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Ectopic hormone production is an uncommon complication of neoplastic lung disease. Rarely, patients may present with signs and symptoms of systemic endocrine dysfunction related to a hormone-secreting tumor. Bronchopulmonary carcinoids are the most common neoplasm implicated in ectopic ACTH-dependent Cushing's syndrome. Persistent hypercortisolism, such as that which occurs in Cushing's syndrome, causes immunosuppression and makes patients vulnerable to opportunistic infections. We present a case of a 42-year-old woman diagnosed with ACTH-dependent Cushing's syndrome which was originally thought to stem from a pituitary lesion as interpreted on magnetic resonance imaging. Her symptoms persisted after undergoing hypophysectomy, and further work-up involving a fine needle aspiration of the left lung revealed an ACTH-producing carcinoid tumor. Before treatment could be administered, the patient developed several new suspicious nodules in the left lung that were shown by fine needle aspiration to be infectious in nature. A Gram stain revealed numerous Gram positive branching organisms, and culture of the specimen grew Nocardia asteroides. Her pulmonary infection was treated with antibiotics and she underwent successful ablation of the carcinoid tumor., (Copyright © 2010 Wiley-Liss, Inc.)

Angiocentric glioma (AG) is a rare central nervous system (CNS) neoplasm that was only recently recognized by the World Health Organization (WHO). AG occurs in a broad age range, shows no gender predilection, and arises superficially in the cerebrum, usually resulting in medically intractable seizures. Most cases are cured by surgical excision alone, consistent with a WHO grade I neoplasm. We report a case of an AG in the right frontal lobe of a 57-year-old female, emphasizing the cytologic and immunohistochemical features, including confirmation and comparison with the surgical specimen. To our knowledge, this is the first report detailing the cytology of AG, including demonstration of important diagnostic findings that were only appreciated in the cytologic preparations and not in the smears or the surgical specimen. We also compare and contrast AG to other entities in the differential diagnosis and include a review of the literature., ((c) 2009 Wiley-Liss, Inc.)

The National Cancer Institute (NCI) sponsored the NCI Thyroid Fine Needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The 2-day meeting was accompanied by a permanent informational website and several on-line discussion periods between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document summarizes matters regarding the utilization of ancillary studies in thyroid FNA (http://thyroidfna.cancer.gov/pages/info/agenda/).

Synovial sarcoma (SS) is one of the most common soft tissue tumors that typically presents in the extremities of young adults, but may occur at any site and affect children during the first decade. Herein we discuss a 12-yr-old male who complained of left foot pain and plantar mass. A fine-needle aspiration biopsy of an 8 cm subcutaneous mass was performed revealing a myxoid spindle cell neoplasm. The cytologic differential diagnosis included a myxoid neurofibroma, neurothekeoma, and a myxoid sarcoma. Subsequent excision of the mass revealed a monophasic fibrous SS with myxoid features. Examination of the tissue by fluorescence in situ hybridization confirmed the presence of characteristic SS SYT gene rearrangement at chromosome 18q11.2. This case underscores that the cytologic distinction of mxyoid spindle cell tumors may be challenging. We report the cytologic features of a myxoid monophasic fibrous SS, and discuss its distinction from other benign and malignant myxoid soft tissue neoplasms., ((C) 2006 Wiley-Liss, Inc.)

Aspergillus, which commonly involves the sinonasal region and upper respiratory tract, is reported for the first time in esophageal brushings in two immunocompromised patients with a history of acute myelogenous leukemia (AML). Aspergillus species was identified in both cases in smears as scattered three-dimensional groups of fungi with 45 degrees angle branching. One case had a local esophageal noninvasive form, while the other, in addition to the esophagus, had disseminated to the spleen. Although Aspergillus is an uncommon cause of esophagitis in immunocompromised patients, its presence may be associated with an extremely poor prognosis as both expired shortly after detecting this fungus on esophageal brushings., (Copyright 2004 Wiley-Liss, Inc.)

