Reporting Pancreatic FNAC using the Papanicolaou System: Still a Diagnostic Challenge.

Introduction: The Papanicolaou Society of Cytopathology System for reporting Pancreaticobiliary Cytology (PSCPC) is a reliable method to classify pancreatic fine needle aspiration cytology (FNAC) smears. However, it is not without practical problems which can diminish the diagnostic accuracy of the cytological diagnosis. Aims and Objectives: To determine the diagnostic pitfalls while reporting cytomorphology of pancreatic lesions according to PSCPC on correlating FNAC findings with histopathology. Materials and Methods: Retrospective analysis of pancreatic FNAC smears received in the Department of Pathology of our tertiary care institute over a period of 2 years was done. The cytological diagnoses were classified according to the Papanicolaou Society of Cytopathology system of reporting pancreaticobiliary cytology and correlated with histopathology. The reasons of cyto-histological discordance were analyzed. Results: Out of 50 cases in which both FNAC and biopsy of pancreatic lesions were done, 34 cases were positive/malignant (Category VI), eight cases were suspicious for malignancy (Category V), three cases were neoplastic (Category IV), two cases were atypical (Category III), two cases were negative for malignancy (Category II), and one case was non-diagnostic (Category I). Out of 50 cases, histopathology was non-diagnostic due to inadequate material in six cases. The cytological diagnoses were compared with histopathology in the remaining 44 cases. Categories III, IV V, and VI were considered as positive for neoplastic pathology. The sensitivity of FNAC to predict neoplastic pathology was 97.5%, while the specificity was 25%. The positive predictive value was 92.9%. Two cases reported as atypical (Category III) turned out to be adenocarcinoma on histopathology. One case reported as neuroendocrine tumor and two cases reported as adenocarcinoma on cytology displayed features of chronic pancreatitis on histology. One case reported as neoplastic mucinous cyst (Category IV) turned out to be adenocarcinoma on histology (limited concordance). Conclusion: The cytopathologist needs to be wary of the potential pitfalls to improve the diagnostic accuracy of FNACs.

Is mediastinal fine needle aspiration cytology required or redundant? A single institution-based correlation study with core needle biopsy.

INTRODUCTION: Fine Needle Aspiration cytology (FNAC) and core needle biopsy (CNB) are rapid, minimally invasive and useful techniques to evaluate mediastinal lesions. OBJECTIVES: To compare cytopathology with histopathology of mediastinal lesions and analyse reasons for discordance. MATERIAL & METHODS: Retrospective analysis was done in a tertiary care centre in North West India over a period of seven and half years from 1stJuly 2016 to 31st December 2023. Only those patients who had undergone FNAC and trucut biopsy of mediastinal masses were included. The cytopathology and histopathology slides were studied to analyse causes of discordance. Sensitivity, specificity, positive and negative predictive values of FNAC were calculated keeping histopathology as gold standard. RESULTS: Out of 57 cases analysed, eight cases were non diagnostic on cytology. Cytology could effectively classify a lesion as non neoplastic (7) or neoplastic (42). For further subtyping, histopathology and Immunohistochemistry (IHC) were required. Out of 27 cases of cytological - histopathological discordance, 8 cases had sampling error, 15 cases had limited concordance where FNAC could predict possibility of tumor and 4 cases were discordant where subtyping of malignancy varied on CNB. Sensitivity of FNAC to predict definite diagnosis was 90.2 %, specificity was 50 %, positive predictive value of FNAC to give a definite diagnosis was 93.9 %, negative predictive value was 37.5 %. CONCLUSION: Evaluation of mediastinal masses requires combination of cytology, histopathology and ancillary techniques like IHC. FNAC and CNB are complementary modalities and both are essential for rapid, accurate and comprehensive diagnosis.

Role of Fine Needle Aspiration Cytology in the Rapid Diagnosis of Pulmonary Infections in Renal Allograft Recipients with Respiratory Failure.

