Fine needle aspiration of soft-tissue lesions

The heterogeneity of soft-tissue neoplasms constantly challenges the diagnostic skills of pathologists. Fine needle aspiration biopsy (FNAB) cytology can provide a quick and relatively safe assessment of soft-tissue masses and can significantly contribute to patient management. This article illustrates the FNAB cytologic features of the most commonly encountered soft tissue lesions and discusses their differential diagnoses.     

Ultrasonography of the thyroid and parathyroid glands

High-resolution thyroid and parathyroid ultrasonography can play an integral part in the diagnosis and management of patients with clinically undifferentiated cervical masses, thyroid carcinomas or adenomas, and primary parathyroid hyperplasia or neoplasia. Because the study is inexpensive, noninvasive, and easily performed, ultrasonography can be performed as a screening test early in the evaluation of a patient, and ultrasound findings can corroborate the results of other diagnostic procedures, leading to a more accurate diagnosis.     

An analysis of fine-needle aspiration biopsy of the thyroid in children and adolescents

Fine-needle aspiration biopsy (FNAB) has proven safe and efficacious in the evaluation nodular thyroid disease in adults. Only one study has evaluated FNAB exclusively in children, for whom the prevalence of thyroid nodules and the probability of malignancy are different. In addition, no study has compared the accuracy of FNAB with that of other diagnostic procedures in the evaluation of thyroid nodules in children. The authors report the results of FNAB in 18 children evaluated for thyroid nodules between 1985 and 1994. The overall accuracy of FNAB was similar to that of other diagnostic procedures, including thyroid scintiscan and ultrasonography, but none of these was sufficiently accurate to be used as the sole predictor of malignancy. There were three false-negative biopsy results; this limited the overall accuracy and suggests that children with negative FNAB results should be monitored cautiously.     

Fenfluramine challenge test in obsessive-compulsive disorder--first results

BACKGROUND: The aim of this study is to evaluate the additional diagnostic significance of immunocytochemical staining of thyreoglobulin (TG) in Fine Needle Aspiration Biopsy (FNAB) of neck lymph-nodes, in patients with a previous history of thyroid carcinoma. METHODS: Twenty-five smears performed by ultrasound-guided FNAB on laterocervical nodes with a 21-23 gauge needle were evaluates. All smears were stained according to Papanicolaou and microscopically examined. RESULTS: Of these 25 smears, 15 were diagnostic and 10 were non diagnostic. Of the 15 diagnostic cases, 10 were positive for metastatic lesions from thyroid neoplasm and the other 4 were classified as reactive lymphoadenitis. One smear for each case was selected for the immunohistochemical stain. All the 10 non-diagnostic cases showed no reaction to thyreoglobulin. Neoplastic cells, from 9 out of 11 cytologically positive smears, expressed thyreoglobulin in the cytoplasm. In one case no reaction was evident and the other one was discarded for technical reasons. In 3 of the 4 cases cytologically classified as lymphoadenitis, immunoreactive thyreoglobulin was not found. In the fourth case, blastic-like cells showed a scanty cytoplasmic rime which was immunoreactive for TG and thus was classified as a metastatic tumour. On this basis, it is suggested that FNAB should be performed routinelly in the diagnostic evaluation of neck masses of unknown origin in patients with a previous history of thyroid neoplasm. CONCLUSIONS: If the FNAB is inconclusive, a second aspiration should be performed while immunoperoxidase stain to evidentiate TG may be an adjuntive diagnostic tool in cytologically negative cases.     