The diagnosis of malignant lymphomas by fine-needle aspiration biopsy (FNAB) is increasing in utilization. The cytomorphologic distinction among the small B-cell lymphomas may be quite difficult. We are unaware of anyone who has compared directly mantle cell lymphoma (MCL) and marginal zone lymphoma (MZL) in FNAB. Our major goal was to examine the cytomorphologic attributes of MCL and MZL and to look for features distinctive of or suggestive of either neoplasm. Seven immunophenotypic MCL and seven immunophenotypic MZL aspirates were evaluated for a number of cytomorphologic features in direct smears. Features favoring MCL include a relatively monomorphic cellular population, prominent nuclear membrane contour irregularities, and mitotic figures. Conversely, a polymorphic cellular population suggested MZL. However, due to extensive overlap of specific cytologic features, the two lymphomas cannot be definitively distinguished based solely on cytomorphology. Although there are cytomorphologic attributes suggestive of either MCL or MZL, considerable overlap exists. Based on an individual case basis, the distinction cannot be made reliably by morphology alone; ancillary studies, e.g., immunophenotyping, are essential., (Copyright 2003 Wiley-Liss, Inc.)

We present our 10-year experience, including clinical utilization and outcomes, with fine-needle aspiration biopsy (FNAB) in Hodgkin's disease (HD). Eighty-six cases from 68 patients with HD that were evaluated by FNAB were identified over a 10-year period. Medical records of these 68 patients were reviewed. Thirty-seven patients with primary HD underwent 41 aspirates. A diagnosis of HD was yielded in 12 and suggested in 13 cases (sensitivity 86.2%, false-positive 0%). Nine were diagnosed as atypical lymphoid cells, four as hyperplasia/other, and three as unsatisfactory. With these diagnoses, six patients began treatment without tissue exam. Thirty-five patients with suspected recurrent HD underwent 45 FNABs. Recurrent HD was confirmed in 15 and suggested in 12 aspirates (sensitivity 81.3%, false-suspicious 14.3%). With these diagnoses, 22 patients began treatment for recurrence without tissue exam. FNAB is useful both for establishing a primary diagnosis and confirming recurrence in HD and thus has a high utilization at our institution. In many instances, patients can begin therapy, negating the need for formal tissue exam., (Copyright 2002 Wiley-Liss, Inc.)

Toxoplasmosis, caused by the intracellular protozoan Toxoplasma gondii, has as its major routes of acquisition either ingestion (of the cyst or oocyte) or transplacental infection (by trophozoites). Transplacental transmission occurs to the fetus in utero or to the newborn at vaginal delivery. Maternally acquired infections can infect the embryo as early as the 7th week of gestation. It has been estimated that 15-17% of maternal infections acquired between the 7th and 14th weeks of gestation are transmitted to the embryo (Lynfield R, Eaton RB., Teratology 1995;52:176-180.). We present a 7-wk-old white male, delivered at 38 wk of gestation, who shortly after birth was found to have hepatosplenomegaly and anemia; he developed liver failure and ascites with persistent anemia during the first week of life. After an extensive, but nondiagnostic, work-up, a paracentesis was performed which led to a diagnosis of congenital toxoplasmosis. This case demonstrates the utility of exfoliative cytology in determining the cause of neonatal ascites, especially of an infectious etiology. To our knowledge, this represents the first reported case of Toxoplasma gondii diagnosed by exfoliative cytology in a pediatric patient.

