A case report on incidentally detected pulmonary sclerosing pneumocytoma: a diagnostic challenge.

Introduction and importance: Pulmonary sclerosing pneumocytoma (PSP) is a rare non-cancerous lung tumor that is usually asymptomatic, but may cause respiratory distress if it becomes large. PSPs are often detected incidentally because of their slow growth, lack of symptoms, characteristic radiographic features, and increased use of imaging studies. Although it is not a malignant tumor, it can mimic malignancy on imaging and histology, leading to misdiagnosis and unnecessary surgery. Case presentation: A 23-year-old asymptomatic female was incidentally diagnosed with PSP during evaluation for a breast fibroadenoma. A chest CT revealed a 3 cm lobulated mass in the left upper lobe. Cytology showed malignant cells with necrotic debris. Immunohistochemistry was positive for TTF-1 and EMA, negative for p63 and AE1/AE3. Histopathology confirmed a well-circumscribed benign neoplasm, consistent with pulmonary sclerosing pneumocytoma. There was no mediastinal lymph node invasion, and the post-surgery prognosis was good. Clinical discussion: PSP is a slow-growing tumor that is often asymptomatic until it reaches a significant size. Owing to their well-circumscribed margins and the presence of calcifications, they are often detected incidentally during imaging studies, such as routine chest radiography or CT scans for unrelated conditions. Although these tumors are often incidental, it is important to diagnose and treat them appropriately to prevent potential complications and malignant transformation. Conclusion: The findings of this study contribute to the existing literature, increase awareness of this rare tumor, and provide insights into its diagnosis, treatment, and follow-up.

A Trespasser in Lymph Node: A Case Report.

Cryptococcal meningitis is a prevalent, opportunistic fungal disease seen in human immunodeficiency virus (HIV)-infected individuals. A lymph node is an unusual presentation site for Cryptococcus and can mimic tuberculosis. Disseminated cryptococcosis is a life-threatening disease that is seen commonly in acquired immunodeficiency syndrome (AIDS). We report a case of an HIV patient who presented with mild pleural effusion, multiple mediastinal, axillary lymphadenopathy with a low CD4:CD8 lymphocyte ratio, and favored clinically disseminated tuberculosis. Further cerebrospinal fluid (CSF) and tracheal aspirate have been done. Tracheal aspirate culture shows a fungal organism resembling Cryptococcus. Later, India ink staining on CSF highlighted the fungal organism Cryptococcus. Cytopathological investigation showed necrotizing inflammation along with fungal organisms, confirming the presence of cryptococcal lymphadenitis.

Cytological diagnosis of hyaline-vascular type of Castleman disease.

Castleman disease (CD) is a rare, benign lymphoproliferative disorder, mostly involving the mediastinal lymph nodes, but can occur wherever lymphoid tissue is found. With only a few published case reports, there needs to be more literature on its cytological findings. We report the case of a 63-year-old female presenting with left upper cervical swelling. Fine needle aspiration cytology smears showed variably sized lymphoid follicles with diminished germinal centers, prominence of follicular dendritic cells, and capillaries traversing some of the follicles. The possibility of a hyaline-vascular type of Castleman disease was suggested. Histopathology confirmed the cytological diagnosis. The index case is being presented to discuss the cytological features of the CD along with its histological and immunohistochemical correlation.

Utility of Acquire 22G-fine needle biopsy (FNB) needle vs the standard 22G needle during Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA): A Randomized Controlled Trial (RCT).

