Hilda Fernandes

Ameboma of the colon with amebic liver abscess mimicking metastatic colon cancer

Amebic colitis is common in developing countries, with its variable and non-specific symptoms. Amebomas occur rarely, resulting from the formation of annular granulation tissue, usually in the cecum and in the ascending colon. This report describes the case of a 59-year-old male who presented with abdominal pain. Radiological examination depicted concentric thickening of the cecal wall with mass formation and a cystic lesion in the liver. The endoscopy performed showed a growth in the ascending colon. Biopsy revealed extensive necrosis and inflammatory cells. The patient was referred to this hospital for surgical treatment with a provisional diagnosis of carcinoma of the colon. Peroperatively, a cecal mass was identified. However, suspected secondaries were not seen on the surface of the liver. Histological examination of the right hemicolectomy specimen revealed cecal and ascending colon amebomas. Trophozoites of Entamoeba histolytica were better recognized after periodic acid-Schiff staining. Treatment with Metronidazole for 2 weeks followed by diloxanide furoate for an additional 2 weeks was administered. The liver lesion resolved completely after 8 weeks. Colonic ameboma accompanied by amebic liver abscess may be misdiagnosed as metastatic colon cancer. A high index of suspicion is essential for diagnosis when dealing with colonic masses and liver lesions, especially in the tropics.

Primary umbilical endometriosis - Diagnosis by fine needle aspiration

Primary (spontaneous) umbilical endometriosis is very rare with an estimated incidence of 0.5-1% of all patients with endometrial ectopia. Endometriosis is a common gynecological condition, the pelvis being the most common site of the disease. Extrapelvic site is less common and even more difficult to diagnose due to the extreme variability in presentation. A 38-year-old woman presented with a blackish nodule over the umbilicus of 3 years duration. Fine needle aspiration cytology of the lesion showed cells in clusters and sheets with background of scant stromal fragment, hemosiderin laden macrophages and RBCs, leading to a suggestion of umbilical endometriosis. Histopathological examination of the excised lesion confirmed the same.

Cytodiagnosis of actinomycetoma

Mycetoma is a late clinical manifestation of a subcutaneous infection produced by bacteria (actinomycetoma) or fungi (eumycetoma). The distinction between eumycetoma and actinomycetoma in Fine Needle Aspiration Cytology (FNAC) is as accurate as histopathology. A 55 year old man presented with a slow growing swelling on the plantar aspect of the right foot which was present for the last 10 years. A clinical diagnosis of soft tissue tumor was made and FNAC was advised. Smears revealed mixed inflammatory infiltrate and foreign body type of giant cells along with clumps of fibrillar organisms. Gram stain done later demonstrated gram positive thin branching filaments. A diagnosis of actinomycetoma was rendered. Histopathology of the excised specimen confirmed the cytologic diagnosis of actinomycetoma. Mycetoma can be accurately diagnosed by FNAC, which is a simple, inexpensive technique for rapid diagnosis. Diagn. Cytopathol. 2009.

Role of FNAC in the Preoperative Diagnosis of Salivary Gland Lesions.

BACKGROUND The characteristic cytologic features of the common salivary gland lesions have been well-delineated in literature. However, there also exist cytologic pitfalls and overlapping features that make an accurate diagnosis difficult in few cases. The present study was designed to compare the cytologic findings of salivary gland lesions with the histologic diagnoses, in order to assess the sensitivity, specificity and diagnostic accuracy of FNAC, with an emphasis on discordant cases. MATERIALS AND METHODS Patients with suspected salivary gland enlargements, who were referred for FNAC, were included in this study, which was done over a 3 year period in a medical college hospital. FNAC was performed by using the standard procedure. Smears were stained by using Papanicolaous and MGG stains. Cytologic diagnosis was compared with histopathologic diagnosis wherever it was available. RESULTS Eighty eight patients with salivary gland swellings were included in the study. The ages of the patients ranged from 15 to 82 years, with the M:F ratio being 1.6:1. Out of 88 cases, 68 had swellings in parotid gland, 19 had them in submandibular gland and one had them in hard palate. Pleomorphic adenoma was the commonest neoplasm which was seen in our study. Mucoepidermoid carcinoma (MEC) was the only malignant lesion seen in our study. One each of Warthins tumour (WT) and MEC were overdiagnosed and underdiagnosed respectively, the reason being squamous metaplasia in WT and subtle nature of malignant cells in low-grade MEC. CONCLUSION WT and MEC can pose problems in cytologicdiagnosis. Sampling errors and interpretational errors can lead todiscordant diagnoses.

