Correlation of clinico-pathologic and radiologic parameters of response to neoadjuvant chemotherapy in breast cancer.

CONTEXT: As of today, there is no validated standard method to assess clinical response of breast cancer to neo- adjuvant chemotherapy (NACT). Some centers use clinical dimensions while others use radiological measurements to evaluate response according to RECIST criteria. AIMS: The aim was to correlate and compare the clinical, radiological, and pathological parameters for assessing the tumor response in patients of breast cancer receiving NACT. SETTINGS AND DESIGN: Single institution, prospective nonrandomized study conducted over a 2-year period. MATERIALS AND METHODS: Patients with diagnosed breast cancer were assessed for response to NACT prior to surgery using clinical and radiological techniques. This was correlated with pathological reponse which was assessed by measuring gross dimensions and Miller-Payne grading of response to chemotherapy. STATISTICAL ANALYSIS USED: Spearman's rho nonparametric. RESULTS: Fifty two patients completed the evaluation (out of 313 cases of ca breast treated during the same period) with a median age of 52.5 years. We noted a 26.9% clinical complete response (CR) and 19.2% had pathological CR. Clinical evaluation had a sensitivity and specificity of 73.5% and 88.5% respectively compared to 14.2% and 100% respectively for radiological assessment. CONCLUSIONS: Clinical assessment of response to NACT shows a higher sensitivity compared to radiological assessment. However the overall low sensitivity and specificity rates of clinical assessment mandate a search for a better method of evaluation.

Nerve-sparing subcapsular resection of head and neck schwannomas: technique evaluation and literature review.

BACKGROUND: The head and neck region harbours crucial structures and hence the surgical technique used to remove schwannomas from this region should cause minimal damage to these structures, with complete removal of pathology. METHODS: This study entailed a retrospective analysis of 10 patients with head and neck schwannomas that were excised using a nerve-sparing subcapsular dissection technique. The primary aims were to assess the functional impact of the surgical technique on the structure of origin and to evaluate local control. RESULTS: One patient with parapharyngeal schwannoma developed symptoms suggestive of 'first bite syndrome' in the late post-operative period. Another patient with facial nerve schwannoma had House-Brackmann grade II weakness in the immediate post-operative period, which subsequently resolved. None of the patients developed recurrence during a median follow-up period of two years. CONCLUSION: The nerve-sparing subcapsular dissection technique provided effective local control of tumour pathology, with relative preservation of neural function post-operatively.

Is hysterectomy needed in ovarian cancer?

CONTEXT: Hysterectomy is an integral part of ovarian cancer surgery. The authors have evaluated the uterine involvement in ovarian cancer in this study. AIMS: Conventionally, removal of the uterus is considered an essential part of ovarian cancer surgery, but rationale for same in absence of its gross involvement is questionable. Aim of this study was to evaluate the microscopic involvement of uterus in ovarian cancer and whether there are any predictors of uterine involvement. SETTINGS AND DESIGN: Retrospective study. MATERIALS AND METHODS: The authors analyzed 128 patients of epithelial ovarian cancer (EOC) operated from 2004 January to 2008 June, who had not undergone hysterectomy previously. Data regarding their demographic, clinical, and pathological findings was collected and analyzed. STATISTICAL ANALYSIS USED: Chi-square test. RESULTS: Most of our patients (n=111) presented with stage III or above. Serous carcinoma was the most common histology encountered (86.7%). Uterus was grossly involved in only 19 patients and microscopic involvement was noted in 20 patients. Only one patient with absence of gross involvement had microscopic disease in the uterus. Involvement of the uterus was found to be independent of stage, type of tumor, laterality, and preoperative chemotherapy. The grade of tumor and gross uterine involvement were only factors that showed statistically significant correlation with microscopic uterine involvement. Only one patient had synchronous endometrial cancer. CONCLUSIONS: Uterine involvement in EOC is not common. Absence of gross uterine involvement reliably predicts absence of microscopic disease.

Cytomorphological and immunocytochemical study of non-Hodgkin's lymphoma in pleural effusion and ascitic fluid.

