Nadir Paksoy

Inhaled Corticosteroids May Reduce Neutrophilic Inflammation in Patients with Stable Chronic Obstructive Pulmonary Disease

Background: Although both inhaled and oral corticosteroids have anti-inflammatory effects causing improvement in clinical symptoms and spirometry in the treatment of asthma, the role of corticosteroids in the management of chronic obstructive pulmonary disease (COPD) is controversial. Objective: To evaluate the effects of inhaled corticosteroids on sputum neutrophilia in clinically stable COPD patients. Methods: In total, 18 patients were enrolled in the study. During 2 months, 9 patients in group A inhaled fluticasone propionate (FP) 500 μg 3 times daily. In group B 9 patients received placebo. All of the patients continued to inhale both salbutamol and ipratropium bromide. In 9 patients, sustained-released theophylline was also administered. Blood samples, spirometric tests, blood gas analyses, and either spontaneous or induced sputum cultures were evaluated on entry into the study, after a 2 months of treatment and following the 6-week washout period. Results: After the 2-month FP treatment, no significant changes in the number of peripheral blood neutrophils, blood gas and spirometry data were observed in both groups. In group A, the total cell number and the number of neutrophils decreased from a mean of 3.4 ± 1.3 × 106 cells/g and 0.6 ± 0.3 × 106 neutrophils/g on entry into study to 1.9 ± 0.6 × 106 cells/g and 0.02 ± 0.01 × 106 neutrophils/g after 8-week treatment with FP, returning to 3.3 ± 1.1 × 106 cells/g and 0.5 ± 0.3 × 106 neutrophils/g following the washout period. The percentages of neutrophils were 55.6 and 77.9% in groups A and B after 2 months of FP treatment. There was no significant change in group B values during the study. Conclusion: These data suggest that neutrophilic inflammation in sputum may be decreased by inhaled corticosteroids in clinically stable COPD patients.

Idiopathic granulomatous mastitis. Report of a case diagnosed with fine needle aspiration cytology.

BACKGROUND Idiopathic granulomatous mastitis (IGM) is a benign, inflammatory breast disease of unknown etiology. Although it is rare, it frequently presents in a manner similar to that of breast carcinoma. CASE A 41-year-old female developed unilateral idiopathic granulomatous mastitis, diagnosed by fine needle aspiration cytology. The clinical presentation and mammographic findings were suspicious for carcinoma. Fine needle aspiration cytology showed granulomatous inflammation. Histopathologic examination revealed a noncaseating, granulomatous lesion. Further clinical, radiologic and laboratory investigations disclosed no etiology. Therefore, we considered the case to be idiopathic granulomatous mastitis. CONCLUSION Cytologically it may be difficult to distinguish IGM from carcinoma of the breast. Typical cytologic findings of the lesion are helpful to rule out cancer. In the differential diagnosis, all known causes of granulomatous changes have to be excluded before a diagnosis of idiopathic granulomatous mastitis is made.

Cervical lymphadenopathy associated with Hashimoto's thyroiditis: an analysis of 22 cases by fine needle aspiration cytology.

OBJECTIVE To analyze the possible association between Hashimotos thyroiditis (HT) and cervical lymphadenopathy in cases diagnosed by fine needle aspiration cytology. STUDY DESIGN Among the patients referred to our laboratory for ultrasound-guided fine needle aspiration cytology of thyroid nodules (USG-FNAC), cases of HT associated with cervical lymphadenopathy were evaluated. RESULTS Between February 2001 and May 2007, HT was diagnosed in 94 (11%) of a total of 856 thyroid USG-FNAC cases. Among these cases, 22 (23%) were associated with single/ multiple cervical lymphadenopathy. In all cases, FNAC of the lymph nodes was consistent with reactive lymphoid hyperplasia. Anti-TPO and anti-Tg antibody results were obtained in 14 of 22 cases with HT. Among these cases, 12 showed positive values. CONCLUSION Clinicians and cytopathologists who encounter thyroid nodules with cervical lymphadenopathy should also include the possibility of HT in the differential diagnosis. A literature search disclosed no report regarding the possible association between HT and cervical lymphadenopathy. Considering the limitations due to lack of immunocytochemical analysis of the thyroid and lymph node aspirates, our study should be taken as a preliminary one.

