Lumps and Bumps on the Abdominal Wall: Role of Fine Needle Aspiration Cytology.

OBJECTIVE: Abdominal wall masses often pose diagnostic challenges for clinicians due to their nonspecific symptoms. They include a wide spectrum of lesions ranging from inflammatory to tumor-like masses and malignancies. The majority of the malignant nodules are metastatic in origin and may be the initial presentation of a primary malignancy; hence, an early diagnosis is important. Fine-needle aspiration cytology (FNAC) is a valuable diagnostic tool in the evaluation of such lesions. This was a retrospective study of the cytomorphological spectrum of abdominal wall masses, conducted at a tertiary health care centre over a three-year period. MATERIAL AND METHODS: The study included patients of all age groups presenting with an abdominal wall mass. These lesions were assessed by FNAC. The diagnosis was made on cytology smears and subsequently correlated with the histopathological diagnosis, wherever possible. RESULTS: Of the 70 cases, 21 were non-neoplastic and 49 neoplastic. A benign neoplasm was the most common lesion (52.9%), followed by non-neoplastic lesions (30%) and malignant neoplasms (17.1%). Lipoma was the most common benign neoplasm and metastasis was the commonest malignant neoplasm. The most common type of tumor metastasising was adenocarcinoma and the primary tumors were predominantly intra-abdominal. No false-negative results were seen. CONCLUSION: Most of the abdominal wall masses display a characteristic cytomorphology, which needs to be identified and recognized by a cytopathologist for an accurate diagnosis. FNAC plays an invaluable role in the detection of metastases, especially at sites such as the umbilicus, which may be the only manifestation of an underlying advanced malignant disease.

Hepatocellular carcinoma presenting as a chest wall mass - An unusual case diagnosed on cytology with review of literature.

Hepatocellular carcinoma (HCC) is associated with an aggressive behavior and a strong tendency for extrahepatic metastasis. Although 5%-15% patients have metastases at diagnosis, presentation with symptoms exclusively related to extrahepatic metastases is rare. An 82-year-old male presented with an isolated left anterolateral chest wall swelling. Ultrasonography revealed a soft tissue mass involving the anterior chest wall with adjacent rib erosion. Serum protein electrophoresis showed increase in beta-2 region. A clinical diagnosis of multiple myeloma was considered. Fine needle aspiration cytology from the swelling showed loosely cohesive clusters of polygonal cells with traversing blood vessels. Cells showed abundant vacuolated to granular cytoplasm, round nuclei with frequent intranuclear cytoplasmic inclusions. A differential of metastatic HCC and renal cell carcinoma was considered. Subsequent imaging showed a 12 cm mass in the liver. Biopsy from chest wall mass with immunohistochemistry confirmed the diagnosis. Lungs and lymph nodes are the commonest sites for metastatic HCC; presentation as chest wall metastasis is rarely reported. The classical cytomorphology of HCC proved useful in diagnosing metastasis at a rare site. Recent studies have shown that beta-2-globulin is a promising biomarker for early diagnosis of HCC in patients with chronic liver disease.

Utility of the Proposed Sydney System for Classification of Fine-Needle Aspiration Cytopathology of Lymph Node: A Retrospective Study at a Tertiary Care Center.

