Diagnostic terminology for reporting thyroid fine needle aspiration cytology: European Federation of Cytology Societies thyroid working party symposium, Lisbon 2009.

A European Federation of Cytology Societies (EFCS) working party of 28 members from 14 European countries met at the European Congress of Cytology in Lisbon in September 2009, with two observers from the USA, to discuss the need for standardising thyroid FNA nomenclature in the light of the National Institute of Cancer (NCI) recommendations resulting from the State of the Science conference in Bethesda in 2007. The data were obtained through two questionnaires sent by email and a transcript of the live discussion at the congress, which is presented in full. The surveys and discussion showed that there were currently no national terminologies for reporting thyroid FNA in the different European countries except in Italy and the UK. Personal, 'local', surgical pathology and descriptive terminologies were in use. All but one of the working party members agreed that thyroid FNA reporting should be standardised. Whilst almost a third would adopt the NCI Bethesda terminology, which offers the advantages of a 'risk of cancer' correlation and is linked to clinical recommendations, more than half favoured a translation of local terminology as the first step towards a unified nomenclature, as has been done recently in the UK. There was some disagreement about the use of: a) the six-tiered as opposed to four or five-tiered systems, b) the use of an indeterminate category and c) the 'follicular neoplasm' category, which was felt by some participants not to be different from the 'suspicious of malignancy' category. The conclusions will be passed to the different national societies of cytology for discussion, who will be asked to map their local terminologies to the Bethesda classification, observe its acceptance by clinicians and audit its correlation with outcome.

Hepatic metastases from the spindle cell variant of medullary thyroid carcinoma: report of a case with diagnosis by fine needle aspiration biopsy.

BACKGROUND: The liver is a common site of neuroendocrine tumors (NTs) metastatic from primaries in the gastrointestinal tract, pancreas, biliary system and lungs. Medullary thyroid carcinoma (MTC) is also a potential source of metastases of NTs. Their metastases to the liver are frequent and can appear several years after the primitive tumor. Although a wide variety of cytomorphologic features are normally exhibited by MTC in smears, a spindle-shaped cell pattern can predominate, complicating the correct interpretation of a metastasis. CASE: A 63-year-old man presented with multiple liver nodules two years after a total thyroidectomy for MTC. Fine needle aspiration biopsy smears of the liver revealed neoplastic cells occurring in loose groupings or lying singly, most of them with a spindle shape and elongated nucleus with the characteristic "salt and pepper" chromatin pattern of a neuroendocrine tumor. Cytoplasmic dendritic processes and intranuclear inclusions were frequently seen. The cytomorphologic features of the tumor were essentially the same as those of the primary MTC. Immunoreactivity for calcitonin confirmed the diagnosis. CONCLUSION: In fine needle aspiration biopsy of liver masses, knowledge of the spindle pattern of the NT is important in order to achieve a correct diagnosis when metastases are the first manifestation of an occult primary tumor. Among neuroendocrine tumors, MTC must be included in the differential diagnosis.

Fine needle aspiration cytology of metastatic hepatic adrenocortical carcinoma mimicking hepatocellular carcinoma: a case report.

BACKGROUND: Adrenocortical carcinoma (AC) is a rare neoplasm, usually considered one of the most morbid and lethal human tumors. It occurs primarily in children and young adults and often presents with advanced and/or metastatic disease. CASE: A 9-year-old boy with a previous diagnosis of adrenocortical carcinoma underwent computed tomography (CT)-guided fine needle aspiration (FNA) for preoperative investigation of a hepatic mass. All smears revealed abundant groups of cells surrounding an interconnective, thin-walled, central vascular core. These cells showed finely vacuolated, large cytoplasm with eccentrically placed nuclei. Occasionally, cells underwent a sudden, marked increase in size, with prominent atypia. Multinucleated, atypical giant cells and high mitotic rate were also evident. The cytologic findings resembled the previous histologic adrenocortical carcinoma features. CONCLUSION: The cytologic features of metastatic hepatic adrenocortical carcinoma may mimic those of hepatocellular carcinoma. However, the presence of atypical multinucleated and pleomorphic cells with microvacuolated cytoplasm and eccentric nuclei as well as the absence of naked nuclei and endothelial linings yield the diagnosis of adrenocortical carcinoma. Nevertheless, other space-occupying liver lesions in children must also be considered. This case demonstrates the usefulness of CT-localized FNA biopsy in hepatic masses in children, and discusses the possible cytologic differential diagnosis.

