Shelly Sehgal

A Cytological Study of Palpable Superficial Nodules of Parasitic Origin: A Study of 41 Cases

Background. Few parasitic infestations present as only superficial palpable subcutaneous or intramuscular nodule. The current study highlights the role of FNAC in the diagnosis of superficial palpable parasitic lesions. Methods. This was a retrospective study in which we reviewed the FNAC record of all patients over a period of two years from September 2011 to August 2013. During this period, FNA was performed on 5954 cases which presented as superficial palpable lump at various sites of body. There were 41 cases diagnosed as parasitic lesion or suspicious of parasitic lesion on cytology which were included in the study. Results. In the present study, most of the patients were children and young adults. The lesions were located over trunk in 18 (43.9%) cases, extremities in 12 (29.3%) cases, and head and neck region in 11 (26.8%) cases. Out of 41 cases, 27 (65.8%) cases were confirmed on cytology and/or histopathology as parasitic lesions, including 21 (51.2%) cases of cysticercosis, 5 (12.2%) cases of filariasis, and one (2.4%) case of hydatid cyst. Cytological findings of remaining cases were suggestive of parasitic lesion. Conclusion. Careful assessment of cytological material is helpful to detect parasite or inflammatory response to parasite even in asymptomatic patients.

Fine-needle aspiration cytology of myoepithelial carcinoma of salivary gland: Diagnostic challenge to cytopathologist.

Myoepithelial carcinoma (MC) is rare malignant salivary gland neoplasm and its cytologic features have been rarely described in the literature. Furthermore, MC shows varied cell types and patterns leading to the wide range of differential diagnosis on cytology. Histopathology and immunohistochemistry (IHC) are necessary to make a definite diagnosis. A 37-year-old female presented with painless, progressive swelling in the infra-auricular region since 2 years. Fine-needle aspiration cytology was performed and cytological possibilities of cellular pleomorphic adenoma and myoepithelial cell neoplasm were rendered and patient was advised excision and histopathologic examination for final diagnosis and subtyping. Final diagnosis of MC was made on hematoxylin and eosin sections and IHC. MC is rare malignant salivary gland tumor showing a clinic-pathologic diversity. The cytological features of MC are diverse and may lack overt feature of malignancy. Pathologists should be aware of this entity while evaluating cytological smears of salivary gland mass.

Histopathological Correlation of Atypical (C3) and Suspicious (C4) Categories in Fine Needle Aspiration Cytology of the Breast

Introduction. According to the National Cancer Institute (NCI) guidelines in 1996, breast lesions are categorized as C1 to C5 on fine needle aspiration (FNA) cytology. Very few studies are available in the English literature analyzing histopathology outcome of C3 (atypical, probably benign) and C4 (suspicious, probably malignant) lesions. Our study aims to correlate FNA cytology of breast lump diagnosed as C3 and C4 lesion with histopathological examination. Methods. During a period of 2 years, 59 cases of C3 and 26 cases of C4 were retrieved from total 1093 cases of breast FNA. All the cases were reviewed by two cytopathologists independently. The final 24 cases of C3 and 16 cases of C4 categories were correlated with histopathological diagnosis. Result. Among C3 category, 37.5% revealed malignant findings, whereas of C4 category, 87.5% were malignant on histopathology. This difference was statistically significant (P = 0.0017). Sensitivity, specificity, positive predictive values, and negative predictive value of C4 category in diagnosing breast malignancy were 60.8%, 88.2%, 87.5%, and 62.5%, respectively. Conclusion. Although FNAC is simple, safe, cost-effective and accurate method for diagnosis of breast masses, one must be aware of its limitations particularly in C3 and C4 categories. Also, since both these categories carry different probabilities of malignancy and thus different management, we therefore, support maintaining C3 and C4 categories.

Aggressive angiomyxoma in pregnancy.

Aggressive angiomyxoma (AA) is a rare, slow-growing mesenchymal neoplasm of vulvo-perineal region. Although AA is common in females of reproductive age, only a few cases during pregnancy have been documented in the English literature. It carries a high risk of local recurrence but rarely metastasizes. The high recurrence rate can partially be due to inadequate excision, which may be due to an incorrect preoperative diagnosis. We present a case of 25-year-old pregnant female presenting with a painless and soft mass attached to left labia majora by a stalk. This mass was clinically thought to be a lipoma. It was completely excised and was diagnosed as AA on histopathology. Gynecologists should consider the diagnosis of AA when a young female especially during her pregnancy presents with a vulvo-perineal mass. Incorrect diagnosis may lead to incomplete excision and recurrence.

