Fine-needle aspiration and the diagnosis of thyroid cancer.

Fine-needle aspiration is a low-cost diagnostic tool, the principal value of which is to determine which patients should undergo surgery. The technique is deceptively simple. Team work and close cooperation among endocrinologists, surgeons, and pathologists are essential for success. Cytologic criteria for diagnosis of the most frequent malignancies found in thyroid aspirates have been provided.

Teflonomas of the larynx and neck.

Intracordal fluorocarbon (Teflon, Mentor O and O Inc, Norwell, MA) injection has been used for decades to correct paralytic dysphonia, a result of unilateral laryngeal paralysis. Infrequently, the Teflon extravasates and infiltrates into the soft tissues of the neck and larynx producing a mass that clinically simulates a malignant lesion. We report eight cases of so-called "Telonomas" of the larynx and neck that have been identified in the files of the Armed Forces Institute of Pathology Otolaryngic Tumor Registry and from the Cytopathology Service at the George Washington University Medical Center. Patients ranged in age from 31 to 72 years. Vocal cord paralysis, treated by Teflon injection, was caused by primary laryngeal carcinoma or metastatic carcinoma (breast, lung) involving the recurrent laryngeal nerve, surgical trauma to the recurrent laryngeal nerve, or postviral neuritis. Subsequent symptomatology, related to extravasation of the Teflon with a resulting "Teflonoma", included a neck mass or persistent hoarseness. Infrequently, there was associated airway obstruction or voice changes. Diagnosis was made by fine needle aspiration or by excision of the suspicious mass and subsequent identification of a foreign body granulomatous reaction with associated birefringent material. Infrared absorption spectrophotometry identified the foreign material as a fluorocarbon which was further substantiated by scanning electron microscopy and energy dispersive x-ray analysis. Surgical removal of the mass alleviated all symptoms.

Subareolar abscess of the breast: diagnosis by fine-needle aspiration.

In a review of more than 1,600 fine-needle aspirates of the breast, the authors identified ten cases of subareolar abscess. This is a clinicopathologic entity well known to surgeons but seemingly unrecognized by pathologists. In this report, the authors describe the cytologic appearance of the lesion, discuss the role of fine-needle aspiration in its diagnosis, and familiarize pathologists with the histology and management of this disease.

Lymphoepithelial cysts of the salivary glands. Histologic and cytologic features.

Fourteen cases of surgically excised lymphoepithelial cysts (13 from the parotid gland and 1 from the submandibular gland) were reviewed for diagnostic histologic features. They showed squamous epithelium-lined cysts within lymph nodes. Lymphocytes, histiocytes, and plasma cells were found in the walls of the cysts. Multinucleated giant cells were present in four cases. The five patients tested for human immunodeficiency virus (HIV) infection were positive, both by enzyme-linked immunosorbent assay (ELISA) and Western Blot. Fine-needle aspiration (FNA) was performed on five cases (two were confirmed histologically). Diff-Quik-stained smears showed a proteinaceous background and a mixed population of lymphocytes, histiocytes, plasma cells, and metaplastic squamous cells. When the above cytologic findings are present on fine-needle aspiration of a major salivary gland lesion, the diagnosis of lymphoepithelial cyst should be considered.

Adenoid cystic carcinoma of the breast.

The clinical, histologic, cytologic, and ultrastructural features of three adenoid cystic carcinomas of the breast are presented. All three neoplasms occurred in postmenopausal women. One patient was treated by wide re-excision of the biopsy site. Two were treated by modified radical mastectomy; no axillary lymph node metastases were found. None of the neoplasms has recurred. Neither estrogen nor progesterone receptors were detected in any of the neoplasms. The histopathologic criteria for the diagnosis of adenoid cystic carcinoma are described, and the differential diagnosis is discussed. Since the cytopathologic features of adenoid cystic carcinoma of the breast appear to be distinctive, the neoplasm can be diagnosed by fine-needle aspiration based upon the presence of the following features: 1) a cellular smear; 2) a uniform population of small, basaloid tumor cells; and 3) small globules of mucoid material surrounded by a rim of neoplastic cells. Ultrastructurally, the predominant cell type has the appearance of a modified myoepithelial cell, but true lumina lined by microvillous epithelial cells are also present. The ultrastructural findings are consistent with the proliferation of neoplastic cells that have the capacity to produce all of the epithelial elements of the breast, i.e., ductal, acinar, and myoepithelial, and so recapitulate the complete ductal or acinar unit.