Amylase crystalloids in salivary gland lesions: report of a case with a review of the literature.

Several types of crystalloids may be found in fine-needle aspiration cytology of salivary gland lesions. Amylase crystalloids (sometimes referred to as nontyrosine crystalloids) are tabular structures with frequent pointed ends that have received little attention until recent years. We report on a parotid cyst containing the latter type of crystalloids in a 51-yr-old white woman. The cytologic and radiologic findings were diagnostic of sialolithiasis. To the best of our knowledge, amylase crystalloids have been observed only in benign salivary gland lesions. Although this statement may be helpful in the diagnostic workup of patients presenting with parotid lumps, we do not recommend rendering a specific diagnosis based on the presence of such crystalloids. Good clinical and radiological correlation, as well as close follow-up, is mandatory in this setting.

X-linked agammaglobulinaemia and squamous lung cancer.

A 32yr-old nonsmoking male, diagnosed as having X-linked agamma-globulinemia, presented with fever, cough with purulent sputum, a very intense back pain and a mass of 10 centimetres in lower left lobe. Diagnostic evaluation revealed a squamous cell carcinoma with very aggressive metastases at L3. Malignancies are the second leading cause of death in children and adults with congenital immunodeficiency disorders, mostly non-Hodgkin lymphomas and gastric and colon adenocarcinomas, but this is the first report of lung cancer in a patient with X-linked agammaglobulinemia. Lung cancer incidence has been reported to be higher in patients with other diseases of the lung, however, there is no clear evidence of the role of bronchiectasis in developing lung cancer. It is possible that a longer survival for patients with X-LA recently diagnosed, and an association of chronic bronchial infection, could favour the development of pulmonary neoplasm.

Fine needle aspiration of breast myofibroblastoma. A case report.

BACKGROUND: The use of fine needle aspiration cytology (FNAC) for the diagnosis of breast diseases in men has received little attention. We report the cytologic and histologic findings of myofibroblastoma of the breast in a 52-year-old man. CASE: Smears disclosed irregular and cohesive sheets of cells, with ill-defined cytoplasm and oval nuclei containing single nucleoli. The nuclear membrane was frequently grooved, and occasional intranuclear cytoplasmic inclusions (pseudoinclusions) were also found. The background was clean and contained scarce collagenous stroma and fragments of myxoid material. To the best of our knowledge, there have been only seven previous reports of breast myofibroblastoma in which the cytologic features are well documented, and none of them mention the presence of pseudoinclusions. CONCLUSION: FNAC could suggest the diagnosis of this distinctly uncommon tumor if evaluated together with the clinical and radiologic findings.

Extracranial metastasis of a glioma: diagnosis by fine-needle aspiration and immunocytochemistry.

Fine-needle aspiration cytology (FNAC) is a well-established method for the rapid diagnosis of metastatic neoplasms. A case of metastatic glioma to the neck is presented. Diagnosis was made by FNAC combined with immunocytological techniques (glial fibrillary acidic protein). To the best of our knowledge, there have only been six previous cases of metastatic gliomas diagnosed by FNAC. FNAC, combined with clinical history and immunocytochemistry, is a rapid and reliable method in the definitive diagnosis of metastatic gliomas.

Neonatal juvenile xanthogranuloma. Report of a case with fine needle aspiration cytologic findings in a soft tissue mass.

BACKGROUND: Juvenile xanthogranuloma is an infrequent, benign histiocytic lesion, the recognition and diagnosis of which by fine needle aspiration biopsy are important for ascertaining whether a case will have a benign course or spontaneous regression. CASE: A case of juvenile xanthogranuloma was located in the upper lip of a newborn male. CONCLUSION: Juvenile xanthogranuloma has characteristic cytologic features that may allow recognition in fine needle aspiration cytology smears.

Seminal vesicle epithelium as a potential pitfall in the cytodiagnosis of presacral masses. A report of two cases.

