Shahed K. Pathan

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.

Pelvic Abscess from Enterobius vermicularis Report of a Case with Cytologic Detection of Eggs and Worms

BACKGROUND Enterobius vermicularis is known to produce perianal and ischioanal abscesses and invade the peritoneal cavity via the female reproductive system, causing pelvic peritonitis. However, there are only rare case reports on the cytodiagnosis of these parasitic lesions. CASE A 28-year-old woman was admitted with a tender left iliac fossa mass and greenish vaginal discharge. Ultrasonogram and computed tomography scan confirmed the presence of a mass lesion suggestive of a tuboovarian abscess. Cytologic examination of the pus obtained during left salpingo-oophorectomy revealed the presence of ova of E vermicularis and fragments of the adult worm in an inflammatory exudate consisting predominantly of neutrophils, eosinophils and occasional epithelioid cell granulomas. Paraffin sections of the tuboovarian mass showed necrotizing epithelioid cell granulomas, but neither ova nor any worm section was identified. Although the possibility of tuberculosis was considered histologically, Ziehl-Neelsen (Z-N) stain for acid-fast bacilli was negative. Z-N staining of the smear and mycobacterial culture of the pus also did not yield positive results. CONCLUSION E vermicularis may cause tuboovarian abscess with necrotizing epithelioid granulomas mimicking tuberculosis. Cytologic examination of the pus is helpful in the diagnosis.

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.

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.

Infarction in a thyroid nodule after fine needle aspiration: report of 2 cases with a discussion of the cause of pitfalls in the histopathologic diagnosis of papillary thyroid carcinoma.

BACKGROUND In case of difficulty in the interpretation of fine needle aspiration (FNA) smears of a thyroid nodule, histopathologic examination is advised to arrive at a definitive diagnosis. On rare occasions, a specific diagnosis may be given based on cytologic examination, but FNA is followed by infarction of the thyroid nodule, with resultant difficulty in interpretation or even misinterpretation of bistopathologic material. We report 2 such cases. CASES Two cases were diagnosed as papillary thyroid carcinoma (PTC) by FNA cytology, but histopathology reports indicated colloid goiters with infarcted nodules. Review of histopathologic material showed features of PTC in the viable tissue at the periphery of nodules. Immunohistochemical study for galectin-3 and CD44 in 1 of the cases supported the diagnosis of PTC. CONCLUSION We suggest that while reporting on an infarcted nodule in paraffin sections of a thyroidectomy specimen, the histopathologist should be careful to look thoroughly at its periphery for the surviving cells and their detailed morphologic features, especially if there is a prior FNA cytology report of a neoplasm.

Cytomorphological and immunocytochemical study of non‐Hodgkin's lymphoma in pleural effusion and ascitic fluid

Introduction:  Non‐Hodgkins lymphoma (NHL) is often complicated by pleural effusion and ascites. The present study is an attempt to categorize the lymphomatous effusions according to the WHO classification, using archival material.

Fine Needle Aspiration Cytology of Breast Masses in Children and Adolescents

Objective To study the distribution and efficacy of fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions in pediatric and adolescent patients. Study Design From January 1993 to December 2006, the cytology reports of 1,404 breast aspirates (178 males and 1,226 females) performed on children and adolescents (ranging from 1 to 21 years) were reviewed. Of these 41, 179, 506 and 678 aspirates belonged to the age group 1-<12, 12-<16, 16-< 19 and 19-21 years, respectively. Results The morphologic spectrum seen in females was inflammatory lesions (4%), benign ductal cells (20%), ductal hyperplasia (0.6%), papillary lesions (0.7%), benign neoplasms (69%), suspicious cytology (0.3%) and cancer (0.3%). Of the benign neoplasms, 98% (831 of 851) were fibroadenomas, with 12 cases of phyllodes (benign), 5 cases of lipoma and 3 cases of adenoma. There were 3 cases of malignancy (2 adenocarcinoma and 1 non-Hodgkins lymphoma). Only 3% of the male breast aspirates provided a diagnostic challenge, while 89% of them showed benign ductal cells. Conclusion FNAC of children and adolescent breast masses is helpful and can reduce the need for open surgery to prevent later deformity. The aspirates are mostly benign and can be managed conservatively.

Mucoepidermoid thymic carcinoma: A challenging mediastinal aspirate

Primary thymic carcinoma—mucoepidermoid cell (MEC) type is rare and only one report describing the cytologic features of this neoplasm in the metastatic site is described. We describe the cytological features of poorly differentiated carcinoma possibly MEC in a 54‐year‐old man who presented with cough, weight loss, and puffiness of face for 3 months. The significance of this infrequently encountered neoplasm lies in its potential confusion of origin of the tumor—thymus or metastases from a primary bronchial MEC. Immunocytochemical profile was suggestive of a thymic carcinoma of the MEC type. Diagn. Cytopathol. 2009.

Spindle cell lipoma: an uncommon tumour with distinctive morphology

Dear Editor, Spindle cell lipoma (SCL) is a relatively uncommon benign neoplasm arising in the subcutaneous tissue of the shoulder and at the back of the neck of older male patients. It represents approximately 1.5% of lipomatous tumours. It is characterized by a mixture of mature fat, bland spindle cells and wiry collagen in a variably myxoid background. There are a few reports of aspiration cytology findings of these tumours in the literature. A cytomorphological appraisal of the tumour is presented. A 45-year-old man presented with a painless, welldefined soft tissue swelling (2 · 2 cm) on the right side of the nape of the neck. The patient stated that the lesion had been present for more than 6 months. The swelling was clinically thought to be an enlarged lymph node or a lipoma. No other masses were noted and the past medical history was otherwise unremarkable. Fine needle aspiration was performed using a 23-gauge needle and a 10-ml syringe fitted onto a Cameco holder. Both alcohol-fixed Papanicolaou and air-dried May-Grünwald–Geimsa-stained slides were prepared. Smears from the aspirated material were cellular. Spindle-shaped cells were seen scattered singly or in aggregates with mature adipose tissue and collagen in varying proportions (Figures 1 and 2). The spindle cells had pale and poorly defined cytoplasm. The nuclei were ovoid or fusiform, basophilic with mild anisonucleosis. Some myxoid material was identified in the aspirate (Figure 2d). Nuclear grooves with intranuclear cytoplasmic inclusions were seen in many nuclei (Figure 1). A few mast cells and ropy, wiry collagen was identified (Figure 2). The cytological diagnosis was that of a benign spindle cell lesion – most likely an SCL. The surgical specimen consisted of a circumscribed piece of adipose tissue measuring 2.2 · 2 · 1.5 cm. Microscopic examination revealed mature adipose tissue and collagen bundles with a proliferation of spindle-shaped cells. The spindle cells were set in a loose stromal matrix and showed minimal pleomorphism (Figure 3). Immunohistochemical examination of the specimen showed clearly positive CD34 and bcl2 (Figure 4) staining in the spindle cell component. SCL was first described by Enzinger and Harvey in 1975 with the aim of distinguishing it from myxoid lipoma/liposarcoma, a frequent misdiagnosis. SCL is a slow-growing benign tumour seen in men between the age of 45 and 70 years. This subcutaneous tumour is frequently located in the neck and upper back. However, unusual locations such as parotid, breast and orbit have also been reported. Cytological findings of SCL are fairly characteristic. The potential clues to diagnosis of SCL include bland spindle cells with only mild nuclear atypia, mature fat, myxoid background, wiry collagen and mast cells. This together with a typical clinical presentation allows a correct diagnosis even on fine needle aspiration. Differential diagnoses for the cytological findings include neurogenic tumours, dermatofibro-