Bushra Al-Ayadhy

Fine Needle Aspiration Cytology of Breast Masses in Children and Adolescents

Objective To study the distribution and efficacy of fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions in pediatric and adolescent patients. Study Design From January 1993 to December 2006, the cytology reports of 1,404 breast aspirates (178 males and 1,226 females) performed on children and adolescents (ranging from 1 to 21 years) were reviewed. Of these 41, 179, 506 and 678 aspirates belonged to the age group 1-<12, 12-<16, 16-< 19 and 19-21 years, respectively. Results The morphologic spectrum seen in females was inflammatory lesions (4%), benign ductal cells (20%), ductal hyperplasia (0.6%), papillary lesions (0.7%), benign neoplasms (69%), suspicious cytology (0.3%) and cancer (0.3%). Of the benign neoplasms, 98% (831 of 851) were fibroadenomas, with 12 cases of phyllodes (benign), 5 cases of lipoma and 3 cases of adenoma. There were 3 cases of malignancy (2 adenocarcinoma and 1 non-Hodgkins lymphoma). Only 3% of the male breast aspirates provided a diagnostic challenge, while 89% of them showed benign ductal cells. Conclusion FNAC of children and adolescent breast masses is helpful and can reduce the need for open surgery to prevent later deformity. The aspirates are mostly benign and can be managed conservatively.

Mucoepidermoid thymic carcinoma: A challenging mediastinal aspirate

Primary thymic carcinoma—mucoepidermoid cell (MEC) type is rare and only one report describing the cytologic features of this neoplasm in the metastatic site is described. We describe the cytological features of poorly differentiated carcinoma possibly MEC in a 54‐year‐old man who presented with cough, weight loss, and puffiness of face for 3 months. The significance of this infrequently encountered neoplasm lies in its potential confusion of origin of the tumor—thymus or metastases from a primary bronchial MEC. Immunocytochemical profile was suggestive of a thymic carcinoma of the MEC type. Diagn. Cytopathol. 2009.

Role of Urinary Cytology in Detecting Human Polyoma BK Virus in Kidney Transplant Recipients

Objective: To report data on the evaluation of the efficacy of urine cytology in detecting BK virus (BKV). Material and Methods: Papanicolaou-stained cytospin preparations of randomly collected urine samples from 8 renal transplant (RTR) patients (5 males, 3 females, age: 23–63 years) who previously tested positive for BKV by PCR in urine or blood or both were studied. Urine sediment from 3 of the patients was processed for ultrastructural examination (EM). Renal biopsies before and after BKV detection were also evaluated. Results: The interval between renal transplant and urine cytology ranged between 2 and 5 years. Urine from females was difficult to assess due to vaginal contamination. In 2 of the 5 urine specimens from male recipients BKV-infected decoy cells were identified. Viral particles suggestive of BKV were identified on EM in 2 of the 3 specimens studied. Kidney biopsies showed morphologic features suggestive of BKV infection in 2 cases, 1 each detected on cytology and EM, respectively. Conclusion: Screening for the presence of decoy cells in urine provides a simple sensitive means for the diagnosis of BKV nephropathy in RTR.

Spindle cell lipoma: an uncommon tumour with distinctive morphology

Dear Editor, Spindle cell lipoma (SCL) is a relatively uncommon benign neoplasm arising in the subcutaneous tissue of the shoulder and at the back of the neck of older male patients. It represents approximately 1.5% of lipomatous tumours. It is characterized by a mixture of mature fat, bland spindle cells and wiry collagen in a variably myxoid background. There are a few reports of aspiration cytology findings of these tumours in the literature. A cytomorphological appraisal of the tumour is presented. A 45-year-old man presented with a painless, welldefined soft tissue swelling (2 · 2 cm) on the right side of the nape of the neck. The patient stated that the lesion had been present for more than 6 months. The swelling was clinically thought to be an enlarged lymph node or a lipoma. No other masses were noted and the past medical history was otherwise unremarkable. Fine needle aspiration was performed using a 23-gauge needle and a 10-ml syringe fitted onto a Cameco holder. Both alcohol-fixed Papanicolaou and air-dried May-Grünwald–Geimsa-stained slides were prepared. Smears from the aspirated material were cellular. Spindle-shaped cells were seen scattered singly or in aggregates with mature adipose tissue and collagen in varying proportions (Figures 1 and 2). The spindle cells had pale and poorly defined cytoplasm. The nuclei were ovoid or fusiform, basophilic with mild anisonucleosis. Some myxoid material was identified in the aspirate (Figure 2d). Nuclear grooves with intranuclear cytoplasmic inclusions were seen in many nuclei (Figure 1). A few mast cells and ropy, wiry collagen was identified (Figure 2). The cytological diagnosis was that of a benign spindle cell lesion – most likely an SCL. The surgical specimen consisted of a circumscribed piece of adipose tissue measuring 2.2 · 2 · 1.5 cm. Microscopic examination revealed mature adipose tissue and collagen bundles with a proliferation of spindle-shaped cells. The spindle cells were set in a loose stromal matrix and showed minimal pleomorphism (Figure 3). Immunohistochemical examination of the specimen showed clearly positive CD34 and bcl2 (Figure 4) staining in the spindle cell component. SCL was first described by Enzinger and Harvey in 1975 with the aim of distinguishing it from myxoid lipoma/liposarcoma, a frequent misdiagnosis. SCL is a slow-growing benign tumour seen in men between the age of 45 and 70 years. This subcutaneous tumour is frequently located in the neck and upper back. However, unusual locations such as parotid, breast and orbit have also been reported. Cytological findings of SCL are fairly characteristic. The potential clues to diagnosis of SCL include bland spindle cells with only mild nuclear atypia, mature fat, myxoid background, wiry collagen and mast cells. This together with a typical clinical presentation allows a correct diagnosis even on fine needle aspiration. Differential diagnoses for the cytological findings include neurogenic tumours, dermatofibro-

