Venkateswaran K. Iyer

Background: Carcinoma of the gallbladder (CaGB) is common in India and its prognosis depends primarily on the extent of the disease and histological type. We aim to study the role of guided fine needle aspiration cytology (FNAC) for diagnosis of CaGB and to evaluate the feasibility of applying world health organization (WHO) classification on fine needle aspiration (FNA) material to predict the outcome of the tumor.Materials and Methods: Retrospective cytomorphologic analysis was performed in all cases of CaGB diagnosed by ultrasound (US) guided FNAC over a period of 2 years. A specific subtype was assigned according to WHO classification based on characteristic cytologic features. These included papillary or acinar arrangement, intra and extracellular mucin, keratin, rosettes and columnar, signet ring, atypical squamous, small, clear, spindle and giant cells. Correlation with histopathology was performed when available.Results: A total of 541 aspirations with clinical or radiological suspicion of primary CaGB were studied. Of these, 54 aspirates were unsatisfactory. Fifty cases were negative for malignancy. Remaining 437 aspirates were positive for carcinoma. Histopathologic diagnosis was available in 32 cases. Adenocarcinoma was the most frequent diagnosis in 86.7% of cases. Mucinous, signet ring, adenosquamous, squamous, small cell, mixed adenoneuroendocrine and undifferentiated carcinoma including spindle and giant cell subtypes were diagnosed identifying specific features on FNAC. Correlation with histopathology was present in all, but one case giving rise to sensitivity of 96.8%. No post-FNA complications were recorded.Conclusions: US guided FNAC is a safe and effective method to diagnose CaGB. Although, rare, clinically and prognostically significant variants described in WHO classification can be detected on cytology.

The Indian Journal of Cancer is an official publication of the Indian Cancer Society and Indian Society of Oncology.

Extramedullary deposits may be the presenting feature of acute myeloid leukemia. An early and accurate diagnosis on cytology will aid in correct patient management. This is especially true for patients with acute megakaryoblastic leukemia (AML M7), where bone marrow aspiration may yield only a dry tap. While cytomorphological features of myeloid sarcoma of other types are well recognized due to its rarity, there are only two case reports discussing the morphological details of megakaryoblastic differentiation on aspiration cytology. We present the case of a 25-year-old patient with extramedullary involvement of lymph node and cerebrospinal fluid by AML M7, describing in detail, the morphological features on aspiration as well as exfoliative cytology.

S. Kaushal, V. K. Iyer, S. R. Mathur and R. Ray Fine needle aspiration cytology of medullary carcinoma of the thyroid with a focus on rare variants: a review of 78 casesBackground:  The cytological features of variants of medullary carcinoma of the thyroid (MCT) are sparsely documented in the literature from case reports. Detailed cytomorphological analysis of MCT variants and features helping to distinguish them from usual MCT are presented here.Materials and methods:  A total of 78 aspirates with a diagnosis of MCT over a period of 10 years were re‐evaluated. Cytomorphological details were reviewed and semiquantitatively analysed. Histology slides were reviewed in 36 cases.Results:  Most aspirates showed classical features of dispersed polygonal or plasmacytoid cells with areas of spindling. In 54 aspirates, a definite cytological diagnosis of medullary carcinoma was made, which in 87.1% was based on cytomorphology alone and in 12.9% was based on immunocytochemistry for calcitonin. In 30.1% of aspirates from MCT, a guarded report of tumour was given in the absence of calcitonin immunocytochemistry. Of the 78 cases, nuclear grooves were seen in 5.1%, intranuclear cytoplasmic inclusions in 28.2%, cytoplasmic granularity in 23.1% and bizarre cells with abrupt anisocytosis in 85.9%. A follicular arrangement was seen in 14.1% and was more frequent in the follicular type (one case) and mixed follicular and medullary carcinoma (one case). Melanin production was seen in aspirates from two cases. One case of the giant cell type of MCT was seen, in which background cells showed large pleomorphic nuclei and numerous bizarre tumour giant cells, prompting a differential diagnosis with anaplastic carcinoma. One example each of the small cell type, paraganglioma‐like MCT and papillary MCT were seen.Conclusions:  MCT has uniform cytological features in the majority of aspirates, including many of the histological variants. Searching for pigment in every aspirate of MCT may be rewarding. The giant cell type of MCT is rare and has to be differentiated from anaplastic carcinoma.