Aggressive fibrous dysplasia of the maxillary sinus

Fibrous dysplasia is usually a slowly progressive, benign disease that develops over several years and presents with deformity or mild symptomatology. Five of 34 patients (ages 4-21 years), who were subsequently diagnosed histologically as having fibrous dysplasia of the maxillary sinus, rapidly developed soft tissue masses of the malar region over a period of less than 4 months with accompanying pain (2 patients) and nasal obstruction and exophthalmos (2 patients). Each was clinically suspected of having a sarcoma; two had been thought to have an "osteofibrosarcoma" on initial biopsy at outside hospitals. After resection, all lesions developed regrowth. At histopathologic examination, both initial and recurrent masses proved to be typical fibrous dysplasia with spicules of woven bone in cellular, sometimes vascular, fibrous tissue. No malignant degeneration was found. On conventional radiography, aggressive fibrous dysplasia produced opacification and expansion of the maxillary sinus and apparent disruption of its wall with an associated soft tissue mass. Computed tomography (CT) demonstrated voluminous heterogeneous masses with "ground glass appearance", calcifications, areas of enhancement, low attenuation, cystic areas, and a thinned, sometimes interrupted, maxillary wall. Despite the aggressive clinical course for both initial and recurrent lesions, the CT findings of a "ground glass" mass with calcifications surrounded by a maxillary sinus wall, even if incomplete, can suggest the diagnosis of aggressive fibrous dysplasia.     

Cytologic findings in a case of T-cell rich B-cell lymphoma: potential diagnostic pitfall in FNA of lymph nodes

Fine-needle aspiration biopsy (FNAB) is a reliable diagnostic technique for most palpable masses. This technique is utilized routinely to diagnose metastatic carcinoma and melanomas in lymph nodes. However, the role of FNAB in the investigation of lymphoproliferative lesions is still controversial. Recent publications have supported the use of FNAB cytology, in conjunction with immunophenotyping, as an accurate, reliable diagnostic modality for the classification of most lymphomas (Sneige et al., Acta Cytol 1990; 34:311-322; Skoog and Tani, Diagn Oncol 1991; 1:12-18; Robins et al., Am J Clin Pathol 1994; 101:569-576; Katz, Clin Lab Med 1991; 11:469-499). We present a case of a T-cell rich, large B-cell lymphoma. Material obtained by FNAB mimicked a reactive process by both cytomorphological and immunophenotypical analysis. This case demonstrates a potential pitfall in the use of FNAB to evaluate lymphoproliferative disorders even when used in conjunction with immunophenotypic studies. The case also emphasizes the need for detailed clinical and prior pathologic information when a cytologic sample is being evaluated for a lymphoproliferative disorder. To our knowledge, the cytomorphologic findings of this particular type of lymphoma have not been previously described as seen on an FNAB.     

MR lesion detection in a breast cancer population

Implementation of MR imaging of the breast as an extension of the existing imaging modalities in the diagnosis of breast cancer was evaluated in a university cancer center, MR imaging of the breast was performed in 54 patients, in whom the MR results were compared with the triple test (the combination of clinical examination, mammographic evaluation, and cytology) and the final histological diagnosis. MR imaging of the breast depicted 30 of the 33 malignancies (sensitivity, 91%). In two of the malignancies, the carcinoma was clinically and mammographically occult. For the three patients with a false-negative MRI diagnosis, the conventional mammography showed suspicions clustered microcalcifications as a sign of in situ carcinoma. For seven patients, MR imaging of the breast incorrectly suggested the presence of a malignant lesion (specificity, 67%). To improve MR specificity, we perform MR-guided ultrasonographic fine-needle aspiration biopsy (FNAB). Although MR imaging of the breast is a highly sensitive examination, conventional x-ray mammography remains the most efficient imaging modality in the diagnosis of breast cancer. In our patient population, MR imaging of the breast had additional value for women with mammographically dense breast tissue and especially for patients with clinical evidence of breast carcinoma that could not be detected with conventional diagnostic methods.     