INTRODUCTION: Fine-needle aspiration cytology (FNAC) is an established first-line technique for the evaluation of lymphadenopathy and, with the help of ancillary testing, can in many instances obviate the need for an open biopsy. The Sydney system was recently proposed to provide consensus guidelines for the performance, classification, and reporting of lymph node FNAC. The present study was undertaken to evaluate its utility and study the impact of rapid on-site evaluation (ROSE). MATERIAL AND METHODS: A retrospective analysis in which 1,500 lymph node FNACs was reviewed and assigned a diagnostic category from the Sydney system. Cyto-histopathological correlation and adequacy parameters were evaluated. OBSERVATION AND RESULTS: The cervical group of lymph nodes was the commonest group aspirated (89.7%). A total of 1,205/1,500 (80.3%) cases were category II (benign), and necrotizing granulomatous lymphadenitis was the most common pathology. The 750 cases with ROSE were subclassified as follows: 15 category I (inadequate), 629 category II (benign), 2 category III (atypia of undetermined significance), 9 category IV (suspicious for malignancy), and 95 category V (malignant). Among 750 cases without ROSE, 75 cases were in category I, 576 in category II, 3 in category III, 6 in category IV, and 90 in category V. Category I was thus significantly lower in the ROSE group compared to the non-ROSE group. Overall, the risk of malignancy was L1-0%, L2-0.20%, L3-100%, L4-92.3%, and L5-100%. Accuracy parameters revealed a sensitivity of 97.7%, specificity of 100%, PPV of 100%, NPV of 99.10%, and diagnostic accuracy of 99.54%. DISCUSSION AND CONCLUSION: FNAC can be used as the 1st line of treatment for lymph node pathology. ROSE can be used as an add-on to FNAC for reducing unsatisfactory rates and help triage material for ancillary testing whenever possible. The Sydney system should be implemented for achieving uniformity and reproducibility.

Langerhans cell histiocytosis: A diagnostic challenge on thyroid fine needle aspiration cytology.

Thyroid gland involvement by Langerhans cell histiocytosis (LCH) is extremely rare. A 28-year-old woman with a history of polyuria, polydipsia and amenorrhoea presented with a diffuse thyroid swelling of 2 months duration. Clinical diagnosis was diabetes insipidus. Endocrine profile was normal. Fine needle aspiration cytology (FNAC) from thyroid revealed numerous large histiocytes with prominent nuclear grooves against an inflammatory background rich in eosinophils. A diagnosis of LCH was made and immunocytochemistry with CD1a confirmed the same. Subsequent skin biopsy also showed LCH. FNAC diagnosis of LCH in thyroid is challenging. The diagnostic pitfalls range from thyroiditis due to the presence of inflammatory cells in the background to papillary thyroid carcinoma due to grooved nuclei. Additional material should be collected at FNAC for ancillary studies to confirm the diagnosis.

Fine-Needle Aspiration Biopsy Cytopathology of Breast Lesions Using the International Academy of Cytology Yokohama System and Rapid On-Site Evaluation: A Single-Institute Experience.

INTRODUCTION: Breast cancer is rapidly emerging as the leading cause of cancer in Indian women. Robust cytopathology and histopathology services are required to tackle this growing burden. The use of rapid on-site evaluation (ROSE) and the International Academy of Cytology (IAC) Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytopathology, which offers structured protocols, are expected to improve breast cytopathology reporting. METHODS: We retrieved the cytopathology slides, categorized them by the IAC Yokohama System and histopathology data of all the patients who had been investigated for breast lesions from September 2016 to December 2018, and compared the cytopathology and histopathology. Risk of malignancy (ROM) and performance metrics, like sensitivity, specificity, predictive values, accuracy, and area under the curve were computed. RESULTS: A total of 1,147 FNABs were evaluated, of which 442 (38.5%) underwent ROSE and 624 (54.4%) histopathology. Reported using IAC categories, our cohort recorded 4.9% inadequate, 65.3% benign, 7.8% atypical, 3.3% suspicious for malignancy, and 18.7% malignant lesions. The overall sensitivity and specificity for identifying in situ and malignant lesions were 99.1% and 99.3%, respectively, and were substantially improved by ROSE. ROSE improved the concordance between cytopathology and histopathology from 76.9% to 90.2%, by reducing inadequate (p < 0.001) cases. The ROM increased along a gradient from inadequate to malignant categories, with the gradient being sharpened by ROSE. The false negativity rate was 0.7% and false positivity rate 0%. CONCLUSION: Incorporating ROSE and the IAC Yokohama System for breast cytopathology reporting improves accurate diagnosis of breast lesions, prevents missed diagnoses, and provides reliable estimates of ROM. These protocols also aid in standardizing a reproducible system for monitoring and auditing of breast pathology services, identify areas that need strengthening, and improve training at pathology centers.

Utility of the Milan system for reporting salivary gland cytopathology: A retrospective 5 years study.