Giant Solitary Fibrous Tumor of the Pleura (SFTPs) associated with paraneoplastic Doege Potter Syndrome

SFTPs are uncommon spindle cell mesenchymal tumors. These tumors arise in pleural as well as in extra pleural sites like liver, orbit, lung, nasal passages, meninges, respiratory tract, thyroid, soft tissues, major salivary glands, kidney, periosteum and spinal cord. SFTPs of thorax are interesting in that they can present with mass effect and paraneoplastic syndrome. Doege Potter Syndrome that is Giant SFTP presenting as hypoglycemic coma is an exceptional presentation of SFTPs. SFTPs are often mistaken for epithelial mesotheliomas. Positivity for vimentin, a marker of mesenchymal cells, negativity for cytoplasmic keratin which is positive in mesotheliomas and expression of Clusters of Differentiation (CD) 34 antigens can confirm the presence of a SFTP. Ultra structural studies further support the fibroblastic nature of these tumors. We hereby report an exceptional case of a 50-year-old lady with giant SFTP presenting with hypoglycemic coma. A diagnostic as well as therapeutic thoracotomy with complete surgical resection of the tumor was performed with complete relief of symptoms.

Fine needle aspiration cytology of male breast lesions - a retrospective study over a six year period.

BACKGROUND Fine needle aspiration cytology (FNAC) has a well-established role in the management of palpable breast lumps. However breast masses in males are rarely aspirated and hence there is limited cytopathologic experience. The aim of our study was to determine the efficacy of FNAC in the diagnosis of male breast lesions and also we attempted to describe the cytomorphological features of some of these lesions. MATERIALS AND METHODS Data on male breast FNAC done between 2008 to 2013 were retrieved from the records of the cytopathology laboratory. FNAC diagnosis were categorized as benign, malignant, suspicious for malignancy and inadequate or unsatisfactory. Cytohistologic correlation was done with data from histopathology records. Sensitivity, specificity and diagnostic accuracy were calculated using standard statistical methods. RESULTS Forty out of 1098 patients undergoing breast FNAC were males. Histopathology was available in 8 (20%) out of 40 cases. There were no false positive or false negative diagnoses. FNAC had a sensitivity, specificity and diagnostic accuracy of 100% for male breast lesions. CONCLUSION FNAC is a very accurate tool for the diagnosis of male breast lesions. It is highly sensitive and specific with good cytohistologic correlation. To reduce the high rate of surgical biopsies of benign male breast masses, we conclude that FNAC should be performed as a standard procedure in the clinical evaluation of male breast lesions.

Fine needle aspiration cytology of adrenal oncocytic neoplasm of uncertain malignant potential.

Sir, Adrenocortical oncocytic neoplasms (AONs) are rare tumors with only about 55 cases reported in the English language literature [1]. Histologic features that predict the biologic behaviour of AONs appear to differ from those of conventional adrenocortical tumors. In 2004, the modified Weiss system was proposed for AONs [2]. A 72-years old male was admitted for evaluation of a palpable abdominal mass. Computer Tomography scan of the abdomen revealed a large heterogeneously enhancing mass lesion arising from the left upper retroperitoneum having clear fat planes with pancreas, spleen and left kidney [Table/Fig-1A]. Possibility of malignant adrenal neoplasm was considered. Image guided Fine Needle Aspiration [FNA] smears were cellular showing singly dispersed polygonal cells with eccentric nucleus and dense granular cytoplasm [Table/Fig-1B]. A few cells were clinging to delicate capillaries in a clean background [Table/Fig-1B] (inset) suggesting a diagnosis of adrenal oncocytic neoplasm. The left adrenalectomy specimen consisted of a 2005 gm solid, encapsulated, globular mass measuring 20 × 15 × 12 cm. Cut surface of the tumor was solid, fleshy tan brown with lobulations of haemorrhage and necrosis [Table/Fig-1C]. The tumor was encapsulated and showed neoplastic cells arranged in a diffuse, solid pattern with multiple foci of haemorrhage, microcystic degeneration and necrosis [Table/Fig-1D]. Tumor cells were uniform with abundant brightly eosinophilic granular cytoplasm, round to oval vesicular nucleus. Mitotic figures, capsular and venous invasion were absent. A final diagnosis of adrenal oncocytic tumor of uncertain potential was given based on modified Weiss Criteria. Electron Microscopy confirmed the oncocytic nature of cells. [Table/Fig-1] [Table/Fig-1]: (1A) - CT scan showing a large well defined mass with heterogenous echotexture; (1B) - Smear showing singly dispersed cells with eccentric nucleus and granular cytoplasm (PAP 40X); (1B inset) - Smear showing tumor cells attached to delicate ... AONs have the potential to behave in a benign fashion, recur or extensively infiltrate into the adjacent organs. Average age at diagnosis is 47 years (range 6-77) with a slight female predilection [3]. Size varies from 2.2 to 20 cm and weight from 8 to 1900 g [1]. In our case the tumor weighed 2005 gm which is the highest so far reported. Imaging characteristics of adrenal oncocytic tumors are described as single case reports . Fibrous encapsulation and heterogeneous areas do not differentiate between benign and malignant oncocytic tumors [4]. Cytopathologic diagnosis of AONs by FNA is described by some authors.[5] Some of the criteria of Modified Weiss system like necrosis and atypical mitosis can be evaluated on cytology. Unfortunately accurate mitotic count, venous invasion and capsular invasion can not be assessed in smears. In the absence of major criteria, it is best to designate the tumor as an oncocytic adrenal neoplasm with a note for a detailed histopathologic assessment. If any minor criteria are present, designation AON of uncertain malignant potential may be rendered. In our case there was no necrosis or atypical mitosis on smears. However due to the large size and heterogeneous areas on CT scan, possibility of malignancy was still considered preoperatively. Only after detailed histopathologic examination, it was designated AON of uncertain malignant potential. Awareness of Modified Weiss criteria will help in averting over diagnosis of malignancy while dealing with FNA of AON.

