Adrenal pheochromocytoma mimicking small cell carcinoma on fine needle aspiration biopsy. A case report

BACKGROUND: Fine needle aspiration biopsy (FNAB) is a sensitive and specific technique in the diagnosis of adrenal tumors. However, in rare cases the cytomorphologic features may mimic small cell neoplasms. CASE: A 54-year-old male presented with a history of hypertension and left flank pain of recent onset. Abdominal computed tomography (CT) showed a 4-cm mass involving the left adrenal gland. Fine needle aspiration biopsy (FNAB) showed groups of small round cells with hyperchromatic nuclei. The findings were highly suspicious for metastatic small cell carcinoma. Subsequently it was learned that the mass had been noted three years earlier on CT studies but had grown from 2.5 to 4 cm. A chest radiograph was unremarkable. The clinical findings were more in keeping with a primary adrenal tumor. Immunohistochemical staining done retrospectively on the cell block showed positive reactivity for chromogranin and neuron-specific enolase. These findings, correlated with the clinical features, were in keeping with a diagnosis of pheochromocytoma. Left adrenalectomy revealed a pheochromocytoma. CONCLUSION: Adrenal pheochromocytoma should be included in the differential diagnosis of small round cell neoplasms seen on FNAB of the adrenal gland. Immunohistochemistry and clinical findings are helpful in reaching the correct diagnosis.     

Ultrasound-guided fine needle aspiration biopsy in the diagnosis of breast cancer recurrence after mastectomy

PURPOSE: To define the accuracy and clinical impact of fine needle aspiration biopsy (FNAB) in diagnosing recurrent breast cancer after mastectomy. MATERIAL AND METHODS: The results of ultrasonography (US) and US-guided FNAB of 175 lesions located at the mastectomy site or in the ipsilateral axilla were reviewed. The final diagnosis was recurrent cancer in 77 cases and benign lesion in 98 cases, as verified by histological examination (n = 77) or follow-up (n = 98). RESULTS: FNAB yielded a representative aspirate in 92.6% of cases. The sensitivity, specificity and overall accuracy of FNAB cytology were 96.1%, 89.8% and 92.6% respectively. US and FNAB cytology were complementary methods in recurrent cancer diagnosis. The cytologic examination increased the specificity of US. The only recurrent tumor which appeared benign both sonographically and cytologically was removed because of a suspicious finding at palpation. FNAB cytologic diagnosis was found to have a clinical impact in 92.2% of the recurrent cases. CONCLUSION: US-guided FNAB provided an accurate adjunct to clinical examination and mammography for diagnosing and excluding breast cancer recurrence after mastectomy.     

Alcohol and traumatic death in Jalisco

Percutaneous fine needle aspiration biopsy (FNAB) were performed in 22 cases of pancreatic lesions. FNAB was done with the help of ultrasonographic guidance in 14 cases and intraoperatively in 2 cases. In rest of the cases it was done without any radiological guidance. Diagnosis was confirmed either by histopathology or exploratory laparotomy by follow-up data in rest of the cases. There was no false positive or negative diagnosis. Nuclear crowding, nuclear enlargement and prominent nucleoli were the important cytological criteria for pancreatic adenocarcinoma. Cytology smears of the islet cell tumour show round to oval monomorphic cells with central to eccentric nuclei and fine reddish granulations in cytoplasm. There was no complication following aspiration. Thus FNAB of pancreas is a relatively safe, reliable and quick technique which can be performed under ultrasound guidance.     

