The role of nipple discharge cytology in the diagnosis of breast disease: a study of 1948 nipple discharge smears from 1530 patients.

In this study a review of 1948 nipple discharge (ND) samples from 1530 patients in the age range of 18-83 years was undertaken to determine whether cytological findings from ND smears could provide useful diagnostic information regarding various breast lesions. The study included 1494 females and 36 males and was carried out during a period of 20 years 8 months. The clinical information in all patients was obtained from clinicians (coauthors), medical records and a review of biopsies in 205 patients who had undergone surgery following the cytodiagnosis. Of the ND samples examined, 1480 were unilateral while 468 were from 234 bilateral ND. The cytodiagnoses were: benign 624, inadequate (despite two to three repeat samples) 492, inflammatory 96, papillary lesion not otherwise specified (NOS) 229, suspicious 22 (21 females, one male) and malignant 67 (63 females, four males). A breast biopsy in the 22 suspicious cases revealed breast carcinoma in 18 cases (females n = 17, male n = 1), atypical ductal hyperplasia (female n = 1), fibroadenoma (female n = 1) and a papilloma in two females. In the 67 cases with a diagnosis of malignancy 65 revealed a breast carcinoma in the biopsy (female n = 62, male n = 3) while one female was diagnosed as fibroadenoma and one male as florid gynaecomastia. In 63 cases (females n = 61; males n = 2) with clinical lumpy areas consistent with the diagnosis of fibrocystic condition in ND, the biopsy confirmed a fibrocystic process. In 53 of 229 cases with ND findings suggestive of a papillary lesion (NOS) the biopsy revealed a papilloma in 41 cases while in 12 cases no lesion was found. In the remaining cases of all the groups only a clinical follow-up and appropriate investigations were performed with no untoward outcome. Based on our study it is felt that cytological examination of ND smears seems to be a reasonably specific method in the diagnosis of malignant and suspicious cases but may be somewhat less specific for other diagnoses.

Cytodiagnosis of neoplasms of the central nervous system in cerebrospinal fluid samples with an application of selective immunostains in differentiation.

In this study cytological findings in specimens of cerebrospinal fluid (CSF) of central nervous system (CNS) tumours (16 primaries, 57 metastatic and 12 suspicious) are presented, which were diagnosed over a period of 7 years in 85 patients (50 females and 35 males) with an age range of 2-76 years. The follow-up included information from clinicians and a review of medical charts, histological correlation and/or further investigations following cytodiagnosis. The patients clinically presented with signs and symptoms of meningeal involvement. The primary tumours included six medulloblastomas, eight gliomas (four glioblastomata multiforme, two anaplastic astrocytomas, and two ependymomas) and two germinomas. The metastatic tumours were 14 melanomas, 19 breast carcinomas, four leukaemias, six B-cell lymphomas, five adenocarcinomas of gastrointestinal origin, seven carcinomas of lung, one retinoblastoma and one neuroblastoma. Twelve cases were reported as suspicious. On further investigations, four of these were from a primary tumour (two glioblastomata multiforme and two anaplastic astrocytomas) while the other eight cases were of a metastasis (one B-cell lymphoma, three breast carcinomas, three melanomas and one adenocarcinoma of gastrointestinal origin). Using a panel of selective immunostains in some of the cases supported the cytological diagnosis and this was considered useful in furthering cytodiagnosis. In 75 of the patients the CSF samples were obtained on a spinal tap while in 10 patients the samples were received as ventricular CSF. There were no false-positive cases. The results of our study suggest that CSF cytology in the diagnosis of CNS tumours is quite reliable and reflects involvement of leptomeninges or the ventricles. Furthermore, the use of selective immunostains can be helpful in confirming the cytological impression and source of the tumour.

The diagnostic value of fine needle aspiration cytology (FNAC) in the assessment of palpable supraclavicular lymph nodes: a study of 218 cases.

