Aisha K. Al-Jassar

Follicular variant of papillary thyroid carcinoma – a cytological study

The cytological diagnosis of classical papillary carcinoma is easily established based on the characteristic architectural and nuclear features. However, the follicular variant of papillary thyroid carcinoma(FVPTC) poses a diagnostic challenge. In this study we analysed the cytological features of 14 histopathologically proven cases of FVPTC. We inferred that a combination of architectural features such as follicles and syncytial clusters and nuclear features, viz grooves, pseudoinclusions and enlarged nuclei with fine chromatin, were helpful in establishing the diagnosis. It is hence suggested that based on the combination of the aforesaid features a diagnosis of FVPTC be offered whenever it is possible. This helps in patient management, obviating the need for a second surgical intervention.

Macrofollicular variant of papillary thyroid carcinoma diagnosed by fine needle aspiration biopsy : A case report

BACKGROUND Macrofollicular variant of papillary thyroid carcinoma (PTC) is an uncommon, recently described thyroid tumor. By frozen section it can be confused easily with goiter or macrofollicular adenoma. CASE A 41-year-old female presented with a huge mass in the right thyroid lobe, cold on scintigraphy. By fine needle aspiration fluid was obtained. Smears of the sediment of the fluid showed epithelial cells with morphologic features diagnostic of PTC. Frozen section diagnosis was benign. CONCLUSION This is the first reported case of macrofollicular variant of PTC diagnosed preoperatively by cytology. In our case the cytology was similar to that of cystic PTC.

Fine needle aspiration cytology of Hodgkin's lymphoma: A cytohistologic correlation study from a cancer center in Kuwait.

OBJECTIVE To assess the diagnostic accuracy offine needle aspiration cytology (FNAC) in the diagnosis of Hodgkins lymphoma (HL). STUDY DESIGN We selected all the cases in which a cytologic diagnosis of HL, suggestive of or suspicious for HL, or HL as the prime differential diagnosis was offered on FNAC. These cases were correlated with histopathologic follow-up. Cases of primary HL diagnosed on cytology but without histopathology were excluded from the study. RESULTS Histopathologic follow-up was available in 46 cases. Of these, 42 were correctly diagnosed as HL, and there was a discorrelation in 4 cases, comprising 3 cases of non-HL (T-cell-rich B-cell lymphoma [TCRBCL]-2, anaplastic large cell lymphoma-1) and 1 case of metastatic carcinoma. Overall accuracy was 91.3%. In 14 cases, the cytologic features were diagnostic ofrecurrence; hence, no histopathologic examination was done. No follow-up was available for the remaining 19 cases, which were excluded from the study. CONCLUSION FNAC is very useful for rapid and accurate approach to the diagnosis of recurrent and most cases of primary HL. Because of morphologic similarities, it is difficult to differentiate HL from anaplastic large cell lymphoma and TCRBCL on FNAC. It is advisable to request a histopathologic examination in all cases of primary HL.

Metaplastic mammary carcinoma with osteoclastic giant cells: a cytological mimicker of fibroadenoma

Dear Editor, We recently came across an interesting breast lesion. A 31-year-old woman presented to the cytology clinic with a 5-cm diameter lump in the upper outer quadrant of the left breast. There was a history of recent increase in size. Fine needle aspiration cytology (FNAC) was performed and reported as a fibroadenoma. Prior to this an ultrasound and a mammography were performed. Based on the report of these tests it was concluded that a malignancy could not be completely excluded. The patient underwent a lumpectomy and due to the equivocal radiological findings, a frozen section was undertaken. This was reported as a fibroepithelial tumour. On histopathological examination, the tumour was relatively well circumscribed and the predominant arrangement was in the form of a cribriform pattern. The tumour cells showed moderate nuclear pleomorphism and mitoses were infrequent. The stroma was collagenized and fresh haemorrhage as well as abundant haemosiderin-laden macrophages were also noted. In addition, many osteoclastic giant cells were seen. These contained five to 20 nuclei and were characteristically located adjacent to the tumour islands (Figure 1). The nuclei were relatively monotonous. Immunostaining showed the carcinomatous component to be positive for carcinoembryonic antigen and the giant cells stained positively for a-1-antitrypsin proving them to be of histiocytic origin. The tumour cells were negative for oestrogen and positive for progesterone receptors. The immunohistochemical staining for Her-2/neu was negative. Based on the overall features this was reported as a metaplastic mammary carcinoma with osteoclastic giant cells. We then retrieved the cytology smears and re-examined them. We observed that the smears were cellular and predominantly showed monolayered sheets of ductular epithelial cells with mild overlapping. A focal acinar arrangement was seen. The tumour cells had relatively monotonous nuclei with mild hyperchromasia. There were numerous spindle-shaped fibroblast-like cells and a few naked bipolar nuclei in the background, along with scattered osteoclastic giant cells (Figure 2). Around most foci the giant cells mingled closely with the epithelial cells. Haemosiderin-laden macrophages were also noted. Both these features were missed on initial reporting. Retrospectively, we were able to categorize this as metaplastic mammary carcinoma with osteoclastic giant cells. Mammary carcinoma with osteoclastic giant cells accounts for 0.5–1.2% of all breast carcinomas. Mammographically, these tumours have well-circumscribed margins and are usually diagnosed as fibroadenoma or cyst. Typically these are seen in the upper and outer quadrant. Grossly it is an ill-defined to well-circumscribed fleshy, dark brown tumour. Microscopic examination reveals a moderately or poorly differentiated invasive ductal carcinoma, often with a cribriform growth pattern. As the name suggests, osteoclastic giant cells are the characteristic finding. These are seen close to the edges of carcinomatous glands. It is likely that these are formed by fusion of histiocytes in the stroma. The stroma shows extravasated RBCs and haemosiderin. The diagnosis of this tumour can be suggested on FNAC based on cellular smears containing tumour cells intermixed with multinucleated giant cells. These may be confused with tumour giant cells which however have pleomorphic hyperchromatic nuclei. In the present case, on initial examination, the abundant cellularity coupled with relatively bland epithelial cells and spindled cells in the background led to the mistaken diagnosis of a fibroadenoma. The osteoclastic giant cells were missed. Clinically too, this was thought to be a fibroadenoma. It has been reported that this lesion mimics a benign tumour on cytology. The other lesions with osteoclastic giant cells include metaplastic carcinoma with cartilaginous differentiation, sarcomas with osteoclastic giant cells and Correspondence: Dr Sanjay Jogai, Kuwait Cancer Control Center, Post Box No. 42262, Shuwaikh – 70653, Kuwait. Tel.: +965 4821362; Fax: +965 4810964; E-mail: sanjayjogai@rediffmail.com