The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires that if a cytology/histology discrepancy is discovered which is significant and affects patient care, an amended report should be issued (Clinical Laboratory Improvement Amendments, Fed Reg 1992;57:7169). Since little is known about such amended reports, a survey was developed to assess how individuals handle discrepancies. The Quality Assurance Task Force from the Papanicolaou Society of Cytopathology created a survey to assess these methods and sent it to all of their members. Fifty-one individuals responded to the survey. Methods vary widely among institutions. On average, 107 cytologic/histologic correlations are performed each month with the discovery of approximately 2 major and 11 minor discrepancies. Thirty-nine responders utilize written amended reports and telephone clinicians when a major discrepancy is found. Thirty-eight individuals indicated that their place of employment has a written policy concerning discrepancies. Time spent in quality assurance issues averaged 8 hr per wk for cytotechnologists and 3 hr per wk for pathologists. Although amended reports are required when significant discrepancies are revealed, a standard practice does not exist.

The clear-cell type of hepatocellular carcinoma is an uncommon variant of hepatoma that can be confused with other clear-cell malignancies. We report on 4 cases of clear-cell hepatocellular carcinoma diagnosed by computed tomography (CT)-guided fine-needle aspiration (FNA) biopsy. All 4 patients were men with a median age of 71 yr (age range 66-76 yr). Three patients presented with a solitary liver mass and no known extrahepatic primary malignancies. The fourth patient, previously diagnosed with non-A, non-B posttransfusion hepatitis, presented with an irregular firm liver and abnormal serum liver function tests. Cytologically, all cases were characterized by hypercellular smears consisting of loosely cohesive groups and individually scattered malignant cells demonstrating anisonucleosis, nuclear hyperchromasia and irregularity, prominent nucleoli, and abundant finely vacuolated to clear cytoplasm. Immunocytochemical staining in three cases revealed focal positivity of the malignant cells for cytokeratin (AE1/3) and alpha-fetoprotein in one case. Electron microscopy (EM) was performed in all cases and revealed ultrastructural features consistent with hepatocellular differentiation. The cytologic differentiation of clear-cell hepatocellular carcinoma from metastatic clear-cell malignancies of renal, ovarian, and adrenal origin, among others, is presented. In addition, EM and immunocytochemistry study of the aspirated material can aid in establishing the correct diagnosis, thereby facilitating appropriate clinical management.

Spindle cells seen in fine-needle aspiration biopsy (FNAB) of the mediastinal lesions can be a component of a wide variety of benign and malignant conditions. Few of these conditions, however, are described in the FNA cytopathology literature. This review discusses the cytopathologic features, differential diagnoses, and potential pitfalls of a variety of lesions with a significant component of spindle cells encountered in mediastinal FNAB. The cytopathology files from four institutions were searched for cases of mediastinal FNAB containing a spindle-cell component that was a key or predominant cytologic feature of the diagnostic specimen. The cytomorphologic features of these cases were analyzed, and their differential features are discussed. Of 196 mediastinal FNABs, 22 (11%) were lesions with significant spindle-cell component: granulomatous inflammation (four); benign nerve sheath tumor (four); thymic cyst (two); spindle-cell thymoma (two); large-cell non-Hodgkin's lymphoma with sclerosis (two); nodular sclerosing Hodgkin's disease (two); liposarcoma (two); spindle-cell squamous carcinoma possibly arising in a teratoma (one); unspecified high-grade sarcoma (one); spindle-cell malignant melanoma (one); and nonspecific fibrous tissue (one). The cytologic features of each lesion were analyzed as an aid for accurate classification. These findings were correlated with radiologic and clinical information when available. The value of ancillary studies performed on aspirated material in selected cases was also reviewed. FNA of mediastinal lesions with significant spindle-cell morphology represents an infrequent and heterogeneous group of entities that may pose significant diagnostic challenges. This review presents the salient cytopathologic features of various spindle-cell lesions of the mediastinum with particular emphasis on differential diagnosis and pitfalls. The pathologist must use caution when interpreting these lesions and ancillary studies may be of significant value in selected cases.