Prevalence and Correlation of Human Papilloma Virus and its Types with Prognostic Markers in Patients with Invasive Ductal Carcinoma of the Breast in Kuwait

OBJECTIVES This study aimed to document the association of human papilloma virus (HPV) and its types in breast carcinoma tissues in Kuwaiti women, and correlate this with known prognostic markers. METHODS The clinicopathological data of archived tissue from 144 cases of invasive ductal breast carcinoma were studied (age, histological grade, size of tumour, lymph node metastases, oestrogen/progesterone receptors and human epidermal growth factor receptor 2 status). HPV frequency was documented using immunohistochemistry (IHC) and chromogenic in-situ hybridisation (CISH). HPV types were documented by CISH using HPV probes. CISH and IHC techniques were compared and HPV correlated with prognostic parameters. RESULTS The HPV prevalence as determined by CISH and IHC was 51 (35.4%) and 24 (16.7%) cases, respectively. The sensitivity of HPV by IHC was 37.3% and specificity was 94.6%. The sensitivity and specificity of HPV-CISH compared to HPVIHC was statistically significant (P <0.001). HPV-CISH was seen in 51 cases. A combination of HPV 6 and 11, and 16 and 18 was seen in 2 (3.9%) cases, and a combination of HPV 6, 11, 31 and 33 was seen in 7 (13.7%) cases. All three HPV probes: 6 and 11, 16 and 18, as well as 31 and 33 were present in 2 (3.9%) cases. The prevalence of HPVCISH in the Kuwaiti and non-Kuwaiti populations was 27 (52.9%) and 19 (37.2%), respectively. No correlation was observed with the prognostic parameters. CONCLUSION The frequency of HPV in breast carcinoma cases in Kuwait was 35.4% (CISH). Of those, 52.9% were Kuwaitis in whom both low- and high-risk HPV types were detected.

Subclassification of pulmonary non-small cell lung carcinoma in fine needle aspirates using a limited immunohistochemistry panel.

Background: Newer treatment modalities require subtyping of non-small cell lung carcinomas (NSCLC). Morphological differentiation is often difficult and various immunohistochemical (IHC) panels have been used to maximize the proportion of accurately subtyped NSCLC. Aim: The aim of this study was to subtype NSCLC on fine needle aspirates (FNA) using a minimal antibody panel. Materials and Methods: Cell blocks from 23 FNA samples with a morphological diagnosis of NSCLC were taken. IHC was evaluated (blinded to clinical data) for thyroid transcription factor-1 (TTF-1), cytokeratin (CK)7, CK20, and tumor protein p63. Results: TTF-1 was positive in 14 and negative in 9 cases. The p63 was positive in two cases each of TTF-1 positive and negative tumors. CK7 was positive in 12 of the 14 TTF-1 positive tumors and 4 of the TTF-1 negative tumors. CK20 was negative in all. All the 14 TTF-1 positive tumors were primary lung tumors, 12 being NSCLC and 2 being squamous cell carcinoma. Five of nine TTF-1 negative tumors were metastatic tumors from endometrium, kidney, and head and neck region (two), and one was an unknown primary. Four of the nine TTF-1 negative tumors were morphologically NSCLC and were clinically considered to be primary lung tumors. Three of these tumors stained positive for CK7 but negative for CK20 and p63, and one case was negative for the immunomarkers. Conclusion: Use of limited IHC panel helps categorize primary versus secondary tumors to the lung. The p63 is a useful marker for detecting squamous cell carcinoma. In countries where antibodies are not readily available, using a limited IHC panel of TTF-1, p63, and CK7 can help further type NSCLC lung tumors.

Epidermal growth factor receptor mutations in nonsmall cell lung carcinoma patients in Kuwait.

Context: Nonsmall cell lung carcinoma (NSCLC) is the most frequently diagnosed form of lung cancer in Kuwait. NSCLC samples from Kuwait have never been screened for epidermal growth factor receptor (EGFR) gene aberration, which is known to affect treatment options. Aims: This study investigated the feasibility of using fine-needle aspiration (FNA) material for mutational screening, and whether common EGFR mutations are present in NSCLC samples from Kuwait. Settings and Design: Eighteen NSCLC samples from five Kuwaitis and 13 non-Kuwaitis were included in this study. Materials and Methods: DNA was extracted from FNA cell blocks and screened for EGFR gene mutations using peptide nucleic acid (PNA)-clamp assay, and EGFR gene amplification using fluorescent in situ hybridization (EGFR-FISH). EGFR protein expression was assessed using immunohistochemistry. Results: Five EGFR mutations were detected in five non-Kuwaiti NSCLC patients (27.8%). EGFR gene amplification was evident in 10 samples (55.5%) by direct amplification or under the influence of chromosomal polysomy. Four samples had EGFR mutations and EGFR gene amplification, out of which only one sample had coexisting EGFR overexpression. Conclusions: Given the evidence of EGFR gene alterations occurring in NSCLC patients in Kuwait, there is a need to incorporate EGFR gene mutational screen for NSCLC patients to implement its consequent use in patient treatment.