José M. Viguer

Fine needle aspiration cytology of pleomorphic adenoma : An analysis of 212 cases

OBJECTIVE To assess the value of fine needle aspiration cytology (FNAC) in the diagnosis of pleomorphic adenoma and to determine the cytologic variations responsible for diagnostic errors. STUDY DESIGN We retrospectively studied 212 cases cytologically diagnosed as pleomorphic adenoma. In 184 a histologic diagnosis was available. Fourteen cases of histologically proven pleomorphic adenomas with a previously erroneous cytologic diagnosis were also reviewed. This study was based on those cases with a histologic diagnosis. RESULTS The sensitivity and specificity of the cytologic diagnosis of pleomorphic adenoma in our series were 92.6% and 98.4%, respectively. In relation to malignancy, the series showed six false negative and three false positive diagnoses. In those cases correctly diagnosed on aspiration (175), a typical cytologic appearance, with no diagnostic difficulties, was observed in 118 cases (67.4%); the remainder showed cytologic variations. Cellular atypia (20.6%), cystic transformation (7%) and the presence of a cylindromatous pattern (5%) resembling adenoid cystic carcinoma were the most common cytologic variations observed and responsible for the majority of the errors. CONCLUSION The cytologic variations in FNAC of pleomorphic adenoma must be considered in order to avoid important errors in the preoperative management of and surgical approach to salivary gland lesions.

Value of Fine Needle Aspiration Cytology in the Initial Diagnosis of Hodgkin’s Disease

OBJECTIVE To evaluate the diagnostic accuracy and pitfalls of fine needle aspiration (FNA) cytology in the initial evaluation of Hodgkins disease (HD) and to assess the influence of the pathologists experience by comparing the results during two periods. STUDY DESIGN A total of 170 cytodiagnoses of HD were reviewed and compared with those on the final histopathologic report. Thirty-three cases of HD with a previous, different cytologic diagnosis were also selected. In all the cases under study, FNA was performed as part of the initial diagnostic approach. From a practical perspective, diagnostic errors were divided into major or minor according to the consequences on patient management. RESULTS Fifteen cytologic diagnoses of HD were followed by a different histologic diagnosis after lymph node biopsy. In 33 cases of HD an erroneous cytologic diagnosis was given prior to biopsy. The sensitivity of the series was 82.4% (86.1% excluding nonrepresentative cases). The positive predictive value reached 91.2%. Sensitivity varied from 79.3% in the first period (1982-1990) to 84.9% in the second (1991-1999) (83.3% and 88.2%, respectively, excluding nonrepresentative cases). Similarly, the positive predictive value increased from 89% to 92.8%. Diagnostic errors with important consequences for patient management diminished from 14 in the first period to 5 in the second. CONCLUSION Cytology offers a rapid and accurate approach not only for the diagnosis of recurrent HD but also for its initial recognition. These results increase the capacity of FNA as a first-level diagnostic technique in the screening of lymphadenopathies.

Posttransplant CD30 (Ki-1)–Positive Anaplastic Large Cell Lymphoma

BACKGROUND Posttransplant lymphoproliferative disorders (PTLDs) are almost always of B-cell derivation and have a strong association with Epstein-Barr virus (EBV). Only rare cases of CD30 (Ki-1)-positive anaplastic large cell (ALC) lymphomas in transplant recipients have been described. EBV has been studied in few of these cases. Pleural effusion is an uncommon clinical manifestation of both PTLDs and CD30-positive ALC lymphoma. CASE A 60-year-old, male renal transplant recipient presented with fever and pleural effusion. Cytologic examination of the effusion revealed a large cell lymphoma. Immunocytologic studies disclosed a T-cell phenotype. Subsequently a cutaneous lesion and an accessory spleen were observed, and cervical lymphadenopathies developed. Fine needle aspiration of lymph nodes confirmed the presence of lymphoma. Histologic and immunohistochemical studies of the lymph nodes, skin and accessory spleen revealed the presence of CD30-positive, T-cell, ALC lymphoma. No EBV DNA was detected by polymerase chain reaction analysis. Despite chemotherapy, the patient died seven months after the initial cytologic diagnosis of lymphoma. CONCLUSION CD30-positive ALC lymphomas are an uncommon variant of PTLDs that should be considered in the differential diagnosis of neoplastic disorders arising in immunosuppressed patients. Cytology and immunocytochemistry are useful diagnostic procedures for their early detection.