Comparison of Five Detection Methods for Helicobacter pylori

OBJECTIVE To evaluate which diagnostic test is preferable for the diagnosis of Helicobacter pylori in patients with gastroduodenal disease. STUDY DESIGN H pylori infection was diagnosed prospectively in 101 patients. Diagnosis of H pylori was made by tests based on five different principles: (1) culture, (2) direct histologic demonstration, (3) imprint cytology, (4) brushing cytology, and (5) gram staining of H pylori. Efficacy of each test was compared. RESULTS All the tests were reliable for diagnosing H pylori infection; 73.3% of patients showed concordance in at least two tests. All the tests were positive in > 50% of patients. Significant concordance between brushing and imprint cytology was also determined. These two tests have almost similar specificity when compared to other tests. CONCLUSION When patients undergo upper endoscopy, we recommend taking biopsy specimens for culture and histology. H pylori can be assessed equally well with all the tests, but imprint and brushing cytology have the advantage of rapid response, specificity, much lower cost and reproducibility.

Adenoid cystic carcinoma of the tongue.

Malignant tumours of the salivary glands in children are extremely rare. We present here a 12-year-old girl initially diagnosed as pleomorphic adenoma on fine needle aspiration biopsy, and adenoid cystic carcinoma (ACC) after the lesion was excised and examined by histopathology. A wide resection of the lesion and bilateral supraomyohyoid neck dissection was performed. To our knowledge this is one of the youngest patients with ACC of the minor salivary glands. Due to its benign histological appearance, the biological agressiveness of ACC is usually underestimated. Although fine needle aspiration cytology (FNAC) is very valuable in diagnosis, cytological variations of pleomorphic adenoma must be considered. ACC of the tongue in a young age group should be treated with wide resection and selective neck dissection if the tumour is localized in places where the risk of metastasis is increased and if there is a clinically palpable lymph node. In such cases the clinician should not avoid radical operations even in a young patient.

Imprint cytology in the diagnosis of Helicobacter pylori : Does imprinting damage the biopsy specimen?

OBJECTIVE To investigate the efficacy of imprint cytology in the diagnosis of Helicobacter pylori infection and whether it damages the biopsy specimen for subsequent histologic examination. STUDY DESIGN Two antral biopsies were taken from 76 patients with dyspeptic symptoms undergoing upper gastrointestinal endoscopy. Imprint cytology was made from the first specimen. This specimen was fixed in 10% formalin and sent for histopathologic examination. The second specimen was directly fixed in 10% formalin for routine histopathologic examination without being used for an imprint. The imprint smears were examined by cytopathologists. The biopsy specimens were examined by pathologists who did not know which specimens were used for the imprints. RESULTS H pylori was seen in smears from 55 (72%) patients and in both biopsy specimens from the same patients. The pathologists could not recognize the biopsy specimens from which the imprints were made. Concordance between imprint cytology and histopathology was 100%. CONCLUSION Imprint cytology is a suitable test for H pylori diagnosis, and imprints do not adversely affect the quality of the biopsy specimen.

Ectopic lesions as potential pitfalls in fine needle aspiration cytology: a report of 3 cases derived from the thyroid, endometrium and breast.

BACKGROUND Ectopic lesions are rarely encountered. Those that are derived from thyroid, breast, endometrium and salivary glands present with palpable masses that can mimic malignancy. Fine needle aspiration cytology (FNAC) is a practical procedure for the differential diagnosis of such lesions but can reveal surprising images for a cytopathologist. CASES Three cases of discrete, ectopic lesions at different locations occurred. Case 1 was a 27-year-old woman. Upon diagnosis of a submandibular mass with a diameter of 1 cm, FNAC was performed. The smears showed crowded thyroid follicular cells comprising papillary clusters. A cytologic diagnosis of papillary thyroid lesion was rendered, Histopathology revealed that this lesion was ectopic thyroid tissue with focal chronic thyroiditis. Case 2 was a 38-year-old woman who presented with a painful mass with a diameter of 2.5 cm in the abdominal wall. The patient had undergone cesarean section 3 years earlier. The case was diagnosed on FNAC as low grade malignancy in which an adenocarcinoma/mesenchymal tumor distinction could not be made. The pathologic examination revealed endometriosis. Case 3 was a 31-year old woman who presented with a palpable nodule in the axillary region with a diameter of 1 cm. The patient had given birth 1 month earlier and was nursing. An FNAC diagnosis of lactation ectopic breast tissue was made. The mass disappeared by the end of lactation. CONCLUSION FNAC of ectopic lesions may prove to be a diagnostic pitfall for cytopathologists. A cytopathologist who encounters a cellularpicturefrom a lesion that is outside the normal anatomic location must use a cautious diagnostic approach. Unless there are clear findings, the cytopathologist must refrain from a diagnosis of malignancy.