Magnetic resonance (MR) imaging of the chest: state-of-the-art

To date, magnetic resonance (MR) is established as an imaging modality in the diagnosis of chest diseases. Because of its excellent distinction of vessels and soft tissue, MR can be performed as the primary imaging procedure before computed tomography in patients with suspected vascular lesions, mediastinal masses, hilar lesions, and pathological changes of the pleura and the chest wall. In these cases, MR is able to provide all the necessary diagnostic information. In other patients, a limited number of MR images may be helpful in cases of equivocal or confusing CT or clinical findings. More detailed information can be obtained, using surface coils or special imaging sequences, i.e. high resolution MR images of the pleura or angiographic images of mediastinal and pulmonary vasculature. From a clinical viewpoint, the most important task for thoracic magnetic resonance nowadays is the pretherapeutic evaluation of intrathoracic masses, the differential diagnosis of benign versus malignant lesions, and the accurate documentation of tumour extent in malignancies including three-dimensional-display to improve surgical or radiation planning. Future directions in thoracic magnetic resonance will be predominantly influenced by postprocessing approaches, specialized imaging techniques, and magnetic resonance-guided interventional applications.     

Simultaneous multilayer arthrotomography of the temporomandibular joint using photostimulable phosphor computed radiography

OBJECTIVE: To compare the image quality of photostimulable phosphor computed radiography (CR) with that of a conventional screen-film system for simultaneous multilayer arthrotomography of the temporomandibular joint (TMJ). METHODS: X-ray attenuation, resolution and granularity was compared. Simultaneous multilayer tomography of TMJ was performed using a skull phantom and diagnostic quality of bone structures estimated. The clinical outcome is demonstrated in two typical cases. RESULTS: X-ray attenuation was larger with CR. Granularity was more prominent in edge-enhanced CR images and was associated with inferior diagnostic quality. However, it was improved by using a higher tube voltage. Clinical CR without edge enhancement showed a similar resolution to the conventional system but this decreased with enhancement. In an enhanced arthrotomogram, the boundary between contrast medium, bone and soft tissue were clearly defined and a fibrous adhesion also easily seen. CONCLUSION: Photostimulable phosphor CR is an acceptable alternative for simultaneous multilayer arthrotomography of the TMJ.     

Adrenal incidentaloma: proposal for a correct treatment

BACKGROUND: The incidence of unsuspected adrenal masses (incidentalomas) based on CT-scan results to be higher than in the past. The aim for our study was to establish some guidelines for an appropriate management. METHODS: From 1986 to 1995, 61 patients with no history or clinical findings suggestive of adrenal mass or adrenal hyperfunction were discovered by radiologic examination to have an incidentaloma larger than 1 cm. In each patient basal biochemical evaluations were obtained to exclude the presence of adrenal cortical or medullary dysfunction. There were 28 men and 33 (54.1%) women, with a mean age of 53 years (range 16-74). 19 patients underwent CT-guided fine-needle biopsy to exclude metastatic tumors. Furthermore in 29 patients 75-Se-selenomethyl-norcholesterol was performed and 17 were studied by MRI. RESULTS: At CT-scan mean lesion diameter was 5.48 +/- 3.76 cm (range 2-23); 32 adrenal masses were right sided and 3 (4.9%) were bilateral. 17 patients had concordant scintigraphic imaging pattern, 6 bilateral uptake and 6 had discordant imaging. CT-guided FNAB showed malignancy in 9. Adrenalectomy was performed in 45 patients according to a score calculated by 4 parameters: age of the patients, size of the mass, scintigraphic pattern, MR imaging. Twenty-four had a score greater than 9 and in the remaining 21 patients in spite of a score lower than 10 adrenalectomy was performed based on: 1) increased size at CT scan follow-up (15 pts); 2) either suspected primitive malignant neoplasm at CT-guided FNAB or history of malignancy (6 pts); 3) elevated 24-hour dopamine (4 pts). In 12 (26.7%) patients a malignant tumor was found. There were not any statistically significant differences (p > 0.05) between the age of the patients with malignant neoplasms and those with benign masses, and between the size of the masses, which were 7.58 +/- 5.93 cm (range 2-23) and 5.03 +/- 2.81 cm (range 3-17) respectively. The difference in scores between the patients with malignant masses (12.17 +/- 2.95) and those with benign ones (9.09 +/- 1.33) was statistically significant (p < 0.01). CONCLUSIONS: Since adrenal incidentaloma have a malignancy rate higher than the other adrenal tumors, it is crucial to outlinesome criteria to sort out the patients at risk for whom adrenalectomy is to be warranted. Based on our results we believe that patients with a score > 9 should undergo adrenalectomy.     

