Journal of Pathology and Translational Medicine

Volume 9(2); December 1998

Original Articles

Quality Improvement Methods in Cervico-vaginal Cytology: Cytologic/Histologic Correlation vs. 10% Random Rescreening .: Ghil Suk Yoon, Jooryung Huh, Kyung Hee Son, On Ja Kim, Gyungyub Gong; Korean J Cytopathol. 1998;9(2):129-138.

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Abstract PDF: Although the success of the Papanicolaou test as a screening tool of cervical cancer is evident, there still exists 2-5% of discrepancy rate by both human and machine. To improve the qualilty of cervico-vaginal cytology, the authors compared cervicovaginal smear with cervical biopsy diagnoses, and analysed the causes of discrepancies. Among 30,922 cervicovaginal smears from June 1996 to April 1997 at our hospital, there were 271 cases of cervicovaginal smear with subsequent cervical punch or LEEP cone biopsies within several months. The biopsies and smears from a total of 98 discordant cases were reviewed. The discrepancy was attributed to sampling errors in 43 cases(43.9%), and to cytologic diagnosis in 49 cases(50.0%). Among these, 43 cases were interpretative errors(categories A;19, B;16 and C;8), whereas six cases were screening errors(categories B;2 and C;4). Among cervical biopsy cases, errors were present in four. As for 10% random rescreening, cytote chnologists reviewed 3,196 of 30,922 smears during the same period. There were 43 cases of screening error(categories A;27, B;16). Cytologic/histologic correlation was superior to 10% random rescreening of negative cases. The most effective method for quality improvement in cervicovaginal cytology was to implement both quality control(rescreening) and quality assurance(cytologic/histologic correlation) programs.

Sensitivity and Scoring of AutoPap 300 QC System for Abnormal Cervicovaginal Cytology .: Sung Ran Hong; Korean J Cytopathol. 1998;9(2):139-146.

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Abstract PDF: The AutoPap 300 QC System is an automated device for the analysis and classification of conventional cervical cytology slides for quality control purpose. These studies evaluated the sensitivity of the AutoPap 300 QC System, and estimated morphologic features other than epithelial abnormality to identify a high quality control(QC) score with the AutoPap 300 QC System. The sensitivity of the AutoPap 300 QC System at 10% review rate for 210 cases of cervicovaginal cytology with low grade squamous intraepithelial lesion(LSIL) and higher grade lesion was assessed, and compared with a 10% random rescreening. The morphologic features, such as presence of endocervical component, dirty background, atrophy, abnormal cell size, and cellularity of single atypical cells were estimated in 45 cases of no review and 30 cases of QC review cases. The AutoPap 300 QC System identified 119(56.7%) out of 210 cases with LSIL and higher grade lesion at 10% review rate. It was more sensitive to squamous cell lesions(50-62%) than to glandular lesions(10%). The dirty background and the scanty cellularity of single atypical cells were significantly related to low QC score. Conclusively, AutoPap 300 QC System is superior to human random rescreen for the identification of false negative smears. The upgrading of this device is required to enhance the detection of glandular lesion and certain inadequate conditions of the slides.

Cytologic Analysis of Adenocarcinoma of the Cervicovaginal Smears .: Jung Yeon Kim, Hye Jae Cho, Kyung Ja Cho, Hong Kyoon Lee; Korean J Cytopathol. 1998;9(2):147-154.

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Abstract PDF: We have investigated the cervicovaginal smears in order to define the cytologic features of uterine adenocarcinomas. Total 22 cases were reviewed(12 cases from the Sanggye Paik hospital, Inje university and 10 cases from the Korea Cancer Center Hospital) from January 1992 to December 1997. Five cases were endometrial adenocarcinomas and the remaining 17 cases were cervical adenocarcinomas. Se venteen cases of cervical adenocarcinomas were divided into endometrioid(6 cases), endocervical(7 cases), mixed endometrioid and endocervical(1 case), papillary (2 cases), and adenosquamous(1 case) carcinomas. The background of endocervical adenocarcinoma was hemorrhagic or inflammatory. The tumor diathesis was less prominent than that of the squamous cell carcinoma. The prominent features of the endocervical type adenocarcinomas were large and loose clusters, large intra cytoplasmic vacuoles, and prominent overlapping and peripheral palisading of nuclei. In contrast, the endometrioid adenocarcinomas showed small and compact clusters, and small intracytoplasmic vacuoles. The detection rate of endometrial adeno carcinoma was lower than that of the endocervical adenocarcinoma.