The aim of this study was to evaluate the diagnostic value of fine needle aspiration cytology (FNAC) in the assessment of palpable supraclavicular lymph nodes. The material was analysed in 218 cases with enlarged supraclavicular lymph nodes in which FNAC was performed by the conventional method. In all cases cytological examination was performed on-site after staining the smears by the Papanicolaou method. In addition, air-dried smears, fixed smears, filter preparations from needle washings and cell blocks were studied. The FNAC diagnosis was supported by examining cell blocks which added the reliability of histological architecture; further support was obtained by tissue biopsy and/or comparison with the primary tumour in some of the cases. Eleven cases were diagnosed as inflammatory lesions and 41 cases were unsatisfactory because of scanty/acellular samples (despite two to three repeat samplings). However, in five of these, malignant tumours were later found on biopsy, which was done for persistent enlargement of the supraclavicular lymph node(s). Fifty-three cases were diagnosed as negative for malignancy (normal cellular elements, n=15; reactive elements, n=38) and 12 cases were suspicious of malignancy. In 11 cases a diagnosis of lymphoma was made on histology and in 90 cases metastatic tumours were diagnosed. The overall sensitivity was 92.7%, specificity 98.5%, positive predictive value 97.3% and the negative predictive value was 94.8%. Based on our study we feel that FNAC of palpable supraclavicular lymph nodes as a first line of investigation is a cost-effective procedure and is not only useful in the diagnosis of various lesions but can also help in deciding on appropriate management. Furthermore, the histological architecture from cell blocks can be correlated with cytology, and such material can be used for appropriate histochemical and immunomarker studies, which can be useful in enhancing the diagnosis.

Fine needle aspiration cytodiagnosis of leiomyosarcoma of the breast. A case report.

BACKGROUND: Leiomyosarcoma of the breast is a rare tumor. Here we present a case in an elderly female in which the diagnosis was suggested from an aspirate sample. CASE: An 80-year-old female presented with an irregular, firm mass in the left breast of a few months' duration. In view of the clinical suspicion of a tumor, fine needle aspiration was performed. It showed a large number of dissociated cells and compact sheets of spindly and round cells with pleomorphic, hyperchromatic and anaplastic nuclei; mitoses; nucleoli; and somewhat-vacuolated, eosinophilic cytoplasm. Examination of the cell block, tumor tissue and immunostaining further suggested the cytologic impression of a leiomyosarcoma. CONCLUSION: Although leiomyosarcoma of the breast is very rare, fine needle aspiration cytology may allow the diagnosis to be suggested. Correlation with cell block findings and the application of appropriate immunostains as an adjuvant to standard cytologic and histologic stains may allow a more confident diagnosis.

The usefulness of a panel of immunostains in the diagnosis and differentiation of metastatic malignancies in pericardial effusions.

Pericardial effusions are not uncommon in patients with an advanced malignancy Rarely malignancies may present initially with a pericardial effusion. Cytological examination of pericardial fluid may be valuable in differentiation of these cases. However, a metastatic tumour in serous effusion may not always show the functional differentiation of the primary tumour. In such a situation, although a wide range of special studies have been suggested for the diagnosis of malignancy we have found the use of a panel of a few common immunostains to be useful in confirming or suggesting the site of a primary tumour. The material for this study consisted of 76 pericardial fluids obtained between January 1991 and October 1998 from 46 males (mean age 59 years) and 30 females (mean age 52 years). Metastatic malignancy was diagnosed in 22 of the 76 patients and in 7/22 cases pericardial effusions were the initial presentation. The subsequent follow-up in the seven cases revealed adenocarcinoma of lung (n = 2), small cell anaplastic carcinoma of lung (n = 1), squamous cell carcinoma lung (n = 1), melanoma leg (n = 1), non-Hodgkin's lymphoma retroperitoneal lymph nodes (n = 1) and carcinoma of the breast (n = 1). Of the remaining 15 cases with a known history of malignancy, eight had cancers (three adeno; two small cell; one poorly differentiated, and two squamous cell types) of the lung; breast (n = 3); colon (n = 1); melanoma (n = 2) and non Hodgkin's lymphoma (n = 1). Immunostains which were useful in the diagnosis were EMA, CEA, cytokeratin, B72.3, HMB45, vimentin, S100, LCA, L26 and kappa and lambda light chains.

Aspiration cytodiagnosis of small cell malignancies found in fine needle aspirate (FNA) of the liver: an immunocytochemical study.