Malignancy rate in nondominant nodules in patients with multinodular goiter: Experience with 1,606 cases evaluated by ultrasound-guided fine needle aspiration cytology

Background: Conventional medical sources recommend the use of fine needle aspiration cytology (FNAC) for single thyroid nodules and the dominant nodule in multinodular goiter (MNG). The purpose of the present study was to analyze the utility of FNAC for multiple thyroid nodules in patients with MNG and to determine the rate of malignancy in teh nondominant nodules. Materials and Methods: Our private practice performed ultrasound-guided FNAC on 1,606 patients between February 2001 and February 1, 2010. In the MNG cases, samples were taken from the dominant nodule and from trhee suspicious / nonsuspicious nodules larger than 1 cm on ultrasound. Ninety-four cases were diagnosed as ‘suspiciously malignant’(SUS) or ‘malignant’ (POS) based on FNAC. Results: The rate of an SUS / POS diagnosis was 5.7% in the dominant nodules; 2.3% of the nondominant nodules had a SUS / POS diagnosis in FNAC (p = 0.0003). Follow-up revealed malignancy in 15 (35.7%) nondominant nodules and in 27 (64.2%) dominant nodules, with 42 MNG cases undergoing surgery. X test showed a ‘p-level of 0.0003’ between the percentages of SUS / POS diagnosis in dominanat and nondominanat nodules. It was less than the significance level of 0.05. Therefore, the result was regarded to be statistically significant. Conclusions: Nondominant nodules could harbor malignancy. The risk of malignancy in nondominant nodules in MNG should not be underestimated. We have shown that the dominant nodule in patients with MNG was in fact about 2.5 times more likely to be malignant than a nondominant nodule. The use of FNAC for nondominant nodules could enhance the likelihood of detecting malignancy in an MNG.

Subacute granulomatous (De Quervain's) thyroiditis: Fine-needle aspiration cytology and ultrasonographic characteristics of 21 cases

Background: Subacute granulomatous thyroiditis (SGT) is an inflammatory disease that presents with different clinical and cytological characteristics. Although the diagnosis is generally made clinically, imaging methods and fine-needle aspiration (FNA) may provide assistance, particularly in atypical cases. The objective of this study is to reveal the ultrasonographic (USG) and cytological characteristics of SGT. Materials and Methods: The clinical, USG and cytological findings of 21 cases diagnosed with SGT were reviewed. Results: Ultrasonographic data was available in 20 cases. A hypoechoic thyroid nodule with irregular margins was detected in 12 of the 20 total cases. Of these, 9 cases complained about pain in the thyroid lodge and generally had unilateral lesions, heterogeneous and hypoechoic areas with indistinct margins, rather than nodular lesions, which were seen in 7 cases. Cytologically, the multinuclear giant cells (MNGCs) found in all cases were accompanied by a dirty background containing varying numbers of granulomatous structures, including isolated epithelioid histiocytes, proliferated/regenerated follicle epithelium cells and inflammatory cells and colloid. Conclusion: Though hypoechoic and heterogeneous areas with irregular margins are strongly associated with thyroiditis, SGT may also appear as painful or painless hypoechoic, solid nodules and generate challenges in differential diagnosis. Although the most remarkable characteristic observed in FNA cytology was the presence of multiple MNGCs with cytoplasm, a dirty background accompanied by mild-moderate cellularity, degenerated-proliferated follicular epithelium cells, rare epithelioid granulomas and mixed type inflammatory cells are characteristic for SGT. The assessment of these radiological and cytological findings in conjunction with clinical findings will assist in the achievement of an accurate diagnosis.

Hereditary Cystinosis Detected by CD68 Staining of the Bone Marrow Biopsies of 2 Siblings.

Cystinosis is an autosomal recessive lysosomal storage disease. We present 2 siblings in whom cystinosis was detected by CD68 immunohistochemical analysis of bone marrow biopsies. The older patient was a 6-year-old boy who had been receiving erythrocyte suspension therapy for 5.5 years because of low hemoglobin levels. The patient was admitted to our hospital because of hepatomegaly, anemia, and thrombocytopenia and underwent a trephine bone marrow biopsy based on a preliminary diagnosis of lipid storage disease. Macrophage-like cells were observed in the hematoxylin/eosin-stained sections. These cells were stained for CD68 to confirm that they were macrophages. Some crystalline structures were seen in the cytoplasm of the macrophages after CD68 staining. These structures were thought to be cystine crystals. The diagnosis of cystinosis was confirmed by a clinical assessment. The 1-year-old sibling of the patient was also examined; this sibling exhibited renal disease and had a family history of consanguineous marriage. Cystinosis was also detected in this sibling by clinical assessment and staining of the patients trephine bone marrow biopsy for CD68. The staining of the bone marrow biopsies for CD68 enabled the patient and his sibling to be diagnosed with cystinosis; these patients were not correctly diagnosed over the previous 6-year period. No similar report was found in the literature regarding this topic.