Fine Needle Aspiration Cytology of Intraoral Lesions .: Ho Jung Lee, Gyungyub Gong, Dong Hae Chung, Jooryung Huh, On Ja Kim; Korean J Cytopathol. 1998;9(2):155-160.

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Abstract PDF: Fine needle aspiration cytology(FNAC) has become a popular method for the diagnosis of a wide variety of both superficial and deep-seated lesions. However, there are few reports about the potential of FNAC for the diagnosis of intraoral lesions. We experienced 44 FNACs from intraoral lesions at Asan Medical Center: 22 from the palate, 6 from the tongue, 5 from the parapharyngeal space, 5 from the lip, 2 from the floor of mouth, 1 from the buccal mucosa, and 3 from other intraoral sites. Histological confirmation was obtained in 32 cases and we analyzed 27 cases excluding 5 cases of inadequate aspirates. Diagnosis was specifically made in 19 of 27 cases(70%) including 1 mucoepidermoid carcinoma, 1 undifferentiated carcinoma, 1 chordoma, 9 pleomorphic adenomas, 1 neurofibroma, and 6 benign lesions. There were three false negative cases(sensitivity, 62.5%) and no false positive cases(specificity, 100%): Two cases diagnosed as "cystic lesion" were confirmed to be mucoepidermoid carcinomas and a case diagnosed as pleomorphic adenoma was proved to be adenoid cystic carcinoma. The results of our study suggest that FNAC is a useful technique in the diagnosis of intraoral lesion.

Nuclear Morphometry of Fibroadenoma and Carcinoma of Breast: Comparison between fine needle aspiration cytology and biopsy.: Jin Hee Sohn, Young Hee Choi, Young Eui Park; Korean J Cytopathol. 1998;9(2):161-168.

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Abstract PDF: Primary breast lesions diagnosed by fine needle aspiration cytology, confirmed by histologic examination were analyzed by morphometry to evaluate the difference between benign and malignant lesions, and the methods obtaining the sample. Four size factors and 5 form factors were evaluated in 22 fibroadenomas and 20 carcinomas by image analyzer(Zeiss Ibas 2000) using the H-E stained slides. Nuclear size was significantly larger in the carcinoma cells than fibroadenoma cells both in the cytology and biopsy specimens, but the form factors were not significantly different. Both fibroadenoma and carcinoma cells were significantly larger in cytologic smear than histologic section. The cells in the cytology were more regular and round than those in histology, but not statistically significant. Fibroadenomas having cellular proliferation and atypism exhibited larger size and more irregular nuclei than non-proliferative fibroadenoma, but not statistically significant. Therefore nuclear morphometric analysis can be a helpful method to diagnose the questionable breast lesions and is a method appropriate for use as a quality control procedure in the fine needle aspiration cytology.

Cytopathologic Analysis on Fine Needle Aspiration Cytologic Misdiagnoses of the Thyroid .: Chan Pil Park, Joo Seob Keum, Won Mi Lee, Moon Hyang Park, Jung Dal Lee; Korean J Cytopathol. 1998;9(2):169-180.

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Abstract PDF: Fine needle aspiration cytology(FNAC) has been used effectively as the initial modality in evaluating various thyroid lesions. We correlated cytologic and histopathologic features to investigate the diagnostic pitfalls of FNAC of the thyroid. A total of 1,593 FNACs of the thyroid were diagnosed at the Department of Pathology, Hanyang University Hospital, from January 1993 to December 1997. There were 963 cytologically benign cases(60.5%), 97 suspicious cases(6.1%), and 75 malignant cases(4.71%). The remaining 458 cases(28.8%) were unsatisfactory. Subsequent surgical resection was done in 192 cases. Seventy-two cases(37.5%) were cytologi cally diagnosed as benign, 45 cases(23.4%) suspicious, 56 cases(29.2%) malignant, and 19 cases(9.9%) unsatisfactory. Histopathologically, 101 cases were benign(11 thyroidites, 52 adenomatous hyperplasias, 34 follicular adenomas, and four Hurthle cell adenomas), and 91 cases malignant(72 papillary carcinomas, 16 follicular carcinomas, one medullary carcinoma, one anaplastic carcinoma, and one granular cell tumor). After excluding 19 unsatisfactory cases, 63 were misdiagnosed. They included 17 benign(three thyroidites and 14 adenomatous hyperplasias), 27 suspi cious(16 follicular adenomas, four Hurthle cell adenomas, and seven follicular carcinomas), and 19 malignant(16 papillary carcinoma, one medullary carcinoma, one anaplastic carcinoma, and one granular cell tumor) lesions. The accuracy rates in the benign, suspicious, and malignant categories were 54.9%, 49.8%, & 92.8%, respectively. The cytological pitfalls were as follows: (1) bloody background, (2) crowded follicular cell clusters indistinguishable between follicular neoplasia and adenomatous hyperplasia, (3) papillary structure, irregular nuclear membrane and pleomorphism mimicking those of papillary carcinoma, (4) indistinct eosinophilia in follicular epithelial cells, (5) unusual cellular components not commonly seen in FNACs of the thyroid.