Low grade papillary adenocarcinoma of minor salivary gland origin. Diagnosis by fine needle aspiration cytology

OBJECTIVE: To describe the diagnostic cytologic features of low grade papillary adenocarcinomas of minor salivary gland origin (LPA) along with its pertinent differential diagnostic entities. STUDY DESIGN: The study was based on a histologically confirmed case of LPA that recurred after multiple excisions. Fine needle aspiration (FNA) was performed during the most recent recurrence. RESULTS: Low-power examination showed geographic sheets and papillary groups of epithelial cells. Individual cells were medium sized, with scant cytoplasm, finely clumped chromatin and occasional prominent nucleoli. Pleomorphism was conspicuously absent. Differential diagnosis included cellular mixed tumor, basal cell adenoma, basal cell adenocarcinoma, low grade mucoepidermoid carcinoma and metastatic papillary carcinoma. CONCLUSION: LPA can be accurately diagnosed by FNA biopsy. However, the cytopathologist must entertain and exclude various differential diagnostic entities.     

Atypical carcinoid tumor of the thymus

We report a male patient with atypical carcinoid tumor diagnosed by anterior mediastinotomy and biopsy after a mass was observed by chance on a chest film. The presence of neuroendocrine markers, notably chromogranin, cytokeratin, synapto-physin and neuro-specific enolase, facilitated diagnosis. Because the tumor was infiltrative, full surgical excision and radiotherapy to the mediastinum (50 Gy) were provided. We describe the incidence, clinical presentation, diagnosis, treatment and prognosis of these tumors.     

Primary cryptococcal infection of the larynx in a patient with AIDS: a case report

From January of 1990 to December of 1992, 6,954 consecutive cytologic breast fine-needle aspiration biopsies (FNAB) were performed at the Laboratory of Pathology of Sant'Anna Hospital in Turin. Of these cases 62% were solid nodes, 35% were cystic nodes, and 2.7% were nonpalpable breast lesions (stereotaxic or ultrasound guided FNAB). We verified 4,110 cases: 913 cases underwent surgery and 3,197 were evaluated clinically, and/or cytologically, and/or with mammography at least 1 yr after the first diagnosis, or checked with the database of the Tumor Registry of Turin. In our series the FNAB sensitivity was 94.6%, specificity was 99.9%, accuracy was 98.8%, inadequate samples were 6.4%, false-negative rate was 1.4%, and false-positive rate was 0.3%. Our results indicate that the use of cell block improves sensitivity (from 85.2 to 94.6%) and strongly reduces false-negative results (from 3.9 to 1.4%). We conclude that FNAB is a discriminant procedure to the surgical biopsy in cases with clinical, ultrasound, or mammographic low or intermediate suspect, contributing to allow a high malignant/benign surgical biopsy rate and to reduce the need for frozen section diagnosis and medical costs.     

Large cell neuroendocrine carcinoma of the thymus

AIM: We highlight the occurrence of an unusual neuroendocrine tumour, a large cell neuroendocrine carcinoma, arising from the thymus. CASE DETAILS: A 68-year-old man with a history of cigarette smoking had a large mediastinal tumour arising from the thymus removed. Two years later the tumour recurred; it was debulked surgically but the patient died 2 months later: Histological examination of both tumour specimens revealed a tumour with an endocrine pattern, composed of large pleomorphic cells with large nuclei and prominent nucleoli. The mitotic count ranged from 19 to 26 per 10 high-power fields and large tracks of coagulative tumour necrosis were present. The tumour cells were strongly positive for neuron-specific enolase (NSE), chromogranin, CAM5.2 and AE1/3, with cytoplasmic dot-like accentuation for the latter three markers. The tumour fulfilled the criteria for a diagnosis of large cell neuroendocrine carcinoma. CONCLUSIONS: Large cell neuroendocrine carcinoma should be distinguished from atypical carcinoid and small cell carcinoma. It is a distinctive neuroendocrine malignancy with a prognosis between that of atypical carcinoid and small cell carcinoma, and needs to be treated aggressively.     