In this study the features of small cell malignancies found in the liver by fine needle aspiration cytology (FNAC) and immunostains required for a diagnosis and differential diagnosis are presented. The material consisted of 197 fine needle aspirates which were performed under image guidance between January 1982 to October 1999. Of these, 30 were diagnosed as small cell malignancies. The age of patients ranged between 46 and 68 years. The aspirated material was examined using Papanicolaou-stained filter preparations and cell blocks, the latter stained with hematoxylin and eosin and a panel of immunoperoxidase stains. The diagnoses based on a correlation of relevant clinical history, cytohistological findings and immunostaining were: metastatic small cell anaplastic carcinoma of lung (n = 6); neuroendocrine tumour (n = 9); non-Hodgkin's lymphoma (n = 4); well-differentiated cholangiocarcinoma (n = 2); metastatic carcinoma of the prostate (n = 2); metastatic adenocarcinoma (n = 4) and metastatic carcinoma breast (n = 3). This study emphasizes the wide range of neoplasms that enter into the differential diagnosis of small cell malignancies found in the liver and a correlation of clinical, cytohistological and immunostaining findings which seem to be useful in suggesting a diagnosis.

Fine needle aspiration cytodiagnosis of primary squamous cell carcinoma of the gallbladder. Report of two cases.

BACKGROUND: Cytologic descriptions of the diagnosis of the rare primary carcinoma of the gallbladder are sparse. The obstacles to the diagnosis are ascribed to vague symptoms and inaccessibility of the gallbladder to biopsy. We describe two cases of primary squamous cell carcinoma of the gallbladder that were diagnosed using fine needle aspiration (FNA) cytology. CASES: Both patients were elderly females with vague symptoms of abdominal pain, jaundice, loss of weight, anorexia and mild fever. Imaging studies showed enlargement of the gallbladder with a soft tissue mass in the fundus and abnormally thickened wall, indicative of a tumor. Also, in case 1, gallstones and enlarged, matted paraaortic and porta hepatis lymph nodes were present. FNA of the gallbladder was done after selection of a suitable puncture site and needle positioning, which was confirmed by computed tomography. The aspirated material was collected as needle and syringe washings, and from half the material filter preparations were made and stained for cytologic study, while the remainder was used for making cell blocks for histologic study. Both cases showed cytohistologic features of a moderately well differentiated, necrotizing squamous cell carcinoma characterized by keratinizing malignant cells with orangeophilic cytoplasm. In both cases immunostaining for high-molecular-weight keratins (AE1/AE3) and cytokeratin (CAM 5.2) was positive, while staining for carcinoembryonic antigen, B72.3 and other markers was negative. CONCLUSION: This study further confirmed that with the widespread use of more-sophisticated imaging techniques, the gallbladder is becoming more readily accessible to visualization. In view of this, FNA cytodiagnosis holds promise as a noninvasive technique in the diagnosis of gallbladder neoplasms.

Incidence of apocrine cells in fine-needle aspirates of gynecomastia: a study of 100 cases.

While the presence of apocrine cells in fibrocystic conditions of the female breast is a common finding in a fine-needle aspirate (FNA) of the breast, such a finding in gynecomastia has only been reported recently in a single case report. This study was undertaken in 100 cases with adequate cellular samples which had been diagnosed as gynecomastia from aspirates which were obtained using a 22-gauge needle and a 5-ml syringe maintaining negative pressure. The material was collected as needle and syringe washings in 30% ethyl alcohol in physiologic saline and the cytologic preparations were made on 3-microm Schleicher and Schuell filters and were stained by the Papanicolaou method. In 3 of the 100 cases, sheets of apocrine cells were noted in addition to clusters of hyperplastic ductal cells. The findings were further confirmed histologically in cell blocks which were made in the 3 cases. Based on our findings, it was concluded that apocrine cells in gyneco- mastia are found in about 3% of cases, and such a finding should be regarded as nonneoplastic, thus avoiding the need of surgical excision.

Fine needle aspiration diagnosis of neuroendocrine tumors in the liver.