Case Reports

Fine Needle Aspiraton Cytology of Polymorphous Low Grade Adenocarcinoma in the Hard Palate: A Case Report .: Wan Seop Kim, Seok Hoon Jeon, Eun Kyung Hong, Moon Hyang Park, Jung Dal Lee; Korean J Cytopathol. 1998;9(2):181-186.

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Abstract PDF: Polymorphous low grade adenocarcinoma(PLGA) is a rare malignant tumor of the salivary gland. It is characterized by diverse histology, bland-looking cytology, indolent behavior and favorable prognosis. The fine needle aspiration cytologic features of PLGA are described. The aspirates from the hard palate in a 33-year-old woman showed cellular smear composed of monotonous small round to oval cells with scanty cytoplasm. Papillary, tubular and cell ball arrangements with characteristic dense stromal spheres were recognized. PLGA could be suggested by fine needle aspiration cytology, if one encountered cellular smear with various architectures and uniform bland-looking cytologic feature.

Alveolar Soft Part Sarcoma of the Lung Diagnosed by Fine Needle Aspiration Cytology: A Case Report .: Dae Su Kim, Young Lyun Oh, Young Hyeh Ko; Korean J Cytopathol. 1998;9(2):187-192.

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Abstract PDF: Alveolar soft part sarcoma(ASPS) is a rare malignant neoplasm with a distinct clinicopathologic entity of which fine needle aspiration(FNA) cytologic findings have been described in only a few reports. Although patients usually present with an isolated soft-tissue mass in the extremity, metastasis can occur in about 13 % of total cases and the most frequent metastatic site is the lung. We have recently experienced a FNA cytologic case of ASPS in the lung. A 23-year-old female patient was admitted to this hospital due to 2-month-history of cough. She had been good in health before the visit. Chest computed tomography revealed multiple, variable sized, bilateral pulmonary nodules. Physical examination and other staging work up revealed no other lesions except for pulmonary nodules. A percutaneous transthoracic FNA was performed from the pulmonary nodules. The smear was cellular and most cells were arranged singly. In addition, a few clusters lined by thin-walled vasculature with a pseudoalveolar pattern were present. Some of the tumor cells were large and polygonal to oval with abundant granular or vacuolated cytoplasm. Most cells were naked nuclei showing finely granular chromatin pattern with prominent central nucleoli.

Fine Needle Aspiration Cytology of the Sclerosing Hemangioma of the Lung: A Report of Five Cases.: Ji Young Kim, Yong Hee Lee, Kwang Gil Lee; Korean J Cytopathol. 1998;9(2):193-200.

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Abstract PDF: Sclerosing hemangioma is a rare, benign neoplasm of the lung, usually presented as a solitary pulmonary nodule in an otherwise asymptomatic middle-aged woman. Cytologically it shows papillary, sheet, and cyst-like arrangements representing three main histologic patterns of papillary, solid, and angiomatous ones, respectively. Herein, we report the fine needle aspiration cytology of 5 cases of sclerosing hemangioma of the lung. The most characteristic finding is cyst-like spaces intimately related to the papillary or solid cell nests. The tumor cells are relatively monotonous, round to oval, small to medium in size. They have small amount of eosinophilic cytoplasm. The nuclei are uniform, round and have small but conspicuous nucleoli. The tumor cells in one of the presenting cases are large with abundant cytoplasm and show moderate nuclear pleomorphism. The nuclear chromatin, however, is fine and even without exception, even in the case showing nuclear pleomorphism. Major differential diagnoses based on the cytologic findings are well-differentiated papillary adenocarcinoma, bronchioloalveolar carcinoma, and carcinoid tumor.