Cytologic features of malignant peripheral nerve sheath tumor.

OBJECTIVE To study the cytomorphologic features of malignant peripheral nerve sheath tumor (MPNST), including the epithelioid cell variant, and to establish differential diagnostic features with benign neurogenic tumors and other sarcomas. STUDY DESIGN Cytologic smears from primary, recurrent and metastatic tumors in 10 patients with MPNST were reviewed. Three patients had neurofibromatosis 1 (NF1), and in two others the tumor arose from a preexisting neurofibroma. Immunocytochemical evaluation of S-100 protein was performed in four cases. A complete pathologic study was available in all cases. To assess the validity of morphologic recognition, a blinded study, including eight cases of spindle MPNST among smears from histologically proven schwannomas, synovial sarcomas, leiomyosarcomas, malignant fibrous histiocytomas and liposarcomas, was performed. RESULTS Neurogenic differentiation was recognizable in four cases (differentiated), while the other four (anaplastic) were indistinguishable from other pleomorphic sarcomas. The presence of elongated, slender, often wavy nuclei and less commonly a delicate, fibrillary metachromatic stroma were features suggestive of nerve sheath differentiation. Other cytologic, as well as clinical, features permitted their identification as malignant. Two cases of epithelioid MPNST disclosed large, polygonal to plasmocytoid tumor cells without specific cytologic features. S-100 immunoexpression was positive in two of the four cytologic samples tested. CONCLUSION Although no morphologic findings are specific to MPNST, the above-mentioned cytologic features may suggest, in differentiated cases, its neurogenic differentiation. On the basis of morphologic features alone, the diagnosis of anaplastic and epithelioid MPNST is not possible, and immunocytochemical and ultrastructural studies are necessary. A specific cytodiagnosis is possible in recurrences, metastases and cases of NF1 or a preexisting neurofibroma.

Enterocystoplasty in children with neuropathic bladders: long-term follow-up.

OBJECTIVE This study assesses clinical outcome, after at least 8 years, of augmentation done before or at puberty in neuropathic bladders. PATIENTS AND METHODS A total of 29 children with neuropathic bladders who did not respond satisfactorily to clean intermittent catheterisation and anti-cholinergic therapy underwent enterocystoplasty at a mean age of 11.8 years (range 3-18). Twenty-one children (72.4%) had vesicoureteral reflux (VUR) and/or ureterohydronephrosis and 22 (75.8%) had dimercapto-succinic acid scars, but all had normal renal function. All patients were followed at regular intervals with urinary tract imaging, serum electrolytes, creatinine, urodynamic evaluation and 24-h urine collection. Urine cytology, cystoscopy and biopsy were performed at the end of follow-up. RESULTS Mean follow-up was 11 years (range 8-14.5) and mean age at the end of follow-up was 22.2 years (range 13.2-31). Urodynamic studies showed a significant improvement in bladder compliance in all patients. Upper urinary tract dilatation disappeared in all, VUR in 13/17 (76.4%), and no new renal scarring occurred in any patient. At the end of follow-up, renal function was normal in all according to serum creatinine, but cystatin C levels were normal in 27 and elevated in two. Significant proteinuria and low concentrations of renin and aldosterone were present in 80% and 82%, respectively. Only one patient had urinary tract infection, three had bladder stones, and in another a catheterisable channel was made. All patients were dry with normal urine cytology and cystoscopy, and no malignant lesions have been found in the biopsy specimens. CONCLUSION Enterocystoplasty has preserved renal function and resolved VUR and/or hydronephrosis in most patients. The future implications of proteinuria and the low serum levels of renin and aldosterone, as well as the best indicator for measuring renal function, have yet to be determined. Close, life-long follow-up, including cystoscopy, is necessary to prevent complications.

Nodular pseudoangiomatous stromal hyperplasia of the breast. Cytologic features.

