metastatic melanotic lesions observed in this case are discussed.     

Fine-needle aspiration of renal masses in adults: analysis of results and diagnostic problems in 108 cases.

Fine-needle aspiration (FNA) biopsy of the kidney has a traditionally well-defined role in the diagnosis and treatment of renal lesions. Recent improvements in renal imaging techniques have also brought renal FNA to the forefront, since small and asymptomatic renal masses are increasingly being detected. Before the physician institutes a treatment plan, such lesions usually require a definitive diagnosis that is best provided by FNA. To assess various aspects of renal FNA, including specimen adequacy, questionable cytologic patterns, and diagnostic pitfalls, we retrospectively evaluate our experience with 108 FNA biopsies performed for the evaluation of renal masses in adults. For each case, the smears were reviewed and correlated with tissue sections from cell blocks, surgical specimens, or autopsy material, when available. The cytologic diagnoses were confirmed by cell block (59 cases), nephrectomy or autopsy (35 cases), or clinical follow-up. Of the 108 FNA biopsy samples, 17 showed evidence of blood, soft tissue, necrotic material, glomeruli, or tubular cells and were classified as unsatisfactory. The following diagnostic categories were noted in the 91 satisfactory aspirates: renal abscess (four cases), benign cyst (30 cases), suspicious lesions (11 cases), and malignant lesions (46 cases). In four cases of renal abscess, FNA found abundant clusters of neutrophils. For the 30 cases interpreted on cytologic evidence as benign cysts, the diagnosis was confirmed in 28 cases; the two remaining cases were acquired cystic kidney and cystic renal-cell carcinoma, respectively. Among the 11 suspicious lesions, the final diagnoses were one benign simple cyst, one angiomyolipoma, two multilocular cystic nephromas, two adult polycystic kidneys, one acquired cystic kidney, three cystic papillary renal-cell carcinomas, and one solid renal-cell carcinoma. Cases classified as suspicious shared characteristic cytologic patterns that distinguished them from simple benign cysts and from classic renal-cell carcinoma. Among the 46 malignant lesions, as evidenced on cytologic examination, 27 were renal-cell carcinomas, five were transitional-cell carcinomas, four were lymphomas, one was a small-cell undifferentiated carcinoma, and nine were metastatic carcinomas. False-positive or false-negative cases were not encountered in this category. In conclusion, FNA is an excellent method to diagnose space-occupying lesions of the kidney. For cystic lesions, cytologic-radiographic correlation is needed to avoid misinterpretation. Our study defines a spectrum of suspicious patterns characteristic of a group of renal lesions that are distinct from both benign simple cyst and straightforward renal malignancy.     

Transthoracic fine-needle aspiration vs concurrent core needle biopsy in diagnosis of intrathoracic lesions: a retrospective comparison of diagnostic accuracy

To assess the value and limitations of fine-needle aspiration (FNA) and core needle biopsy (CNB) in the diagnosis of intrathoracic lesions, we retrospectively compared the diagnostic accuracy of 362 FNA and concurrent CNB procedures performed on 350 patients. Based on the final diagnoses that were determined based on combined information from biopsy, resection, clinical, radiologic, and microbiologic findings, the study cases were grouped into 188 malignant, 161 benign, and 13 inconclusive lesions. FNA and CNB yielded similar diagnostic accuracy for malignant tumors (85.1% vs 86.7%) and epithelial malignant neoplasms (86.4% vs 85.2%), whereas CNB yielded better diagnostic accuracy (96%) than FNA (77%) for nonepithelial malignant neoplasms. Combined FNA and CNB substantially improved the rate of malignancy diagnosis (95.2%). Of 161 benign cases, 50 were proven to be benign-specific lesions; FNA provided specific diagnosis in 20 (40%) and CNB in 46 (92%). The remaining 111 benign lesions yielded benign-nonspecific findings on both specimens. These results indicate that CNB should be obtained when clinical or radiologic findings do not match the cytologic findings or nonepithelial lesions and benign lesions are considered likely.     

Pleomorphic adenoma with predominant plasmocytoid myoepithelial cells: a diagnostic pitfall in aspiration cytology. Case report and review of the literature

Fine-needle aspiration (FNA) biopsy of the salivary gland is a sensitive and specific diagnostic tool. However, diagnostic problems are sometimes encountered in interpreting some cases, not only in differentiating benign from malignant cases but also in the specific classification of these neoplasms. We report a case of a pleomorphic adenoma with predominant plasmocytoid myoepithelial cells arising in minor salivary glands from the hard palate in a 78-year-old patient, which was falsely diagnosed as a carcinoma on liquid-based cytology (ThinPrep (TP)). The differential diagnosis of salivary gland tumors with predominant myoepithelial cells on FNA biopsy is discussed.     

Cytologic findings of a clear cell parathyroid lesion

On fine‐needle aspiration (FNA) biopsy, clear cell parathyroid lesions can be misdiagnosed as thyroid neoplasms, salivary gland neoplasms, paraganglioma, or even metastatic renal cell carcinoma. We report the clinicopathological, cytologic, and histologic findings of a clear cell parathyroid tumor in a 64‐year‐old HIV‐positive patient. A computed tomography (CT) scan with contrast showed a heterogeneous and enhancing mass at the inferolateral aspect of the left thyroid lobe. FNA showed a cellular smear with many single and loosely clustered tumor cells with finely granular and vacuolated light‐purple cytoplasm and central nuclei. Occasional microfollicular structures were noted. No colloid was seen. This FNA was misdiagnosed as a follicular neoplasm of the thyroid. Sections of the excised mass showed large polyhedral cells with well‐defined cell membranes and clear cytoplasm with a small amount of eosinophilic granular material. These clear cells were positive for pancytokeratin and PTH immunohistochemical stains. These results favored a diagnosis of parathyroid Water Clear Cell Adenoma. This brief report highlights the cytologic findings of clear cell parathyroid lesions and their potential diagnostic pitfalls. Diagn. Cytopathol. 2013;41:725–728. © 2013 Wiley Periodicals, Inc.     