Fine needle aspiration cytology of epithelioid hemangioendothelioma of soft tissue

Dear Dr. Bedrossian: We report an interesting case of epithelioid hemangioendothelioma of soft tissue in an 80-year old farmer who presented to pathology department with left upper forearm swelling size 10 3 7 cm for the past 5 years. On physical examination, the swelling was soft to slightly firm with irregular surface. It was located in superficial plane and was free from underlying musculature. Patient had no systemic complaints. Ultrasonographic examination of the swelling revealed a large well-defined isoechoic to hypoechoic lesion measuring 10 3 6 cm in left upper forearm superficial to flexor group of muscles. The lesion showed large fluid filled spaces suggestive of blood and no surrounding infiltration was evident. His routine investigations including hemogram, urine routine examination, chest X-ray, and ultrasound abdomen were all within normal limits. Fine needle aspiration (FNA) of the lesion was performed using 23G needle and May-Grunwald-Giemsa stained smears were examined. FNAC demonstrated cellular smears of loosely cohesive clusters of bland ovalto spindle-shaped cells having pink basement membrane like material (Figs. 1 and 2) and many capillary like fragments in a haemorrhagic background. Admixed with these cellular fragments were many polygonal (epithelioid), mildly atypical cells having abundant dense cytoplasm (Fig. 3). These atypical cells had round to reniform hyperchromatic nuclei with irregular nuclear margins and prominent nucleoli. Many intranuclear inclusions were also seen (Fig. 4). The cytoplasm of atypical cells at place showed fine vacuoles. Based on these observations, possibility of vascular neoplasm was suggested and the patient was advised excision of the lesion. Subsequently, excised specimen was received as soft tissue irregular mass measuring 12 3 7 cm. Cut surface of the lesion was soft to firm having gray tan appearance with small blood filled spaces. Hematoxylin and eosin-stained slides revealed a vascular tumor. Tumor cells were arranged in solid nests and cords (Fig. 5). There were roundto spindle-shaped cells with moderate to abundant

Clear cell hidradenoma of breast mimicking atypical breast lesion: a diagnostic pitfall in breast cytology

Clear cell hidradenoma (CCH) is an uncommon skin adnexal tumor arising from eccrine glands. Although several kind of skin adnexal tumors arise in the breast tissue, CCH of the breast is an extremely rare entity. Failure to identify its cytomorphologic features and rarity of this tumor may lead to misdiagnosis on fine needle aspiration cytology. Hereby we report a case of 30-year-old female who presented with painless lump in left breast since 10 months. Fine needle aspiration cytology of lump yielded fluid material. On May-Grunwald-Giemsa stained smears, a possibility of atypical breast lesion was considered and patient was advised a biopsy examination. Final diagnosis of CCH was made on histopathologic examination. Awareness of cytomorphologic features of breast CCH will prevent misdiagnosis as malignant or atypical breast lesions and will allow for correct management of the patients.