BACKGROUND: Various types of needles are available to perform endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). A relatively new needle for EBUS-TBNA, the Acquire Fine Needle Biopsy (FNB) device, has recently become available. METHODS: Consecutive subjects with lymphadenopathy >1 cm undergoing EBUS-TBNA were randomized to the Acquire 22-G EBUS-FNB needle and the standard 22-G EBUS-TBNA needle groups. RESULTS: A total of 86 subjects were randomized (43 in each group). The diagnostic yield of EBUS-TBNA was similar between the two groups: (36/43) 83.7% in the 22-G EBUS-FNB group and (34/43) 79.1% in the standard 22-G EBUS group (p = 0.58). The sampling adequacy, stations sampled, number of stations sampled, number of needle passes, and mean duration of the procedure between the two groups were also similar. Visible tissue clot core was obtained in a significantly greater proportion of subjects in the 22-G EBUS-FNB group (93.0% vs 46.5%, p < 0.001). Visibly bloody samples were more frequent in the 22-G EBUS-FNB group (74.4% vs 51.2%, p = 0.03). There was no difference in the complication rates between the two groups (p = 0.15). CONCLUSION: We did not observe a difference in the diagnostic yield of the Acquire 22-G EBUS-FNB needle compared with the standard 22-G EBUS needle. CLINICAL TRIAL REGISTRATION: Clinical Trial Registry of India (CTRI) https://ctri.nic.in/ (CTRI/2021/08/035589).

Accuracy and efficacy of Ion robotic-assisted bronchoscopic fine needle aspiration of lung lesions.

INTRODUCTION: The Ion Endoluminal Platform (ION) (IEPI Intuitive, Sunnyvale, CA), a minimally invasive robotic-assisted bronchoscopy platform, was recently US Food and Drug Administration approved for the performance of fine needle aspirations (FNAs) and biopsies of peripheral lung lesions. Rapid on-site intraoperative diagnosis (IOD) of FNAs and/or frozen section of biopsies help surgeons confirm adequate sampling of the targeted lesion and allow definitive treatment in selected cases. MATERIALS AND METHODS: We retrospectively reviewed our experience with all FNAs of lung lesions sampled by interventional pulmonologists and thoracic surgeons using Ion from September 2020 to December 2022. IOD rendered during adequacy assessment were compared with final cytology diagnoses (Cyto-FD) and the ultimate final diagnoses (U-FD). The U-FD was based on the sum of all clinical, imaging, cytologic, and histologic diagnoses of the lung lesion which the clinical team used to treat the patient. RESULTS: The IOD and Cyto-FD were concordant in 62% of the 423 lesions that underwent intraoperative evaluation, yielding a sensitivity of 67% and a specificity of 99% for malignancy. The Cyto-FD and U-FD were concordant in 51% of the lesions with a sensitivity and specificity for malignancy of 66% and 100%, respectively. CONCLUSIONS: IODs rendered during Ion were highly accurate but only moderately sensitive for a diagnosis of malignancy.

Correlation between ultrasonographic and cytologic features of thyroid nodules: a single-center cross-sectional study.

A thyroid nodule is managed according to the clinical context, ultrasound (US) findings, and fine needle aspiration (FNA) results. Most thyroid nodules are benign; however, nodule classification is crucial to avoid unnecessary thyroid surgery. We conducted this study to compare the findings of fine-needle aspiration cytology (FNAC) expressed using the Bethesda system with the features of thyroid US classified using the EU-TIRADS classification to assess the risk of malignancy. A descriptive and analytical study involving 99 patients with thyroid nodules followed up in the Department of Endocrinology-Diabetology and Nutrition. Data were collected from medical records and analyzed using SPSS software V21. FNA was performed on 121 nodules using the BETHESDA system. These nodules were classified as malignant, suspicious for follicular neoplasm, and suspicious for malignancy in 5.8%, 5%, and 1.7% of cases, respectively. As for the EU-TIRADS 2017 classification, 59.5% of benign nodules were classified as EU-TIRADS III, whereas 66.7% of malignant nodules were classified as EU-TIRADS V and significantly related to malignant prediction (P = 0.000). The size of nodules was significantly correlated to the risk of malignancy (P = 0.013). Seventy-five percent of nodules with central vascularity were malignant (P = 0.012). Irregularity of nodule contours was significantly associated with the risk of malignancy, as 30% of nodules with irregular contours were Bethesda VI (P = 0.003). Hypoechogenicity was found in 77.8% of malignant nodules (P = 0.004). Additionally, only 9.2% of the nodules were taller than wide, of which 37.5% were malignant (P = 0.012). For a safe management strategy, US-guided FNAC should be performed on each suspicious thyroid nodule, given the correlation between EU-TIRADS classification features and the risk of malignancy.