Kidney-specific expression of a novel mouse organic cation transporter-like protein

OBJECTIVE: To assess the anterior mediastinal mass in recurrent testicular cancer, with relation to thymic hyperplasia after treatment. METHODS: The anterior mediastinal regions were fully evaluated by chest computed tomography (CT) at the initial staging and after treatment in 24 of 44 patients with testicular cancer. RESULTS: One patient with stage IIB tumor had thymic hyperplasia before treatment, and one with stage III had benign thymic hyperplasia after chemotherapy with salvage surgery. Three of 4 patients who had recurrence had an anterior mediastinal mass. One had benign thymic hyperplasia confirmed by histology and 2 had metastatic tumor confirmed by histology and clinical course, in which the mass became so enlarged that it obstructed major vessels. CONCLUSION: Although the relationship of the CT finding to the response to treatment in the anterior mediastinal mass and other metastatic lesions provide some clues helpful in differentiating benign from malignant masses, surgical exploration is recommended for the patient with an indication for salvage surgery.     

Mesenchymal chondrosarcoma of the retroperitoneum. Report of a case diagnosed by fine needle aspiration biopsy with immunohistochemical, electron microscopic demonstration of S-100 protein in undifferentiated cells

BACKGROUND: Mesenchymal chondrosarcoma (MC), first described in 1959 by Lichtenstein and Bernstein, is an uncommon tumor of the soft tissues and bone defined by the coexistence of nests of well-defined cartilaginous tissue within a proliferation of primitive mesenchymal cells. CASE: A 27-year-old, white female consulted a physician for a left lumbar mass associated with sciatica-type pain, asthenia, anorexia and weight loss. Abdominal computed tomography showed a 20-cm, retroperitoneal neoplasm that occupied the lower half of the left abdominal flank. Fine needle aspiration biopsy showed clusters of small round cells mixed with islets of mature cartilage. Immunomarking for electron microscopy, carried out with 15 nm of A protein/colloidal gold, showed specific immunoreactivity to S-100 protein in the nuclear chromatin, nucleoli, Golgi apparatus, plasma membrane and cytosol of cells with more developed organelles. CONCLUSION: The diagnosis of MC rests on recognition of the biphasic component of small, undifferentiated cells and cartilage islets. In aspirates with only undifferentiated cells, demonstration of ultrastructure-specific immunoreactivity to S-100 protein may contribute to the final diagnosis.     

Amino acids and vitamins prevent culture-induced metabolic perturbations and associated loss of viability of mouse blastocysts

BACKGROUND: Subsequent to the publication of a report in 1984 entitled "Poorly Differentiated ("Insular") Carcinoma: A Reinterpretation of Langhans "wuchernde Struma," poorly differentiated insular thyroid carcinoma (PDITC) has become recognized as a distinct thyroid neoplasm. It is classified morphologically and biologically as an intermediate entity between well-differentiated (papillary and follicular) and undifferentiated (anaplastic) thyroid carcinomas. Only a few publications have addressed the findings with fine needle aspiration biopsy (FNAB). CASE: A 67-year-old female presented for evaluation of a massively enlarged thyroid gland. Fine needle aspiration biopsy of the thyroid with a 22-gauge needle showed many large, multilayered, round to oval nests of tumor cells, 0.2-0.4 mm in diameter. Rosettelike configurations of 8-15 cells, 0.025-0.050 mm in diameter, were also observed. Nests of neoplastic cells in the histologic sections were virtually identical to those in the fine needle aspiration biopsy specimens. When the patient developed metastatic cervical adenopathy one year later, a microfollicular pattern was seen on both the FNAB and histologic sections. CONCLUSION: When nests of tumor cells, 0.2-0.4 mm in diameter, are identified in a thyroid FNAB specimen, PDITC should be included in the differential diagnosis. A microfollicular pattern in a metastatic lymph node does not exclude the possibility that the primary tumor is a PDITC.     

