Journal of Cytology

IMAGES IN CYTOPATHOLOGY
Year
: 2019  |  Volume : 36  |  Issue : 4  |  Page : 215--216

Fine-needle aspiration cytology of mammary analog secretory carcinoma of the parotid gland: A diagnostic conundrum


Meera Balakrishnan1, Smiley Annie George2, Bahiya E Haji1, Issam M Francis3,  
1 Department of Cytopathology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
2 Department of Histopathology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
3 Department of Pathology, Faculty of Medicine, Kuwait University, Jabriya, Kuwait

Correspondence Address:
Dr. Meera Balakrishnan
Department of Cytopathology, Mubarak Al-Kabir Hospital, P.O. Box 43787, 32052, Jabriya
Kuwait




How to cite this article:
Balakrishnan M, George SA, Haji BE, Francis IM. Fine-needle aspiration cytology of mammary analog secretory carcinoma of the parotid gland: A diagnostic conundrum.J Cytol 2019;36:215-216


How to cite this URL:
Balakrishnan M, George SA, Haji BE, Francis IM. Fine-needle aspiration cytology of mammary analog secretory carcinoma of the parotid gland: A diagnostic conundrum. J Cytol [serial online] 2019 [cited 2019 Dec 12 ];36:215-216
Available from: http://www.jcytol.org/text.asp?2019/36/4/215/268414


Full Text



Mammary analog secretory carcinoma (MASC) is a recently described salivary gland neoplasm with the parotid gland being the most common location, defined by the t (12;15) (q13;q25) translocation that results in ETV6-NTRK3 gene fusion product. Fine-needle aspiration cytology (FNA) can pose diagnostic difficulties due to the overlapping cytological features with acinic cell carcinoma (AciCC), mucoepidermoid carcinoma (MEC), oncocytic salivary neoplasms, low-grade cystadenocarcinoma, and pleomorphic adenoma (PA).[1] Herein, we highlight cytological features and ancillary studies that would help in a more precise preoperative diagnosis of MASC.

A 28-year-old male presented to the cytology department of our hospital, for FNA of a nontender parotid gland swelling which was progressively increasing in size for the past 2 years. Computed tomography scan showed a well-defined cystic lesion about 2 cm × 3.2 cm × 2.6 cm involving the left parotid gland. FNA showed several clusters of atypical epithelial cells, some of them in papillary groups [Figure 1]a and [Figure 1]b. The cells possess moderate-to-abundant cytoplasm with multiple intracytoplasmic vacuoles, round nuclei with bland chromatin, and small nucleoli. There were few clusters of metaplastic squamous cells and numerous foamy macrophages in a mucinous background [Figure 1]c and [Figure 1]d. A diagnosis of low-grade salivary gland neoplasm with the possibility of MEC/AciCC was made. A histological correlation was advised. Subsequently, the patient underwent superficial parotidectomy. The surgical specimen comprised the superficial lobe of the parotid gland (12 g, 4.5 cm × 3.3 cm × 1.5 cm) which on sectioning showed a well-delineated cystic tumor (1.8 cm × 1.5 cm × 0.6 cm). Histological evaluation revealed an extraductal unencapsulated solid and cystic neoplasm with varied architectural patterns such as tubular, papillocystic, microcystic, and cribriform patterns [Figure 2]a. The constituent cells were small-to-medium-sized with oval-to-round nuclei with pale chromatin, an occasional small nucleolus, and abundant pink to eosinophilic bubbly cytoplasm [Figure 2]b. The microcysts contained luminal eosinophilic colloid-like secretions [Figure 2]b. The tumor showed strong diffuse expression of CK8/18, PANCK, CK7, EMA, S-100, GCDFP-15, and negative for p63 and DOG-1 [Figure 2]c and [Figure 2]d. Mucicarmine stain highlighted the intracellular and extracellular mucin vacuoles. Based on the histological and immunohistochemical studies, a diagnosis of MASC was made. Unfortunately, fluorescence in situ hybridization for the demonstration of ETV6-NTRK3 was not available in our hospital. The patient is well and under follow-up till date.{Figure 1}{Figure 2}

