Mrinmay K. Mallik

Role of Fine Needle Aspiration Cytology in the Diagnosis of Swellings in the Salivary Gland Regions: A Study of 712 Cases

Introduction: A mass in the salivary gland region often presents a diagnostic challenge with regard to its site of origin (salivary versus nonsalivary), benign or malignant nature, and tissue-specific diagnosis. The present study describes the utility of fine-needle aspiration (FNA) cytology in the diagnosis of these lesions. Subjects and Methods: Over a 6-year period (January 1994 to December 1999), 712 patients aged between 6 months and 91 years (median, 37 years) were subjected to FNA of swellings in their salivary gland regions. Male:female ratio was 1.28:1. The swellings were mostly located in the parotid (323 cases), submandibular (343 cases), and upper cervical region (27 cases). Swellings of oral (5 cases) and sublingual (2 cases) sites were rare. The lesions diagnosed by FNA cytology were compared among the major salivary glands. Cytologic diagnoses were correlated with histology in 45 cases. Results: Benign nonneoplastic lesions were the most common (73%), followed by neoplasms (20%), and those with atypical cytology (1%). Cytologic material was inadequate in 6% cases. Parotid gland region was involved more frequently by neoplasms (27.1%) than the submandibular gland region (13.7%, p < 0.0001). Inflammatory processes affected the submandibular gland region more commonly (42.0%) than the parotid (32.6%, p = 0.0164). Pleomorphic adenoma was the most common neoplasm (61.5%), followed by Warthin’s tumor (12.6%). Malignancies accounted for 10.5% of neoplasms. Frequency of involvement of parotid by Warthin’s tumor (16.7%) was significantly higher than that of submandibular gland (2.3%, p = 0.0191). However, the submandibular gland was more commonly affected by malignancy than the parotid gland (p = 0.0003). Sensitivity, specificity, and diagnostic accuracy of FNA cytology for all neoplastic lesions of the salivary gland were 94.6, 75.0, and 91.1%, respectively. The corresponding figures for malignancies were 60.0, 95.0, and 91.1%, respectively. Conclusion: FNA cytology is very useful for the diagnosis of salivary gland lesions. However, sampling and interpretation errors may occur. The low specificity for the diagnosis of neoplasms as a whole and the poor sensitivity for malignancies found in our study can be attributed to the relatively small number of benign nonneoplastic and malignancy cases with available histopathologic diagnoses.

Cytomorphological spectrum in scar endometriosis: a study of eight cases

Objective:  Endometriosis due to ectopic endometrial tissue that responds to hormonal stimulation and is extremely rare in a surgical scar appearing in 0.1% of women who have undergone Caesarean section. Fine needle aspiration cytology (FNAC) can be a valuable diagnostic aid in the evaluation of these subcutaneous abdominal masses.

Papillary Thyroid Carcinoma and Its Variants in Fine Needle Aspiration Smears

OBJECTIVE To study the fine needle aspiration (FNA) cytologic features of papillary thyroid carcinoma (PTC) with special reference to its tall cell variant (TCV), which is the most aggressive of the variants. STUDY DESIGN Fifty-four PTC cases were classified into variants, and the frequency of well-known morphologic criteria was determined. Four parameters were quantitatively analyzed based on a study of 200 consecutive neoplastic follicular cells: shape of cells, color of cytoplasm, intranuclear cytoplasmic inclusion (INCI) and nuclear grooves. RESULTS The PTC cases included 6 TCV (> or = 30% tall cells), 8 cases with a significant tall cell component (sig. TCC) having 10-29% tall cells, 17 usual variant (UV), 17 follicular variant (FV) and 6 miscellaneous variants. TCV differed significantly from UV and FV in having a higher tall cell count, higher count of cells with reddish cytoplasm and INCI, and higher frequency of cases with lymphocytic infiltration. PTC (with significant tall cell component [TCC]) differed significantly from TCV with regard to tall cell count and lymphocytic infiltration, from UV with respect to tall cell count and monolayered sheets, and from FV with respect to tall cells, INCI, grooved nuclei, acinar formation, fire-flare appearance and giant cells. CONCLUSION TCV was cytologically distinct from other variants. The biologic behavior of PTC cases with significant TCC, which morphologically seem to be a group intermediate between TCV on the one hand and UV and FV on the other, however, needs to be carefully monitored.

