Over the last several years the continually heard mantra "Do More with Less" has kept fine needle aspiration biopsy cytopathology at the forefront of rapid diagnostic procedures for superficial and deep masses. Cytologic criteria have been refined for innumerable diagnoses. The sophisticated use of immunocytochemisty, cytometry, in situ hybridization and other molecular analyses has continued to advance and refine diagnostic accuracy. This conference explores the strengths and limitations of aspiration cytopathology in eight specific situations. Each faculty is well known for his/her expertise in FNA cytopathology and has particular interest and experience in the body site they have chosen for discussion.

Case 1 - Breast

submitted by:
Andrea E. Dawson
Cleveland Clinic Foundation
Cleveland, Ohio

Clinical Summary:

A 75-year-old woman presents with a 9 mm lobulated breast mass on a screening mammogram. An ultrasound is performed that shows that the mass is partially cystic. An ultrasound guided FNA is done and sent to cytology.

Figure 1A - This breast FNA is moderately cellular. Large epithelial clusters with papillary architecture are present. Numerous single epithelial cells can be identified with cuboidal to columnar shape. These findings are suggestive of a papillary neoplasm. (Papanicolaou stain, low power)

Figure 1B - A higher power photomicrograph of loosely cohesive clusters of cells shows tall columnar cells with hyperchromatic nuclei. When these cells are identified in an aspirate that has papillary features a papillary carcinoma can be favored. (Papanicolaou stain, high power)

Case 2 - Thyroid

submitted by:
William C. Faquin
Massachusetts General Hospital
Boston, Massachusetts

Clinical Summary:

A 27-year-old woman presents with a palpable 3.0 cm mass in the right thyroid gland that had been slowly enlarging over the past six months. An FNAB was performed.

Figure 2A - Hypercellular smears containing large loosely cohesive clusters of crowded follicular cells with a "nested" appearance. (Papanicolaou stain, low power)

Figure 2B - The individual follicular cells had scant cytoplasm and were uniform in size with round to oval nuclei. (Papanicolaou stain, medium power)

Figure 2C - At higher magnification the individual follicular cell nuclei were moderately pleomorphic with slightly clumped chromatin. (Papanicolaou stain, high power)

Case 3 - Lymph Node

submitted by:
Ann T. Moriarty
Ameripath Indiana
Indianapolis, Indiana

Clinical Summary:

A 73-year-old woman was noted at the time of cardiac catheterization to have bilateral inguinal adenopathy. The adenopathy had been present for several months. The patient denied symptoms of fever or night sweats, but had reported a 15 lb. Weight loss over the past several months. A fine needle biopsy was performed of the left 4x3x3 cm inguinal lymph node.

Figure 3A - Highly cellular smear demonstrating a small sized lymphocytic population. There are "lymphoglandular bodies" in the background, and the lymphocyte nuclei are smaller than the nucleus of the histiocyte. The population is relatively monotonous. There is only mild variation in cell size. (Romanowsky stain, medium magnification)

Figure 3B - Details of the small lymphocytic population. There is coarse chromatin and nuclear irregularity. Nucleoli are inconspicuous. Although the chromatin is coarse, it is not "clumped" as in the nucleus of the small central lymphocyte. (Romanowsky stain, high power)

Figure 3C - The Papanicolaou stained preparation emphasized the monotony of cell size. The cells appear smaller in the alcohol fixed preparations; the nuclei are smaller than the histiocyte nuclei. The chromatin is course and the nuclear irregularities are not as obvious. (Papanicolaou stain, high magnification.)

Case 4 - Soft Tissue

submitted by:
Scott E. Kilpatrick
Women's and Children's Hospital
Chapel Hill, North Carolina

Clinical Summary:

The patient is a 19-year-old man with a soft tissue mass involving the right buttock and lung masses.