INTRODUCTION: Non-Hodgkin's lymphoma (NHL) is often complicated by pleural effusion and ascites. The present study is an attempt to categorize the lymphomatous effusions according to the WHO classification, using archival material. METHODS: May-Grünwald-Giemsa and Papanicolaou-stained smears of 31 lymphomatous effusion specimens were reviewed. Of these, detailed cytological assessment was done on 12 pleural effusions and ten ascitic fluid specimens from 22 patients using the WHO lymphoma classification system. Immunocytochemical studies were performed in 21 specimens. RESULTS: Based on cytomorphological features, the 22 lymphomatous effusion specimens were categorized into lymphoplasmacytoid lymphoma (1), follicle centre cell (FCC) grade-1 (centrocytic) lymphoma (3), FCC grade-2 (centrocytic-centroblastic) lymphoma (3), FCC grade-3 (centroblastic) lymphoma (4), large cell immunoblastic lymphoma (4), lymphoblastic lymphoma (2), anaplastic large cell lymphoma (3) and miscellaneous types (2). Immunocytochemically, the lymphoma cells were T-cell (positive for CD3) and B-cell type (CD20 positive) in five and six cases respectively. CONCLUSION: Cytological examination of pleural effusion and ascitic fluid samples, supported by immunocytochemical studies, may be useful for the classification of lymphomas under the WHO system.

Cytoplasmic colloid inclusions in thyroid lesions: a cytomorphological study based on fine needle aspiration.

INTRODUCTION: Intracytoplasmic lumens (ICL) with or without magenta material and transgressing vessels are features of Hürthle cell neoplasms (HCN). After detection of intracytoplasmic colloid inclusions (CIs) including targetoid (magenta) body-like structures in the Hürthle cells (HC) in a case of Hashimoto's thyroiditis (HT), we reviewed cases of HT, thyroid neoplasms, hyperplastic nodules (HN) and colloid goitres to determine the frequency of these structures. Further, an attempt was made to find out the significance of CIs. METHODS: FNA smears of 120 HT, 101 colloid goitres, 11 HN, and 76 neoplastic goitres were examined. The presence of CIs and empty ICL were noted in epithelial cells in these lesions. An attempt was made to find out the difference between HT with and without CIs in respect of various cytomorphologic features. The groups were compared using the Fisher's exact test of probability. RESULTS: The CIs were present in 36 (30.0%) of HT, 26 (34.2%) of neoplastic goitres, 3 (27.3%) of HN, and 4 (4.0%) colloid goitres. As compared to colloid goitres, CIs were present in a significant higher number of cases in HN (P = 0.0202), neoplastic goitres (P < 0.0001), and HT (P < 0.0001). Among neoplasms the frequency of CIs in HCN (75.0%) was significantly higher than that of papillary thyroid carcinoma (PTC) (33.3%, P = 0.0466), and follicular neoplasm (14.3%, P = 0.0083). The CIs were more frequent in HC in HT and HCN but in follicular cells (FC) in other lesions. The HT cases with CIs differed significantly from those without CIs in respect of HC and their cellularity, cellularity of reactive lymphoid cells, extracellular colloid and empty ICL. CONCLUSION: Care should be taken not to diagnose HT cases with an excessive Hürthle cell component and CIs, and PTC cases with Hürthlization and CIs, as HCN in FNA smears. Based on review of the literature and our findings, it is suggested that the Hürthle cell metaplasia in HT is a survival response of FC and the presence of CIs in Hürthle cell may represent their limited ability to synthesize colloid.

Cytodiagnosis of nipple discharge: a study of 602 samples from 484 cases.

