Extramedullary plasmacytoma diagnosed by fine needle aspiration cytology. A report of four cases

A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System

BACKGROUND

The evaluation of lymph nodes (LN) by fine-needle aspiration cytology (FNAC) is routinely used in many institutions but it is not uniformly accepted mainly because of the lack of guidelines and a cytopathological diagnostic classification. A committee of cytopathologists has developed a system of performance, classification, and reporting for LN-FNAC.

METHODS

The committee members prepared a document that has circulated among them five times; the final text has been approved by all the participants. It is based on a review of the international literature and on the expertise of the members. The system integrates clinical and imaging data with cytopathological features and ancillary techniques. The project has received the endorsement and patronage of the International Academy of Cytology and the European Federation of the Cytology Societies.

RESULTS

Clinical, imaging, and serological data of lymphadenopathies, indications for LN-FNAC, technical procedures, and ancillary techniques are evaluated with specific recommendations. The reporting system includes two diagnostic levels. The first should provide basic diagnostic information and includes five categories: inadequate/insufficient, benign, atypical lymphoid cells of undetermined/uncertain significance, suspicious, and malignant. For each category, specific recommendations are provided. The second diagnostic level, when achievable, should produce the identification of specific benign or malignant entities and additional information by utilizing ancillary testing.

CONCLUSION

The authors believe that the introduction of this system for performing and reporting LN-FNAC may improve the quality of the procedure, the report, and the communication between cytopathologists and the clinicians. This system may lead to a greater acceptance and utilization of LN-FNAC and to a better interdisciplinary understanding of the results of this procedure.

Liquid-based cytologic findings of solitary extramedullary plasmacytoma in thyroid: a case report identified with fine-needle aspiration cytology

Preoperative cytologic diagnosis of solitary extramedullary plasmacytoma (SEP) presents a challenge to cytopathologists because this tumor rarely occurs as a primary thyroid malignant neoplasm. In this report, we provide the first description of liquid-based cytomorphologic findings of SEP observed on fine-needle aspiration biopsy (FNAB) of the thyroid. A 56-year-old woman with a history of Hashimoto thyroiditis presented with a growing nodule in the thyroid. The liquid-based preparation obtained from FNAB showed numerous dispersed plasmacytoid cells with occasional loosely cohesive aggregates of tumor cells. Cells were round to oval in shape, with eccentrically located nuclei. Hyalinized perinuclear vacuoles were found in the cytoplasm of the tumor cells. Initial cytological findings, including those of immunochemistry using a cell block preparation, were consistent with plasmacytoma. Histopathological examination subsequent to thyroidectomy revealed a plasmacytoma in the thyroid. Plasma cell neoplasms were not concurrently detected in tissues other than the thyroid. On the basis of preoperative FNAB findings, a specific diagnosis of SEP in the thyroid can be difficult because this tumor is rare. Moreover, diagnosis is impeded because SEP in the thyroid resembles other, more common thyroid lesions, including both benign and malignant neoplasms. Careful cytomorphologic examination and supportive studies may be required to fully confirm a diagnosis of SEP.

Rhinosporidiosis of the left wrist joint: a case report

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi. It usually occurs in the mucous membranes of nose, nasopharynx, and eyes, and less commonly in extra nasal sites such as skin, bones, genitalia, and even the internal organs. Rhinosporidiosis occurs in the wrist joint with isolated bony involvement is rare. We report one such case in a 50-year-old man who presented with a non-tender, fixed swelling over his anterolateral aspect of left forearm. Radiography and computed tomography showed a lytic destructive lesion involving the distal radius, ulna, carpals, and base of metacarpals. Biopsy revealed features of rhinosporidiosis. The patient underwent below-elbow amputation.

Plasmacytoma of tonsil diagnosed by fine-needle aspiration cytology

Extramedullary plasmacytoma of tonsil is rare. Even though biopsy is necessary for final diagnosis, fine-needle aspiration cytology (FNAC) can provide useful information in the management of such cases. We report a case of plasmacytoma of tonsil diagnosed by FNAC in a 43-year-old man who presented with a swelling in the right tonsillar area. FNAC smears revealed sheets of plasma cells at various stages of maturation. Subsequent histopathological and immunohistochemical studies confirmed the diagnosis of plasmacytoma. This case is reported for the rarity of site for extramedullary plasmacytoma and to highlight the usefulness of FNAC in lesions of tonsil.

Extramedullary plasmacytoma, a report of five cases diagnosed by FNAC

OBJECTIVE

To review cytological findings and diagnostic challenges in the use of fine needle aspiration in the diagnosis of extramedullary plasmacytoma.

METHODS

Five cases of extramedullary plasmacytoma that were initially diagnosed on fine needle aspiration cytology over a period of two years in Sir Ganga Ram Hospital were reviewed.

RESULTS

The cytological findings were similar in all five cases. The smears were cellular and composed of plasmacytoid cells arranged singly and in clusters, with varying pleomorphism, bi- and multinucleation and mitotic figures. Presence of anaplasia, increased plasmablasts, numerous naked nuclei and unusual location of the tumour were some of the challenges faced during the cytological evaluation.

CONCLUSIONS

Extramedullary plasmacytoma may occur either as an initial presentation or as a secondary involvement by multiple myeloma. Fine needle aspiration is a reliable technique for its rapid diagnosis.