Ossifying fibromyxoid tumor — Diagnostic challenge for a cytopathologist

Sir, We present an interesting case of a 51-year-old male who presented with a history of a gradually increasing, painless swelling on the right wrist, for the past — three to four months. Local examination showed a firm swelling measuring 3 cm in diameter, free from overlying skin and underlying muscles. The patient did not given any history of trauma. A plain radiograph of the wrist revealed a well-circumscribed soft tissue tumor, with an incomplete shell of calcification. No involvement of the underlying bone was seen. The patient was advised Fine Needle Aspiration (FNA) Cytology. FNA was performed with a 23 gauge needle. Scanty blood mixed aspirate was obtained. Smears were both air-dried and wet-fixed, and stained with May-Grunwald-Giemsa (MGG) and Papanicolaou stains, respectively. The FNA smears were moderately cellular showing predominantly singly scattered dispersed cells and a few cells arranged in clusters [Figures ​[Figures11 and ​and2].2]. At few places, small rosette-like aggregates were also seen [Figure 3]. The tumor cells were polygonal to spindle-shaped, having round-to-oval paracentral nuclei [Figures ​[Figures22 and ​and33 inset] and moderate-to-abundant cytoplasm, in the background of scanty myxoid stroma. The nucleus showed bland nuclear chromatin and small inconspicuous nucleoli. No cytological atypia, mitosis, or necrosis was seen. Based on the clinicoradiological and cytological features, a cytodiagnosis of benign mesenchymal tumor with possibility of ossifying fibromyxoid tumor (OFMT) was rendered and histopathological confirmation advised. Figure 1 Cytology smears showing moderate cellularity, cells present in clusters (Giemsa, ×40) Figure 2 Cytology smears showing moderate cellularity, cells present in clusters (Papanicolaou, ×40) and inset shows dispersed cells with paracentral nuclei (Papanicolaou, ×40) Figure 3 Cytology smears showing dispersed cells and few cells arranged in rosette-like structure (Giemsa, ×40) and inset shows dispersed cells with paracentral nuclei (Giemsa, ×40) Subsequently, the excised specimen was received, as a well-circumscribed, encapsulated mass, measuring 3.5 × 3.0 cm. The cut surface was gray-white, solid, homogenous, and firm in consistency [Figure 4], with a gritty sensation near the subcapsular area. Multiple sections showed a well-encapsulated tumor, with a partial shell of calcification [Figure 5a]. The tumor cells were arranged in large diffuse sheets [Figure 5b], cords, and nests, within the myxohyaline matrix [Figure 6]. Individual cells had an epithelioid appearance, with uniform cell-to-cell spacing. The tumor cells were round-to-ovoid, with vesicular nuclei, having small nucleoli and pale moderate cytoplasm [Figure 6 inset]. Few cells showed nuclear grooving. Mitotic counts varied from 0 – 1 / 50 high power field. No area of cytological atypia or necrosis was observed. The panel of immunostains comprising of cytokeratin (CK), Vimentin, S-100, smooth muscle actin (SMA), and epithelial membrane antigen (EMA) was applied using standard protocols, with the streptavidin-biotin complex technique. The tumor cells showed positivity for S-100 and vimentin and negative for the rest of the markers [Figures ​[Figures7a7a-​-7d].7d]. The final diagnosis of OFMT was made, and the patient was kept on follow-up. Figure 4 Gross specimen showing a well-circumscribed, encapsulated mass with a homogenous cut surface Figure 5 (a) Section showing tumor with calcification in the capsule (H and E, ×10) (b) Section showing tumor cells arranged in diffuse sheets (H and E, ×10) Figure 6 Section showing tumor cells embedded in myxoid stroma (H and E, ×10) and inset shows rounded-to-ovoid cells with vesicular nuclei and moderate cytoplasm (H and E, ×40) Figure 7 (a) Section showing cytoplasmic and nuclear S-100 positivity in tumor cells (S-100, DAB, ×40) (b) Section showing focal vimentin positivity in tumor cells (Vimentin, DAB, ×40) (c) Section showing tumor cells negative for CK (CK, DAB, ×40) ... Ossifying fibromyxoid tumor of the soft tissue was first described in a series of 59 cases from the Armed Forces Institute of Pathology, by Enzinger, in 1989.[1] It is a rare tumor of uncertain differentiation. OFMT almost exclusively affects adults (mean age of 50 years), with only rare examples documented in children.[2] There is a slight male predominance. OFMTs are present as relatively small (mean size 3 cm), painless, well-defined subcutaneous masses, which involve the extremities, in approximately 70% of the cases. Radiologically, OFMT presents as a well-circumscribed mass, with an incomplete rim of calcification / ossification in the periphery.[3] The cytomorphological features of OFMT have not been adequately described in literature. To the best of our knowledge, there are only four cytological descriptions[4–7] of OFMT to date. Out of which one is that of a malignant variant of OFMT[7] and another has been misdiagnosed as a follicular neoplasm, because the lesion had a pre-thyroid location, and FNAC showed epithelioid cytomorphology in rosette-like aggregates.[5] The remaining case reports have shown moderate-to-high cellularity and myxoid matrix material, with small clusters and dispersed oval-to-spindle cells embedded in the matrix. We also report similar findings; however, the matrix material was relatively less in our smears, as compared to the previously mentioned case reports. Histopathology and immunohistochemistry (IHC) further confirm the diagnosis of OFMT. Typical OFMT shows a tumor composed of lobules and cords of small bland cells in a myxohyaline background, with frequent peripheral ossification. The cytological differential diagnosis includes lesions with fibromyxoid stroma and epithelioid-to-spindle cell cytomorphology.[8] The list includes glomus tumor, chondroid syringoma, epithelioid schwannoma, epithelioid smooth muscles tumors, and tumors with pseudosarcomatous differentiation, such as, nodular fasciitis, proliferative fasciitis, myositis ossificans, and low-grade fibromyxoid sarcoma [Table 1].[9–13] None of these lesions shows the characteristic rim of calcification in the capsule, which is characteristic of the radiological picture and sections of OFMT. Further immunohistochemistry with a panel comprising of CK, EMA, Vimentin, SMA, and S-100, can aid in rendering the correct diagnosis and ruling out the differentials. The malignant variant of OFMT needs to be differentiated from the extra-skeletal myxoid chondrosarcoma, extra-skeletal osteosarcoma, and epithelioid malignant peripheral nerve sheath tumor (MPNST). Table 1 Cytological differential diagnosis of OFMT The clinical behavior in most cases is that of a benign tumor, but almost 22% show local recurrence[14] and distant metastases have been seen in 6% of the cases.s[15] Hence, it is now considered to be a tumor with intermediate malignancy. The histogenesis of this rare tumor is debatable, although recent studies have suggested neuroectodermal differentiation.[16] Features associated with aggressive behavior are high cellularity, high nuclear grade, mitotic activity > 2 / 50 hpf, area of necrosis, vascular invasion, prominent spindling, and deposition of centrally placed osteoid.[17] Such a lesion, with aggressive morphology, has higher chances of local recurrence. Folpe et al.[18] proposed the criteria for diagnosis of atypical and malignant OFMT. To conclude, OFMT is a rare soft tissue neoplasm of intermediate malignant potential. With increasing use of aspiration cytology in the preoperative diagnosis of soft tissue neoplasms, a cytopathologist needs to be aware of the cytological features of this uncommon neoplasm in order to facilitate an accurate diagnosis.