Fine-needle aspiration cytology findings in a case of aggressive angiomyxoma: A case report and review of the literature

Aggressive angiomyxomas are uncommon but distinct soft-tissue neoplasms occurring predominantly in the pelvis and peritoneum of females, but they have occasionally been reported in association with inguinal hernias in males. Histologically, these neoplasms are characterized by a proliferation of spindle- or stellate-shaped cells widely separated by loose myxoid stroma in which is dispersed a prominent vascular component. The vascular component is comprised of large, thick-walled vessels that generally do not show an arborizing pattern. Mitotic activity has been exceedingly low in the cases reported. Because of their occurrence within the groin, these lesions may undergo fine-needle aspiration (FNA). Cytologic examination of this material will reveal hypocellular smears containing scattered spindle cells with bipolar cytoplasmic processes, as well as bland stellate cells. The nuclei are fusiform to oval with a bland chromatin pattern. The stromal cells lie in a background of watery myxoid material. While specific diagnosis by FNA is not possible, the recognition of this cytologic appearance should exclude lymphoproliferative processes as well as metastatic disease from the differential diagnosis. Careful attention to cytologic detail should also help exclude certain other myxoid neoplasms, especially myxoid liposarcoma. Once the myxoid stromal nature of the proliferation is recognized, a differential diagnosis of myxoid lesions can be considered along with a recommendation for open biopsy to establish the definitive diagnosis. Diagn. Cytopathol. 16:425–429, 1997. © 1997 Wiley-Liss, Inc.     

Salivary gland lesions with a prominent lymphoid component: Cytologic findings and differential diagnosis by fine-needle aspiration biopsy

Fine-needle aspiration (FNA) is an accepted technique for the preoperative diagnosis of salivary gland nodules. The majority of salivary gland nodules are pleomorphic adenomas and offer little difficulty in diagnosis. Most diagnostically difficult lesions fall into one of four morphologic categories represented by squamous-cell-containing lesions, clear cell neoplasms, neoplasms with a prominence of stromal material, and lymphocyte-containing lesions. Herein, we describe our experience with a series of 61 histologically confirmed cases in which the smears contained a prominent or predominant number of lymphocytes. The differential diagnosis is discussed and points of diagnostic aid enumerated. Diagn. Cytopathol. 1997;17:183–190. © 1997 Wiley-Liss, Inc.     

Primary vascular neoplasms unique to the spleen: littoral cell angioma and splenic hamartoma diagnosis by fine-needle aspiration biopsy

We report the fine-needle aspiration (FNA) biopsy diagnosis of two rare cases of primary vascular neoplasms unique to the spleen: a littoral cell angioma from a 31-yr-old Caucasian woman and a splenic hamartoma from a 46-yr-old black man. The cytologic features of splenic hamartoma and of littoral cell angioma of the spleen were described three times in cytologic literature: two were bench-top aspirates and one was FNA biopsy thought to be metastatic carcinoma. To the best of our knowledge, the current two cases were the first diagnosed by FNA biopsy. Our approach to the FNA biopsy diagnosis of these rare vascular neoplasms via compact cell block and immunohistochemistry is described. The differential diagnosis with other primary vascular splenic neoplasms is also discussed.     

Phosphaturic mesenchymal tumor diagnosed by fine-needle aspiration and core biopsy: a case report and review of literature

Oncogenic (tumor-induced) osteomalacia is a rare paraneoplastic syndrome of phosphate wasting that is frequently associated with phosphaturic mesenchymal tumor (PMT). As the cytologic features of this tumor apparently have not been reported, we describe the fine-needle aspiration (FNA) findings for PMT that arose from the gluteal soft tissue in a patient with hypophosphatemia and multiple fractures secondary to osteomalacia. Smears from the computerized tomography (CT)-guided FNA showed groups of spindle cells having elongated nuclei, fine to moderately coarsely granular chromatin, inconspicuous nucleoli, and delicate cytoplasm. Marked nuclear atypia, mitotic figures, and necrosis were absent. The differential diagnosis included a variety of benign and malignant spindle cell neoplasms such as monophasic synovial sarcoma, leiomyoma, peripheral nerve sheath tumor, fibrosarcoma, and, less likely, metastatic melanoma and sarcomatoid carcinoma. The bland-appearing cytologic features of a spindle cell tumor in a patient with osteomalacia should suggest the diagnosis of PMT.     

Pleomorphic hyalinizing angiectatic tumor: cytomorphologic features on fine-needle aspiration

Pleomorphic hyalinizing angiectatic tumor (PHAT) is a rare low-grade neoplasm occurring predominantly in the subcutaneous tissue of the lower extremity, which is characterized histologically by intermixed bland spindle cells and larger pleomorphic cells, ectatic blood vessels with fibrin, and prominent hyalinization. Here we describe the cytologic features of PHAT seen on fine-needle aspiration of a right calf mass in a 46-year-old man. The smears were cellular, composed predominantly of bland spindle cells dispersed singly as well as in tissue fragments and characterized by open chromatin and small nucleoli. A second population of pleomorphic spindle cells with coarse chromatin, prominent nucleoli, and occasional intranuclear pseudoinclusions was also present. Many of the pleomorphic cells surrounded hyalizined vessels. No mitotic figures were identified. The cytologic diagnosis was a "spindle cell lesion, NOS" with the differential diagnosis including benign lesions and low-grade neoplasms, including PHAT and schwannoma.