Prospective controlled assessment of fine-needle prostatic aspiration.

In this study, the cytologic diagnosis obtained by transrectal fine needle prostatic aspiration was compared to the histologic diagnosis obtained by prostatic needle biopsy or transurethral prostatic resection. Confirmation of all diagnoses occurred 91 per cent of the time: 96 per cent with benign prostatic hyperplasia, 77 per cent with carcinoma, and 100 per cent with prostatitis. Inadequate sampling for cytologic diagnosis occurred at the initiation of this study. False positive cancer diagnosis did not occur. False negative cancer diagnosis prompted appropriate follow-up. Fine-needle prostatic aspiration is a painless, simple to learn, minimally invasive, easily repeated, outpatient procedure for determining prostate pathology. The procedure should be part of each urologist's diagnostic capability.

The Arias-Stella reaction revisited.

The Arias-Stella reaction was observed in five cases of normal human gestational endometrium. The earliest case was in the endometrium lodging an ovum having an estimate age of 17 days. The Hertig collection at the Carnegie Institute constitutes the basis of the present study. This finding further supports the belief that the Arias-Stella reaction is a physiologic endometrial response to viable trophoblastic tissue.

Sclerosing lipogranuloma of male genitalia. Review of 23 cases.

In 1950 the term "sclerosing lipogranuloma" was introduced to designate a praticular subcutaneous granulomatous reaction that was believed to be a "local reactive process following injury to adipose tissue." Subsequent reports have shown that exogenous lipid injections probably are responsible for this lesion. We have studied 23 cases involving penis, scrotum, spermatic cord, and perineum, nine of which had been previously reported. We have been able to identify paraffin hydrocarbons by means of infrared-absorption spectrophotometry in 21 of these cases. We belive this entity should be redefined as a "local reactive process following injection of exogenous lipids into the subcutaneous tissues." In conventional microscopical sections, the lesion must be differentiated from adenomatoid tumor, sclerosing liposarcoma, and lymphangioma.

Thyroglossal duct cysts: diagnostic criteria by fine-needle aspiration.

OBJECTIVE: To document the cytologic diagnostic criteria of fine-needle aspirations of thyroglossal cysts. DESIGN: Midline cervical masses were studied by fine-needle aspiration, and those 11 thyroglossal cysts that were resected served as a baseline for the evaluation of aspirates from 33 similar lesions that were not removed. SETTING: Physicians' offices, hospital outpatient clinics, and the aspiration service of a university department of pathology. PATIENTS: Forty-four patients noting a mass in the anterior neck or found by physicians to have such a mass. INTERVENTIONS: Fifty-one aspirations (second aspirates in seven patients); surgical removal of the cysts in 11 patients. MAIN OUTCOME MEASURES: Aspirates were examined for cells, other particulate matter, and any extracellular material in the background. RESULTS: Smears from thyroglossal cysts are low in cellularity, and inflammatory cells are more numerous than epithelial cells. CONCLUSIONS: Fine-needle aspiration contributes to an accurate preoperative diagnosis of thyroglossal cysts, allowing a Sistrunk procedure to be performed in these patients rather than an inappropriate local resection.

Cytologic diagnosis and ultrastructure of fine-needle aspirates of ganglion cysts.

This report describes 28 ganglion cysts in 21 patients. The presence of a colorless to pale-yellow gelatinous material in the aspirate is pathognomonic of ganglion cyst. The smears are fairly monotonous, and show abundant mucoid material, single cells resembling histiocytes, a few tight clusters of cells, some collagen fibers, and some red blood cells with altered shapes. Ultrastructural studies performed on five specimens reveal the fibroblastic and/or histiocytic nature of the cells in the aspirates.

Biochemical analysis of thyroid cyst fluid obtained by fine-needle aspiration.