A retrospective review of 189 fine-needle aspiration (FNA) biopsies of the mediastinum from four university medical centers was performed. Review of Diff-Quick- and Papanicolaou-stained direct smears was performed from a series of 189 FNA biopsies along with surgical pathology correlation obtained in 42% of the cases. There were 28 (14.8%) nondiagnostic or unsatisfactory for diagnosis cases. Of the satisfactory FNA specimens with histologic correlation, 12 cases (6%) were discordant. These errors primarily involve subclassification of small-cell malignancies involving the mediastinum, including a misdiagnosis of small-cell carcinoma for lymphoma. Large-cell lesions that were problematic included the accurate diagnosis of Hodgkin's lymphoma including the separation from non-Hodgkin's lymphoma. Large-cell lymphoma with sclerosis was misinterpreted in two cases due to distortion of cells by the mesenchymal tissue and sparsely cellular smears. In two cases classification of primary germ-cell tumors and separation from metastatic carcinoma was a problem. In general, FNA of the mediastinum is an accurate procedure, but can be challenging in a minority of cases due to sparse cellularity of the lesions and accurate classification of a variety of neoplasms that occur in this region. These 12 discordant cases serve as the basis of our report.

Gout, a disease resulting from the effects of hyperuricemia and a crystal-induced arthropathy, may produce soft tissue masses (tophi) which mimick neoplasia clinically and radiographically. We have recently diagnosed three cases of gouty tophus, two of which were clinically suspected to represent sarcomas, by fine-needle aspiration biopsy (FNAB) after extensive radiologic and clinical evaluation. There were two women and one man. aged 71, 73, and 50 yr, with palpable soft tissue masses that involved the right forearm, right hand, and right foot, respectively, Biopsies were obtained by using 25-gauge needles without the aid of general anesthesia. Morphologically, aggregates and disassociated slender, needle-shaped crystals were abundant and easily recognized on both Diff-Quik and Papanicolaou stains. By using a polarizing microscope with a first-order red compensator, the crystals showed negative birefringence, characteristic of sodium urate. Benign-appearing histiocytes, foreign-body-type giant cells, neutrophils, and amorphous debris were scattered among the diagnostic crystals. The diagnosis of gouty tophus can be easily established with FNAB in conjunction with compensated polarizing microscopy. Application of FNAB in the initial evaluation of appropriate soft-tissue masses provides a cost-effective diagnostic method, preventing more costly and often unnecessary clinical and radiologic tests.

Chondroblastoma of bone is a well-characterized entity. When the radiographic features are classic and the lesion is present in typical locations (i.e., epiphysis of a long bone), the diagnosis is often easily established by fine-needle aspiration biopsy and/or surgical curettage. Tumors in unusual locations, in older patients, or when complicated by aneurysmal bone cysts may pose more diagnostic difficulty. We report four examples (three primary and one-recurrent) of chondroblastoma of bone diagnosed by fine-needle aspiration biopsy. All patients were men, ranging from 18 to 28 yr of age. Sites of involvement included the acromion process of the scapula, left humerus, right ischium, and left distal femur. Three of the tumors were diagnosed as chondroblastoma on fine-needle aspiration cytology; the fourth case, involving the scapula, consisted mostly of a large aneurysmal bone cyst and remained unrecognized until surgical curettage was performed. Typical-appearing chondroblasts were present in three of the cases; osteoclast-type giant cells were observed in all four cases. Matrix material consistent with chondroid was also identified in all cases. We believe that in the absence of inflammatory cells, the presence of classic-appearing chondroblasts, even without chondroid matrix, is sufficient for a diagnosis of chondroblastoma of bone.