Cytologic Features of Adenoma Malignum of the Uterine Cervix: A Case Report.: Hyun Joo Choi, Young Shin Kim, Kyo Young Lee, Chang Suk Kang, Sang In Shim; Korean J Cytopathol. 1998;9(2):201-206.

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Abstract PDF: Adenoma malignum is an extremely well-differentiated variant of cervical adeno carcinoma in which the cells composing the tumor lack the typical cytological features of malignancy. The prognosis of this rare tumor is poor in spite of high degree of differentiation. The cytologic characteristics are extremely bland, so frequently make a confusion of adenoma malignum with endocervical glandular hyperplasia. We report a case of adenoma malignum in a 36-year-old woman who complained of mucoid vaginal discharge and vaginal bleeding. The cervicovaginal smear showed endocervical cells exhibiting a spectrum of atypical changes. The cells were arranged in multilayered strips and monolayered sheets. Individual cells ranged from cuboidal to columnar; typically the columnar cells had abundant lacy or vacuolated cytoplasm. The smear showed the majority of only atypical cells and small numbers of frankly malignant cells.

The Cytologic Features of Adenoid Cystic Carcinoma of the Uterine Cervix: A Case Report .: Seung Yeon Ha, Hyuni Cho, Young Ha Oh, Geun Shin Lyu; Korean J Cytopathol. 1998;9(2):207-212.

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Abstract PDF: Adenoid cystic carcinoma of the uterine cervix is a rare tumor accounting for less than 1% of all cervical adenocarcinoma. This tumor is characterized by aggressive biological behavior with frequent local recurrence or metastatic spread, postmenopausal onset, and occasional association with conventional squamous cell carcinoma. The cytologic diagnosis of adenoid cystic carcinoma in the uterine cervix is often difficult because of negative smear due to intact overlying mucosa, cytologic findings mimicking endometrial cells, and masquerade as squamous cell carcinoma. Recently we have experienced a case of adenoid cystic carcinoma arising in the uterine cervix, which was identified on the routine Papanicolaou smear and was histologically confirmed by the consequent biopsy. The smear showed abundant cellularity composed of relatively uniform cells. The tumor cells were arranged in small clusters, acini, naked cells, and loose sheets with abortive cribriform pattern. There were scattered globoid basement membrane-like materials and tumor diathesis. The nuclei were pleomorphic and showed hyperchromatic and coarsely granular choromatin with inconspicuous nucleoli. The punch biopsy of the uterine cervix showed typical histologic findings of adenoid cystic carcinoma characterized by tumor nests composed of hyperchromatic uniform basaloid cells, cribriform pattern, and cylindrical hyaline bodies.

Fine Needle Aspiration Cytology of Glycogen-Rich Clear Cell Carcinoma of the Breast: A Report of Two Cases .: Wan Seop Kim, Won Mi Lee, Eun Kyung Hong, Moon Hyang Park, Jung Dal Lee; Korean J Cytopathol. 1998;9(2):213-219.

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Abstract PDF: Glycogen-rich clear cell carcinoma of the breast is an unusual variant of carcinoma with a recorded incidence of 1.4-3% of breast carcinomas. The cytologic characteristics have not been well described. We report two cases of glycogen-rich clear cell carcinoma with corresponding fine needle aspiration(FNA) cytologic findings and compare them to infiltrating ductal carcinoma and other clear cell malignancies with a review of literature. One was a 62-year-old woman exhibiting a palpable mass of the right breast. The smears showed atypical tight cell clusters and individually scattered single cells containing foamy or clear abundant cytoplasm with well defined cytoplasmic margins. Mild to moderate nuclear pleomorphism and a prominent nucleolus were present. The other was a 42-year-old woman who was admitted with a right breast mass. The smears showed moderately cellular, tightly cohesive tumor cells. The cytoplasmic outline was generally well demarcated. The tumor cells contained foamy to clear abundant cytoplasm with large and small vacuoles. The nuclear pleomorphism was marked. Both tumors resected by modified radical mastectomy, were diagnosed as glycogen-rich clear cell carcinoma. Histologically, the clear cell nature of tumor cells were not characteristic enough to predict this type of the tumor. Some cytologic features can be distinguished other clear cell breast cancer from glycogen-rich carcinoma. Recognition of these unusual patterns in a breast FNAC should raise the suspicion of a clear cell carcinoma including glycogen-rich subtype. Cytological localization of glycogen using PAS and D-PAS staining may permit the correct identification and differential diagnosis of this tumor.