Despite the relatively ready availability of thyroid cyst fluid specimens, little has been published on their biochemical composition. We measured the concentrations of 18 analytes in thyroid cyst fluid specimens from benign (n = 17) and malignant (n = 3) lesions and in homogenates of normal thyroid tissue (n = 5). The concentrations of an additional five analytes were measured in selected cyst fluid specimens only. Compared with normal human serum specimens, we found that in thyroid cyst fluid specimens the activities of acid phosphatase, aspartate aminotransferase, amylase, and lactate dehydrogenase, and the concentrations of iron and total bilirubin were highly increased. The concentration of glucose was low. The gross appearance of the fluids and the presence of certain analytes were consistent with a hemorrhagic origin of most of the benign and malignant cyst fluid specimens. Other biochemical markers, however, indicated colloidlike features and/or an admixture of thyroid tissue components to the cyst fluid. Although we have limited data for cyst fluid specimens from malignant thyroid lesions, we found no evidence that the results of any of the common biochemical tests would distinguish benign from malignant lesions.

Thymoma mimicking thyroid papillary carcinoma: another pitfall in fine-needle aspiration.

Thymomas are composed of a mixture of epithelial and lymphoid cells. When the lymphoid cells predominate, the possibility of malignant lymphoma must be considered. Recently, a thymoma mimicking lymphoblastic lymphoma was reported in this journal as a diagnostic pitfall in a mediastinal aspiration. We encountered another diagnostic pitfall at the other end of the spectrum: a thymoma with a dominant epithelial component in which a papillary carcinoma of thyroid had to be considered in the differential diagnosis.

Cytology of pseudomyxoma peritonei: report of two cases arising from appendiceal cystadenomas.

Pseudomyxoma peritonei is the clinical term for the diffuse deposition of mucus within the peritoneal cavity secondary to a mucinous tumor of the ovary or appendix. This gelatinous ascites, or "jelly-belly," may result in death from loss of intestinal function and intestinal obstruction caused by peritoneal implants rather than visceral invasion. Microscopic evaluation of peritoneal fluid is frequently an initial diagnostic test; however, in a search of the recent literature we were surprised to find only one case report of the cytologic features. This prompted us to report the cytologic findings in the peritoneal fluid of two cases of pseudomyxoma peritonei arising from appendiceal mucinous cystadenomas.

Fine-needle aspiration of thyroid lesions in 57 pregnant and postpartum women.

Palpable thyroid nodules are common in women. The thyroid gland may enlarge in response to hyperemia, relative iodine depletion, and slight stimulation by beta Human Chorionic Gonadotrophin (HCG) during pregnancy. The presence of goiter or a discrete nodule requires investigation. Fine-needle aspiration (FNA), a reliable diagnostic tool, can be safely used during pregnancy. The tenet that a "histologic hyperplasia" accompanies the physiologic hyperplasia of pregnancy may hamper FNA interpretation. We reviewed 97 (10 previous, 46 pregnant, 13 postpartum, 1 spontaneous abortion, and 27 follow-up) aspirates of thyroid nodules from 57 patients. Cytologic diagnoses were divided into five categories: 31 benign, 7 cellular adenomatoid nodules, 5 suspicious for papillary carcinoma, 12 papillary carcinomas, and 2 follicular neoplasms. There were an unanticipated number of carcinomas. Lesions present before pregnancy did not show "progression" or significant change. No characteristic features ascribable to pregnancy were identified. Standard diagnostic criteria may be used in the evaluation of FNA of thyroid nodules from pregnant patients.

Lipomas of anterior neck simulating thyroid nodules: diagnosis by fine-needle aspiration.

The anterior neck is an unusual location for lipomas. Cervical lipomas can be mistaken for non-functioning thyroid nodules. We report eight cases from our files diagnosed by fine needle aspiration (FNA). Our purpose is to call attention to this simple technique in establishing an accurate diagnosis and how it can contribute to better patient management by avoiding unnecessary thyroid suppressive therapy and/or surgery. We advocate using FNA as the initial diagnostic test on palpable masses in the neck. The differential diagnosis must include thyroid lipomatosis, thyrolipoma or adenolipoma, amyloid goiter with fatty infiltration, and fat-containing thyroidal neoplasms (papillary carcinoma and follicular neoplasms).

"Cellular adenomatoid nodules" of the thyroid: review of 219 fine-needle aspirates.