Background: Renal transplantation is the treatment of choice in patients with end-stage renal disease. However, allograft recipients are at a higher risk of infection due to immunosuppressive therapies. This study aimed to analyze the utility of fine needle aspiration cytology (FNAC) lung in the etiological diagnosis of pulmonary infections in renal allograft recipients with respiratory failure. Materials and Methods: This is a retrospective study done in post-renal transplant patients presenting with pulmonary infections and respiratory failure in the past 7 years, in whom image-guided lung FNAC was done for diagnosis. Results: A total of 35 renal allograft recipients presenting with respiratory failure and having focal or diffuse pulmonary opacities (lesions) on radiological imaging were subjected to lung FNAC. The mean age of the patients was 41.1 ± 11.8 years (range 19-72), with the majority being males (n = 28, 80%); six (17.1%) of them were on invasive ventilation. The diagnostic yield of FNAC in our cohort was 77.1% (27 out of 35). Microorganisms were isolated in 21 cases (60%), with Nocardia being the most common (nine cases, 25.7%), Mycobacterial tuberculosis identified in six patients (17.1%), Aspergillus in three (8.6%), and one (2.9%) each had atypical Mycobacterium, zygomycetes, and Cryptococcus. FNAC suggested viral cytopathic effect in five patients, and cytomegalovirus (CMV) quantitative polymerase chain reaction test was found positive in four of these. One case was diagnosed as adenocarcinoma lung. Conclusion: Lung FNAC is a useful for establishing the etiological diagnosis of pulmonary lesions in renal transplant patients with respiratory failure.

Red Cell Distribution Width and Ratio of Red Cell Distribution Width-to-Total Serum Calcium as Predictors of Outcome of Acute Pancreatitis.

Background: Current severity assessment scores of acute pancreatitis (AP) include multiple variables, the results of which are available only after 48 h of admission. Red cell distribution width (RDW) and total serum calcium (TSC) are simple routine parameters related to inflammatory status and results of which are readily available. Aim: The aim of this study was to evaluate RDW and RDW: TSC within 24 h of hospital admission as predictors of outcome (severity and mortality) and intervention (medical/percutaneous drainage/surgical) required by patients of AP. Materials and Methods: All the patients diagnosed with AP at a tertiary care hospital were enrolled for the study. Values of RDW and TSC along with data regarding the treatment given were collected. Diagnosis and severity were defined according to the revised Atlanta classification 2012. Results and Interpretation: Cutoff value for RDW (area under the receiver operating characteristic curve [AUROC]: 0.997; P = 0.000) to predict the severity of AP was 16.25% (sensitivity - 100% and specificity - 97.1%,) (sensitivity - 100% and specificity - 97.1%, positive predictive value - 92.31%, negative predictive value - 100%, and Youden Index - 0.971), while that of RDW:TSC (AUROC: 1; P = 0.000) was 2.42 (sensitivity - 100%; specificity - 100%, positive predictive value - 100%, negative predictive value - 100%, and Youden Index - 1.00). Similarly, the cutoff value for RDW (AUROC: 0.947; P = 0.000) to predict mortality in AP was 17.20% (sensitivity - 100%; specificity - 87.4%, positive predictive value - 38.89%, negative predictive value - 100%, and Youden Index - 0.874) and that of RDW-to-TSC ratio (AUROC: 0.975; P = 0.000) was 2.9 (sensitivity - 100%; specificity - 96.6%, positive predictive value - 70%, negative predictive value - 100%, and Youden Index - 0.966). Conclusion: Our study found that RDW and RDW: TSC were quick, convenient, economic, sensitive, and dependable prognostic predictors of severity and mortality in patients with AP.

Peritoneal malignant mesothelioma: Slippery like an eel to diagnose on cytology-case series of 3 cases.

INTRODUCTION: Peritoneal malignant mesothelioma is an extremely rare tumor and is a difficult diagnosis to be made on cytology alone. We report 3 cases where the cytologic features were misdiagnosed as carcinoma/lymphoma but histopathology and immunohistochemistry (IHC) established the diagnosis of malignant mesothelioma. CLINICAL DETAILS: Case 1 was a 60-year-old man with multiloculated ascites and omental caking. Peritoneal fluid was reported as malignant on cytology but was misclassified as adenocarcinoma. Case 2, a 45-year-old man with ascites and peritoneal nodularity, radiologically mimicking peritoneal carcinomatosis, was also reported positive for malignancy on ascitic fluid cytology. Fine-needle aspiration (FNAC) from omental fat revealed signet ring cells, thus misleading to cytologic diagnosis of adenocarcinoma. Case 3 was a 63-year-old man with perisplenic mass with extensive omental caking and peritoneal nodularity that was also suspected to be peritoneal carcinomatosis on radiology. FNAC smears from perisplenic mass showed sheets of plasmacytoid cells. On cytology, the differential diagnoses offered were neuroendocrine tumor or non-Hodgkin lymphoma. The diagnosis of malignant mesothelioma was established only after IHC on histopathologic sections in all these cases. None of our patients had history of prior asbestos exposure. CONCLUSION: In such clinical scenarios, with radiology suggesting peritoneal carcinomatosis, the cytologic features need corroboration by IHC/fluorescence in situ hybridization on cell block or biopsy to correctly identify malignant mesothelioma and differentiate it from metastatic carcinomatous deposits and benign mesothelial proliferation.

