Neelaiah Siddaraju

Immunohistochemical distinction between mesothelial and adenocarcinoma cells in serous effusions: A combination panel-based approach with a brief review of the literature

BACKGROUND The prognostic and therapeutic significance of differentiating adenocarcinoma (AC) from reactive mesothelium (RM) in effusions cannot be overemphasized. To avoid diagnostic errors, ancillary techniques like immunohistochemistry are employed. However, results vary and no universal standard has been accepted so far. OBJECTIVE To study the combined diagnostic efficacy of epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), E-cadherin (EC), calretinin (CAL), desmin (DES) and vimentin (VIM) in distinguishing RM from AC cells in serous effusions. STUDY DESIGN Unequivocally diagnosed cases of 39 adenocarcinomatous and 38 RM populations were studied using sections from 49 formalin-fixed, paraffin-embedded cell blocks. MATERIALS AND METHODS The immunomarkers were applied on cell block sections using the avidin-biotin peroxidase technique. The distribution/intensity of immunostaining in mesothelial and AC cells were graded semiquantitatively. STATISTICAL ANALYSIS USED Fischers exact test was used to calculate the efficacy of individual markers and their combinations. RESULTS EMA was the best single marker for AC, with 100% sensitivity and 97.37% specificity. For the mesothelial cells, CAL exhibited 100% sensitivity and 92.31% specificity. DES was more specific than CAL but had a poor sensitivity of 55.26%. EC, CEA and VIM had unsatisfactory predictive values precluding their use as individual diagnostic markers. Among the combinations, two panels--EMA+ AND (CAL- OR DES-) for ACs and CAL+ AND (EMA- OR CEA-) for RM had 100% specificities and sensitivities. CONCLUSIONS Most panel studies on fluid cytology are based on the arbitrary use of individual markers with the best statistical values, leading to a less than accurate diagnostic assessment. We believe that statistical parameters calculated in combination provide for a more practical and objective evaluation as well as allowing for meaningful comparative studies.

Pure neuritic leprosy with nerve abscess presenting as a cystic, soft tissue mass: Report of a case diagnosed by fine needle aspiration cytology

Pure neuritic leprosy (PNL) with nerve abscess manifesting as a huge, cystic, soft tissue mass is highly uncommon. Fine needle aspiration cytology can serve as an important initial diagnostic modality in such an instance.

Significance of eosinophils in diagnosing Hashimoto's thyroiditis on fine-needle aspiration cytology

BACKGROUND Hashimotos thyroiditis (HT) is the most common cause of hypothyroidism in those areas of the world where iodine levels are sufficient. Fine-needle aspiration cytology (FNAC) can accurately diagnose this lesion in most of the patients. However, a small percentage of cases may be missed due to inherent limitations of this procedure. Therefore, cytologic clues to increase sensitivity of diagnosis need to be searched for. AIMS To assess whether an eosinophilic infiltration of the thyroid gland has a higher association with HT than colloid goiter. MATERIALS AND METHODS The study was a case-control study. Smears obtained by FNAC of 50 case, each of HT (which served as cases) and colloid goiter (which served as controls) were observed. The number of eosinophils and neutrophils per high-power field (HPF) was counted in all the smears. The eosinophil-neutrophil ratio in the smears, diagnosed as HT, was then compared with that of colloid goiter using unpaired t-test. RESULTS Smears diagnosed as HT was found to have a significantly higher eosinophil-neutrophil ratio than smears diagnosed as colloid goiter (P value 0.0001). CONCLUSION Eosinophilic infiltration of the thyroid gland has higher association with Hashimoto thyroiditis.