Solitary Cutaneous Mastocytoma in an Adult Diagnosed on Cytology: A Rare Case Report.

Mastocytosis is characterized by the proliferation of neoplastic mast cells in various organs, which can have either cutaneous or systemic presentation. Solitary cutaneous mastocytomas are most commonly seen in the pediatric age group but rarely present in adults. Histopathology of cutaneous mastocytoma is well described in the literature but only a few studies are available describing the cytomorphological features. We present a case of a 19-year-old female who presented with a 6-month history of a right supraclavicular single, 0.5 × 0.5 cm, well-defined, reddish-brown round nodule. The fine needle aspiration cytology (FNAC) smears were highly cellular showing monomorphic cells, predominantly dispersed singly and occasionally in small clusters. The cells were round to oval, with moderate cytoplasm containing coarse metachromatic granules. Toluidine blue stain and CD117 immunocytochemical stain confirmed the presence of mast cell granules. Based on the cytomorphology, staining, clinical history, and examination, a diagnosis of solitary cutaneous mastocytoma was rendered. FNAC plays a pivotal role in diagnosing mast cell tumors and even obviates the need for tissue biopsy in selected cases.

Rare case of stromal predominant Wilm's tumour with rhabdomyoblastic differentiation in FNAC smears.

The FNAC smear and histopathology of stromal predominant Wilm's tumour with rhabdomyoblastic Differentiation along with immunostaining in a 7-year-old male. In this paper, the diagnostic potential of FNAC in identifying rare histological variants of paediatric renal tumours is highlighted.

Endoscopic ultrasound (EUS) elastography-guided fine-needle aspiration cytology (FNAC) versus conventional EUS FNAC for solid pancreatic lesions: A pilot randomized trial.

BACKGROUND: Endoscopic ultrasound guided fine-needle aspiration (EUS FNA) is the first-line modality to diagnose suspected solid pancreatic malignant lesions. Elastography-guided FNA has been shown to improve the diagnostic yield of EUS FNA but prospective studies are limited. The aim of the study was to compare diagnostic accuracy, sensitivity and specificity of conventional and elastography-guided EUS FNA in patients with suspected malignant pancreatic solid masses. METHODS: Patients with suspected malignant solid pancreatic lesions presenting to our institute from July 2021 to January 2023 were recruited and randomized to conventional and elastography-guided EUS FNA using a 22-G EUS FNA needle. Diagnostic accuracy, sensitivity, specificity and positive and negative predictive values were calculated. RESULTS: Total 48 patients were initially screened for inclusion in the study, of which six were excluded and 42 patients underwent randomization. Finally, 20 patients in each group underwent the assigned intervention and were analyzed further. Baseline patient characteristics were similar in conventional FNA and elastography-guided FNA group with median age 52 (range 29-74) years and 51.8 (range 31-72) years, respectively, males being 70% and 75%, respectively. Median size of the lesion was 34 mm (range 14-48 mm) and 37 (range 18 to 50 mm), respectively, for both conventional and elastography arm. The average size of the lesion was 35.7 mm. Overall, the diagnosis of adenocarcinoma was made in 65% of cases. In the remaining cases, diagnoses were inflammatory mass, Castleman's disease, solid pseudopapillary epithelial neoplasm (SPEN), diffuse large B-cell lymphoma (DLBCL), pancreatic gastrointestinal stromal tumor (GIST) and metastasis. Conventional EUS FNA had diagnostic accuracy, sensitivity, specificity and positive and negative predictive values of 90%, 87.5%, 100%, 100% and 62.92%, respectively, and elastography-guided EUS FNA had diagnostic accuracy, sensitivity, specificity and positive and negative predictive values of 85%, 100%, 100% and 54.59%, respectively. No severe adverse events were noted. CONCLUSION: There is no significant difference between conventional and elastography-guided EUS FNA in terms of diagnostic accuracy, sensitivity, specificity and positive and negative predictive values. Both techniques appear safe and effective for characterizing solid pancreatic masses and elastography did not score numerically over the conventional arm.