Diagnostic role of fine needle aspiration cytology (FNAC) in the evaluation of gall bladder lesions: an institutional experience.

BACKGROUND: Carcinoma of the gall bladder is the most common malignancy of the biliary tract. Ultrasonography guided Fine Needle Aspiration Cytology (FNAC) plays a crucial role in early detection of gall bladder (GB) lesions. Early diagnosis of GB lesions is a necessity in view of rising trend in GB carcinoma related mortality in India. The aim of this study is to determine the diagnostic accuracy of pre-operative ultrasonography guided FNAC in the diagnosis of GB masses. METHODS: This was a retrospective observational study performed at a tertiary care university hospital over a period of one and a half years. A total of 47 patients with clinico-radiological suspicion of GB malignancy were subjected to USG guided FNA. 20 of these patients underwent diagnostic Trucut biopsy in addition to FNA. RESULTS: Forty-one out of 47 patients analyzed were positive for malignancy with female preponderance; MF ratio of 0.6:1. There were 29 females (61.8%) and 18 males (38.2%) in the range of 34 to 85 years. Cytomorphology was inconclusive for malignancy in two patients and unsatisfactory in one case. Two were labeled as chronic cholecystitis and one as acute cholecystitis. Adenocarcinoma was the most common malignancy found in 36 patients (76.6%). CONCLUSION: USG guided FNAC is a rapid, safe and successful diagnostic procedure with high sensitivity for diagnosis of GB lesions. In the present scenario of increasing incidence of GB malignancy, FNAC has proved to be a useful first choice of investigation in the detection of GB lesions.

Synchronous high-grade bladder carcinoma associated with chronic lymphocytic leukemia: A rare entity in Indian literature.

B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) is one of the common lymphoproliferative disorders with an increased risk of developing subsequent neoplasms of epithelial and mesenchymal origin. The decreased immunity and B-cell dysfunction in CLL probably accounts for this emergence of secondary malignancy. Breast, brain, skin and prostate tumors have been reported as usual coincident malignancies of CLL, while in occasional cases CLL may occur with malignancies of other solid organs, such as skin, lung, heart, and prostate. Synchronous CLL with urothelial carcinoma (UC) is an infrequent occurrence. We report this case because of its rarity in Indian literature and interesting hematological, immunophenotypic, histopathological, and cytopathological features of metastatic high-grade UC in a 61-year-old male with CLL.

Cerebrospinal fluid pleocytosis in immunocompromised patients: Can it be Cryptococcus.

Cryptococcal meningitis commonly affects immunocompromised cases and can have varied presentation. In some instances, the presence of a plethora of inflammatory cells on cerebrospinal fluid (CSF) in an immunosuppressed patient can lead to further investigations, which unravel the presence of cryptococcal meningitis. The aim of this retrospective study was to analyze the spectrum of CSF findings of immunosuppressed patients who were diagnosed to have cryptococcal meningitis. Retrospective analysis of CSF cytospin slides exhibiting pleocytosis and belonging to immunocompromised patients was performed, and these cases were found to have cryptococcal meningitis. Out of 932 cases of CSF (January 2016-July 2017), 10 had pleocytosis and 5 of these 10 cases demonstrated spores of Cryptococcus. Male-to-female ratio was 1:1.5. All the patients were immunocompromised and had CSF leukocytosis. Lymphocytes and monocytes were present in all samples while only one case showed plasma cells. Spores of Cryptococcus were also noted in all the cases and highlighted on India Ink Preparation and Gomori Methenamine Silver stain. All the cases were positive for agglutination-based cryptococcal antigen assay, except one where the test was not done. All immunosuppressed patients having pleocytosis in CSF were found to have cryptococcal infection. Therefore, pleocytosis in CSF in any immunosuppressed patient should raise the suspicion of cryptococcal meningitis. The pathologist and the clinician need to be vigilant in such scenarios to rule out any opportunistic infection and investigate the patient thoroughly for any underlying immunosuppression.