Fine-needle aspiration cytology of eccrine hidrocystoma

Sir, We present a case of 59-year-old woman who presented with solitary small translucent cystic nodule measuring 1 cm in diameter on the left shoulder which had been present for 3 months. The patient denied any significant complaints associated with the lesion. The physical examination was noncontributory. The patient underwent FNA and scanty, clear fluid was aspirated. May Grunwald Giemsa (MGG) and Papanicolaou stained cytological smears and cytospin preparation showed scanty cellularity comprising small sheets of cuboidal cells against a proteinaceous background [Figures ​[Figures11 and ​and2].2]. The cells were uniformly sized having round-to-oval nuclei with inconspicuous nucleoli and scant-to-moderate pink granular cytoplasm. There was no evidence of any cytological atypia and no papillary structures were seen in our smears. Cytological diagnosis of the cystic lesion with the possibility of benign adnexal neoplasm was rendered and patient was advised excision of the lesion for confirmation and subtyping. Figure 1 Photomicrograph showing monolayered sheets of benign ductal cells (MGG, 10×) and inset showing loosely cohesive acini of benign ductal cells with moderate cytoplasm (MGG, 40×) Figure 2 Photomicrograph showing loosely cohesive cluster of benign ductal cells with moderate cytoplasm (Papanicolaou, 40×) Subsequently, the excision biopsy was received as fibrofatty tissue measuring 1 × 0.6 × 0.2 cm. Hematoxylin and eosin stained sections revealed a dilated, cystic cavity in lower dermis and subcutis. The cyst wall was lined by a double layer of small cuboidal epithelium [Figure 3]. At places, a single layer of flattened epithelium with nuclei arranged parallel to the cyst wall was present. Small papillary projections extending into the cavity were also identified. Small eccrine ducts were present in close approximation to the cyst. Final diagnosis of eccrine hidrocystoma (EH) was made and the panel of immunostains comprising of CK7 and S100 was applied. The luminal cells stained positive for CK7 [Figure 4a] and abluminal cells showed positivity for S100 [Figure 4b], thus confirming diagnosis of solitary EH. Figure 3 Photomicrograph showing cystic spaces lined by a double layer of cuboidal epithelium thrown into small papillae at places (H and E, 10×) and inset showing cystic spaces lined by a double layer of cuboidal epithelium (H and E, 40×) Figure 4 (a) Photomicrograph showing cytoplasmic CK7 positivity in luminal cells (CK7, DAB, 40×), (b) Photomicrograph showing cytoplasmic S100 positivity in abluminal cells (S100, DAB, 10×) Hidrocystomas are rare, benign cystic lesions of the skin. They can be either eccrine or apocrine and are found predominantly on the head and neck region. EH are small and tense thin-walled cysts ranging from 1 mm to 6 mm in diameter and can occur as single or multiple lesions. They are found predominantly in adult females and are located mostly on periorbital and malar regions.[1,2] In our case the lesion was located on the left shoulder, which is relatively a rare site for EH. EH is currently classified in two major groups: the Smith type, which is more prevalent solitary type and Robinson or multiple types. The individual lesions of multiple types are similar to Smith type, except they are smaller.[3] EH usually result from dilation of cystic excretory eccrine glands due to retention of sweat and blockade and dilation of sweat duct.[1] Tokura et al.[4] suggested that solitary EH is derived from the secretory coil and multiple ones are derived from the duct. Apocrine hidrocystoma (AH) is closest differential which needs to be ruled out before making final diagnosis of EH.[1,5–8] AH are also cystic lesions found mostly on the head and neck and arise from proliferation of apocrine gland. AH is usually solitary with diameter of 3-15 mm. AH also affects the same age group as EH. However, AH should be regarded as cystic adenoma rather than a retention cyst as the secretory cells do not appear flattened. Also, the cyst wall in AH is composed of inner layer of secretory, columnar epithelium which lies above the outer myoepithelial cell layer. At places, the secretory epithelium shows decapitation and papillary projections, which is not usually seen in EH. PAS positive granules are observed in AH unlike EH which are negative on PAS staining.[1] On IHC, solitary EH, typically shows CK7 positivity in luminal cells and S100 positivity in abluminal cells.[1,8,9] AH and multiple EH are negative on S100 staining. In contrast, AH shows positivity for GCDFP15 suggesting origin from glandular secretory spirals.[1,3] Clinically, other cystic lesions such as epidermal inclusion cyst, comedone, mucoid cyst, hemangioma, lymphangioma, and steatocystoma multiplex are considered in differential.[1] But all these lesions differ from EH both cytological [Table 1] and histologically. Very often, hidrocystomas (mostly AH) present as blue-black colored nodules and hence its differentiation from melanoma and basal cell carcinoma Table 1 is important.[10] We suggest that prior to excision biopsy needle aspiration can successfully establish diagnosis of EH and helps to rule out other common benign cystic and malignant skin conditions. Cytologic reports describing EH are relatively rare and few case reports that exist describe cytomorphology of AH only.[11,12] Hence, cytopathologist needs to be aware of the FNA picture of this benign cystic lesion to be able to make a correct diagnosis. Table 1 Cytological differential diagnosis of Eccrine hidrocystoma We presented this paper with the aim to document cytologic picture of EH. In our case we report sheets and small groups of benign ductal cells with scant-to-moderate granular cytoplasm. No papillary structures were seen in our case. AH, on the other hand, show papillae and loosely cohesive cells with abundant cytoplasm suggesting secretory activity. Other benign cystic and malignant skin lesions can also be successfully ruled out on needle aspiration, thus guiding the clinician regarding extend of excision needed and further course of treatment. EH are completely benign and successfully treated on excision biopsy without any recurrence after the excision.[13–15] To conclude, hidrocystomas are benign cystic lesions that typically occur in the facial region. Eccrine and apocrine hidrocystoma comprise two main groups and are closest mimics clinically. However, EH can be differentiated from apocrine counterpart on needle aspiration and also from other common benign cystic and malignant skin lesions [Table 1]. The cytopathologist should, therefore, keep in mind this entity while considering differentials for benign cystic lesions of skin. Histopathology and IHC may be used to further confirm the diagnosis.