Ten neuroendocrine tumors (NET) in the liver are presented, in which the diagnosis was made on fine needle aspiration cytology and cell blocks from the aspirate. In seven of the patients with liver metastasis, a biopsy-proven extrahepatic primary NET had been previously diagnosed, while in three patients no extrahepatic neoplasm could be identified, suggesting that the NET may have been a primary in the liver. Based on cytomorphological findings the cases were typed as either round cell type, spindle cell type or polygonal cell type. In all cases, immunopositivity for neuroendocrine markers provided reliable evidence of the cell of origin and distinguished them from well-differentiated hepatocellular carcinoma, adenocarcinomas and other neoplasms, which sometimes may present a diagnostic dilemma.

Fine needle aspiration cytodiagnosis of secretory carcinoma of the breast.

Secretory carcinoma (SC) of the breast is a rare variant of breast malignancy and its cytological features in fine needle aspirates have only recently been described. In this communication, our experience with four cases of SC of the breast is presented in which the diagnosis was established on fine needle aspiration cytology (FNAC). In all cases, the samples were cellular and featured diffuse, prominent, intracytoplasmic vacuoles and secretion in malignant cells and occasional signet-ring like forms. The cytodiagnosis of SC in all the cases correlated with subsequent examination of cell blocks of the aspirate and tissue. Cytochemical stains showed diffuse positivity for mucin by alcian blue stain in the vacuolated cells which was periodic acid-Schiff positive and resistant to diastase digestion. Oil-red O staining was negative. Immunopositivity to carcinoembryonic antigen, cytokeratin (CAM 5.2), B72.3 and epithelial membrane antigen was found in malignant cells. The cytodiagnostic criteria for SC of the breast, characteristic cytological features which are useful in a correct FNAC diagnosis and differentiation from other pertinent breast carcinomas, are discussed.

Fine-needle aspiration cytology of the breast in a case with abundant acellular calcific material indicative of soft-tissue calcinosis.

Since calcific deposits in soft tissue may clinically resemble a tumor, it is feasible to investigate them by fine-needle aspiration (FNA) cytology. In this presentation we describe a case in the breast with extensive accumulation of acellular liquid calcific material which was sampled by the noninvasive technique of FNA, and which was indicative of nonfamilial soft-tissue calcinosis. A 48-yr-old, perimenopausal woman on a routine mammogram showed a well-defined, 1-cm partially cystic opacity in the left upper quadrant of the breast. All other investigations were normal, and no significant family or medical history was present. Under ultrasound guidance FNA was done, and about 1 ml of thick whitish fluid was obtained. Cytopreparations only showed abundant acellular calcium. The patient refused any further treatment and elected to be under the care of her family physician, according to whom she was clinically well with no changes in mammograms for the last 2 yr. The case is interesting, since the cytohistologic findings in aspirate sample appeared to be strongly indicative of soft-tissue calcinosis, which to our knowledge has not been previously reported.

Fine needle aspiration cytodiagnosis of sialadenitis with crystalloids.

OBJECTIVE: To assess the utility of fine needle aspiration cytology in the diagnosis of sialadenitis with crystalloid formation in four patients that presented with a swelling of the parotid gland. STUDY DESIGN: The swelling was aspirated in all the cases using a 22-gauge needle, and aspirates were submitted as needle and syringe washings in a cytology fixative (30% ethyl alcohol in physiologic saline). From these washings filter preparations were made on Sartorius or Gelman filters (pore size, 3 microns) and stained by the Papanicolaou method. Additionally, cell block preparations were made from the aspirate. After processing, sections were cut and stained by hematoxylin-eosin, Prussian blue, alcian blue, mucicarmine, and Von Kossa and congo red stain. No air-dried smears were made, and no electron microscopic studies were done. RESULTS: Stained cytologic preparations and cell blocks showed numerous nonbirefringent crystalloids of varying sizes and shapes appearing as rectangles, needles, squares and rods mixed with neutrophils and rare multinucleated giant cells. No salivary gland components were seen, and all special staining was negative. CONCLUSION: Fine needle aspiration cytology not only provided an accurate diagnosis of sialadenitis with crystalloids but also resulted in adopting conservative management and avoiding unnecessary surgery.

Fine-needle aspiration cytology of adenoid cystic carcinoma of the breast.