Feasibility of Masood's cytological index for screening breast lesions in low resource setting.

Fine needle aspiration cytology has long been an accepted diagnostic modality in combination with physical examination and mammography to investigate breast lesions. In the present era, more proficient methods such as stereotactic mammographically guided breast biopsy is the preferred choice, however, in low resource setting, FNAC still remains the most cost effective and sampling modality to diagnose breast cancer. With the intention to evaluate the efficacy and limitations of FNAC in evaluation of breast lesions in low resource setting, we employed the Masood's cytological staging system to stratify the breast lesions and correlate them with histopathology wherever possible. All breast lesions aspirates were analyzed and classified according to the Masood's cytological scoring system and correlated with histopathological findings wherever adequate material was available. A total of 776 patients were studied of which 23 aspirates were unsatisfactory, 120 aspirates were categorized as inflammatory breast disease. Six hundred and thirty-three cases were classified according to Masood's cytological system. Nonproliferative breast diseases (Group I) encompassed maximum cases with 55% followed by carcinoma in situ and invasive cancers (Group IV) with 39% and proliferative breast disease without atypia (Group II) and with atypia (Group III) which had equal number of cases constituting 2.4% each. Cyto-histopathological correlation done in 102 cases revealed 100% concordance in group IV and 75% concordance in group III while it could not be performed in Group I and II as no histopathological specimen was available in those patients. Masood Cytological grading for breast aspirates is a reliable and an easily reproducible system which can be used to formulate appropriate treatment protocols in cases presenting with breast lesions.

Hepatic fine-needle aspiration cytology: The role of rapid on-site evaluation in the assessment of hepatic lesions.

BACKGROUND/AIMS: Radiologically guided fine-needle aspiration cytology (FNAC) of internal organs is not cost-effective. Rapid on-site evaluation (ROSE) of smears by a cytopathologist can improve the diagnostic yield of FNACs and save time and money by reducing the need for repeat procedure/biopsy. To determine the role of ROSE in the diagnostic outcome of hepatic lesions by comparative analysis of FNAC with and without ROSE by a cytopathologist. MATERIALS AND METHODS: Hepatic FNACs were retrospectively analyzed over two separate time periods from January 2011 to June 2013 and from January 2015 to July 2016. Smears from 2015-2016 were subjected to ROSE by a cytopathologist after staining with toluidine blue for 1 min to assess adequacy of the material. Final report was given after hematoxylin and eosin, May Grünwald Giemsa, and Papanicolaou staining were performed. Chi-square test (non-parametric) was used to determine if there was a statistically significant increase in the diagnostic yield with ROSE. RESULTS: During 2011-2013, of the 160 radiologically guided FNACs for hepatic lesions, 22 were non-diagnostic, whereas during 2015-2016, of 142 radiologically guided hepatic FNACs, only six were non-diagnostic. With the application of ROSE, there was a statistically significant increase in the diagnostic yield of hepatic FNACs from 86.25% to 95.8% (p=0.015). CONCLUSION: ROSE performed by a cytopathologist using toluidine blue can increase the diagnostic yield of hepatic FNACs and reduce the cost of healthcare by eliminating the need for a repeat procedure.

Coinfection of Sarcina ventriculi and Candida in a patient of gastric outlet obstruction: An overloaded pyloric antrum.

Sarcina ventriculi is a rare gram-positive, anaerobic bacteria, associated with delayed gastric emptying. We report a case of a 45-year-old lady, who presented with features of gastric outlet obstruction, and coinfection of S. ventriculi and Candida was detected on examining gastric brushings and biopsy. S. ventriculi is identified by its peculiar configuration in the form of tetrads and octets. Coexistence of S. ventriculi with other organisms is highly unusual.

Entamoeba histolytica: A surprising coexistence with adenocarcinoma - Never brush aside brushings for biopsy.