To find out the gross and microscopic differentiating features between nipple discharges (ND) due to various breast lesions, smears of 602 ND samples from 484 cases were reviewed by one of the investigators (D.K.D.). The reviewed cytodiagnoses were as follows: benign nipple discharge (59.1%), inflammatory ND (6.5%), ?papillary lesions (2.5%), papillary lesions (20.6%), papillary lesions with atypia (3.8%), duct cells with atypia (0.2%), suspicious for malignancy (0.5%), malignant ND (1.2%), and inadequate (5.6%). Following review, samples with epithelial abnormalities (?papillary lesion, papillary lesion with and without atypia, duct cells with atypia, suspicious for malignancy, and malignancy) increased from 16.6% to 30.4% of adequate samples (P < 0.0001). 37.9% unilateral ND samples showed epithelial abnormalities, as opposed to 18.9% of bilateral ND samples (P < 0.0001). Bloodstained ND showed epithelial abnormalities in 41.5% samples, as compared to 22.1% of ND with other specified gross characteristics (P < 0.0001). The samples with epithelial abnormalities differed significantly from benign and inflammatory ND in respect of frequency of benign duct cells, duct cells with atypia, papillary clusters with or without atypia, malignant cells, columnar cells, red blood cells, inflammatory cells, and background lipid vacuoles (P < 0.01 to < 0.0001). The ND samples with suspicious and malignant cytology, besides the presence of malignant cells (P < 0.0001), differed significantly from rest of the lesions in respect of foam cells (P < 0.0001), red blood cells (P < 0.01), and inflammatory cells (P < 0.05). When compared with histopathological diagnosis in 20 cases, the benign or malignant nature of the lesion was correctly identified in ND in 80% cases. The ND cytologies in 7 histologically proved malignant cases were malignancy (3 cases), suspicious for malignancy (1 case), papillary lesion with atypia (1 case), papillary lesion (1 case), and benign ND (1 case).

Fine needle aspiration cytology diagnosis of a cutaneous granular cell tumor in a 7-year-old child. A case report.

BACKGROUND: Granular cell tumors are neoplasms of uncertain histogenesis, although a neural origin is favored. Most reports on the cytologic features of granular cell tumors have been on lesions from the breast or respiratory tract. However, there are only a few reports on fine needle aspiration (FNA) cytologic diagnosis of cutaneous or soft tissue granular cell tumors. CASE: A 7-year-old girl presented with a skin lesion on her right forearm of one year's duration. The FNA smears showed sheets and clusters of oval to polygonal cells with an abundant amount of granular cytoplasm. Many single, scattered cells with similar morphology were seen in the background. Immunostaining for S-100 protein showed granular cytoplasmic positivity. The tumor was diagnosed as a benign granular cell tumor. The histopathology report on the excised lesion confirmed the FNA diagnosis. CONCLUSION: The cytopathologic features of granular cell tumors presenting as skin lesions are distinctive enough to allow a correct diagnosis on FNA cytology.

Fine needle aspiration cytology of primary non-Hodgkin's lymphoma of the tongue. A case report.

BACKGROUND: Fine needle aspiration cytology (FNAC) of extranodal non-Hodgkin's lymphoma of the tongue has rarely been described. CASE: A 47-year-old male was referred to the cytology laboratory for FNAC of a 3-cm-diameter swelling on the dorsum of the tongue, with a primary clinical diagnosis of soft tissue tumor. FNAC smears showed discrete, monomorphic, round to oval cells with scanty, deep blue cytoplasm. The nuclear margin was regular, with occasional prominent nucleoli and fine nuclear chromatin. The background showed many lymphoglandular bodies. The cells were strongly positive for leukocyte common antigen. A cytologic diagnosis of high grade non-Hodgkin's (NHL) was offered and subsequently confirmed by histopathology. CONCLUSION: Primary NHL of the tongue is relatively rare. As there are no characteristic clinical features of extranodal NHL of the tongue, FNAC may be useful for rapid diagnosis and management of such cases.

Fine needle aspiration cytology of Langerhans cell histiocytosis of the thyroid. A case report.