Fine Needle Aspiration Cytology of Invasive Ductal Carcinoma with Osteoclast-like Giant cells: A Case Report .: Eun Ha Jung, Hye Rim Park, Jin Hee Sohn; Korean J Cytopathol. 1998;9(2):221-226.

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Abstract PDF: Malignant tumors of the breast with stromal multinucleated giant cells are rare entity of uncertain clinical significance. There have been few reports on the fine needle aspiration cytologic(FNAC) findings about these rare tumors. We report a FNAC case of invasive mammary carcinoma with osteoclast-like giant cells not only for its rare occurrence but in particular for its distinctive cytologic picture on aspirated material. The patient was a 40-year-old woman who presented with a right breast mass for one month. Mammography showed a well-demarcated rounded mass density without calcification. The aspirates of FNAC were highly cellular and two main cell types were seen; malignant epithelial cells and osteoclast-like multinucleated giant cells. The carcinoma cells occurred singly or arranged in loose clusters with ill-defined cytoplasm, oval nuclei, coarse chromatin and small but distinct nucleoli. The multinucleated giant cells showed variable number of nuclei with prominent nucleoli and abundant dense oxyphilic cytoplasm. The immunocytochemical studies suggested that osteoclast-like giant cells were not of epithelial origin, but rather of histiocytic origin.

Cytologic Findings of Infectious Mononucleosis Lymphadenitis: A Report of Four Cases .: Jin Hee Sohn, Eun Ha Jung, Hye Rim Park; Korean J Cytopathol. 1998;9(2):227-232.

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Abstract PDF: Infectious mononucleosis(IM) is an acute self-limiting lymphoproliferative disorder associated with infection by the Epstein-Barr Virus(EBV), with the characteristic triad of fever, sore throat, and cervical or generalized lymphadenopathy. And also there are atypical lymphocytes in the peripheral blood. Cytological findings of IM lymphadenitis are characterized by a florid immunoblastic and atypical lymphoid cell proliferation. However, the small number of cases were studied by fineneedle aspiration cytology(FNAC) even though there was a complexity of lymph node pathology. It is important to recognize the reactive pattern of IM that would initiate EBV study and to avoid unnecessary biopsy. We studied findings of lymph node FNAC from 4 patients with EBV infection confirmed by EBV-specific serologic studies. All of the cases were positive for viral capsid antigen(VCA) and one case was positive for anti-EBV nuclear antigen(EBNA). Cytologically, all of the cases exhibited high cellularity and atypia with great numbers of large immunoblastic lymphocytes.

Fine Needle Aspiration Cytology of Clear Cell Sarcoma: A Case Report.: Sung Chul Lim, You Kyung Chung, Dong Chool Kim, Yoon Kyung Lee, Eun Taik Shin; Korean J Cytopathol. 1998;9(2):233-233.

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Abstract PDF: Clear cell sarcoma(CCS) is an uncommon soft tissue sarcoma that occurs in tendons and aponeuroses, usually of the lower extremities and is believed to be of neural crest origin that have a capability to produce melanin. These tumors commonly metastasize and have a very poor prognosis. The fine needle aspiration cytologic finding of CCS is not well documented. We recently experienced a case of CCS. The patient was a 54-year-old male with painful swelling of the right inguinal area. Fine needle aspiration cytology revealed polygonal or fusiform tumor cells with clear or granular cytoplasm and vesicular nuclei containing one or two nucleoli. Im munohistochemical staining for S-100 protein and HMB-45 revealed strong positivity, and variable developing stages of premelanosomes were observed by electron microscopy in the excised specimen.

Fine Needle Aspiration Cytology of Lipoblastoma: A Report of Two Cases.: So Yeong Oh, Myoung Ja Chung, Woo Sung Moon, Myoung Jae Kang, Dong Geun Lee; Korean J Cytopathol. 1998;9(2):241-244.

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Abstract PDF: Lipoblastoma is a rare benign neoplasm occurring exclusively in children below the age of three years. It affects chiefly the upper and lower extremities, and less commonly head and neck area, trunk, mediastinum, mesentery, and retroperito neum. We present two cases of lipoblastoma occurring in the mediastinum of a 21-month-old boy and in the back of a 15-month-old boy. The characteristic features of Fine needle aspiration cytology smears were the presence of immature fat cells in the form of spindle-shaped cells, stellate cells and vacuolated lipoblasts along with lipocytes against a myxomatous background. Two tumors were histologically confirmed to be lipoblastomas. Lipoblastoma can be cytologically diagnosed by considering the cytologic findings and the age of the patient.

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