Small cell carcinoma of the large intestine is a rare, extremely aggressive malignancy often associated with an overlying adenoma. We report three cases of metastatic small cell carcinoma of the colon diagnosed by fine-needle aspiration (FNA) biopsy. Two of the patients were women (ages 33 and 46 yr old) and one was a man (69 yr old). FNA biopsy established the diagnosis of metastatic small cell carcinoma involving the liver (2 cases) and soft tissue of the scapular region (1 case). In one patient, the FNA diagnosis of hepatic metastases preceded identification of the primary site. Subsequently, the patient was found to have a small cell carcinoma subadjacent to a colonic villous adenoma, illustrating the importance of investigating villous lesions of the colon in patients with metastatic small cell carcinoma of unknown primary origin (especially in non-smokers). All three cases showed the characteristic cytologic features of small cell carcinoma. Ancillary studies performed on aspirated material confirmed the diagnosis of small cell carcinoma in one case. Immunocytochemical studies revealed punctate cytokeratin and diffuse neuron-specific enolase (NSE) positivity of the malignant cells. Ultrastructurally neurosecretory granules were evident. To the best of our knowledge, this is the first FNA cytologic report of metastatic small cell carcinoma of the large intestine. This FNA report also demonstrates when a small cell carcinoma is detected in a metastatic site in a patient lacking a lung primary, a likely primary site could be adjacent or beneath a polypoid lesion of the colon.

Bile peritonitis (BP) is a rare but acute and serious condition that may be associated with high mortality. BP results from generalized or localized leakage of bile into the peritoneal cavity. At best, radiologic studies may be suggestive of BP. We observed a spectrum of cytologic findings in aspirated peritoneal fluids (PF) from 3 patients with BP. Occasional bile pigment-laden macrophages, extracellular lakes of green stringy material admixed with variable numbers of histiocytes, mesothelial cells, and acute and chronic inflammatory cells, were seen. Numerous candida were present in one case. To the best of our knowledge, this is the first report describing the cytologic features of BP. Cytology is a simple, rapid, and cost-effective means of examining PF, and can therefore play a significant role in establishing the diagnosis of BP. Early recognition of BP can result in rapid, therapeutic intervention that may prevent significant morbidity and mortality.

The mediastinum is the host for a number of relatively unusual primary neoplasms, as well as a frequent recipient of metastatic tumors. From the perspective of fine-needle aspiration cytomorphology, several distinct patterns are yielded. The polygonal (or epithelial-like) cell pattern may be seen with benign and malignant thymomas, germinomas, embryonal carcinoma, and many metastatic carcinomas. An intimate admixture of small lymphocytes with these epithelial cells may occur in this category. The small cell pattern may be produced by malignant non-Hodgkin's lymphomas, neuroblastoma, carcinoid tumors, and metastatic oat cell carcinoma. Uncommon morphologic forms of thymoma and carcinoid tumors, as well as benign mesenchymal lesions, may yield a picture of a spindle-cell proliferation. In addition to cytomorphology, the cytologist needs to integrate clinical, radiographic, immunocytochemical, and ultrastructural data to formulate a final diagnosis.

Germ cell tumors (GCT) are neoplasms that originate predominately in the ovary and testis. Tumors of germ cell origin only very uncommonly arise in extragonadal sites. We have diagnosed ten primary malignant extragonadal GCT arising in the mediastinum, retroperitoneum, liver, and sacrococcygeal region by fine-needle aspiration biopsy (FNAB). Patient ages ranged from 1 to 54 years; the majority were males. Our series included three seminomas, three yolk sac tumors (YST), one choriocarcinoma, one embryonal carcinoma, and two mixed, poorly differentiated GCT. In aspirates, seminomatous elements are dissociated with uniform mononucleate cells having large vesicular nuclei and prominent nucleoli. A tigroid background is produced with Diff-Quik-stained smears. YST yields cohesive clusters of cells with large nuclei, vacuolated cytoplasm, and extracellular hyaline matrix (spheres or hyaline globules). Giant multinucleate tumor cells are seen in choriocarcinoma. Embryonal carcinoma yields cellular smears of hyperchromatic cells with scant cytoplasm arranged predominantly in glandular or papillary formations. Ultrastructural (four cases) and immunocytochemical (seven cases) studies of aspirated material corroborated our cytologic interpretations. Aneuploid tumor cells were found by flow cytometry in aspirated material from a YST. Subsequent histologic examinations were performed on eight, and all were confirmatory. Although extragonadal GCT are relatively uncommon, they need to be considered in FNAB material from midline mass lesions. Ancillary studies were useful in confirming their diagnosis.