Prevention of the major complications of diabetes mellitus. What is the evidence?]

AIMS: Although fine needle biopsy (FNB) is a well established diagnostic technique there continues to be controversy concerning its use in the pre-operative assessment of intraparotid masses. The purpose of this study was to evaluate the diagnostic accuracy, specificity and sensitivity of FNB in parotid tumours and consequently to asses its clinical value. METHODS: Over a 6-year period, 129 consecutive patients with parotid masses underwent pre-operative FNB evaluation and in 121 of these cases the cytological diagnosis was confirmed. RESULTS: Out of the 86 cases cytologically diagnosed as benign, two false negative results were obtained by FNB, whereas out of the 38 cytological diagnoses of malignant tumours one case was found histologically to be Warthin's tumour. In the FNB results of the two cases suspicious for malignancy, one was confirmed histologically as malignant. Three cases of FNB with inadequate material were found to be benign lesions. In this trail, the diagnostic accuracy of FNB was 96.7%, the specificity, 97.6% and the sensitivity, 95%. CONCLUSIONS: Our results show that FNB is a valuable examination technique in the pre-operative evaluation of parotid masses.     

Cutaneous lymphoma with extensive periarticular involvement in a horse

Two months after colic surgery, subcutaneous masses were found on the ventral and lateral portions of the thorax of a 3-year-old Hanoverian-cross filly. Six months later, the filly was admitted for evaluation of severe lameness. Arthrocentesis of the tarsocrural joint yielded clotted sanguineous material; however, unusual multinucleated giant cells were seen. Radiography of the right tarsus revealed soft tissue opacity and degenerative joint disease. The filly was euthanatized to prevent further suffering. At necropsy, multiple soft-tissue masses were located throughout the fascial planes of the tarsi and in the subcutis of the ventral and lateral portions of the thorax. Neoplasms consisted primarily of a large number of mature well-differentiated T lymphocytes. On the basis of these findings, the diagnosis was cutaneous lymphoma with unusual involvement of periarticular tissues. Severe degenerative joint disease in the right tarsus did not appear to be associated with the tumors.     

Correlation of fine needle aspiration biopsy and fluoride-18 fluorodeoxyglucose positron emission tomography in the assessment of locally recurrent and metastatic head and neck neoplasia

OBJECTIVE: Patients with primary head and neck neoplasia can present during follow-up with suspected recurrence, and both fine needle aspiration biopsy (FNAB) and fluoride-18 fluorodeoxyglucose positron emission tomography (FDG-PET) scan are available methodologies for evaluating these patients. Our objective was to retrospectively correlate patients who underwent both FNAB and FDG-PET scan in order to assess the possibility of recurrent neoplasia. STUDY DESIGN: The cytopathology files at Saint Louis University Health Sciences Center were retrospectively searched for patients with known primary head and neck malignancies beginning in 1995. Suspected recurrence and local metastases evaluated by both FNAB and FDG-PET scan were correlated. RESULTS: Twenty-eight patients received a combined total of 37 FNABs with concurrent FDG-PET scans. The majority of patients had primary oropharyngeal squamous cell carcinoma with intermixed, single cases of other primary head and neck neoplasms. Thirty of the 32 aspirates with recurrent or locally metastatic disease had combined positive findings by both FNAB and FDG-PET scan, yielding a sensitivity of 94%. One nonspecific and one negative FDG-PET scan came from a patient who had disease confirmed by FNAB. Five patients had negative findings by both methods that were supported by the subsequent clinical course. CONCLUSION: FNAB can provide confirmatory evidence of disease in a clinically suspicious abnormality with nonspecific FDG-PET results. FNAB and FDG-PET are highly sensitive for tumors in cases of clinically suspected recurrence and locally metastatic disease.     