BACKGROUND: Whenever abdominoperineal resection is performed because of a rectal adenocarcinoma, the prostate and seminal vesicles may be displaced backward to the presacral space, giving rise to a false radiologic image of a presacral tumor. Due to cytologic atypia associated with the epithelium of seminal vesicles, there is a real possibility, in fine needle aspiration biopsy (FNAB), of erroneously giving a malignant diagnosis. CASES: Two men, aged 53 and 57 years, presented with presacral masses three months and six years, respectively, after abdominoperineal resection for rectal adenocarcinoma. In both cases, FNAB smears showed some groups and single cells with large and irregular nuclei. These cells suggested a recurrence of carcinoma. The presence of cytoplasmic coarse pigment and a background with spermatozoa and blobs of inspissated secretory product were sufficient to determine that these presacral masses represented the seminal vesicles. CONCLUSION: Awareness that seminal vesicles may give rise to a radiologic impression of presacral tumor after abdominoperineal resection of the rectum will avoid unnecessary FNAB and a cytologic false positive diagnosis of colorectal adenocarcinoma.

Aspiration biopsy of pleomorphic lipoma of the breast. A case report.

BACKGROUND: It is well known that subcutaneous lumps in the breast may create diagnostic confusion. We report, for the first time in the cytologic literature, the features of a pleomorphic lipoma in the breast. CASE: Pleomorphic lipoma of the breast was aspirated, showing typical floret cells and mononuclear, hyperchromatic cells with scalloped nuclei, masquerading as malignancy. CONCLUSION: Pleomorphic lipoma has rather typical cytologic features that may allow its recognition when they are present in the proper clinical setting. This report illustrates another diagnostic pitfall in fine needle aspiration biopsy of the breast.

Liesegang rings in a dermoid cyst of the floor of the mouth. Report of a case with cytologic findings.

BACKGROUND: Eosinophilic, ring-shaped structures, referred to as Liesegang rings (LRs), have been identified in aspirates from many organs, usually in relation to cystic or inflammatory lesions, but never before in relation to a dermoid cyst. CASE: LRs were intermingled with squamous cells in aspirates from a cyst of the floor of the mouth. The patient, a 23-year-old man, presented with a sublingual mass that had recently grown. Histopathologic study showed a ruptured dermoid cyst with mural foci of granulomatous foreign body reaction mixed with numerous ringlike structures, LRs. CONCLUSION: To the best of our knowledge, this is the first reported case of LRs in a dermoid cyst. Pathologists should be aware of this association when diagnosing cystic lesions.

Granulomatous reaction to silicone in axillary lymph nodes. A case report with cytologic findings.

BACKGROUND: Silicone lymphadenopathy is a rare complication in patients with breast implants and is often confused with metastases from breast carcinoma. CASE: A 36-year-old female who had undergone bilateral breast augmentation six years earlier was referred for a mass in the left axilla. Fine needle aspiration showed a granulomatous reaction to birefringent material with predominance of foreign body giant cells in a lymphoid background. CONCLUSION: This report illustrates the usefulness of fine needle aspiration in axillary nodes of patients with breast implants in ruling out malignancy and diagnosing implant disruption.

Horseshoe kidney presenting as a retroperitoneal mass. Report of a case diagnosed by fine needle aspiration cytology.

BACKGROUND: Horseshoe kidney is a renal congenital anomaly. It is the result of the fusion of either upper or lower poles of both kidneys, appearing as a horseshoe-shaped structure. This anomaly is very frequent: it can be found in about 1 of every 50-1,000 autopsies). CASE: Computed tomography performed routinely after pancreatitis in a 37-year-old female showed a retroperitoneal mass of uncertain origin. Fine needle aspiration cytology (FNAC) smears evidenced normal renal tissue. Urography confirmed the diagnosis of horseshoe kidney. CONCLUSION: This is the first reported case of horseshoe kidney diagnosed by FNAC. It demonstrates the utility of FNAC for diagnosis of retroperitoneal masses, especially if they are asymptomatic.

Cytologic aspect of fibrolamellar hepatocellular carcinoma in fine-needle aspirates.