Cytomorphologic Study of Hashimoto’s Thyroiditis and Its Serologic Correlation

OBJECTIVE To analyze the cytomorphologic spectrum of Hashimotos thyroiditis (HT) on fine needle aspiration cytology (FNAC) and to correlate cytologic findings with serologic parameters STUDY DESIGN One hundred fifty patients diagnosed with HT on FNAC were subjected to serologic studies. A detailed cytologic examination was done with an attempt to grade thyroiditis, lymphoid:epithelial (L:E) ratio and intensity of lymphocytic infiltrates. Any additional lesion or feature seen in association with HT was recorded. Thyroid hormonal assay and thyroid antibodies were evaluated using appropriate methods. Cytologic findings were correlated with the serologic parameters and analyzed using the chi2 test and Fishers exact test. RESULTS Apart from the usual cytomorphologic spectrum of HT, significant findings recorded in a fair number of cases were abundant colloid, follicular hyperplasia, fire flares, eosinophils and HT-associated neoplasms. Grading of thyroiditis and lymphocytic infiltration showed no correlation with the clinical severity of HT, while a high L:E ratio was strongly correlated with thyroid peroxidase positivity (p = 0.004). Presence of fire flares and macrophages correlated positively with hyperthyroidism, with p values of 0.002 and 0.005, respectively. Thyroid peroxidase positivity showed a strong association with HT (p = 0.001) as compared to HT coexisting with follicular hyperplasia/Hashitoxicosis/neoplasm. CONCLUSION The present study gives an account of the cytomorphologic spectrum of a large series of HT cases, with its serologic correlation, emphasizing the importance of a careful interpretation of fine needle aspiration smears in the presence of colloid, follicular hyperplasia or a coexisting neoplasm.

Fine Needle Aspiration Cytology of Oncocytic Lipoadenoma of the Parotid Gland

BACKGROUND Oncocytic lipoadenoma is an uncommon benign salivary gland tumor. There are only rare case reports of this distinct entity in which only the histopathologic aspects are discussed. Fine needle aspiration cytologic (FNAC) findings of oncocytic lipoadenoma have not yet been documented. CASE A 50-year-old woman presented with a slow-growing swelling in the left parotid region that was clinically interpreted as a soft tissue tumor, with a differential of neurofibroma/lipoma. FNAC showed moderate cellularity, with oncocytic cells arranged predominantly as microacini in a prominent lipoid background. The adipose tissue background of the cytologic smears was ignored as material derived from the normal fat tissue; based on the oncocytic population of cells, a diagnosis of oncocytoma was considered. A remote possibility of acinic cell carcinoma with oncocytic features was also suggested. However, histopathologic examination showed it to be an oncocytic lipoadenoma, a tumor we were unaware of at the time of cytodiagnosis. CONCLUSION Both cytopathologists and histopathologists need to be aware of oncocytic lipoadenoma of the salivary gland in order to diagnose it precisely. The clinicocytopathologic correlation highlighted in our case will be useful for cytopathologists in preoperative interpretation and diagnosis.

Preoperative fine needle aspiration cytologic diagnosis of spindle cell myoepithelioma of the parotid gland: a case report.

BACKGROUND There are only rare case reports of preoperative fine needle aspiration cytologic (FNAC) diagnosis of myoepithelioma of the salivary gland. Myoepitheliomas with pure spindle cell morphology may simulate a variety of benign or malignant spindle cell soft tissue tumors. CASE A 54-year-old woman presented with a history of progressively increasing swelling in the right parotid region. The clinical diagnosis was parotid malignancy. Routine FNAC yielded highly particulate material. The smears were cellular, with tissue fragments, clusters of spindle cells and numerous small globules and strands of bright magenta material. High cellular yield and pure spindle cell population with an accentuated chromatin pattern in Papanicolaou-stained smears simulated a low-grade spindle cell soft tissue sarcoma. A vague resemblance to a schwannoma was also noted. However, based on the characteristic findings of the May-Grünwald-Giemsa (MGG)-stained smears, a preoperative diagnosis of myoepithelioma was made and confirmed by subsequent histopathologic examination and immunohistochemistry. CONCLUSION Cytologically, spindle cell myoepithelioma of the salivary gland may simulate low-grade spindle cell soft tissue sarcoma or schwannoma. However, optimal sampling of the lesion and logical interpretation of the MGG-stained smears, in the appropriate clinical situation, allow a confident preoperative diagnosis of these tumors.

Needle Tract Sinus Following Aspiration Biopsy of Papillary Thyroid Carcinoma

BACKGROUND Fine needle aspiration biopsy (FNAB) of the thyroid is a simple and safe investigation. Dissemination of malignant cells during FNA for papillary thyroid carcinoma is extremely uncommon. CASE We report a 49-year-old woman who presented with a multicystic goiter and palpable cervical lymph nodes. Three sessions of FNAB (a total of 12 needle passes) from a complex cyst overlying the thyroid isthmus using a 22-gauge needle failed to reveal malignant cells. Following the FNAs she developed a persistent discharging sinus at the needle insertion site. Exploration of the neck and histopathologic examination confirmed a well-differentiated papillary thyroid carcinoma infiltrating the skin and strap muscles at a single focus. Debulking surgery with adjuvant radiotherapy had a satisfactory outcome in our patient. CONCLUSION Skin sinus formation might have been prevented in our case by using a needle with a caliber < 22 gauge and avoiding multiple sessions of aspiration of the same thyroid nodule.