Soft-tissue lesions pose an intimidating challenge to diagnostic interpretation by fine-needle aspiration cytology. To better characterize such aspirates, we investigated a subgroup of lesions which yielded a large amount of chondromyxoid and myxoid stroma (CMS). Thirty-three cases (22 malignant lesions, 11 benign lesions) in which CMS was a prominent feature of the smears were studied. The most common malignant neoplasms were extraskeletal chondrosarcoma (6 cases), myxoid liposarcoma (6), and malignant fibrous histiocytoma (5). The benign entities consisted of ganglion cyst (4), myxoma (3), and neurofibroma (2). Of the aspirates from 22 malignant neoplasms, 15 (68%) contained opaque stroma, and in 18 (81%) the stroma was distributed as discrete clumps or fragments; all extraskeletal chondrosarcomas and chordomas contained these features. Additionally, in five of six chondrosarcomas the matrix exhibited cells within lacunae. Except for a tracheal chondroma which extended into the adjacent soft tissue, no benign aspirates had all three of these cytologic features. Twenty-three aspirates (70%) were moderately or highly cellular; all but two of these were malignant. Moderate to marked nuclear atypia occurred in 13/22 (59%) malignant and 1/11 (9.0%) benign aspirates. With a few exceptions, aspiration smears of benign lesions with abundant CMS were characterized by low cellularity, semitransparent amorphous stroma, and lack of nuclear irregularity. Recognition of variations in the character of the background material in addition to traditional cytologic criteria can aid in the diagnosis of benign and malignant chondromyxoid and myxoid aspirates of soft tissue.

The American form of Burkitt's lymphoma is a high-grade malignancy which usually involves the abdomen in children and young adults. There is only a limited literature which describes the cytologic features of Burkitt's lymphoma in serous effusions. We present three children with Burkitt's lymphoma initially diagnosed by effusion cytology. The first patient, an 11-yr-old boy, presented with bilateral pleural effusions, ascites, and abdominal masses and had diagnostic pleural fluid cytology without tissue confirmation (ultrastructural examination was performed on the effusion specimen). He died 7 months after the initial diagnosis. The second patient, a 9-yr-old boy, presented with ascites and abdominal masses and had diagnostic peritoneal fluid cytology with a subsequent confirmatory chest wall biopsy. The third patient, a 16-yr-old girl, presented with a 2-month history of irregular menses, a large pelvic mass, lymphadenopathy, and liver masses. Although an ovarian malignancy was clinically suspected, cytologic examination of her peritoneal fluid revealed Burkitt's lymphoma. Surgical exploration revealed involvement of her right ovary, cecum, and terminal ileum. The second and third patients are currently alive with no apparent disease following chemotherapy. In all three patients, effusion cytology revealed Burkitt's lymphoma, characterized by a uniform population of non-cohesive lymphoid cells with noncleaved nuclei, prominent multiple nucleoli, and scanty-to-moderate basophilic cytoplasm. Cytoplasmic and/or nuclear vacuoles were also seen, more prominent in Diff-Quik-stained, air-dried smears. These cases demonstrate the importance of recognizing the cytologic features of Burkitt's lymphoma, as serous fluid may be the initial diagnostic specimen.

