Mona Agnihotri

Utility of the Paris System in Reporting Urine Cytology

Objective: To find out the utility of The Paris System (TPS) in reporting urine cytology and to compare it with the reporting system currently used in our laboratory. Study Design: This retrospective study was undertaken over a period of 1 year during which slides of all the urine specimens sent for cytological examination were retrieved from our laboratory filling system. They were blindly reviewed and reclassified according to TPS. Surgical follow-up was obtained from the uropathology services of our department. Results: A total of 176 cases were meticulously reviewed. The mean age of the patients was 52 years, and 71% of cases presented with hematuria. Histopathological follow-up was available in 34 cases. Reporting by TPS detected 13.0% high-grade urothelial carcinoma (HGUC) and 5.1% atypical urothelial cells versus 7.3 and 11.9% by the current reporting system, respectively. The sensitivity and diagnostic accuracy for detecting HGUC of TPS were higher than those of our reporting system. Conclusion: TPS has increased the rate of detection of HGUC and reduced the rate of reporting “atypical” urothelial cells. TPS has also standardized the diagnostic criteria, thereby bringing uniformity and reproducibility into the system of reporting for urine cytology.

Dysplastic Megakaryocytes and Eosinophilic Precursors in the Diagnosis of Myeloid Sarcoma on Lymph Node Fine-Needle Aspiration Cytology: A Case Series

Objective: To analyze the cases diagnosed as myeloid sarcoma on fine-needle aspiration cytology (FNAC) of lymph nodes. Study Design: Ten cases of lymph node aspirate diagnosed as myeloid sarcoma were analyzed. FNAC was performed as a routine outpatient procedure in all cases. Correlation with peripheral smear, bone marrow examination, flow cytometry and cytogenetics was done wherever possible. Results: Diagnosis of a hematologic malignancy, before fine-needle aspiration, was available in only 2 cases. All 10 cases showed eosinophilic precursors while five aspirates showed megakaryocytes with dysplastic forms. Of the 10 cases, 3 were diagnosed as acute myeloid leukemia, 3 as chronic myeloid leukemia, 1 case as juvenile myelomonocytic leukemia, 1 case proved to be precursor T acute lymphoblastic leukemia/lymphoma and 2 patients did not show blasts on peripheral blood smear but showed blasts, dysplastic megakaryocytes and eosinophilic precursors in the aspirate. Conclusion: Thorough workup to search for an underlying hematological malignancy should be done whenever dysplastic megakaryocytes and/or eosinophilic precursors are seen in lymph node aspirate.

Hydatid disease of the spine: A rare case

Hydatid disease or hydatidosis is the most widespread zoonosis caused by Echinococcus granulosus. Liver and lungs are the most common sites. Bone involvement is rare and reported in 0.5%–4% with spinal involvement reported in 50% of these cases. We present a case of spinal hydatidosis in a 35-year-old male presenting with lower extremity weakness and numbness. Magnetic resonance imaging (MRI) of the spine showed multiple cystic lesions at the T9–T11 level with involvement of the paraspinal muscles. The lesion was seen intraspinal, intradural, intramedullary, and epidural. Radiological impression was aneurysmal bone cyst. The patient underwent laminectomy, and the excised cysts showed characteristic features of hydatid cyst (HC) on histopathology. The patient was started on antihelminthic therapy postoperatively. MRI is a diagnostic modality for HC, but the unusual location and absence of characteristic features can cause diagnostic difficulty. A high index of suspicion should be kept in patients residing in endemic areas and presenting with unusual cystic lesion of spine.