Fine Needle Aspiration Cytology in Recurrent Amelanotic Melanoma

BACKGROUND Amelanotic melanoma can mimic a wide variety of epithelial and nonepithelial malignant tumors. Varied cytomorphology of melanoma has been described on exfoliative and fine needle aspiration cytology (FNAC). We report a case of recurrent amelanotic melanoma to highlight its varied cytomorphologic features, which may cause diagnostic problems on cytologic and on histologic examinations. CASE A 63-year-old male presented with nodular swellings in the right anterior chest wall, right axilla and back. A nodule in the chest had been excised 6 months earlier. Clinically, the lesion was interpreted as recurrent soft tissue sarcoma. FNAC revealed malignant cells with highly varied morphology with plasmacytoid and pleomorphic malignant cells with occasional fibrocollagenous tissue strands showing adherent neoplastic cells. A cytologic diagnosis of pleomorphic malignant tumor was suggested, and the original histologic slides were reviewed; they showed a striking alveolar pattern that vaguely resembled an alveolar rhabdomyosarcoma. However, on immunohistochemistry, the tumor cells were S-100 and melan-A positive and desmin negative. A final diagnosis of amelanotic melanoma was made. CONCLUSION Awareness of the highly varied cytomorphology of amelanotic melanoma minimizes the diagnostic difficulty on fine needle aspiration smears. Suitable immunohistochemical markers are of great value in difficult situations.

Fine needle aspiration of follicular variant of papillary thyroid carcinoma presenting with pleural effusion: a case report.

BACKGROUND Malignant pleural effusion in association with mesothelioma, bronchogenic carcinoma and breast carcinoma is common, although less frequently reported with other malignancies. We report a follicular variant of papillary thyroid carcinoma (FVPTC), diagnosed on fine needle aspiration cytology (FNAC) of thyroid and lymph nodes and subsequently proved to have metastasized to the pleural cavity. CASE A 46-year-old man presented with history of breathlessness, thyroid swelling, pleural effusion and bilateral cervical lymphadenopathy. FNAC of the thyroid swelling and the lymph nodes showed features of FVPTC with cervical lymph node metastasis. Pleural fluid examination led to suspicion of pleural involvement by metastatic deposit, confirmed by subsequent pleural biopsy. CONCLUSION Thyroid malignancies presenting with pleural effusion are rare. In this case, although pleural fluid cytology suggested involvement of pleura, a definitive diagnosis could be rendered only on pleural biopsy. An ancillary aid, such as immunocytochemistry, could have helped establish pleural involvement on routine pleural fluid cytology alone. This case emphasizes the possible existence of rare cases of FVPTC that may be associated with a dismal prognosis. In our case, initial diagnosis of FVPTC could be made only on correlating FNA features of thyroid aspirate with those of lymph node aspirate.

Fine needle aspiration cytology of epithelioid angiosarcoma: a case report.

BACKGROUND Malignant vascular tumors are rare. Few studies have described cytomorphologic features of hemangioendothelioma and angiosarcoma on fine needle aspiration cytology (FNAC). Malignant vascular tumor with epithelioid morphology can create diagnostic difficulty, as the cytology may simulate that in other nonvascular malignant tumors. We describe epithelioid angiosarcoma, diagnosed on FNAC, in which a differential diagnosis of histiocytosis and inflammatory granulation tissue was considered. CASE A 20-year-old man presented with forehead and scalp swellings. The forehead lesion was radiologiocally associated with a lytic lesion in the bone. FNA resulted in high cellular yield, and smears revealed prominent vascular pattern with endothelial cell atypia and histiocytoid/epithelioid neoplastic cells, occasional mitotic figures and a few cells displaying nuclear grooving. Smear background showed a significant number of neutrophils. Epithelioid hemangioendothelioma/angiosarcoma, histiocytosis and inflammatory granulation tissue were considered. A cytologic diagnosis of epithelioid angiosarcoma/epithelioid hemangioendothelioma was suggested and confirmed on histopathologic and immunohistochemical examination. CONCLUSION Cellular aspirates from malignant epithelioid endothelial tumors involving bone may be cytologically mistaken for histiocytosis and, rarely, inflammatory granulation tissue. However, prominent vascular pattern with striking endothelial cell atypia, presence of mitotic figures and careful search for presence of endothelial differentiation are helpful in accurate cytologic diagnosis.