Hepatic leiomyosarcoma is a rare malignancy to involve the liver, occurring as a primary liver sarcoma in patients without an underlying medical disorder, as a metastatic malignancy, and with increasing incidence, as a primary tumor in AIDS patients. A series of hepatic leiomyosarcomas diagnosed by FNA biopsy, including the first reported case in an adult AIDS patient, were reviewed with respect to cytomorphologic features. The series consisted of five men and two women ranging from 24 to 72 years of age. One case was a primary hepatic lesion in a 24-yr-old man with AIDS and six were metastatic from a number of sites (stomach, small bowel, retroperitoneum, vena cava, and seminal vesicle). Two cytologic patterns were identified. Aspirates of spindle-cell leiomyosarcomas (six cases) generally produced hypocellular smears composed primarily of small irregular clusters of cells with blunt-ended, uniform, overlapping nuclei. The differential diagnosis included benign reactive processes and other benign and malignant spindle-cell neoplasms. The aspirate of an epithelioid leiomyosarcoma (one case) revealed a second pattern characterized by highly cellular smears with many single polygonal cells having eccentric, malignant nuclei and a characteristic clear quality to the cytoplasm in Papanicolaou-stained material. This epithelial appearance generated a differential diagnosis that included hepatocellular carcinoma, metastatic carcinoma, and melanoma. Careful integration of clinical information, cytomorphologic features, and ancillary studies will allow specific FNA diagnosis of hepatic leiomyosarcoma in most cases.

Myeloproliferative disease may be associated with extramedullary hematopoiesis (EH). Clinically, however, the differential diagnosis of solid masses in these patients includes not only EH but also inflammatory lesions and malignant neoplasms, including granulocytic sarcoma. We report the fine-needle aspiration (FNA) cytology of extramedullary hematopoiesis in five patients with a history of myeloproliferative disease. All of the masses developed subsequent to the diagnosis of myeloproliferative disease. Two of the patients had chronic myelogenous leukemia, one had essential thrombocythemia, and two had an unspecified chronic myeloproliferative disorder. The patients ranged in age from 50 to 88 years, and all presented with solid masses involving the kidney (two aspirates), liver (one aspirate), and lymph nodes (three aspirates). One of the lymph node aspirates was from a paratracheal lymph node. Cytologically, the lesions were composed of varying numbers of hematopoietic cells from all three hematologic cell lines. The Diff-Quik stain was especially helpful in the recognition of the hematopoietic cells such as granulocytic precursors, eosinophils, and megakaryocytes. In several cases, the megakaryocytic component was particularly prominent. In one case, the Factor VIII immunoperoxidase stain was used to confirm the megakaryocytic lineage of the multinucleated cells. The cytologic differential diagnosis, which includes granulocytic sarcoma, inflammatory disorders, and other lesions containing multinucleated giant cells, is discussed.

Familial hemophagocytic syndrome (FHS) is a rare, fatal disorder of childhood demonstrating failure to thrive, fever, hepatosplenomegaly (HSM), recurrent infections, pancytopenia, and histologically, the infiltration of reticuloendothelial organs by benign-appearing histiocytes demonstrating hemophagocytosis. We report two fatal cases of FHS including a 3 year-old female who underwent fine-needle aspiration (FNA) biopsy of the liver in the initial workup of the disease (case 1) and an 8 month-old boy with ascites and HSM having peritoneal fluid cytology submitted as the first specimen for morphologic examination (case 2). In case 1, the FNA cytologic findings included benign hepatocytes and scattered mature and reactive lymphocytes and histiocytes. The histiocytes demonstrated fine to coarse cytoplasmic vacuoles and erythrophagocytosis. The diagnosis was confirmed at autopsy which revealed extensive lymphohistiocytic infiltrates in various organs including the central nervous system. In case 2, the peritoneal fluid cytology specimen contained numerous atypical and degenerating mononuclear lymphoreticular cells which were dispersed as a single cell suspension admixed with infrequent mesothelial elements; hemophagocytosis was not appreciated. Subsequent liver biopsy revealed portal tracts and sinusoids infiltrated by benign but atypical histiocytes with hemophagocytosis. Bone marrow examination and then autopsy confirmed the diagnosis of FHS. A panel of immunocytochemical studies was performed in the first case which was an aid in confirming the diagnosis of FHS and ultrastructural examination of the second case revealed well-developed erythrophagocytosis. Both patients had siblings who died of FHS. Although not diagnostic, cytomorphology may suggest FHS.