BACKGROUND: Langerhans cell histiocytosis (LCH) of the thyroid is a rare condition, and fine needle aspiration cytology (FNAC) of this entity has rarely been described. CASE: FNAC was done on a 3-cm-diameter thyroid swelling in the left lower lobe of the thyroid gland. Smears showed a large number of lymphocytes, eosinophils, thyroid follicular cells and discrete, large cells with prominent nuclear grooves. Mitotic activity was frequent. A cytologic diagnosis of LCH was offered. Subtotal thyroidectomy was performed, and the cytologic diagnosis was confirmed by histology. CONCLUSION: LCH of the thyroid has certain salient diagnostic features. The presence of histiocytes with prominent nuclear grooves, reactive lymphoid cells and eosinophils along with benign thyroid follicular cells should raise the suspicion of this rare entity on FNAC smears of the thyroid.

Cytologic grading and DNA image cytometry of breast carcinoma on fine needle aspiration cytology smears.

OBJECTIVE: To correlate the cytologic grade of breast carcinoma with DNA image cytometry (ICM) and nuclear area on fine needle aspiration cytology (FNAC) smears. STUDY DESIGN: In this prospective study, FNAC material from 28 breast carcinomas were studied for cytologic grade and DNA ICM. Breast carcinomas were classified as grade 1-3 (low to high). DNA histograms were classified by the modified Auer method. Degree of hyperploidy (DH), ploidy balance (PB) and nuclear area (NA) were measured on Feulgen-stained smears by a CAS 200 image cytometer. Cytologic grade was correlated with DNA ICM findings and NA. RESULTS: There were 3 cytologic grade 1, 13 grade 2 and 12 grade 3 breast carcinomas. Seven of eight cases of hypertetraploid aneuploidy were grade 3 tumors. All cytologic grade 1 tumors were diploid. There were significant differences in DH, PB and NA in different grades of breast carcinoma (one-way ANOVA). CONCLUSION: DNA image cytometry in combination with cytologic grading might offer additional information for the characterization of breast carcinomas diagnosed by FNAC. These observations are of particular interest with the introduction of preoperative chemotherapy.

Role of nuclear grooves in the diagnosis of papillary thyroid carcinoma. A quantitative assessment on fine needle aspiration smears.

Thirty-four cases of papillary thyroid carcinoma and 69 control cases consisting of 17 follicular neoplasms, 5 Hürthle cell neoplasms, 7 medullary carcinomas, 6 thyrotoxic goiters, 19 chronic lymphocytic thyroiditis cases, 3 subacute thyroiditis cases and 12 colloid goiter cases were studied for nuclear grooves. Such grooves were seen in 100% of papillary carcinoma and in 75-100% of other thyroid disorders, but their number was strikingly higher in papillary carcinoma. A quantitative assessment for nuclear grooves was made based on counting 500 follicular cells in hematoxylin and eosin (H&E)-stained and May-Grünwald-Giemsa (MGG)-stained smears. In H&E-stained smears of papillary carcinoma the number of cells with nuclear grooves (227.3 +/- 99.96 SD) was significantly higher as compared to other thyroid disorders (P < .01 to < .001). Eighty-eight percent of papillary carcinoma had nuclear grooves in > or = 20% tumor cells, whereas none of the other thyroid diseases exceeded this level. In MGG-stained smears the number of cells with nuclear grooves (40.7 +/- 32.83 SD) was also significantly higher as compared to other thyroid disorders (P < .05 to < .001). Of papillary carcinomas, 67.6% had > or = 4% cells with nuclear grooves, whereas 0-40% of other thyroid diseases exceeded this level. Nuclear grooves were significantly higher in H&E-stained smears of papillary carcinoma as compared to MGG-stained smears (P < .001). Based on this objective assessment, nuclear grooves were a useful criterion in the diagnosis of papillary thyroid carcinoma in H&E-stained smears but were not as reliable in MGG-stained smears.

Metaplastic carcinoma of the breast in a renal transplant recipient. Initial diagnosis by fine needle aspiration cytology and immunocytochemistry.