Idiopathic retroperitoneal fibrosis – a potential pitfall for fine needle aspiration cytology

Dear Editor, Idiopathic retroperitoneal fibrosis is a well recognized condition which is diagnosed combining clinical, radiological and histopathological findings. However, experience with cytological findings is limited. We herein describe a case in which fine needle aspiration was performed. A 53-year-old man presented to the cytology clinic with a clinical diagnosis of a retroperitoneal tumour (? lymphoma). Fine needle aspiration was performed under ultrasound guidance. The smears revealed scanty cellularity with few large anaplastic cells with oval to round pleomorphic nuclei and a background of activated lymphocytes, plasma cells and neutrophils (Figure 1). No Reed–Sternberg cells were seen. Although the findings were not conclusive, a possibility of anaplastic large cell or Hodgkin’s lymphoma was offered and biopsy was advised for a conclusive diagnosis. A few days later a 1 · 1 · 1 cm firm and fibrous tissue fragment was received for histopathological examination. Microscopy showed predominant bundles of dense eosinophilic collagenous tissue with scattered inflammatory infiltrate, comprising lymphocytes, plasma cells, a few eosinophils and histiocytes (Figure 2). Fibrosis infiltrated into adjacent fat. In places there were lymphoid aggregates. Inflammation was also seen in a perivascular distribution. There was no vasculitis. Based on the overall features a diagnosis of idiopathic retroperitoneal fibrosis was offered. Cytology smears were retrieved and reviewed. Cells misinterpreted as atypical cells were actually histiocytes as was confirmed on histopathological examination. In addition to the inflammatory component smears showed clumps of pink amorphous material (probably collagen) and few spindle cell fragments. Reports describing fine needle aspiration findings of idiopathic retroperitoneal fibrosis are limited. In both reports, the authors found inflammatory cells and fibrous tissue as the cytological findings. In our case, the predominant component was inflammatory and this coupled with the presence of seemingly atypical cells misled us to suggest the possibility of a

Metastatic medullary thyroid carcinoma to the breast in a patient with combined medullary and papillary carcinoma of thyroid—A case report

We report the fine‐needle aspiration cytology of a case of medullary thyroid carcinoma (MTC) metastatic to the breast in a 66‐year old female within two years of diagnosis of the thyroid tumor. The aspirate of the breast metastases revealed a plasmacytoid population of cells in loose clusters and singly with mild to moderate pleomorphism. Nuclear groves and occasional intranuclear cytoplasmic inclusions were seen. The cells stained positive for calcitonin and negative for thyroglobulin. Use of immunocytochemical methods proved useful to diagnose metastasis which was essential in planning treatment. Cases of metastatic MTC to the breast diagnosed on fine‐needle aspirates reported in the literature are reviewed. Diagn. Cytopathol. 2015;43:343–348.

A Proposed Methodology for Evaluating Secondary Screening (Rescreening) Instruments for Gynecologic Cytology

The potential benefit of these devices is that they may increase the overall sensitivity of any one gynecologic cytology screening event by detecting the presence of possible abnormal cells missed upon primary screening. Because primary screening (i.e., first-time examination of a slide) is not 100% sensitive, rescreening is used to detect these false negatives. Secondary screening devices are intended to focus manual rescreening on slides that are more likely to harbor missed abnormalities than on slides selected randomly. Secondary screening instruments may be used in place of or in addition to secondary manual rescreening.