Thyroid involvement in cystic echinococcosis: a systematic review.

BACKGROUND: Thyroid Hydatid Cyst (THC), a pathological state induced by the larval form of Echinococcus granulosus, represents a multifaceted clinical entity with nonspecific symptoms, making both diagnosis and treatment intricate. The current understanding of THC's attributes is somewhat limited. To gain a broader perspective on the disease's clinical and epidemiological characteristics, we have systematically reviewed the existing literature. METHODS: We performed an extensive review of articles on THC across four key scientific databases: PubMed, Scopus, Web of Science, and Google Scholar. Our study encompassed all patients diagnosed with THC through post-surgical pathology or Fine Needle Aspiration Cytology (FNAC) examinations, extracting clinical, epidemiological, and therapeutic data of THC patients from publications up to October 2023. RESULTS: From 770 articles, 57 met our criteria, detailing 75 THC patients. The gender ratio was 2.36 females per one male. The patients averaged 36.1 years old, with common symptoms including neck mass, hoarseness, shortness of breath, and dysphagia. The left lobe was involved in most patients, and only 21.3% had extrathyroidal involvement. Cysts averaged 36.4 mm in diameter, with cystic nodules being the most frequent imaging finding (91.2%). Serological tests were performed for 42.6% of cases, of which 62.5% were positive. Surgery was undertaken in 71 patients (94.6%). CONCLUSION: Cystic echinococcosis (CE) of the thyroid should be considered as part of the differential diagnosis in patients with cervicofacial mass, especially in endemic countries. The present study provides reliable data to improve our understanding of the features of the disease for a better diagnosis and management.

The diagnostic conundrum of hyper eosinophilia-Sheer tenacity of a parasite.

We present an interesting and rare case of Capillaria hepatica infection in a 2-year-old boy, who presented with fever, rash, hepatomegaly and peripheral eosinophilia. FNAC of hepatic lesion showed parasitic eggs and PCR from the aspirate confirmed the diagnosis. We describe the cytomorphological features and provide educational multiple-choice questions related to the topic.

Preoperative cytopathological investigatory aids in the diagnosis of salivary gland lesions.

Salivary gland lesions are a group of heterogeneous lesions inclusive of non-neoplastic and neoplastic lesions. History, clinical examination and preoperative investigations attempt to minimise the challenges faced in diagnosing these diverse lesions. Preoperative investigations include imaging and cytopathology. The advent of onsite evaluation methods to ensure sample adequacy and newer reporting systems that assign risk of malignancy has improved the sensitivity and specificity of cytopathology. The scope of this review is limited to the preoperative cytopathological investigations and the diagnostic challenges met in reporting salivary gland tumours.

Parotid Enlargement as a Rare First Site of Manifestation in Extramedullary Acute Lymphoblastic Leukemia: A Case Report.

Parotid neoplasm in children is very rare, and most of these tumors are benign. Parotid enlargement in children is usually caused by infection or inflammation. We report a case of a 12-year-old boy who presented with the initial manifestation of bilateral parotid enlargement. He complained of two weeks of parotid swelling, during which the tumor gradually increased in size as he battled a monthlong on-and-off fever. An intravenous antibiotic was administered, as the first diagnosis was infection. Imaging studies of the swelling displayed features of infection, which was not resolved by the antibiotic. Fine-needle aspiration cytology was initially planned to establish a diagnosis. However, due to other findings in the clinical examination, such as bilateral scrotal swelling with abnormal blood work, the child was referred to other specialists for further assessment. Eventually, he was diagnosed with B-cell acute lymphoblastic leukemia by a hematology team.