This is a review of the cytologic and clinicopathological findings seen in a series of six fibrolamellar hepatocellular carcinomas (FL-HCC) studied by means of fine-needle aspiration (FNA). A comparison of several cellular measurements (cell, nuclear and nucleolar sizes, and N/C ratios) of FL-HCC, ordinary hepatocellular carcinoma (O-HCC), and normal hepatocytes was also carried out in order to find out if these figures could be of help in the cytologic diagnosis. Aspirates were made up of a rather monotonous population of large discohesive cells resembling the morphology of the oncocytes seen in thyroid aspirates; trabecular arrangement of tumor cells was not observed. Cytoplasmic pale bodies and hyaline cytoplasmic bodies were seen in variable quantities. Microbiopsies displaying the fibrolamellar pattern were observed in four cases. FL-HCC individual tumor cells were larger than individual O-HCC tumor cells (P < 0.001), as were nuclear (P < 0.007) and nucleolar sizes (P < 0.001), but N/C ratio of O-HCC was higher than the N/C ratio of FL-HCC (P < 0.005). Based on the findings, a single cell aspirated from an FL-HCC is three times the size of a normal hepatocyte and 1.60 times the size of a single cell aspirated from a well-differentiated O-HCC. The cytologic findings of FL-HCC are very characteristic and permit a correct diagnosis of this liver malignancy, provided the cytopathologist is aware of the clinical, demographic, CT-image, biochemical, and pathological features of this neoplasm. Diagn. Cytopathol. 21:180-187, 1999.

Fine-needle aspiration biopsy of the adrenal glands: A ten-year experience.

We report on our experience in FNA biopsy of the adrenal gland: 177 biopsies performed in the last 10 years. Cytologic diagnoses were divided into four groups: nondiagnostic aspirates (28%), primary adrenal lesions (13%), metastatic neoplasms (33%), and negative cases with known extra-adrenal malignancies (25%). Among diagnostic smears and excluding the latter group, the procedure was 100% specific for malignancy, and 98% of the lesions were correctly diagnosed. There were no known false-positive or false-negative samples. Quality of diagnosis improves with careful smearing (avoids artifacts) and immediate evaluation (raises adequacy rates) by the pathologist. Although the primary or secondary nature of most adrenal masses is readily apparent, it is essential to correlate the clinical, laboratory, and cytologic findings to reach the correct diagnosis. Furthermore, we believe that the primary site of many adrenal metastases must be defined on the basis of clinical data. Diagn. Cytopathol. 1999;21:92-97.

Lymphoepithelial cyst with crystalloid formation. Cytologic features of two cases.

BACKGROUND: The presence of amylase crystalloids (AC) in cystic lesions of the parotid gland is a rare occurrence and has been diagnosed to date as sialadenitis. We report the first two cases of parotid lymphoepithelial cyst (LC) containing this type of crystalloid. CASES: Case 1, a 56-year-old male, presented with a 3-cm parotid cyst. Fine needle aspiration (FNA) was performed on the mass. Smears showed numerous crystalloids identical to those described as crystallized amylase. Case 2, a 36-year-old female, had a 2-cm parotid mass. FNA smears exhibited the same features as did case 1. The two patients were treated with superficial parotidectomy, and an LC containing AC was diagnosed in both cases. CONCLUSION: When the above findings are present on FNA of parotid gland, the diagnosis of LC must be considered.

Breast carcinoma in situ in a male. Report of a case diagnosed by nipple discharge cytology.

BACKGROUND: Cytologic evaluation of abnormal nipple secretion is a well-established method for the rapid diagnosis of breast carcinoma in females. However, less attention has been focused on male patients presenting with nipple discharge. CASE: A case of intraductal carcinoma of the male breast was diagnosed by nipple discharge cytology alone. CONCLUSION: This report illustrates the usefulness of nipple discharge cytology in the diagnosis of early breast carcinoma in males.

Metastatic squamous cell carcinoma in a liver graft. Report of a case diagnosed by fine needle aspiration.

BACKGROUND: Fine needle aspiration is a well-established and safe method for the diagnosis of focal liver lesions, but it has played a limited role in the transplant setting. CASE: A case of metastatic squamous cell carcinoma in a liver graft was diagnosed by fine needle aspiration. The tumor developed in the right pyriform sinus five years after an orthotopic liver transplantation was performed. CONCLUSION: With the improvement of survival rates following liver transplantation, metastatic tumors should be considered in liver grafts with space-occupying lesions. Therefore, fine needle aspiration is adequate for diagnosis and is cost-effective and safe.