Figure 4A - Highly cellular smear composed of individually dispersed and scattered, small cohesive clusters of tumor cells. (Diff-Quik stain, low power)

Figure 4B - Tumor cells appear round to ovoid with high nuclear to cytoplasmic ratios. (Diff-Quik stain, high power)

Figure 4C - Tumors cells have round hyperchromatic nuclei with inconspicuous nucleoli and scant rims of cytoplasm. (Papanicolaou stain, high power)

Case 5 - Breast

submitted by:
Dr. Andrea E. Dawson
Cleveland Clinic Foundation
Cleveland, Ohio

Clinical Summary:

A 29-year-old woman presents with a smoothly outlined spherical mass on a screening mammogram. An FNA is performed.

Figure 5A - This aspirate is a high cellularity with numerous single epithelial cells. A stromal fragment is apparent in this photomicrograph which might raise the possibility of a fibroadenoma, however, the marked cellularity and discohesion is worrisome. (Papanicolaou stain, low power)

Figure 5B - A higher power shows a monomorphic population of small bland nuclei in clusters and singly. The cells have feature of lobular neoplasia. This aspirate was from a fibroadenoma that was extensively involved by LCIS. (Papanicolaou stain, high power)

Case 6 - Thyroid

submitted by:
Dr. William C. Faquin
Massachusetts General Hospital
Boston, Massachusetts

Clinical Summary:

An 86-year-old woman presents with an 8.0 cm right thyroid mass. An FNAB was performed.

Figure 6A - Aspirate smears were cellular and composed of a pure population of follicular cells with oncocytic features (Hurthle cells). Individual cells were large with enlarged, round nuclei, fine chromatin and prominent nucleoli. (H&E stain, high power)

Figure 6B - Occasional scattered Hurthle cells have markedly enlarged nuclei, greater than twice the diameter of others. (H&E stain, high power)

Figure 6C - Crowded clusters of Hurthle cells are seen as well as individual cells. Focally a crowded group of hyperchromatic spindle cells is present. (H&E, medium power)

Case 7 - Lymph Node

submitted by:
Dr. Ann T. Moriarty
Ameripath Indiana
Indianapolis, Indiana

Clinical Summary:

The patient is a 42-year-old male who presented with a painful right mandible and submandibular area. He had a firm, fixed, "woody" infiltration of the skin and soft tissue overlying the entire right mandible. A CT scan of the mandible demonstrated a 4.4 x 1.8 cm mass extending along the lingual aspect of the anterior right hemimandible, without direct osseous extension. There was enlargement of the right mental foramen and the inferior alveolar nerve.

Figure 7A - The CT scan at the level of the anterior mandible demonstrating a mass extending into the buccinator space. It has homogeneous attenuation. There is no direct osseous involvement. (CT scan of mandible with contrast.)

There were also two enlarged lymph nodes, one in the submental triangle and one high in the superior cervical chain. The patient denied fevers, weight loss, night sweats or other adenopathy. A fine needle biopsy was performed.

Figure 7B - The smears are cellular and are composed of single cells. There is a background of small lymphocytes and a second population of cells that are "intermediate" in size and have nuclei approximately the same size as histiocyte nuclei. They have scant cytoplasm. (Romanowsky stain, high power)

Figure 7C - In a thinner portion of the smear, background lymphoglandular bodies are seen. The delicate blast like chromatin pattern is noted in the intermediate sized cells. Nucleoli are inconspicuous. (Romanowsky stain, high power)

Figure 7D - The Papanicolaou stained smears demonstrate delicate chromatin pattern. Nucleoli are inconspicuous, and there is little cytoplasm. (Papanicolaou stain, high power)

Case 8 - Soft Tissue

submitted by:
Dr. Scott E. Kilpatrick
Women's and Children's Hospital
Chapel Hill, North Carolina

Clinical Summary:

The patient is a 20-year-old male graduate student with a right axillary "lymph node".

Figure 8A - Cellular aspirate smear comprised of mostly discohesive, bland-appearing spindle-shaped cells. (Diff-Quik stain, low power)

Figure 8B - Individual spindle-shaped cells have round to oval nuclei, inconspicuous nucleoli, and variable amounts of tapering cytoplasm. A few cell clusters are present. (Diff-Quik stain, high power)

Figure 8C - Spindle-shaped cells as seen in Image 8B. These cells resemble bland fibroblasts. (Papanicolaou stain, medium power)