Fine‐needle aspiration (FNA) and pleural fluid cytology diagnosis of benign metastasizing pleomorphic adenoma of the parotid gland in the lung: A case report and review of literature

Lesions that contain abundant benign myoepithelial cells, including pleomorphic adenomas of salivary gland origin, may present a diagnostic challenge in fine‐needle aspiration (FNA) specimens. Benign metastasizing pleomorphic adenoma is a rare neoplasm, in which the benign appearing pleomorphic adenoma, without any histological evidence of malignancy, metastasizes to distant sites including lung. In the absence of clinical history of a pre‐existing myoepithelial neoplasm, the presence of myoepithelial cells in the lung or any other organs besides salivary glands may create diagnostic difficulty. Here we present the cytologic findings of such a metastatic tumor found in the lung FNA and pleural fluid specimens from a 64‐year‐old woman, with a history of local recurrent salivary gland pleomorphic adenomas, who presented with multiple bilateral pulmonary nodules and pleural effusion. The diagnosis of benign metastasizing pleomorphic adenoma was made based on clinical information and cytomorphology, and confirmed by immunocytochemistry. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Fine-needle aspiration diagnosis of squamous cell carcinoma in a lymph node involved with small lymphocytic lymphoma: case report and review of the literature

Diagnosis of two distinct malignant entities existing concurrently and at the same location (synchronous malignancy) by fine- needle aspiration (FNA) is unusual but may occur. Small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) in particular is associated with an increased incidence of secondary tumor, likely due to associated immunodeficiency. Co-occurrence of some carcinomas such as squamous cell carcinoma (SCC), may show especially aggressive behavior. A 57-year-old Caucasian male presented with recurrent upper extremity lymphedema and diffuse lymphadenopathy of the axillary and cervical regions. FNA of a large cervical lymph node was diagnostic for both atypical lymphocytic proliferation and SCC. Flow cytometric analysis showed the atypical lymphocytic proliferation to be positive for CD5, CD23, CD19, CD20, HLA-DR, CD38, and the population was kappa light chain restricted. These cells were negative for CD-10 and FMC-7 antigens, suggesting a phenotype of B-cell SLL/CLL. We report a rare occurrence of metastatic SCC to a lymph node infiltrated by SLL/CLL. The diagnosis was achieved by a combination of cytomorphologic examination of FNA smears, immunohistochemical staining of cell block material, and flow cytometry on the sample obtained by FNA. To the best of our knowledge, only three cases of SCC metastasis to SLL/CLL diagnosed by FNA have been reported in the English literature. Though rare, awareness of such a possibility and careful cytological examination under the appropriate clinical conditions is warranted.     

Fine‐needle aspiration of the diffuse sclerosing variant of papillary thyroid carcinoma masked by florid lymphocytic thyroiditis; A potential pitfall: A case report and review of the literature

The diffuse sclerosing variant of papillary thyroid carcinoma (DSV–PTC) is a rare tumor with aggressive behavior that requires aggressive treatment. Despite characteristic clinical and histological features that easily permit diagnosis, pre‐operative fine‐needle aspiration cytology (FNAC) diagnosis is often challenging and thus delays diagnosis. We describe the cytological features of a case of DSV–PTC diagnosed by FNAC in a 30‐year‐old woman presenting with an ill‐defined mass in her neck lasting for 2 months. Ultrasonograpy revealed a heterogeneous enlargement of both thyroid lobes suspicious for a lymphoproliferative syndrome. Flow cytometry showed a suspect B‐lymphocyte population. FNAC showed in five out of six slides an overwhelming presence of slightly atypical monomorphic small lymphocytes. The remaining slide showed syncytial tissue fragments of follicular cells with nuclear enlargement and pleomorphism, irregular nuclear membrane, grooves with scattered intranuclear inclusions, squamous metaplastic epithelium, and abundant psammoma bodies. A diagnosis of DSV–PTC was rendered and confirmed by total thyroidectomy and lymph node dissection. Our report supports the possibility of obtaining a preoperative diagnosis of DSV–PTC by FNAC. In the case of diffuse thyroid enlargement, adequate sampling of the thyroid and the presence of the combination of features described in our case permitted the diagnosis of this PTC variant. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Aspiration biopsy cytomorphology of primary pulmonary germ cell tumor metastatic to the brain