Fine needle aspiration biopsy of extramedullary leukemia

OBJECTIVE: To study the cytologic features and role of fine needle aspiration biopsy (FNAB) in the diagnosis of extramedullary leukemia. STUDY DESIGN: Forty-one cases of extramedullary leukemia diagnosed by FNAB were analyzed along with their detailed clinical and hematologic features. RESULTS: Common sites of leukemic involvement were lymph nodes (34), skin (4), orbit (1), eyelid (1) and breast (1). The most common variety of leukemia was chronic myeloid in the chronic phase (17). Twenty-six patients were referred to the cytology clinic for FNAB as the initial screening test. In the majority of fresh cases, leukemia was not the first possibility considered, and FNAB played an important diagnostic role. No gross discrepancy was noted in any of the cases. CONCLUSION: FNAB is helpful in the diagnosis of extramedullary involvement by leukemia because of the good morphologic detail of blasts and other granulocytic cells. However, for more accurate subclassification of a hematologic disorder, other hematologic investigations are mandatory.     

Cartilaginous tumors of the larynx. A report of two cases with definitive diagnosis by fine needle aspiration and computed tomography

BACKGROUND: Cartilaginous tumors of the larynx are rate tumors with an indolent course. In the past they were diagnosed by radiographic or computed tomographic imaging and laryngoscopic or surgical biopsy. The literature contains few examples of fine needle aspiration biopsy of these tumors. CASES: Smears of the fine needle aspirates from two cases of cartilaginous tumors of the larynx consisted of a mucinous background containing chondroid fragments of benign-appearing lacunar cells. Cytomorphologic and architectural features of smears and cell block preparations correlated well with histologic sections for subsequent surgical specimens. Both tumors were classified by cytology and histology as low grade cartilaginous tumors. CONCLUSION: Fine needle aspiration biopsy, together with typical computed tomographic images, is adequate for diagnosis, cost-effective and safe and can be performed in an outpatient setting.     

The thoracoscope as diagnostic tool for solid mediastinal masses

BACKGROUND: Despite the accuracy of percutaneous biopsy of mediastinal masses under CT scan or sonographic control, there is still a need for surgical biopsy because of difficult location or because of insufficiency of the percutaneous biopsy, especially for those tumors requiring an immunological classification. METHODS: The thoracoscopic approach to mediastinal masses is an alternative to the usual surgical biopsies performed through thoracotomy, sternotomy, or anterior mediastinotomy. The procedure is performed under general anesthesia and one-lung ventilation. RESULTS: In a series of 47 cases, a histological diagnosis was obtained in 44 cases (93.6%). There was one hemorrhagic complication requiring thoracotomy (2.1%). The mean postoperative duration of stay was 3.2 days. CONCLUSIONS: Thoracoscopy is the method of choice in case of failure or contraindication of percutaneous biopsy. There is still a role for mediastinoscopy in treating paratracheal lymph nodes.     

Fine needle aspiration cytology of malignant chondroid syringoma: a case report

BACKGROUND: Chondroid syringoma, a tumor of the eccrine glands, was previously called mixed tumor of skin as it has both mesenchymal and epithelial elements. Malignancy in this tumor is extremely rare. Although there are a few reports describing the cytomorphologic features of chondroid syringoma, the cytologic findings of its malignant counterpart have not been described. CASE: A 40-year-old female presented with a recurrent swelling on the scalp of one year's duration. Fine needle aspiration yielded blood-mixed gelatinous material. May-Grünwald-Giemsastained smears showed epithelial cells arranged in cordlike structures and ill-formed glands against a myxomatous background. The epithelial cells had scanty cytoplasm and markedly pleomorphic nuclei with prominent nucleoli. A few cells in the stroma had a halo around them and a resemblance to cartilage cells. A preoperative diagnosis of malignant chondroid syringoma was made. The tumor was excised, and the cytologic diagnosis was confirmed on histopathology. CONCLUSION: Cytomorphologic features of a rare case of malignant chondroid syringoma are reported for the first time. The presence of malignant epithelial cells against a myxoid background with a few chondroid foci helped in making a correct preoperative diagnosis.     