Supraclavicular lymphadenopathy - initial manifestation of prostatic carcinoma

To the Editor, This is in reference to the article “Left cervical lymph node metastasis – An initial presentation of prostatic adenocarcinoma” published in Journal of Cytology volume 23,1. We wish to share our experience with a similar case. The most common sites of metastatic spread of prostatic carcinoma are the regional lymph nodes and bones of the pelvis and axial skeleton. Enlarged lymph nodes, usually pelvic but rarely left supraclavicular or axillary can sometimes be a presenting symptom. A fifty five year old male presented with a mass in the left side of neck present since 20 days. It measured 1.5 cm in diameter and was firm. Patient gave history of loss of weight and difficulty in evacuating bladder, which was present since 3 to 4 years. Fine needle aspiration cytology performed from the lymph node showed cellular smears showing epithelial cells in sheets, clusters and in acinar pattern (Fig 1). The nuclear chromatin was fine and the cytoplasm moderate in amount. A diagnosis of metastatic adenocarcinoma was offered. Per-rectal examination revealed nodular hard prostate. Ultrasonography showed a nodule in the prostate. No enlarged pelvic nodes were seen. PSA levels were 642 ng/ml. Prostatic biopsy showed features of adenocarcinoma of prostate (Fig 2). A final diagnosis of prostatic adenocarcinoma with distant metastasis was made. Patient underwent bilateral orchidectomy two weeks after the biopsy and was put on hormonal treatment. Cervical and supraclavicular lymph node involvement has been reported in 0.4% to 1% of all cases of metastatic prostate cancer. However cervical lymphadenopathy as the initial presentation of prostatic carcinoma is rare. In supradiaphragmatic spread of carcinoma prostate, it has been postulated that tumour cells lodge in the nodes, which are close to the entry of thoracic duct into left subclavian vein by retrograde spread. Fine needle aspiration is recommended to determine the diagnosis because it has high sensitivity and specificity and can be easily performed. Possibility of prostate carcinoma should always be considered in the differential diagnosis of elderly men with cervical lymphadenopathy, even in the absence of lower urinary tract symptom. Once the diagnosis is established hormone treatment has been shown to be of benefit even in patients in the advanced stages of the disease.

A clinicohematological evaluation of pancytopenia in a tertiary care hospital in South India

Objective: The aim of this study is to study the incidence of the underlying etiology of pancytopenia presenting at our institution with a clinical and hematological correlation. Materials and Methods: A prospective study of 12 months′ duration was carried out, which included patients of all age groups. Of the 60 patients presenting with pancytopenia, bone marrow aspiration and biopsy were done on 30 cases, after taking an informed consent. Patients who had received previous blood transfusion and were on chemo- and radiotherapy were excluded. A detailed clinical examination of all cases was carried out. Results: The most common etiology of pancytopenia in our study was normoblastic erythroid hyperplasia (30%), followed by megaloblastic anemia (20%). This was followed by acute myeloid leukemia (13.3%) and closely by micronormoblastic erythroid maturation (10%) and miscellaneous etiologies. Conclusion: The varied causes of pancytopenia can be attributed to the geographic area, genetic differences, stringency of diagnostic criteria, and differences in the methodology used. There are varying trends in its clinical pattern, treatment modalities, and outcomes. The severity of pancytopenia and the underlying pathology determines the management and prognosis. Thus, identification of the correct cause will help in implementing the appropriate therapy.

Fungal foot abscess caused by Aureobasidium pullulans culture diagnosis of fine needle aspiration cytology material in a clinically unsuspected patient

Subcutaneous mycosis includes a large spectrum of infections caused by a heterogeneous group of fungi. Fungal infections of the skin can be identified in scrape preparations of lesions and Fine Needle aspirates of abscesses, with recognition of the specific morphological features such as hyphae and branching. We report a fungal abscess caused by Aureobasidium pollulans by smears and culturing the material obtained from Fine Needle Aspiration Cytology.