Rare carcinoma ex-pleomorphic adenoma of buccal mucosa: case report and review of literature

Carcinoma ex pleomorphic adenoma (CXPA) is exceedingly rare in minor salivary glands of oral cavity. We present a case of CXPA arising from buccal mucosa in a 44-year-old male patient. The man presented to surgery outpatient department with right buccal mucosa swelling. Clinical impression suggests a neoplasm of buccal mucosa and the patient was sent for fine needle aspiration cytology. By examining the cytological smears, possibility of carcinoma was revealed. The mass was dissected and excised with safety margins. Examining Hematoxylin and Eosin slides, final diagnosis of CXPA was given. Patient did not turn for regular follow-ups and presented 1 year after surgery with recurrence at the same site. CXPA is an uncommon malignant tumor with highly aggressive biological behavior. Its occurrence in sites like buccal mucosa is rare. Hence, quite a diagnostic challenge at such sites cause diagnostic difficulties.

Dermatofibrosarcoma Protuberans in a Child: A Case Report

Background. Dermatofibrosarcoma protuberans (DFSP) is an intermediate grade soft tissue neoplasm originating from the dermal layer of the skin. It usually occurs in adults; however, it can rarely be seen in infancy and childhood. Diagnosis of DFSP in children is quite difficult-given-rarity of this lesion, its variegated appearance, and its presentation sometimes at unusual sites. Case. We present the case of five-year-old boy who came with painless lesion on a forehead. Fine needle aspiration cytology (FNAC) suggested possibility of mesenchymal neoplasm. Patient was advised excision biopsy. Final diagnosis of DFSP was made based on histopathological findings. The patient was then advised reexcision surgery with wide margins. The patient was lost to followup and later turned up after two months with recurrence of a similar swelling at the same site. Conclusion. DFSP in children is rare and difficult to diagnose. Treatment of childhood DFSP is often delayed leading to incomplete excision. Hence, there is need to recognize and appropriately manage this uncommon childhood neoplasm.