MASC typically occurs in the adult population over the wide age range of 14–77 years (average age of 45 years) with male predominance. In 70% of the cases, parotid glands are involved. Less common subsites include submandibular glands and other oral cavity subsites such as the soft palate, buccal mucosa, base of tongue, and lips.[2]

An upfront diagnosis of MASC on FNA is often difficult as their cytological features overlap with those of AciCC, MEC, Warthin's tumor, low-grade cystadenocarcinoma, and PA.

The salient cytological features of MASC described in the literature are monomorphic population of cells in clusters, papillary groups, and singly dispersed eosinophilic cells with round nuclei, small nucleoli, and multivacuolated cytoplasm. Extracellular and intracellular mucins were also described.[1]

MASC is most often confused with AciCC. The features that aid in the diagnosis of AciCC are the presence of basophilic cytoplasmic (zymogen) granules which are PAS diastase-resistant and the absence of mucin production.[2] Other helpful features of AciCC are nuclei with macronucleoli and abundant arborizing vessels. However, granular AciCC can be really challenging, which can be resolved using immunohistochemical studies. MASC shows positivity for S-100 and mammoglobulin and is negative for DOG-1. The reverse staining pattern is observed in AciCC. At molecular level, the demonstration of the ETV6-NTRK3 fusion gene is characteristic of MASC.[2],[3]

The clear and vacuolated cells of MASC may be mistaken for low-grade MEC, particularly the presence of intracellular mucin in both tumors. However, MASC does not have the intimate mixture of epidermoid cells and intermediate cells that characterize MEC. On close scrutiny, MASC cells tend to be multivacuolated as opposed to univacuolation in MEC.

Salivary duct carcinoma and PA can rarely be confused with MASC. The former is characterized by greater nuclear pleomorphism and higher grade. The myxoid stroma of PA can be confused with mucin production in MASC, but the metachromatic nature of the material in PA should be helpful in differentiation.[3],[4]

Finally, metastatic renal cell carcinoma (RCC) could be a consideration, given the low-grade appearance with common clear cells and histiocyte-like cells we observed in MASC. However, RCC is characterized by perivascular nesting, macronucleoli, and often cytoplasmic metachromatic stromal material. Certainly, a history of renal tumor would also be helpful in this differential diagnosis. If doubt remains, performing immunohistochemistry for renal markers such as RCC, CD10, and PAX8 on cell block material would resolve the diagnosis.[5]

MASC should also be in the differential diagnosis of FNA of salivary gland tumors, especially when AciCC and MEC are considered. The cytological features along with clinical findings, immunohistochemical studies complemented by molecular studies on cell block can produce a more accurate preoperative diagnosis of MASC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Samulski TD, LiVolsi VA, Baloch Z. The cytopathologic features of mammary analog secretory carcinoma and its mimics. Cytojournal 2014;11:24.
2Gaopande VL, Kulkarni MM, Khandeparkar SG, Joshi AR. Mammary analog secretory carcinoma parotid gland: Case report of a recently described tumor with review of literature. Asian J Oncol 2017;3:139-43.
3Parekh V, Stevens TM. Mammary analogue secretory carcinoma. Arch Pathol Lab Med 2016;140:997-1001.
4Hijazi N, Rahemtulla A, Zhou C, Thomson T. An FNA pitfall: Mammary analog secretory carcinoma mistaken for acinic cell carcinoma due to cytoplasmic granules. Hum Pathol Case Rep 2014;1:58-61.
5Bishop JA, Yonescu R, Batista DA, Westra WH, Ali SZ. Cytopathologic features of mammary analogue secretory carcinoma. Cancer Cytopathol 2013;121:228-33.