BACKGROUND: Fine-needle aspiration cytology (FNAC) is an established technique for preoperative diagnosis of salivary gland lesions; however, lack of a uniform reporting system has been a handicap. The main aims of this study were to evaluate the utility of the - "The Milan System for Reporting Salivary Gland Cytopathology" (MSRSGC) and ascertain the risk of malignancy (ROM) for each category. METHODS: All salivary gland FNACs over 5 years (January 2014-December 2018) were reviewed and assigned a diagnostic category from the MSRSGC. Clinical data were taken from Cytology records. Cytodiagnosis was correlated with histopathology wherever available and ROM was calculated. RESULTS: A total of 120 salivary gland FNACs were studied. Age ranged between 5 and 85 years, male:female ratio was 2:1 and parotid was the commonest gland aspirated. Cases were reclassified as I non-diagnostic (2.5%), II non-neoplastic (15%), III atypia of uncertain significance-AUS (1.7%), IV A neoplasm benign (50%), IV B neoplasm of uncertain malignant potential (12.5%), V suspicious for malignancy (5%), and VI malignant (13.3%). Follow-up was available in 70 (58.3%) cases. The sensitivity, specificity, negative predictive value, and positive predictive value were 92.3%, 100%, 100%, and 98.27% respectively. ROM was non-neoplastic (0%), AUS (50%), neoplasm benign (0%), neoplasm of uncertain malignant potential (28.6%), suspicious for malignancy (100%), and malignant (100%). CONCLUSION: Salivary gland FNAC is a reliable diagnostic tool and the "Milan system" will further increase FNA reliability, help risk stratification, and improve patient care.

Warthin-Finkeldey giant cells-A useful clue for the cytodiagnosis of Kimura disease: A report of three cases.

Kimura disease (KD) is a rare, idiopathic chronic inflammatory disorder that usually presents as unilateral painless lymphadenopathy or soft tissue swelling of the head and neck region in young Asian males. The disease lacks pathognomonic clinical and cytomorphological features and can be mistaken for many reactive and malignant conditions. We report three cases of KD presenting as bilateral swelling of the head and neck region, and describe the cytomorphological features of each. In the correct clinical setting, a polymorphous lymphoid aspirate with eosinophils and Warthin-Finkeldey giant cells should raise a suspicion of KD and prompt further work up.

Fibroadenoma versus phyllodes tumor: a vexing problem revisited!

BACKGROUND: Fibroepithelial lesions of the breast include fibroadenoma (FA) and phyllodes tumor (PT). Fibroadenomas are benign while phyllodes tumor range from benign, indolent neoplasms to malignant tumors capable of distant metastasis. Our study was to determine the select cytologic features that can accurately distinguish FA from PT. METHODS: A retrospective review was performed of patients who had histopathology follow up of FA or PT and on whom a pre-operative fine needle aspiration was performed. Cytologic criteria i.e. epithelial component, stromal component and background cellularity were assessed. RESULTS: 46 FA and 24 PT were specimens were reviewed. Median age and tumor size for FA and PT were 23.0 and 39.0 years, and 2.0 and 5.0 cm, respectively. Univariate analysis and regression models based on generalized estimating equations revealed that large opened out, folded epithelial sheets, frayed and irregular stromal fragment contours, spindle stromal cell nuclei, spindle cell nuclei in the background and background cell atypia are significant cytological predictors of PT. The GEE regression model achieved 78.9% diagnostic accuracy (p <  0.001) in identifying PT based on cytological features. Median epithelial: stromal ratio was 3.4 and 2.6 for FA and PT, respectively. CONCLUSION: Presence of large, opened out, folded epithelial sheets, frayed and irregular stromal contours with spindle nuclei, background spindle cells and atypia can help distinguish PT from FA.

Diagnostic utility of urine cytology in detection of decoy cells in renal transplant patients: Report of five cases and review of literature.