A. Nayak, V.K. Iyer and S. Agarwala The cytomorphologic spectrum of Wilms tumour on fine needle aspiration: a single institutional experience of 110 casesObjective:  To analyse the cytomorphologic spectrum of Wilms tumour (WT) on aspirates, the largest series reported to date.Study design:  Adequate aspirates from paediatric renal tumours over a period of 17 years were reviewed and selected if subsequent excision showed WT or aspirates were diagnostic for WT and clinical/radiological evidence consistent with that diagnosis. Smears were re‐examined for the proportion of components, degree of pleomorphism and mitosis.Results:  Of 110 aspirates, smears were triphasic in 44 (40.0%), biphasic (blastema and tubules) in 36 (32.7%) and monophasic (blastema alone) in 30 (27.3%). Stromal predominance was seen in 11 aspirates (10.0%) and five showed rhabdomyoblastic differentiation; all 11 were triphasic. Mean mitotic rate was 9.3/5000 cells (range 4–39/5000). Nuclear atypia not amounting to anaplasia and without atypical mitoses was seen in 15 (13.6%); these presented diagnostic problems. Two aspirates (1.8%) were considered anaplastic (unfavourable), both having atypical mitoses. Criteria similar to histology (i.e. 3‐fold or more variation in nuclear size, marked hyperchromasia with bizarre nuclei and atypical mitoses in a biphasic or triphasic aspirate) helped in distinguishing anaplastic WT. Histopathological correlation in 67 cases showed good correlation of blastemal predominance, stromal predominance and anaplastic histology with the corresponding cytology. However, 9/27 (33.3%) triphasic tumours had only blastemal cells on corresponding aspiration because of sampling error. Cytokeratin was positive in 4 of 20 aspirates with blastema alone.Conclusions:  Aspirates from WT were triphasic or biphasic in the majority (72.7%), permitting cytological diagnosis, which was improved by cytokeratin immunocytochemistry. Blastemal and stromal predominance on histology correlated well with cytology, but many triphasic tumours showed only blastema on aspiration. Anaplastic WT can be detected on aspirates using criteria similar to histology.

E. Sigamani, V. K. Iyer and S. Agarwala Fine needle aspiration cytology of infantile haemangioendothelioma of the liver: a report of two cases Background:  Fine needle aspiration cytology (FNAC) of infantile haemangioendothelioma of the liver (IHL) has not previously been described because routine use of FNAC is contraindicated due to the risk of bleeding.Methods and materials:  Two patients presented with progressively increasing right upper quadrant abdominal mass. The index case was a girl aged two and a half years with a large single mass in the right lobe of the liver. The second was a 3‐month‐old girl in whom ultrasonography revealed multiple hypoechoic lesions in the liver. Ultrasound‐guided fine needle aspiration had been performed on both patients. May‐Grünwald‐Giemsa stained smears from these two patients were reviewed and correlated with histopathology.Results:  Both aspirates showed predominantly normal hepatocytes and bile ductules amongst which tumour cells were admixed. The latter were oval to spindle‐shaped with scant cytoplasm and wavy, kinked and indented nuclear outlines. The non‐epithelial character of the tumour cells was apparent and helped to rule out hepatoblastoma. One case showed extramedullary haemopoiesis. The diagnosis of IHL was established on subsequent excision in the first case and a wedge biopsy in the second case. CD34 and factor VIII R antigen were positive in the tumour cells.Conclusion:  Radiological diagnosis of IHL is possible in a majority of cases, but sometimes features may overlap with hepatoblastoma and fine needle aspiration may be performed inadvertently. Characteristic kinked nuclei and intermixed normal liver tissue might suggest IHL in the differential diagnosis of a spindle cell vasoformative tumour.