Hodgkin's lymphoma: Diagnostic difficulties in fine-needle aspiration cytology

It is commonly believed that cytodiagnosis of Hodgkins lymphoma (HL) is much easier than that of non‐Hodgkin lymphoma (NHL). However, recognition of certain NHL subtypes with Reed‐Sternberg (R‐S)‐like cells and results of immunohistochemical studies point to the contrary. To study the limitations of cytology in diagnosis of HL, fine‐needle aspiration (FNA) smears of 130 lymphoma or suspected lymphoma cases were reviewed. Initial and reviewed cytodiagnoses were compared with histopathology in 89 cases. Immunocytochemical and immunohistochemical studies were performed in 56 and 59 cases, respectively. Among histologically diagnosed HL cases, definitive cytodiagnosis of HL (initial as well as reviewed) was significantly less frequent than cytodiagnosis of NHL among histologically diagnosed NHL cases (P = 0.0328 and = 0.0001, respectively). On the other hand, cytologically diagnosed HL/NHL cases were significantly more frequent in the former group (P = 0.0001 and = 0.0018, respectively). ALCL and TCRBCL were the two NHL subtypes which created confusion with HL in FNA smears. Twenty‐one cytohistological concordant HL cases and equal number of discordant cases were compared. When compared with discordant group, the patients in concordant group were significantly younger (P = 0.045). Hodgkin/Hodgkin‐like cells and typical R‐S cells were significantly more frequent in FNA smears of the concordant group (P = 0.0478 and = 0.0431, respectively). Immunocytochemical and immunohistochemical studies showed good correlation with histological diagnosis of HL. It is suggested that proper interpretation of cytologic features, together with use of immunocytochemical parameters can help in reducing the margin of error in cytodiagnois of HL. Diagn. Cytopathol. 2009.

Changing Spectrum of Squamous Cell Abnormalities Observed on Papanicolaou Smears in Mubarak Al-Kabeer Hospital, Kuwait, over a 13-Year Period

Objective: The aim of this study was to determine the incidence of squamous cell abnormalities in cervical cytology in Mubarak Al-Kabeer Hospital, Kuwait, and to document any change in the pattern of these lesions. Materials and Methods: Over a 13-year period (1992–2004), 86,434 cervical smears were studied in Mubarak Al-Kabeer Hospital, Kuwait. Conventional Pap smears were first examined by cytotechnicians and finally reported by cytopathologists. The smears were classified according to the modified Bethesda system. The age of presentation of squamous cell abnormalities in Kuwaiti women was analyzed. Results: Smears from 83,052 (96.09%) patients were found satisfactory for reporting while the remaining 3.9% was unsatisfactory. Atypical squamous cells of undetermined significance (ASCUS) were seen in 1,790 (2.2%) cases, atypical glandular cells of undetermined significance (AGUS) in 630 (0.8%) cases, low grade squamous intraepithelial lesion including human papillomavirus changes (LSIL) in 824 (1.0%) cases, high grade squamous intraepithelial lesion (HSIL) in 189 (0.2%) cases, and carcinoma in 79 (0.1%) cases of which 44 (0.05%) were squamous cell carcinoma. A comparison of average cases/annum during the study period revealed a significant increase in ASCUS from 1.13 to 2.83% (p < 0.001) and AGUS from 0.33 to 1.08% (p < 0.001). However, the percentage of LSIL, HSIL and carcinoma detected in Pap smears remained the same. Conclusion: A significant linear trend (p < 0.001) was observed in satisfactory smears, ASCUS and AGUS over the years. However, no significant change was found in the detection of LSIL, HSIL and carcinoma. A reduction in the age of LSIL/HSIL and an increasing trend in the number of Kuwaiti women over the years was also observed which makes screening of young women essential in Kuwait.

Cytomorphology of hyaline-vascular Castleman's disease: A diagnostic challenge

Objective:  Hyaline‐vascular Castlemans disease (CD) is difficult to diagnose on fine needle aspiration and may be mistaken to be a lymphoreticular malignancy because of the presence of large cells having nuclei showing atypical features. The cytomorphological findings in three histopathologically documented cases of hyaline‐vascular CD were evaluated to a set of cytomorphological criteria which could help in the identification of this condition on aspirate smears.

Contribution of immunocytochemical stainings for galectin-3, CD44, and HBME1 to fine-needle aspiration cytology diagnosis of papillary thyroid carcinoma

In cytology practice some papillary thyroid carcinoma (PTC) cases have indeterminate diagnoses and overlapping cytological features with benign lesions. This study was undertaken to find out if immunocytochemistry using Galectin‐3, CD‐44 and HBME‐1 could be of help in such situations. Forty‐six cases consisting of 22 malignancy (PTC) cases, 7 suspicious of (S/O) PTC, 1 follicular neoplasm, 5 follicular lesion of undetermined significance (FLUS), and 11 benign (colloid goiter) cases diagnosed by FNA were included in this study. Staining reactions were graded in a sliding scale of –, 1+, 2+, 3+, and 4+. In an assessment of 100 cells, each cell with weak, and moderate to strong positive reaction were assigned a score of 1 and 4, respectively. Staining reaction of ≥+2 and scores >100 were considered positive. Frequency of cases with ≥+2 reaction, and scores >100 for each of Galectin‐3, CD‐44, and HBME‐1 were significantly higher in PTC or combined PTC and S/O PTC cases as compared with FLUS and benign cases taken together (P = 0.01744 to 0.00000). When the cases were compared according to histological malignant and benign diagnoses, the difference was also significant in respect of ≥+2 reaction, and scores >100 for Galectin‐3 and CD44 (P = 0.04923 to 0.00947); however, there was no significant difference, when these parameters for HBME1 were compared. Galectin 3, CD 44, and to some extent HBME 1 are useful immunocytochemical parameters with potential to support FNAC diagnosis of PTC, especially in situations with difficult differential diagnoses. Diagn. Cytopathol. 2014;42:498–505.