Determination of fetal biparietal diameter without the use of ultrasound in squirrel monkeys

OBJECTIVE: Granuloma annulare is an uncommon benign inflammatory dermatosis characterized by the formation of dermal papules with a tendency to form rings. There are several clinically distinct forms. The subcutaneous form is the most frequently encountered by radiologists, with the lesion presenting as a superficial mass. There are only a few scattered reports of the imaging appearance of this entity in the literature. We report the radiologic appearance of five cases of subcutaneous granuloma annulare. DESIGN AND PATIENTS: The radiologic images of five patients (three male, two female) with subcutaneous granuloma annulare were retrospectively studied. Mean patient age was 6.4 years (range, 2-13 years). The lesions occurred in the lower leg (two), foot, forearm, and hand. MR images were available for all lesions, gadolinium-enhanced imaging in three cases, radiographs in four, and bone scintigraphy in one. RESULTS: Radiographs showed unmineralized nodular masses localized to the subcutaneous adipose tissue. The size range, in greatest dimension on imaging studies, was 1-4 cm. MR images show a mass with relatively decreased signal intensity on all pulse sequences, with variable but generally relatively well defined margins. There was extensive diffuse enhancement following gadolinium administration. CONCLUSION: The radiologic appearance of subcutaneous granuloma annulare is characteristic, typically demonstrating a nodular soft-tissue mass involving the subcutaneous adipose tissue. MR images show a mass with relatively decreased signal intensity on all pulse sequences and variable but generally well defined margins. There is extensive diffuse enhancement following gadolinium administration. Radiographs show a soft-tissue mass or soft-tissue swelling without evidence of bone involvement or mineralization. This radiologic appearance in a young individual is highly suggestive of subcutaneous granuloma annulare.     

Primary fibrosarcoma of the right ventricle

Mexican literature has information of two fibrosarcomas in the atria. In the present work the first fibrosarcoma of the present work the first fibrosarcoma of the right ventricle found in Mexico is presented. This case behaved clinically, electrocardiographically, and phonomechanocardiographically like an Ebstein's disease, with the exception that in the phono a giant "a" wave was found. A review is mad of the clinical history, EKG, radiologic, and phono findings, as well as the laboratory analysis and data found in the autopsy.     

Common wrist injuries

Patients with wrist injuries often present to primary care physicians. Many times, mild clinical injury involves significant damage to carpal bones and soft tissue elements. The long-term outcome of these injuries depends on prompt diagnosis and appropriate therapy. Familiarity with the functional anatomy and physical examination of the wrist, accompanied by radiologic evaluation, may aid the physician in differentiating simple sprains from potentially debilitating wrist injuries.     

Fine needle aspiration biopsy of the liver. Principal diagnostic challenges

Fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice for evaluation of liver lesions. Although primarily applied to malignant disease, it is also used in the evaluation of benign conditions. Improvements in imaging techniques and advances in cytologic interpretations, as well as production of new biopsy needles, have all contributed to the rapid increase in radiologically guided liver FNAB.     

Imaging in pediatric urology

A multitude of disorders of the genitourinary tract can occur in children. Although some entities may be diagnosed clinically, radiologic imaging is often necessary for diagnosis and management. The radiologic work-up has been discussed using a problem-oriented approach in five clinical situations: urinary tract infection, hydronephrosis or hydroureter, trauma, swollen scrotum, and hematuria. This discussion provides some general guidelines, although the evaluation of each child may need to be individualized depending on their specific clinical symptomatology.     

Tuberculosis of the chest wall: CT findings

To assess the CT features of tuberculosis of the chest wall, the CT findings in four patients with documented tuberculous chest wall infection were reviewed. Two patients were Caucasian and two were of Chinese origin. All had normal immune status. In two cases tuberculosis involved the ribs, in one the costal cartilage, and in one the sternoclavicular joint. Computed tomography demonstrated osseous and cartilaginous destruction (in four), soft tissue masses with calcification (in two), and rim enhancement following intravenous contrast medium administration (in two). Underlying pleuroparenchymal tuberculosis was present in two cases. Tuberculosis of the chest wall is characterized by bone or costal cartilage destruction and soft tissue masses that may demonstrate calcification or rim enhancement with or without evidence of underlying lung or pleural disease.