Karen S. Thompson

Synovial metastasis: diagnosis by fine-needle aspiration cytologic investigation.

Synovial metastases are a rare occurrence. Only 28 cases have been reported in the literature, 10 of which were diagnosed by fluid cytologic evaluation. We discuss 2 additional cases in which the diagnosis was made by fine‐needle aspiration cytologic investigation. The first case is of a 47‐yr‐old man with small‐cell carcinoma of the lung metastatic to the right knee joint; the second is of a 71‐yr‐old man with non‐Hodgkins mixed‐cell nodular lymphoma also involving the right knee joint. The clinical features of these cases are similar to previously published instances of secondary synovial tumor, namely in regard to sex distribution (14 male and 16 female patients), age range (13–96 yr, mean 59 yr), and histologic types (adenocarcinoma, 13 cases; squamous‐cell carcinoma, 4; lymphoma, 3; renal clear‐cell carcinoma, 3; unknown origin, 2; rhabdomyosarcoma, 1; melanoma, 1; chordoma, 1; pulmonary clear‐cell carcinoma, 1; and Ewings sarcoma, 1). The condition usually has poor prognosis, with average patient survival of <5 mo. Diagn Cytopathol 1996;15:334–337.

Breast and cutaneous mycobacteriosis: Diagnosis by fine-needle aspiration biopsy

The breast and skin are considered to be rare sites of extrapulmonary mycobacterial infection, comprising 0.1% to 0.5% of all tuberculosis cases, respectively. Fine‐needle aspiration biopsy (FNAB) is a rapid and minimally invasive approach to diagnose extrapulmonary tuberculosis, and has been used successfully in identifying tuberculous lesions in the lymph nodes, thyroid, kidney, pancreas, vertebrae, and testis.

Metastasis of unknown origin: The role of fine‐needle aspiration cytology

Metastasis of unknown origin (MUO) manifests either as a tumor deposit in an organ, often cervical lymphadenopathy, or as a multiorgan carcinomatosis. As a diagnostic and therapeutic challenge, the definition of its cell type and possibly its origin is imperative, although a limited diagnostic investigation is usually recommended. At Hines VA Hospital, from 1986 to 1994, there were 116 cases with admitting clinical diagnosis of MUO, evaluated by fine‐needle aspiration cytology (FNAC). The ages of patients ranged from 29 to 82 years (mean 56 years). All were male; Caucasians predominated. The FNAC examination with Diff‐Quik and Papanicolaou smears were complemented with special and immunostains in 48 cases (41%) and electron microscopy in 93 cases (80%). The FNAC involved lymph nodes in 57 cases (49%), liver in 27 cases (23%), skin in 22 cases (19%), bone in six cases (5%), lung in three cases (3%), and pleura in one case (1%). The neoplasm was generally cell typed, and there were 60 adenocarcinomas/poorly differentiated carcinomas, 26 small‐cell carcinomas (SCC), 23 squamous‐cell carcinomas (SQCC), and six undifferentiated large‐cell carcinomas. The primary source was defined in 30 cases (26%), consisting of lung in 11 cases, prostate in nine, kidney in four, colon in four, pleura in one, and peritoneum in one. Clinical correlation also supported a lung origin for the SCC, while the majority of the SQCC in upper and middle cervical lymph nodes were considered head‐and‐neck tumors. Our results affirm that FNAC is a viable and simple procedure in MUO investigations. Diagn. Cytopathol. 1998;18:319–322.

Metastatic papillary oncocytic carcinoma of the pancreas to the liver diagnosed by fine-needle aspiration

A 37‐year‐old white male with a large pancreatic mass was referred to our institution with a hypodense liver lesion detected on CT scan. A fine‐needle aspiration (FNA) was performed on the liver lesion. Diff‐Quik smears demonstrated scattered papillary structures and single neoplastic cells with abundant well‐defined dense granular cytoplasm. Eccentrically located nuclei were noted with single prominent nucleoli. Cell block preparations showed papillary structures lined by cells with abundant pink granular cytoplasm, hyperchromatic nuclei, and prominent single nucleoli. Electron microscopic examination displayed numerous but poorly preserved mitochondria. The diagnosis of papillary carcinoma with oncocytic features was made. Only two previous cases of pancreatic oncocytic tumors diagnosed by FNA have been reported in the literature. We present an additional case, notable in that the diagnosis was made in a metastatic liver nodule. Diagn. Cytopathol. 1998;18:291–296.

Cytopathologic evaluation of lung carcinomas presenting as brain metastasis

Brain metastasis is an uncommon initial presentation of lung carcinoma. One arm of this analysis is a retrospective review of 137 cases of surgically diagnosed solitary brain metastasis, which were eventually found to be of lung origin, encountered at Hines VA Hospital during the period 1958 to 1996. The second arm is composed of fine‐needle aspiration biopsy specimens of primary lung tumor in 23 patients with an initial clinical diagnosis of brain metastasis and without the benefit of surgery, seen from 1981 through 1996. Our results in both analyses indicate that pulmonary adenocarcinoma is the predominant primary tumor that initially manifests as a brain metastasis, approaching 76% (107 and 17 cases, respectively), followed by small‐cell carcinoma at 20% (24 and five cases, respectively) and large‐cell undifferentiated carcinoma and squamous‐cell carcinoma at 2% each. The predominance of adenocarcinoma as a source of brain metastasis in lung cancer patients probably reflects its rising incidence overall of late. Collateral findings also suggest that surgical resection of a solitary and small brain metastasis as well as of a discrete lung primary, whenever feasible, as the most effective procedure to improve survival and quality of life of patients. Diagn. Cytopathol. 1999;20:325–327.