A 46-year-old woman presented with a mass in the left breast and left axillary lymphadenopathy. Five years earlier she had received a renal transplant from an unrelated donor because of end-stage renal failure secondary to adult polycystic kidney disease. She was on immunosuppression therapy in the form of cyclosporine, azathioprine and prednisolone. Fine needle aspiration cytology of the breast mass showed a metaplastic (sarcomatoid) carcinoma, whereas the axillary lymph node aspirate suggested carcinosarcoma. Immunocytochemical studies revealed dense positivity for vimentin in the sarcomatous component and positivity for epithelial membrane antigen in the epithelial component. Rare cells were positive for cytokeratin. The cytodiagnosis was confirmed by excision biopsy of axillary lymph nodes. The patient died on the fourth postoperative day following left mastectomy and axillary clearance. The histopathology report of the breast tumor showed sarcomatoid carcinoma.

Fine needle aspiration cytologic diagnosis of axillary accessory breast tissue, including its physiologic changes and pathologic lesions.

Sixty-nine cases of axillary accessory breast tissue, including its physiologic changes and pathologic lesions, were diagnosed by fine needle aspiration cytology. The age of the patients ranged from 13 to 40 years, with a median of 25, and all were female. The cases presented with swellings in the left axilla in 16 cases, right axilla in 30 cases and both axillae in 23 cases. The common clinical diagnoses included accessory breast tissue (23.2%), lipomatous lesion (17.4%), lymphadenopathy (18.8%) and swellings not otherwise specified (30.4%). In 8.8% cases two of the possibilities were considered. The cytodiagnoses included axillary accessory breast tissue (47 cases), axillary breast tissue with pregnancy or lactational changes (15), cystic disease (4) and fibroadenoma (3). One of the cystic disease cases showed granulomatous inflammation. Although no case of carcinoma in axillary breast tissue was diagnosed during the study period, there were two cases of malignancy in axillary swellings (diagnosed as metastatic carcinoma) when no primary was detected in the breasts.

Intranuclear Reinke's crystals in a testicular Leydig cell tumor diagnosed by aspiration cytology. A case report.

Fine needle aspiration cytologic findings in a Leydig cell tumor of the testis are described. Besides the rarity of case reports on fine needle aspiration cytologic diagnosis of this tumor, the present case was of interest because of the finding of numerous intranuclear and intracytoplasmic Reinke's crystals as well as some lying free between the cells. In a few cells the intranuclear crystals were seen to orient themselves in a row, with a nipplelike protrusion of the nuclear membrane as if being pushed by the crystals. Besides the well-formed crystals, many nuclei showed irregular, thin, groovelike spaces that may have been earlier stages of crystal formation. These findings suggested the intranuclear formation of Reinke's crystals. Extranuclear crystals were seen to fuse in pairs and hence to appear thicker than the intranuclear crystals. The crystals lying free between the cells also showed a linear arrangement in places. The crystals were more numerous with May-Grünwald-Giemsa (MGG) staining. Intranuclear crystals were seen only in MGG-stained smears.

Cytodiagnosis of tuberculous lymphadenitis. A correlative study with microbiologic examination.

One hundred two of 272 cases of cytodiagnosis of tuberculous lymphadenitis were subjected to mycobacterial examination by Ziehl-Neelsen staining on direct and concentration smears and by culture. Cytomorphologically the cases were categorized into four types: 1, predominantly necrotic material; 2, typical caseating epithelioid cell granulomas and giant cell formation; 3, only noncaseating epithelioid cell granulomas with or without giant cells; and 4, doubtful presence of epithelioid cells. Ziehl-Neelsen staining for acid-fast bacilli (AFB) was positive in 25% in direct smears, 26.5% in concentration smears and 29.5% in both combined. The cultures for mycobacteria were positive in 49%; combined smear and culture positivity was found in 56.9%. Maximum culture positivity was seen in cases with type 1 smears (56.9%) followed by types 2 (44%) and 3 (40%). The percentage of AFB positivity was similar in type 1 and type 2 smears (32.2% and 30%, respectively); however, AFB were present in large numbers in type 1 smears as compared to type 2 and 3 smears. In type 3 smears AFB positivity was found in 20% of cases. Cases with type 4 smears were negative for AFB in smears and culture. In eight cases (7.8%) the smears were positive for AFB, whereas the cultures were negative, indicating that negative culture examination still does not exclude the possibility of tuberculosis. However, culture is essential to a characterization and determination of drug sensitivity.