We reviewed 219 consecutive thyroid aspirates previously diagnosed as "cellular adenomatoid nodule," applying the criteria presented in this paper and reclassifying them as 146 adenomatoid nodules (AN), 31 cellular adenomatoid nodules (CELL-AN), 29 cellular adenomatoid nodules vs. follicular neoplasms (CELL-AN vs. FN), 5 follicular neoplasms (FN), 2 FN of oxyphilic cell type, 4 papillary carcinomas, and 2 chronic lymphocytic (Hashimoto's) thyroiditis. Of the 146 adenomatoid nodules, 14 occurred in multinodular goiters on histologic examination. Of the 31 CELL-AN, five had surgery: two were follicular adenomas, one was papillary carcinoma, and two were multinodular goiters. Of the 29 CELL-AN vs. FN, 11 had surgery: six were follicular adenomas, two were follicular carcinomas, two were multinodular goiters, and one was Hashimoto's thyroiditis. Surgery on four FN showed follicular adenomas (a fifth patient was lost to follow-up). Of the two FN of oxyphilic cell type, one was a multinodular goiter and the other a follicular adenoma with oxyphilic cells. Three of the four papillary carcinomas were confirmed histologically (one patient was lost to follow-up). Of the two cases showing Hashimoto's thyroiditis, one was diagnosed as FN on repeat aspiration and follicular carcinoma at surgery. After review, we identified 40 patients at higher risk of harboring a neoplasm and 31 with cellular adenomatoid nodules. Twenty-five underwent surgery with the above results. In the classification of follicular lesions of the thyroid by FNA, adherence to strict cytologic criteria helps identify those patients who will benefit most from surgery.

Eight cases of Sister Mary Joseph's nodule diagnosed by fine-needle aspiration.

We report eight cases of umbilical metastases (Sister Mary Joseph's nodules) diagnosed by fine-needle aspiration. The primary carcinoma was below the diaphragm in seven patients. There was one false-negative diagnosis. We advocate the use of fine needle aspiration as the initial diagnostic test. It is a simple, fast, accurate, and relatively inexpensive means of making the definitive diagnosis. It can spare patients invasive procedures that are not clearly of benefit.

Follicular variant of papillary carcinoma of the thyroid: fine-needle aspirates with histologic correlation.

Crile and Hazard reported in 1953 a follicular pattern of papillary thyroid carcinoma. Little has been said about this pattern in the cytologic literature. From more than 8,000 thyroid aspirates in our files, we reviewed all those diagnosed as "follicular variant of papillary carcinoma," "suspect follicular variant of papillary carcinoma," and "follicular neoplasm vs. follicular variant of papillary carcinoma." Also, we reviewed all aspirates in which a diagnosis of follicular variant of papillary carcinoma had been made on surgically excised glands, regardless of the cytologic diagnosis; 63 aspirates from 45 patients were collected. All smears were air-dried and stained with Diff-Quik. Most smears were very cellular ("tumor cellularity"), and the neoplastic follicular cells formed empty follicles, rosettes, tubules, and papillary structures. Nuclei were twice the size of red blood cells, had smooth contours, were hyperchromatic, and varied in shape but not much in size. Nuclear overlapping was common. Some nuclei had one small and almost pointed end, thereby resembling arrowheads. Intranuclear inclusions, multinucleated histiocytes, and psammoma bodies were uncommon. Pink-stained colloid was frequent.

Sialadenitis with crystalloid formation: a report of six cases diagnosed by fine-needle aspiration.

Six cases of sialadenitis diagnosed by fine-needle aspiration contained large numbers of crystalloids. Light microscopy, ultrastructure, and chemical analysis suggest that the crystalloids represent crystallized salivary alpha-amylase. The inflammatory swelling may mimic benign and/or malignant neoplasms of the salivary glands. Drainage and/or antibiotic therapy may allow surgery to be avoided in these patients.

Hashimoto's thyroiditis: fine-needle aspirations of 50 asymptomatic cases.

The cytologic findings from 50 cases of asymptomatic Hashimoto's thyroiditis diagnosed by fine-needle aspiration are reviewed. All patients were referred for fine-needle aspiration by the same physician: 48 because of thyroid enlargement and the clinical suspicion of Hashimoto's thyroiditis, two because of a small thyroid nodule. Positive antimicrosomal (antithyroid peroxidase) and/or antithyroglobulin antibody titers (performed by the same laboratory using the same technique) were present in only 25 of 48 patients evaluated. Cytologic findings included a predominantly lymphocytic process in 92% of the cases and a predominantly oxyphilic (Askanazy/Hürthle) cell process in 8% of the cases. It is likely that all patients were in an early stage of the autoimmune process. Our data indicate that the incidence of Hashimoto's thyroiditis is considerably higher than when recognized only by serologic tests for antibodies.