Donor leukocyte transfusion as treatment for relapsed chronic myelogenous leukemia after allogeneic bone marrow transplantation

We reviewed 4 cases of high-grade transitional-cell carcinoma (TCC) of the urinary tract with solitary pulmonary metastases that were studied by transthoracic needle aspiration biopsy cytology. There were two grade II and two grade III TCCs. The two grade II tumors yielded, in needle aspirates, syncytial tumor-cell clusters showing ill-defined, granular cytoplasm and slightly pleomorphic nuclei with inconspicuous nucleoli. In one case the tumor-cell cluster showed a focal acinar arrangement, mimicking cells of an adenocarcinoma. In both cases the electron microscopy (EM) study of aspirated tumor cells revealed epithelial cells with well-formed cell junctions, intracytoplasmic vesicles, apical short microvilli, and focal interdigitation of lateral cell membranes, suggesting a urothelial neoplasm. The two grade III TCCs yielded, in needle aspirates, pleomorphic malignant cells singly and in small clusters, showing well-defined, granular cytoplasm and pleomorphic nuclei containing prominent nucleoli, suggesting a poorly differentiated adenocarcinoma or an anaplastic large-cell carcinoma. By EM examination the aspirated tumor cells from one case revealed well-formed cell junctions, intracytoplasmic vesicles, poorly formed microvilli, and focal interdigitation of lateral cell membranes, suggesting a urothelial differentiation. In the other case the tumor cells were pleomorphic cells with occasional cell junctions and no ultrastructural features as seen in the other 3 cases of TCC. The tumor cells from the two grade II TCCs showed strong immunopositive reaction with keratin 7 antibody and weakly positive reaction with carcinoembryonic antigen antibody (CEAA), while those of the two grade III TCCs displayed only a weak and focal immunopositive staining with keratin 7 antibody and strong reaction with CEAA.     

Choroidal melanoma in an African-American albino

PURPOSE: To report the rare occurrence of choroidal melanoma in an African-American albino. METHODS: A 68-year-old African-American man with oculocutaneous albinism developed an amelanotic choroidal mass in his left eye. A transvitreal fine-needle aspiration biopsy was performed to confirm the diagnosis, and the patient was treated with iodine 125 plaque radiotherapy. RESULTS: The cytology of the needle biopsy showed spindle cells with nuclear atypia and prominent nucleoli. The cells showed positive immunoreactivity for HMB-45, supporting the diagnosis of choroidal melanoma. CONCLUSION: To our knowledge, this is the first reported case of a choroidal melanoma occurring in an African-American albino.     

Gastrointestinal autonomic nerve tumor (plexosarcoma): report of a case with fine needle aspiration biopsy and histologic, immunocytochemical and ultrastructural study

BACKGROUND: Gastrointestinal stromal tumors (GISTs) encompass a large group of mesenchymal neoplasms that display common cytologic spindle-shaped morphology on light microscopy. Immunocytochemical and ultrastructural studies can demonstrate several patterns of differentiation. CASE: A 70-year-old male presented with two intraabdominal small bowel masses. The cytopathologic features of a fine needle aspiration biopsy (FNAB) included plump spindle cells in densely populated aggregates or in a fasciculated pattern, without significant pleomorphism. An epithelioid component in a lobular arrangement with abundant, eosinophilic cytoplasm was also noted. The nuclei were vesicular, with a very evident, eosinophilic nucleolus and finely distributed chromatin. Groups of loosely cohesive cells with slender, dendritic-like cytoplasm were evident. Immunocytochemical study of the embedded, fine needle aspirated fragments of the neoplasm demonstrated immunoreactivity for vimentin and neuron-specific enolase. Cytokeratin immunoreactivity or muscular, vascular, neuroendocrine or nerve sheath differentiation failed to be demonstrated. The cytologic and immunocytochemical findings correlated well with the histologic features of the neoplasm. The morphologic diagnosis was confirmed by ultrastructural study. CONCLUSION: FNAB and immunocytochemistry can be valuable in making the correct diagnosis between gastrointestinal stromal tumors.     