Fine-Needle Aspiration Cytology of Breast Lesions with Spontaneous Infarction: A Five-Year Study

Objective: To put forth the cytological features and diagnostic pitfalls of spontaneously infarcted breast lesions on fine-needle aspiration cytology (FNAC). Study Design: We present 19 cases of spontaneously infarcted breast lesions encountered on FNAC over a 5-year period. Histological follow-up was correlated wherever available. Results: The majority of cases were seen in the second decade of life. The smears in all 19 cases were cellular. The cytomorphologic findings were scattered dyscohesive cells (n = 16), ghost cells (n = 11) and necrosis (n = 10). The dyscohesive cells were small and had a normal nuclear cytoplasmic ratio with pyknotic nuclei. The presence of viable epithelial cells or stromal fragments helped in the diagnosis of the primary breast lesion and was seen in all 19 cases. Cytology diagnoses were infarcted fibroadenoma (n = 11), infarcted breast lesion (n = 3), Phyllodes tumor (n = 2), papillary lesion (n = 2) and infarcted benign breast lesion (n = 1). Histopathology was available in 13 cases, 12 were concordant and 1 was inadequate for primary diagnosis. Conclusion: An infarcted breast lesion poses diagnostic difficulties on cytology. It needs to be differentiated from inflammatory lesions and malignancy. A cytopathologist should be aware of the entity and recognize its cytomorphologic features.

Eccrine Spiradenoma of the Vulva

A 23-year-old woman presented with a gradually increasing swelling on the left labia majora since 2 years. The lesion measured approximately 1.5 9 1 cm and was soft, well circumscribed and slightly painful and tender. Clinical impression was lipoma and was excised. Histopathologic examination showed well-demarcated multiple basophilic tumour nodules, comprising of lobules of round–oval cells arranged in acinar, trabecular and diffuse pattern. The stroma surrounding these lobules was hyalinised. Two types of distinctive cells were observed: the periphery showed small, dark, basaloid cells, with hyperchromatic nuclei, while cells with large nucleus and pale cytoplasm were located in the centre and towards the lumen (Fig. 1a, b). Mild to moderate lymphocytic infiltrate and many blood vessels were also observed. The histomorphology was characteristics of an eccrine spiradenoma. The vulvar region contains dense apocrine glands, anogenital mammary-like glands, eccrine glands and folliculosebaceous units [1]. Benign and malignant lesions derived from these adnexal structures are found in the vulva but are rare [1]. Baker et al. [1] in his retrospective study of 32 years identified 189 vulvar adnexal lesions. Most of these lesions were benign (70%), with hidradenoma papilliferum being the most common, followed by syringoma and various types of cysts [1]. Other lesions included were rare cases of tubular adenoma, poroma, spiradenoma, hidradenoma, cylindroma, sebaceoma and trichoepithelioma [1]. He identified only two cases of spiradenoma, but details were not documented. Eccrine spiradenoma (ES) is an uncommon benign adnexal neoplasm originating from the eccrine glands and has characteristic clinical and histomorphological features [2]. It usually occurs in the 2nd–4th decade of life as a painful solitary well-circumscribed dermal nodule with pink or blue hue [2]. Rarely, it may present as multiple lesions in a linear zosteriform pattern [2]. The lesion is one of the classically painful cutaneous lesions, others being angiolipoma, endometrioma, dermatofibroma, neuroma, neurilemmoma, glomus and leiomyoma [3]. The common sites for ES are head and neck, upper trunk or extremities [4]. There are sporadic case reports of unusual sites which includes breast, ear, nail fold and face [4]. Vulva is a very rare site and not reported. Histologically, ES is a well-circumscribed dermal tumour showing multiple basophilic nodules surrounded by hyalinised stroma, resembling lymph node when observed under a low power microscope. The pathognomonic features are the presence of two-cell populations: a central cluster of pale large cells surrounded by small, dark, basaloid cells, with hyperchromatic nuclei [2]. In certain cases, lymphocyte infiltrate and significant vascular proliferation can be observed. Dermal cylindroma is a close differential diagnosis of ES, but its commonest site of occurrence is scalp and displays ‘‘jigsaw puzzle’’ pattern of tumour cells with prominent hyaline matrix on histology [2]. Other differentials include trichoepithelioma and glomus tumour. ES can be syndromic (Brooke–Spiegler syndrome) and also has a potential for malignant transformation. Malignant spiradenoma generally arise in a long-standing benign ES [5]. Thus, early and correct diagnosis is critical. Occurrence at rare sites can cause diagnostic difficulties, but knowledge of characteristic morphology will navigate towards the right diagnosis. & Mona Agnihotri mona.agnihotri2@gmail.com

Endoscopic ultrasound guided brush/fine-needle aspiration cytology: A 15-month study

Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) has become increasingly popular for the diagnosis and staging of gastrointestinal diseases and peri‐gastrointestinal lesions. The application of FNA/Brush has dramatically expanded the clinical utility of EUS.