The Great Impostor: A challenging case of small-cell melanoma with isolated adrenal metastasis.

Small-cell melanoma masquerading as an adrenal non-Hodgkin lymphoma. The index report illustrates the deceptive cytomorphologic features of a small cell type malignant melanoma metastatic to the adrenal gland. The diagnosis was confirmed by performing immunocytochemistry on the cell block sections. The key cytomorphologic mimics and their distinctive features have also been highlighted.

The Sydney system for lymph node FNA biopsy cytopathology: A detailed analysis of recent publications and meta-analysis and a proposal for the components of an ideal prospective study of a cytopathology reporting system.

BACKGROUND: The Sydney system for fine-needle aspiration biopsy of lymph nodes has five categories, stressing the role of correlation of cytopathology with clinical, ultrasound, and ancillary findings to achieve diagnosis. The five categories constitute a hierarchical system with increasing risk of malignancy from benign to atypical, suspicious, and malignant categories, which informs recommendations for further workup to achieve a final diagnosis as possible. This article analyzes 10 publications using the Sydney system and a meta-analysis of nine of these studies. The primary goal of the analysis is to ascertain the causes of the large ranges in risk of malignancy for the "atypical" and "inadequate" compared to "benign," "suspicious," and "malignant" categories, which were comparable to well-established reporting systems. Research protocols are proposed to improve future studies. METHODS: PubMed literature search from January 2021 to December 2023 identified studies evaluating performance of the Sydney system. RESULTS: Ten studies showed heterogeneity with clinical setting, study design, ultrasound use and rapid on-site evaluation, operator, cutoff points for "positive" cases, with inherent partial verification biases, resulting in a wide range of risk of malignancy, specificity, and sensitivity values. CONCLUSION: Analysis shows the large range is due to heterogeneity of the studies, which suffer from biases and variable statistical analysis that are ultimately included in any meta-analysis, detracting from the usefulness of the risk of malignancy derived by the meta-analysis. Components for ideal analyses of reporting systems are presented.

Medullary Thyroid Carcinoma: A Unique Case Report.

Medullary thyroid carcinoma is a rare neuroendocrine tumor derived from parafollicular C-cells. It can be inherited as part of syndromes, such as familial medullary thyroid cancer (FMTC) and multiple endocrine neoplasia type 2 (MEN 2), or it can arise sporadically. We herein report a unique case of medullary thyroid carcinoma in a 50-year-old male who presented with a neck mass. Fine needle aspiration cytology (FNAC) of the thyroid and histopathological examination revealed a diagnosis of medullary thyroid carcinoma. Both carcinoembryonic antigen (CEA) and calcitonin are the key serum markers utilized in the diagnosis and monitoring of medullary thyroid cancer (MTC). Thorough evaluation, prompt identification, and efficient treatment constitute the pivotal measures for ensuring favorable survival outcomes.

Thyroid Fine-Needle Aspiration: The Current and Future Landscape of Cytopathology.

Thyroid cytology is a rapidly evolving field that has seen significant advances in recent years. Its main goal is to accurately diagnose thyroid nodules, differentiate between benign and malignant lesions, and risk stratify nodules when a definitive diagnosis is not possible. The current landscape of thyroid cytology includes the use of fine-needle aspiration for the diagnosis of thyroid nodules with the use of uniform, tiered reporting systems such as the Bethesda System for Reporting Thyroid Cytopathology. In recent years, molecular testing has emerged as a reliable preoperative diagnostic tool that stratifies patients into different risk categories (low, intermediate, or high) with varying probabilities of malignancy and helps guide patient treatment.