Fine Needle Aspiration Cytologic Diagnosis of Toxoplasma Lymphadenitis

BACKGROUND: Fine needle aspiration (FNA) cytologic diagnosis of toxoplasmic lymphadenitis with demonstration of a tissue cyst containing bradyzoites has been very rarely reported. CASE: A 17-year-old female presented with a mobile, painless, 2-cm-diameter swelling over the right suprascapular area. Clinical diagnosis was lipoma. FNA smears showed features of reactive lymphoid hyperplasia, including tingible body macrophages and groups of epithelioid histiocytes. A Toxoplasma cyst with bradyzoites was also demonstrated in a Papanicolaou-stained smear. Following FNA cytodiagnosis, serologic tests revealed a high titer of IgG and the presence of IgM-specific antibodies to Toxoplasma gondii, indicating active/recent disease. CONCLUSION: FNA cytology is a valuable tool for the diagnosis of toxoplasmic lymphadenitis. Papanicolaou stain is appropriate for demonstration of the parasite. Serology is an excellent adjunct in clinching the diagnosis.

Fine Needle Aspiration Cytology Diagnosis of a Cutaneous Granular Cell Tumor in a 7-Year-Old Child

BACKGROUND: Granular cell tumors are neoplasms of uncertain histogenesis, although a neural origin is favored. Most reports on the cytologic features of granular cell tumors have been on lesions from the breast or respiratory tract. However, there are only a few reports on fine needle aspiration (FNA) cytologic diagnosis of cutaneous or soft tissue granular cell tumors. CASE: A 7-year-old girl presented with a skin lesion on her right forearm of one years duration. The FNA smears showed sheets and clusters of oval to polygonal cells with an abundant amount of granular cytoplasm. Many single, scattered cells with similar morphology were seen in the background. Immunostaining for S-100 protein showed granular cytoplasmic positivity. The tumor was diagnosed as a benign granular cell tumor. The histopathology report on the excised lesion confirmed the FNA diagnosis. CONCLUSION: The cytopathologic features of granular cell tumors presenting as skin lesions are distinctive enough to allow a correct diagnosis on FNA cytology.

Kikuchi-fujimoto disease in fine-needle aspiration smears: A clinico-cytologic study of 76 cases of KFD and 684 cases of reactive hyperplasia of the lymph node

Kikuchi‐Fujimoto disease (KFD) is cytologically characterized by a polymorphous lymphoid cell population, abundant karyorrhectic debris and histiocytes, many of which are crescentic (Kikuchi histiocytes). As per reviewed literature, KFD may be confused with tuberculosis, lymphoma, and reactive hyperplasia of lymph nodes (RHLN). Since RHLN was found to be a major challenging factor during routine cytodiagnosis of KFD in our material, we tried to find out the differentiating clinico‐cytologic features between 76 KFD and 684 RHLN cases seen in Kuwait. 63.2% of KFD were in 3rd and 4th decades of life as compared to 40.2% of RHLN (P = 0.0002). Male to female ratio was 1: 2.45 for KFD and 1:1.09 for RHLN (P = 0.0022). Kuwaiti:non‐Kuwaiti ratio was 1:2.04 for KFD and 1.31:1 for RHLN (P < 0.0001). Capillary networks was present in 71.1% of KFD smears and 52.6% of RHLN (P = 0.0023). Tingible body macrophages and dendritic reticulum cells were detected in 17.1% and 22.4%, respectively, in KFD as opposed to 50.1% and 58.8%, respectively, in RHLN (P < 0.0001). Kikuchi histiocyte count ranged from 2 to 36% in KFD and was ≥10% in 31 (40.8%). Rare Kikuchi histiocytes were detected in 16 (2.3%) of RHLN cases but in none of them the count exceeded 1%, whereas their count was >1% in all KFD cases (P < 0.0001). Thus, KFD cases differed significantly from RHLN in respect of age and sex distribution, Kuwaiti:non‐Kuwaiti ratio, and cytomorphologic features such as capillary networks, Kikuchi histiocyte count, dendritic reticulum cells, and tingible body macrophages. Diagn. Cytopathol. 2013;41:288–295.