Extragonadal germ cell tumors are uncommon and such tumors originating from the lung parenchyma are extremely rare. This is a case of 68‐year‐old female who was admitted with complaints of right‐sided weakness, inability to maintain her balance, right‐sided headache, and bloody sputum. Her workup revealed two enhancing brain lesions and large lung mass involving the left lower lobe. Fine‐needle aspiration (FNA) of the lung followed by craniotomy was performed and the patient was initially diagnosed with lung adenocarcinoma metastatic to the brain based on the cytomorphology of the lung FNA and histology of the brain mass. However, retrospective investigation revealed markedly elevated alpha fetoprotein (AFP) of which the cytopathologist was unaware at the time of diagnosis. A review of the cytology and surgical specimen slides, as well as immunohistochemistry (IHC) on the brain tumor and FNA cell block were preformed. On the basis of the slides review, clinical findings, and immunostaining results, a diagnosis of primary pulmonary mixed germ cell tumor, containing choriocarcinoma and yolk sac elements, with brain metastases, was retrospectively made. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Value of cytopathologist‐performed ultrasound‐guided fine‐needle aspiration as a screening test for ultrasound‐guided core‐needle biopsy in nonpalpable breast masses

Fine‐needle aspiration (FNA) of breast masses in the United States has been on the decline for the last decade and has been largely replaced by ultrasound‐guided core‐needle biopsy (UG‐CNB). Some studies show core‐needle biopsy (CNB) is superior to FNA in terms of absolute sensitivity, specificity, and inadequate rate. However, the importance of a skilled aspirator, experienced cytopathologist, and immediate cytological evaluation (ICE) in FNA is often not considered. CNB is more expensive, invasive, risky, and painful than FNA. This prospective study examines the value of cytopathologist‐performed ultrasound‐guided FNA (UG‐FNA) with ICE as a screening test for cytopathologist‐performed UG‐CNB on nonpalpable or difficult‐to‐palpate solid breast masses visible on ultrasound. One hundred twenty consecutive nonpalpable or difficult‐to‐palpate presumably solid breast masses in 109 female patients from January2, 2008 to June 30, 2008 underwent cytopathologist‐performed UG‐FNA with ICE. Twenty cases were converted to cytopathologist‐performed UG‐CNB because ICE was inadequate, hypocellular, atypical, suspicious, or malignant. Patients with clearly benign cytology did not undergo UG‐CNB. UG‐FNA with ICE reduced the percentage of patients undergoing UG‐CNB by 87%. A new role for cytopathologist‐performed UG‐FNA of nonpalpable breast masses has been identified. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Fine needle aspiration cytology in a case of fibrous dysplasia of jaw

Fibro‐osseous lesions of the jaw comprise of a spectrum of diseases which include osseous dysplasia, fibrous dysplasia, and ossifying fibroma. The differentiation amongst these individual pathological lesions is difficult and a combined clinico‐radiological and histological correlation is essential for exact categorization. Fine needle aspiration cytology (FNAC) is frequently carried out to distinguish between benign and malignant lesions of the jaw as is a quick and reliable modality of investigation which guides in further management. We report, a case of a jaw swelling in a young male, diagnosed as fibrous dysplasia on FNAC. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Fine‐needle aspiration biopsy of granular cell tumor of the tongue: A technique for the aspiration of oral lesions

Granular cell tumor is most commonly located in the tongue. Despite this common location, there are few reports of fine‐needle aspiration biopsy (FNAB) of the tongue, likely because this is a sensitive area for most patients, and many cytopathologists do not have experience aspirating oral lesions. We report a case of FNAB of a granular cell tumor of the tongue in a 29‐year‐old man with an unusual presenting history and without symptoms. The diagnosis was made based on the cytomorphology of the direct smears and immunohistochemistry on cell block material. We will also describe cytologic features of the neoplasm, differential diagnosis, and our technique for obtaining the material, as we feel this can be repeated by experienced cytopathologists. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Fine needle aspiration findings in malignant ameloblastoma: A case report and differential diagnosis

We present a case of malignant ameloblastoma presenting in the posterior mandible and cervical lymph nodes of an African American child. This case is somewhat unusual in that the patient was an adolescent and presented with metastatic disease. This partly clinical as well as cytologic diagnosis was facilitated by the presence of typical ameloblastoma cytology in multiple cervical lymph nodes adjacent to the histologically confirmed intraosseous ameloblastoma. Although cytology is helpful in diagnosing ameloblastoma, its features are by no means definitive as there are several cytologic mimics. A high index of suspicion is therefore necessary to confirm or exclude ameloblastoma when evaluating any jaw lesion and/or adjacent enlarged lymph nodes by cytologic examination. Adequate sampling is paramount to accurate diagnosis, and is especially important when attempting to distinguish ameloblastoma from ameloblastic carcinoma. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Medullary thyroid carcinoma presenting as rectangular cell type on fine‐needle aspiration

Medullary thyroid carcinoma typically presents as dyscohesive plasmacytoid, spindled, or polygonal cells on fine‐needle aspiration smears. We recently encountered a case of sporadic medullary thyroid carcinoma that presented as a hypercellular aspirate composed of cohesive aggregates of rectangle‐shaped cells. The case was mistakenly reported as a hypercellular follicular neoplasm on cytology. Subsequent thyroidectomy revealed medullary carcinoma. We draw attention to this distinctive rectangular cell type as an additional morphology for medullary thyroid carcinoma. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.