Adenoid cystic carcinoma (ACC) of the breast is a rare variant of breast malignancy and has a better prognosis than its counterpart in the salivary glands. In this communication, our experience with seven cases of ACC of the breast is presented in which the diagnosis was established on fine-needle aspiration cytology (FNAC). The cytologic samples in all cases were cellular and featured three-dimensional clusters of uniform ductal epithelial cells with cystic spaces, bland nuclei, fine chromatin, and scanty cytoplasm arranged around spheres or cores of homogenous material. The cytodiagnosis of ACC in all cases correlated with subsequent examination of cell blocks of the aspirate and tissue. The cytodiagnostic criteria for ACC of the breast which are useful in a correct FNAC diagnosis are discussed.

A trial of two methods of taking cervical smears: the Aylesbury spatula plus cytology brush compared to the Cervex broom.

AIMS: To compare the adequacy of cervical smear taking, using the Aylesbury spatula plus cytology brush with the Cervex broom. METHODS: Two cervical smears were taken at the same visit, the women acting as their own controls. In Group 1 comprising 81 women, the first smear was taken using the Cervex broom. In Group 2 comprising 97 women, the first smear was taken using the Aylesbury spatula followed by the cytology brush. The tips of the samplers were sent to the laboratory in a cytology container with 30% ethyl alcohol in saline, for analysis of residual cells. RESULTS: It took experienced staff two or three smears before they were adept at taking an adequate Cervex broom sample as defined by the presence of endocervical cells. Both techniques were equally good at detecting significant abnormalities. When the Cervex broom was used first there were more smears with no blood present but when bleeding occurred there was no significant difference between the two groups. Both techniques were well accepted by the women. CONCLUSIONS: Although it is more expensive than the Aylesbury spatula and the cytology brush the Cervex broom has the advantage of allowing a simple one step procedure, thereby reducing the potential for air drying.

Aspiration cytodiagnosis of clear cell hepatocellular carcinoma in an elderly woman. A case report.

The cytohistologic features of a clear cell hepatocellular carcinoma are described. The case occurred in an elderly woman. An aspirate was obtained from a solitary mass in the right lobe of the liver. The liver carcinoma was found to be the clear cell type, with infrequent bile and hyaline (Mallory body-like) bodies in the cytoplasm. The fact that clear cell type hepatocellular carcinoma possesses specific cellular characteristics and immunocytochemical features renders this case report useful in establishing a correct cytohistologic diagnosis, especially since this tumor variant shows a striking resemblance to "clear cell" tumors that originate in other organs and that may cause a diagnostic dilemma.

Diagnosis of umbilical metastasis (Sister Mary Joseph's nodule) by fine-needle aspiration: an immunocytochemical study.

During a ten year period, since we introduced needle aspiration cytology at our institution, we have diagnosed five cases of umbilical metastasis (Sister Mary Joseph's nodule). In none of the cases was any false negative or false positive diagnosis rendered and the primary carcinoma was found below the diaphragm. In all the five cases, cell blocks of the aspirate were subsequently prepared, and highlighted the histologic features of the tumour which corresponded with the cytologic diagnosis. Immunohistochemical staining on the aspirate material in all the cases was considered quite useful in substantiating the cytohistologic diagnosis. Based on our findings, we suggest that fine-needle aspiration cytology as an initial diagnostic procedure in cases suspected of umbilical metastasis should be considered, since it is not only a simple, fast, accurate, and inexpensive diagnostic procedure, but can also save the patient from an invasive surgical procedure, the benefit of which is questionable.

Diagnosis of metastatic carcinoma of stomach using fine catheter aspiration cytology.

The value of fine catheter aspiration cytology organs of the peritoneal cavity in the diagnosis of a metastatic carcinoma is illustrated by this case report. The finding of unequivocal malignant cells was quite unexpected and led to an investigation of the gastrointestinal tract which demonstrated a primary carcinoma in the stomach. This was further confirmed on a biopsy of the tumor and cell block preparations of aspirated material on which immunostaining was done and which further substantiated the light microscopic cytohistologic diagnosis. The findings presented in this article further emphasize the value of fine catheter aspiration cytology in not only identifying tumor type or predicting the source of the primary but also in managing patients admitted with abdominal pain as an emergency who may be saved from an unnecessary laparotomy which would have otherwise been done for a diagnosis.