Two Cases of Primary Yolk Sac Tumor of the Liver in Childhood: Case Reports and Literature Review

Primary yolk sac tumor of the liver is an extremely rare neoplasm, with fewer than 20 cases reported. We evaluated 2 pediatric cases (21-month-old and 23-month-old female patients), who presented with liver masses and markedly raised serum α-fetoprotein (AFP). One patient received a partial hepatectomy and another patient underwent a liver biopsy, both of which showed characteristic features of yolk sac tumor, with tumor cells staining strongly positive for AFP. There was no evidence of an extrahepatic primary source. Both of our patients have been healthy, without evidence of recurrent tumor, and their AFP level remains in the normal range after their chemotherapeutic treatments.

Multivesiculated macrophages: their implication in fine-needle aspiration cytology of lung mass lesions.

Alveolar macrophages are almost invariably present in percutaneous fine‐needle aspiration cytology of the lung. They may predominate, appear foamy and finely vesiculated, or may reflect the cellular composition of the lung mass lesion. In a review of 172 cases of “negative for malignant cells” from the percutaneous lung fine‐needle aspiration cytology file in an 8‐year period at Hines VA Hospital, the vacuolated macrophages were evaluated qualitatively and quantitatively. Among the 53 cases (34%) showing vacuolated macrophages, only 5–25% of the cells were multivesiculated, the cytoplasmic vacuoles were few, focal, and occasionally global, and the majority of the vacuolated macrophages contained anthracotic or hemosiderin pigments. One case exhibited striking multivesiculation in at least 95% of macrophages and also in bronchial and alveolar cells, fibroblasts, and endothelial and inflammatory cells, a finding consistent with amiodarone toxicity (index case 1). The diagnosis was confirmed on subsequent transbronchial lung biopsy. In another patient with clinical HIV infection, the multivesiculation was also seen in 95% of the macrophages with associated acute inflammatory exudate, coccobacilli, and a positive culture for Rhodococcus equi (index case 2). In most cases, the vacuolated macrophages are reactive and inflammatory. Occasionally, as in our index cases they may actually indicate a specific diagnosis. Diagn. Cytopathol. 1998;19:98–101.

Pleural effusion cytology of embryonal rhabdomyosarcoma.

This case report concerns an embryonal rhabdomyosarcoma of the testis in a 31‐yr‐old white male patient who underwent radical left orchiectomy, followed by combined irradiation and chemotherapy, and who 2 yr later presented with dyspnea at rest, nonproductive cough, and lower back pain for 1 wk. Chest radiographs demonstrated a bilateral pleural effusion and diffuse infiltrating lesion of the pleurae, mimicking a mesothelioma. The pleural fluid displayed noncohesive, malignant, small, round cells about 2–5 times larger than mature lymphocyes. They had large, darkly staining, pleomorphic nuclei and bubbly cytoplasm with poorly defined borders. The diagnosis of embryonal rhabdomyosarcoma was supported by a positive myosin immunostaining and ultrastructural findings of intracytoplasmic actin and myosin‐type microfilaments. Our case is also notable in that the tumor was a pure rhabdomyosarcoma involving a testicular origin, and the patient is the oldest reported in the literature. Diagn. Cytopathol. 16:270–273, 1997.

Utilization of fine-needle aspiration cytology in the diagnosis of neoplastic superior vena caval syndrome.

Superior vena caval syndrome often presents as an acute or subacute oncologic emergency that requires immediate action, usually with high‐dose radiotherapy. With improved chemotherapeutic regimens for various malignancies, prompt and appropriate treatment of the syndrome is possible. Tissue diagnosis, therefore, is pursued, but invasive procedures are commonly associated with technical difficulties and complications. We find fine‐needle aspiration biopsy a rapid, highly reliable, and well‐tolerated procedure in selected situations and herein report 17 patients with initial presentation of superior vena caval syndrome efficaciously diagnosed with fine‐needle aspiration cytology. The cell types were eight lung small‐cell carcinomas, four poorly differentiated adenocarcinomas, two undifferentiated large‐cell carcinomas, and one each of malignant large‐cell lymphoma, myxoid liposarcoma, and thymic large‐cell neuroendocrine carcinoma. Further experience, however, is warranted with this widely available procedure. Diagn. Cytopathol. 1998;19:84–88.

Fine-needle aspiration cytology of epithelioid leiomyoblastoma.

Purpose. Epithelioid leiomyoblastomas comprise the majority of gastric sarcomas and are uncommon in other parts of the gastrointestinal tract. Diagnosis of this lesion by fine-needle aspiration cytology has been occasionally described in the literature. Two additional cases are herein reported. Subjects . A 66-year old male with an omental mass and a 47-year old male with a perihepatic tumor. Results and Discussion. Cytologic materials in both cases showed predominantly round or epithelioid cells, along with polygonal to spindle cells, occuring singly and in clusters, with oval to spindle-shaped nuclei.The nuclei were monotonous, usually banal, and centrally-located with only focal suggestion of pleomorphism and rare mitosis. Eosinophilic cytoplasm was noted in most of the cells, some demonstrating vacuolation. Electron microscopy supported a primitive smooth cell derivation of the neoplastic cells. Conclusions. The cytomorphology of the tumors of the two cases reported here is not adequately known. More cases need to be collected and studied.