A case of relapsed thymic carcinoma that responded remarkably to chemotherapy with CPT-11

A chemotherapeutic protocol for advanced thymic carcinoma has not been established as yet. We described a case of advanced and relapsed thymic carcinoma that responded remarkably to subsequent chemotherapy with CPT-11. A 61-year-old man was admitted to our hospital because of facial edema and general fatigue. Chest X-ray and CT scan showed anterior mediastinal tumor which involved large vessels and pericardium. CT guided needle biopsy yielded a diagnosis of squamous cell type of thymic carcinoma. The patient was initially treated with ADOC (ADM, CDDP, VCR, CPA) chemotherapy and had successfully controlled for six months. However, the mediastinal tumor recurred and radiotherapy and nedaplatin plus ETP therapy were not effective. Then, CPT-11 chemotherapy (80 mg/m2, 2 weeks) was performed. The patient showed a partial response after two courses of CPT-11 chemotherapy. This case suggests that CPT-11 is a useful chemotherapeutic agent for advanced thymic carcinoma.     

Conformational study of a collagen peptide by 1H NMR spectroscopy: observation of the 14N-1H spin-spin coupling of the Arg guanidinium moiety in the triple-helix structure

A 36-month-old girl had a 3-week history of proptosis of the right eye. Computed tomography showed an ill-defined homogeneous mass filling the intraconal space. Histopathologic examination and immunohistochemistry findings of an incisional biopsy specimen were consistent with malignant undifferentiated tumor with rhabdoid features. Despite chemotherapy (a combination of vincristine sulfate and dactinomycin) and radiotherapy, massive orbital recurrence occurred 6 months later and orbital exenteration was performed. The recurrent tumor was composed entirely of pleomorphic epithelial cells with prominent nucleoli and many filamentous cytoplasmic inclusions. Immunohistochemical staining showed positive immunoreactivity for vimentin, cytokeratin, and epithelial membrane antigen, and negative immunoreactivity for muscle-specific antigen, melanoma, neural, and histiocytic markers. Electron microscopy excluded myogenic differentiation and showed that the filamentous cytoplasmic inclusions were composed of whorls of intermediate filaments. Aggressive chemotherapy with a combination of vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide phosphate was continued after exenteration. At 17 months' follow-up, orbital debulking surgery with externalization of the maxillary sinus was performed because of massive tumor recurrence in the right orbit and growth into the maxillary sinus. The child died 23 months after initial diagnosis from tumor invasion into the central nervous system. Extrarenal rhabdoid tumor is a rare orbital mass that carries a poor prognosis.     

Positive economic and diagnostic accuracy impacts of on-site evaluation of fine needle aspiration biopsies by pathologists

OBJECTIVE: To investigate the impact of pathologists' immediate evaluation of fine needle aspiration biopsy (FNAB) on increasing diagnostic yield and decreasing related expenses. STUDY DESIGN: All FNABs performed at our 420-bed hospital between January 1992 and December 1994 were reviewed. The 1992-1993 FNABs were all performed without pathologist attendance. Smears were wet fixed in 95% alcohol and later stained by the Papanicolaou or hematoxylin and eosin methods. The remaining aspirated material was collected in Saccomano's preservative, and a cell block was made. Nearly all the 1994 FNABs were performed with the pathologist present; he examined air-dried, Diff-Quik-stained smears for preliminary evaluation of the aspirate. An average of three passes were done. The rest of the procedure was as usual. RESULTS: The total number of 1992-1993 FNABs was 227 (108 + 119); of them, 104 (46%) were inadequate for diagnosis. In contrast, the 1994 FNABs totaled 169, with only 40 (24%) inadequate for diagnosis. The vast majority of the aspirates were done on deep-seated lesions under computed tomography (CT) guidance. CONCLUSION: The results of our experience indicate that on-site evaluation by a pathologist greatly increases the diagnostic yield. Another advantage is the significant financial savings as compared to excisional tissue biopsy. In general, the expenses of a CT-guided FNAB (e.g., pancreas) average around $1,400, while charges for excisional biopsy under general anesthesia with a subsequent two- to three-day hospitalization average about $7,720.