Entamoeba histolytica has been rarely reported as superadded infection over carcinomatous growth on rectal brushings. We present a case of 68-year-old male who presented with abdominal pain and bleeding per rectum who was found to have an ulceroproliferative growth on sigmoidoscopy. Rectal brushings revealed coexistence of E. histolytica with malignant cells of adenocarcinoma. No organism was detected on biopsy of the tumor, which also showed adenocarcinoma, because of possible surface colonization of the tumor by Entamoeba. This case highlights the role of rectal brushings in detecting superadded infection in a case where both brushings and biopsy were performed. It is always important to report infection superadded on malignancies for optimum management of the patients.

Role of FNA and Special Stains in Rapid Cytopathological Diagnosis of Pulmonary Nocardiosis.

BACKGROUND: Nocardia, a gram-positive aerobic bacillus of the Actinomycetales family, is a significant opportunistic pathogen in immunocompromised individuals. Clinical and radiological features of pulmonary nocardiosis are nonspecific and can be misdiagnosed as tuberculosis, pneumocystis, staphylococcal or fungal infections, or as malignancy. Aspiration cytology with special stains is a quick and effective approach for accurate diagnosis. MATERIALS AND METHODS: We present 7 cases of pulmonary nocardiosis, admitted to the pathology department in a tertiary-care hospital in Punjab. Clinical findings, immune status, laboratory tests, chest radiographs, and computed tomography scans were reviewed. Cytologically, special stains like 1% Ziehl-Neelsen (ZN), 20% ZN, periodic acid-Schiff (PAS), Grocott methenamine silver (GMS), and reticulin stains were studied along with May-Grünwald Giemsa, Papanicolaou, and hematoxylin and eosin. RESULTS: All the patients were immunocompromised. The radiological changes were nonspecific. Cytomorphology showed acute and chronic inflammatory infiltrates with necrosis. None of the cases showed well-defined granulomas. GMS, modified 1% ZN and, Gordon and Sweet reticulin stains highlighted the delicate filamentous bacteria in all cases. PAS and 20% ZN stain for tuberculous bacilli were uniformly negative. CONCLUSION: FNAC can provide a quick and accurate diagnosis of nocardiosis and thereby facilitate timely medical management.

"Polka Dot Macrophages" on cytology of bilateral adrenal masses-Nailing disseminated histoplasmosis.

Histoplasma capsulatum is a saprophytic fungus that in immunocompetent individuals causes self-limited pulmonary infection; however, in immunosuppressed patients involvement of the reticuloendothelial system, alimentary tract, urinary tract, and central nervous system is fairly common. Rarely patients present with bilateral adrenal masses which mimic tuberculosis and metastasis on radiology because of associated central necrosis. Ultrasound guided FNAC aided by special stains like Periodic Acid Schiff (PAS) and Gomori Methenamine Silver (GMS) may help in early diagnosis in such dubious cases. Polka dot macrophages were the clue to diagnosis of histoplasmosis on toluidine blue rapid staining, Hematoxylin & Eosin, and Pap stained smears. We report this case because of its rarity, diagnostic difficulty on radiology, and rapidity of diagnosis by FNA due of its characteristic cytomorphology.

Melanotic neuroectodermal tumor of infancy: Cytology and histopathology of a rare lesion at an uncommon site.

Melanotic neuroectodermal tumour of infancy is a rare, pigmented neoplasm generally arising in infants during the first year of life. The cytological features are rarely described in the literature. This case due to its rarity and unusual site emphasising the cytopathological features and the necessity of histology for differentiating it from other round cell tumours has been presented. Diagn. Cytopathol. 2016. © 2016 Wiley Periodicals, Inc.

Intraoperative diagnosis of hydatid cyst of the ovary masquerading as tumor.

Hydatid disease, caused by the larval stage of Echinococcus granulosus, is found most commonly in the liver and lungs, but no organ is immune. The ovarian involvement is often secondary to a cyst's dissemination localized in a different site. Occasionally, the cyst enlarges, thus mimicking an ovarian tumor. Patients with hydatid cysts at unusual locations present with atypical presentations and pose a diagnostic dilemma. A high index of suspicion is required in order to make a correct diagnosis pre-operatively to prevent spillage of the cyst contents during surgery. We report a case of hydatid cyst in the ovary in a young female. Diagn. Cytopathol. 2017;45:267-269. © 2016 Wiley Periodicals, Inc.