OBJECTIVE To define and discuss the cytologic findings in six cases of nodular pseudoangiomatous stromal hyperplasia (PASH) of the breast. STUDY DESIGN Retrospective evaluation of the medical records, cytologic and histologic material from six patients with palpable mammary PASH. Cases in which PASH was associated with other predominant mammary lesions were not included in the study. RESULTS A total of six patients with histologically proven PASH underwent aspiration in nine occasions (three patients studied twice). Clinically, five patients were diagnosed as having fibroadenoma or another benign lesion, and in one patient carcinoma was suspected. In two patients, mammography disclosed rapid growth of the lesion. Seven aspirations, performed on five patients, were diagnosed as fibroadenoma (n = 5) or fibroadenomatous lesion (n = 2). An eighth aspiration was cystic and reported as fibrocystic disease. The last case was erroneously diagnosed as suspicious for carcinoma. Even after revision, the cytologic similarities of PASH with fibroadenoma were remarkable. Most smears were less cellular than those of conventional fibroadenomas. Epithelial clusters showed variable size, with a predominance of medium to small groups. Stromal elements were minimal or absent. Background cellularity was composed of round to oval naked nuclei and others with spindle shapes. Occasional epithelial clusters showed cellular dissociation and slight atypia. CONCLUSION Due to the absence of specific cytologic features and similarities to fibroadenoma, a precise diagnosis of PASH cannot be made on cytologic material. However, the majority of cases can be diagnosed correctly as benign, allowing appropiate treatment.

Fine needle aspiration cytology of follicular dendritic cell sarcoma : A case report

BACKGROUND Follicular dendritic cell (FDC) sarcoma is a rare, recently described neoplasm that shows differentiation similar to that of follicular dendritic cells. It must be differentiated from metastatic neoplasms and other rare, nonlymphoid nodal lesions. CASE REPORT A 76-year-old man underwent fine needle aspiration of a recurrent laterocervical mass. Sixteen months earlier, the original tumor was excised and proved to be an FDC sarcoma. Smears exhibited a dual cell population composed of large cells with abundant cytoplasm and a lymphoid component that consisted mainly of lymphocytes and plasma cells. Large cells were atypical and distributed in ill-defined groups and as single cells. Nuclei were round to oval and pleomorphic, with irregular contours and nucleoli. Binucleation and multinucleation were occasionally seen. After the cytologic diagnosis, the tumor was excised and showed typical histologic and immunophenotypic features of FDC sarcoma. CONCLUSION The morphologic features of FDC sarcoma seem characteristic enough to permit its preoperative recognition. Its cytologic definition increases our knowledge of rare, nonlymphoid, primary nodal tumors, allowing better differentiation from metastatic neoplasms.

Fine needle aspiration of toxoplasmic (Piringer-Kuchinka) lymphadenitis: a cytohistologic correlation study.

OBJECTIVE To define the cytomorphologic features of toxoplasmic lymphadenitis (TL) and to establish the diagnostic sensitivity and specificity of the cytologic diagnosis. STUDY DESIGN A cytohistologic correlation study of 11 patients in which a histologic diagnosis of TL was available. These cases were analyzed in a blind study among other cases of nonneoplastic lymphadenopathies. The results of the study are expressed in terms of diagnostic sensitivity and specificity. Although not included in the study, 3 other cases of TL with serologic confirmation were also reviewed. RESULTS Microgranulomas were a characteristic finding in TL. They consisted of small clusters of epithelioid histiocytes, each with abundant cytoplasm and an eccentric, oval nucleus. Diff-Quik-stained smears had cytoplasm with particularly pale staining and a homogeneous appearance. Most microgranulomas had a monotonous appearance with a few, small lymphocytes accompanying the epithelioid cells. No necrosis, suppurative changes or giant cells were present. Blind examination by 4 reviewers led to a correct diagnosis of TL in 9 of the 11 cases. Eight of the 9 cases were recognized by each of the 4 reviewers. One false positive diagnosis was made by 1 of the reviewers. The sensitivity of the diagnosis was 72.7-81.8% and the specificity 98.8-100%. CONCLUSION This study showed high sensitivity and specificity for the cytologic diagnosis of TL. Given the appropriate clinical context, the presence of characteristic epithelioid microgranulomas permits a diagnosis of TL. The cytologic diagnosis can be easily confirmed with serologic studies, thereby avoiding biopsy.

Role of fine needle aspiration cytology in the diagnosis and management of Warthin’s tumour of the salivary glands

J. M. Viguer, B. Vicandi, J. A. Jiménez‐Heffernan, P. López‐Ferrer, P. González‐Peramato and C. Castillo
Role of fine needle aspiration cytology in the diagnosis and management of Warthin’s tumour of the salivary glands

Hodgkin's disease mimicking suppurative lymphadenitis: A fine-needle aspiration report of five cases

Spontaneous, suppurative‐necrotizing changes associated with Hodgkins disease (HD) are not infrequent. They are mostly observed in the nodular sclerosis variant of HD and can cause an erroneous histologic diagnosis of suppurative lymphadenitis.