Salivary Gland Fine-Needle Aspiration: The Current and Future Landscape.

Fine-needle aspiration represents a valid tool for the diagnosis/management of salivary gland lesions. The past years assessed the lack of uniform diagnostic reports for salivary cytopathology leading to interpretative issues. In 2015, an international group of cytopathologists developed an evidence-based tiered classification system for reporting salivary gland fine-needle aspiration (FNA) specimens, the "Milan System for Reporting Salivary Gland Cytopathology" (MSRSGC). The present landscape of salivary cytology is represented by the growing adoption of the MSRSGC and the assessment of its diagnostic role. The future landscape is characterized by the increasing role of ancillary techniques for diagnostic and prognostic purposes.

Occult Thyroid Carcinoma with Cervical Lymph Node Metastasis: A Rare Case Report.

Cervical lymph node metastasis is one of the most common clinical presentations of papillary thyroid carcinoma (PTC). Occult thyroid carcinoma is described as absence of primary tumour or with presence of microcarcinoma in thyroid with cervical lymph node metastasis. Frequency of occult thyroid cancer has decreased due to developments in imaging and improved accuracy of histological examinations. 38 year old male presented to us with complaints of swelling over the left side of neck for the past 2 months. Ultrasonography was suggestive of multiple suspicious enlarged nodes in left level II, III, IV and V and fine needle aspiration cytology showed features of metastatic PTC. He was planned for total thyroidectomy with central compartment clearance and bilateral functional neck dissection. Final histopathology staging was pT0N1b. Radioactive iodine (RAI) screening showed residual functioning thyroid and later therapeutic RAI was administered. He has been on regular follow up and disease free for 1 year post treatment. Occult thyroid carcinoma is a rare diagnosis with multiple treatment plans. Few hypothesis for this entity includes tumor regression, ectopic thyroid carcinoma or missed pathological findings.

Utility of the United Kingdom National Health Services Breast Screening Program Diagnostic Protocol in Fine-needle Aspiration Cytology with Cell Block Preparation in Cases of Palpable Breast Lumps: A Reliable, Fast, and Accurate Diagnostic Method for the Assessment of Breast Lumps with Histopathologic Correlation.

Introduction: A palpable breast lump is a common diagnostic problem for clinicians and surgeons. Fine-needle aspiration cytology (FNAC) has many advantages such as less cost, less sample processing time, less pain, less chance of hematoma, and less discomfort. FNAC with cell block preparation further increased both sensitivity and specificity by nearly 100%. With the cell block preparation, we can also use newer tests like estrogen receptor-progesterone receptor-human epidermal growth factor receptor 2. Aims: The aim of this study was to derive conclusions about the correlation, including sensitivity, specificity, positive and negative predictive values (NPVs), and the diagnostic accuracy of FNAC, with or without cell blocks, compared to the final histopathology in cases of palpable breast masses. Materials and Methods: A cross-sectional prospective study was conducted after getting approval from the Human Ethics Research Committee from January 2018 to December 2019, which included 65 patients. Patients diagnosed clinically for breast lumps who underwent diagnostic FNAC with cell block, followed by a histopathological examination at our hospital, were included in the study. Results: FNAC without cell block sensitivity, specificity, positive predictive value (PPV), NPV, efficiency rate, and diagnostic accuracy are 91.3%, 100%, 100%, 90.1%, 86.2%, and 96.5%, respectively. FNAC with cell block sensitivity, specificity, PPV, NPV, efficiency rate, and diagnostic accuracy are all 100%. All of our results beat the standard estimate. Conclusions: Fine-needle aspiration cytology is a patient-friendly, easy, reliable, repeatable, and simple diagnostic test. Whenever it is combined with cell block preparation, improves the accuracy of FNAC diagnosis which is more accurate and comparable to golden-standard biopsy with histopathology examination.