In the United States, the initial morphologic diagnosis of nephroblastoma is usually determined on a nephrectomy specimen prior to the initiation of any additional therapy. Such an approach, however, is not appropriate in all children; we believe that fine-needle aspiration biopsies (FNAB) should be the initial diagnostic procedure in a minority of patients with suspected Wilms' tumor. One such group of patients is those who present with stage IV disease, especially when it is considered unresectable. Herein we present two children with advanced Wilms' tumor to support our contention. The initial microscopic diagnosis in each was made by FNAB. Following chemotherapy, predominantly necrotic Wilms' tumors were excised. Both patients are alive with no evidence of residual disease or untoward affects from the aspiration procedure.

The fine-needle aspiration (FNA) cytology of two cases of granulocytic sarcoma involving the breast is reported along with the FNA cytology of one case of myeloid metaplasia (extramedullary hematopoiesis) involving an axillary lymph node. Two patients had known myeloproliferative disorders, while granulocytic sarcoma of the breast was the initial presentation of an unsuspected acute granulocytic leukemia in the other patient. Diff-Quik-stained preparations aided in the diagnosis of all three cases. Immunoperoxidase stains for factor VIII-related antigen helped confirm the megakaryocytic differentiation of the cells in the FNA cytology of myeloid metaplasia. Electron microscopic (EM) examination performed on the aspirated material also showed megakaryocytic differentiation of the bizarre cells. FNA cytology can make a specific diagnosis of granulocytic sarcoma and myeloid metaplasia. The workup of these unusual extramedullary myeloproliferative masses was aided when immunocytochemistry and EM were performed on the aspirated material.

The unique cytomorphologic aspects of a cardiac angiosarcoma in pericardial fluid are presented. Smears and cell block preparations revealed clusters of malignant pleomorphic oval to spindle-shaped cells concentrically layered about amorphous acellular cores. The cytologic findings were correlated with histologic, immunohistochemical, and electron microscopic findings in the necropsy material.

This report describes the fine-needle aspiration (FNA) cytologic findings of 15 cases of sarcomas involving the breast out of a combined series of 2,064 breast FNA biopsies, including 580 malignancies, thereby accounting for 2.6% of all the malignant breast tumors. The series consisted of 14 women and one man with a mean age of 48.4 yr (range, 29-63). There were eight cases of cystosarcoma phyllodes, including one malignant cystosarcoma phyllodes. Three benign cystosarcoma phyllodes had a significant concomitant atypical epithelial hyperplasia, which lead to a misdiagnosis of carcinoma in two of the cases. The third case was correctly identified as recurrent cystosarcoma phyllodes. In retrospect, features suggestive for cystosarcoma phyllodes and unusual for breast carcinoma include increased numbers of naked nuclei and hypercellular stromal fragments. Sarcomatous patterns in our four metaplastic carcinomas included chondrosarcoma (two cases), malignant fibrous histiocytoma (MFH) (one case), and fibrosarcoma (one case). Two additional pure primary MFHs (both of which had electron microscopic confirmation) and one metastatic fibrosarcoma to the breast were encountered. Recognition of unusual cytologic patterns for breast carcinoma should suggest the possibility of a primary or metastatic sarcoma to the breast. Potential pitfalls for misdiagnosis include the presence of atypical epithelial hyperplasia in some cases of cystosarcoma phyllodes, along with occasional cases having patterns indistinguishable from a fibroadenoma. The pleomorphic and bizarre cellular features can suggest the diagnosis of metaplastic and pure sarcomas of the breast, although the potential exists for confusion with very poorly differentiated carcinoma. FNA diagnosis of sarcomatous lesions of the breast is essential in order to insure proper surgical treatment.