BK polyoma virus (PV) is one of the commonest post-transplant viral infections, affecting approximately 15% of renal transplantation recipients, leading to graft failure in more than half of cases. The epithelial cells with polyoma viral inclusions in urine cytology specimens are termed "decoy cells" to caution pathologists not to misdiagnose these cells as cancer cells. The infected cells in urinary sediments are characterized by enlarged nucleus, basophilic intranuclear homogenous inclusions, and ground glass chromatin, which may cause diagnostic error in urine cytology. We report five cases of renal transplant patients, in which urine sample was positive for decoy cells. Routine urine cytology of post renal transplant patients with worsening renal function is a useful screening procedure to rule out PV reactivation, before ascertaining transplant rejection. Its cost-effectiveness in addition to the short processing time makes it an invaluable tool in the evaluation of transplant recipients with symptoms suggestive of graft rejection.

This 'Rose' Has no Thorns-Diagnostic Utility of 'Rapid On-Site Evaluation' (ROSE) in Fine Needle Aspiration Cytology.

Fine needle aspiration (FNA) cytology is a basic diagnostic technique used to investigate superficial and deep swellings. Rapid on-site evaluation (ROSE) using toluidine blue (TB) is easily available, cheap, cost-effective, can be used both for testing adequacy and giving provisional diagnosis. To evaluate the role of ROSE using toluidine blue staining in arriving at a diagnosis in comparison to routine stains. A total of 1500 cases of FNA of palpable swellings from sites like salivary gland, breast, thyroid, lymph node, and soft tissue lesions [non-image guided] during a 9-month period were studied. All the cases were evaluated by ROSE using toluidine blue stain and routine Giemsa/PAP staining. The results were compared in each case. Only 2% cases proved inadequate on TB, Giemsa and PAP combination, commonest site of inadequacy being lymph node. Adequate sample was obtained within two passes in 92.5% cases. The turn-around time (TAT) was 1 day in 96.4% of cases. The average time for making a provisional diagnosis on TB was 3 minutes. There was 99.2% concordance between TB and final cyto-diagnosis. Validity parameters: sensitivity 98%, specificity 100%, positive predictive value 100%, negative predictive value 99.8%, efficacy 99.2% and false negative 1.94%. ROSE using toluidine blue is a reliable means of demonstrating sample adequacy, for making a provisional diagnosis and guiding collection of diagnostic material for microbiology, immunocytochemistry (ICC), cell block and molecular testing etc. The technique is easy enough for general laboratories to incorporate into their routine practice. ROSE can be called as the "frozen section of cytology".

Primary actinomycosis of anterior abdominal wall: A rare occurrence, diagnosed on fine needle aspiration cytology.

Actinomycosis, a chronic suppurative and granulomatous infection, is caused by Actinomyces israeli. The common clinical presentations are cervicofacial, abdominal, and thoracic regions. Abdominal wall actinomycosis following pelvic or intraperitoneal involvement is known, but isolated abdominal wall involvement is extremely rare and can mimic malignancy. We report a case of primary actinomycosis of anterior abdominal wall, diagnosed on fine needle aspiration cytology (FNAC). Identifying fluffy colonies and branching swirling filaments positive for fungal and Gram stain on cytology smears aid correct diagnosis. FNAC is an effective and reliable tool for early diagnosis of actinomycosis. The treatment is centered around antibiotics, and thus it is essential to diagnose accurately and avoid unnecessary surgery.

Multiple tuberous and tendinous xanthomas diagnosed on fine-needle aspiration cytology-report of a rare case.

Xanthomas are papulonodular skin lesions present in lipoprotein metabolism disorders, which result in cholesterol deposits in subcutaneous tissue, tendons, ligaments, periosteum, etc. A 11-year-old male presented with multiple soft tissue swellings, prominently over joints. Fine-needle aspiration (FNA) from multiple sites had similar appearance with foamy histocytes and giant cells. Oil Red O and polarized microscopy were also positive for fat. We describe an unusual case of tendinous and tuberous xanthoma diagnosed by cytology. Acquaintance with fine-needle aspiration cytology findings in xanthomas can help to avoid the need of surgical biopsy, as xanthomas can regress on medical therapy alone.