Primary cutaneous rhinosporidiosis diagnosed on FNAC: a case report with review of literature

Rhinosporidium seeberi causes granulomatous inflammation of mucocutaneous sites, presenting most frequently as polypoidal lesions in the nose. Sites like the conjunctiva, trachea, nasopharnyx, skin, and genitourinary tract are less frequently involved. Primary cutaneous lesion is extremely rare. We report the fine needle aspiration cytology (FNAC) of rhinosporidiosis occurring as a primary cutaneous lesion. FNAC of polypoidal and warty skin growths on leg in a 28-year-old male revealed numerous sporangia and spores of R. seeberi. There were no mucocutaneous lesions. Histopathologic examination confirmed the diagnosis. Globular bodies in endospores of R. seeberi are specific; their demonstration confirms diagnosis of rhinosporidiosis. FNAC or scrape cytology is economical and reliable in preoperative diagnosis of suspected and unsuspected cutaneous lesions of R. seeberi.

Cytodiagnosis of multiple myeloma presenting as orbital involvement: a case report

Background

Plasma cell neoplasms represent autonomous proliferations of plasma cells and can manifest as diffuse myeloma with systemic involvement (plasma cell myeloma or multiple myeloma), monoclonal gammopathy of undetermined significance (MGUS), or as variants of plasma cell myeloma such as indolent myeloma, smoldering myeloma, osteosclerotic myeloma, plasma cell leukaemia and non-secretory myeloma. Localized neoplastic proliferation of plasma cells presents as solitary plasmacytoma of bone or extramedullary plasmacytoma. Involvement of orbit can occur as a solitary plasmacytoma, or as part of systemic involvement in multiple myeloma, the clinical outcome being significantly worse in the latter setting.

Orbital involvement in multiple myeloma is very rare with less than 50 cases reported in the literature. Early cytological diagnosis of such lesions is vital for timely institution of appropriate therapy. As far as we are aware only six previous cases of cytological diagnosis of multiple myeloma involving the orbit are on record.

Case presentation

A 37 year old male presented with low grade fever showing evening rise, headache, diplopia and swelling in the right periorbital and temporal region. Imaging studies revealed destructive lesion of sphenoid, frontal bone and zygomatic arch with soft tissue component extending to infratemporal fossa and orbit. A fine needle aspirate from the temporal region swelling showed features of a plasmacytoma, and subsequent workup confirmed the presence of systemic disease. A final diagnosis of multiple myeloma with orbital involvement at presentation was made.

Conclusion

Present case describes the extremely rare presentation of multiple myeloma with orbital involvement and highlights the utility of cytology in such lesions. Fine needle aspiration diagnosis of plasmacytoma at extramedullary sites offers an opportunity for non-invasive verification of systemic involvement, and thus plays a major role in early diagnosis and management of these patients.

Fine-needle aspiration diagnosis of plasmacytoma presenting as breast masses in a patient on estrogen therapy for prostate cancer

We describe a 79-yr-old man with a history of androgen-independent metastatic prostate cancer treated with exogenous estrogens presenting with bilateral breast masses associated with bilateral axillary lymphadenopathy. Although the findings on physical examination with the concomitant history of estrogen therapy for metastatic prostate cancer raised the clinical suspicion of breast cancer, fine-needle aspiration (FNA) cytology identified the lesions as multiple myeloma.

Fine-needle aspiration cytology of a para-aortical solitary plasma-cell tumor

Extramedullary plasma-cell tumor (EMP) is a very rare disease and mainly arises in the head and neck area. An EMP arising in the paraaortical space was diagnosed by fine needle aspiration cytology and immunocytochemistry, in a 48-year-old male. Smears were cellular and showed dissociated monomorphic plasma cells. Immunocytochemistry demonstrated monoclonal expression of kappa-light immunoglobulin chain and CD38 positivity. Cytomorphology and immunocytochemical profile allowed a definitive diagnosis of plasmacytoma.

Rhinosporidiosis of the parotid duct cyst: cytomorphological diagnosis of an unusual extranasal presentation

This cytology report highlights a case of rhinosporidiosis of the parotid duct cyst not associated with nasal manifestations. In an endemic area, one should be familiar with its morphologic features in fine-needle aspiration cytology even on scanty material, for it could be one of the investigations in the initial workup of a case.

Plasmacytoma of the larynx diagnosed by fine-needle aspiration cytology: a case report

Extramedullary plasmacytoma is a rare lesion. The use of fine-needle aspiration for diagnosis of plasmacytoma has been described in a few sporadic reports. To the best of our knowledge, none of these reports described the cytologic findings from plasmacytoma of the larynx. We report on a case of laryngeal plasmacytoma in a 79-yr-old man diagnosed by fine-needle aspiration cytology. The patient had a history of a plasmacytoma involving the sixth thoracic vertebra diagnosed in 1996, which progressed to multiple myeloma in 1997. He received treatment in the form of local radiation to the skeletal vertebrae and chemotherapy. Two years later, the patient presented with a large neck mass. Computed tomography (CT) was done at an outside facility, and the radiologic impression was of a large right glottic carcinoma with invasion into the right thyroid cartilage. Because of the history of multiple myeloma, a fine-needle aspiration (FNA) biopsy was performed of the laryngeal mass. Cytologic examination demonstrated atypical plasma cells arranged in a dissociative fashion, consistent with a plasmacytoma. Although there are previous surgical pathology reports of laryngeal plasmacytoma, to the best of our knowledge, this is the first report of plasmacytoma of the larynx diagnosed by FNA cytology.

Rhinosporidiosis presenting with two soft tissue tumors followed by dissemination

Rhinosporidiosis is caused by Rhinosporidium seeberi. Most mycologists believe that R. seeberi is either a Chytridium related to the Olpidiaceae (order Chytridialis, class Chytridiomycetes) or a Synchytrium. This is the first documented case of tumoral rhinosporidiosis in a Sri Lankan and the third documented case in the world literature. A 44 year old male presented with a large mass above the thigh and a similar mass over the anterior chest wall, both masses contained R. seeberi. Later examination of the patient revealed nasal polyps, confirming that the tumors were due to systemic spread of this infection.