Anaplastic large cell lymphoma: A great mimic on cytology

Anaplastic large cell lymphoma (ALCL) is a T-cell lymphoma, accounting for <5% of non-Hodgkins lymphoma. Cutaneous involvement can be primary or secondary arising in systemic ALCL. The diagnostic feature in both is the presence of pleomorphic, CD30 positive hallmark cells. We present a case of ALCL in a 19-year-old male presenting as an ulcerated scalp swelling. Clinical impression was actinomycosis or scrofuloderma. Cytology smears showed large dispersed pleomorphic cells with hyperlobated nuclei and multinucleated giant cells. The differentials considered were ALCL, rhabdomyosarcoma, and poorly differentiated carcinoma. Immunocytochemistry (ICC) showed positivity for leukocyte common antigen (LCA) and CD30 while negativity for desmin, favoring ALCL. Computed tomography (CT) showed a lytic paravertebral lesion. Subsequently, both paraspinal and scalp lesions were biopsied and immunochemistry confirmed the diagnosis of ALCL. Thus, cutaneous involvement in ALCL can resemble inflammatory and other neoplastic lesions clinically and cytologically. Hence, a high index of suspicion and ICC can aid in the correct diagnosis on fine needle aspiration cytology (FNAC).

Ψ Multiple eccrine spiradenomas with a zosteriform pattern—Report of a rare case diagnosed on fine needle aspiration cytology

Department of Pathology, Seth G.S. Medical college and King Edward Memorial Hospital, Parel, Mumbai, Maharashtra, 400012, India Correspondence Mona Agnihotri, Assistant Professor, Department of Pathology, Seth G.S. medical college and K.E.M. hospital, Parel, Mumbai-400012, India. Email: mona.agnihotri2@gmail.com Funding information: Disclosure of grants/funding: No funding. K E YWORD S FNAC, eccrine spiradenoma, multiple

Human Immunodeficiency Virus Lymphadenitis Patterns on Fine-Needle Aspiration Cytology

Objective: The aim of this work was to study the microscopic patterns of human immunodeficiency virus (HIV) lymphadenitis on fine-needle aspiration cytology (FNAC) and correlate them with cluster of differentiation 4 (CD4) counts. Study Design: A retrospective study of known HIV-positive patients who underwent lymph node FNAC over a period of 5 years (2009-2013) was undertaken. The cytology slides were retrieved and reviewed. Out of 317 cases, 38 (11.7%) were diagnosed as HIV lymphadenitis. We analysed the cytomorphological patterns of HIV lymphadenitis and correlated them with the CD4 cell counts. Results: Smears of HIV lymphadenitis were classified akin to histology patterns (A, B, and C) depending on cellularity, number of tingible body macrophages, mitosis, apoptotic bodies, plasma cells, Warthin-Finkeldey giant cells, and proliferating blood vessels. Thirty-one cases showed pattern A, 3 showed pattern B, and 4 were of pattern C. Pattern A had the highest CD4 cell count. Conclusion: Histologic patterns of HIV lymphadenitis are recognisable on FNAC smears. These can offer a clue to the diagnosis and guide further workup, even in the absence of history. The changes can mimic those of the infective lymphadenitis, Castleman disease, and lymphoma. Hence, the clinical history, serological correlation, and awareness of cytomorphology can aid the correct diagnosis.

Fine Needle Aspiration of a Subcutaneous Nodule Showing Eggs of Adult Filarial worm

A 22-year-old male, presented with a 2x2 cm, slightly tender nodule over medial aspect of upper arm near the elbow joint. There was no history of increase in size of the swelling, fever, cough or cold or any abscess formation.