Journal of Cytology
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   Table of Contents - Current issue
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October-December 2020
Volume 37 | Issue 4
Page Nos. 159-216

Online since Tuesday, November 10, 2020

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ORIGINAL ARTICLES  

Role of FNAC in extramammary tumors metastatic to the breast p. 159
Arshi Tandon, Trupti Patel, Kanwalpreet Kaur, Majal Shah, Priti Trivedi
DOI:10.4103/JOC.JOC_99_20  
Background: Metastasis to the breast of an extra-mammary origin is very rare. FNAC plays an important role in differentiating non-mammary breast metastasis from primary malignancy. This study aimed to analyze the cytomorphological criteria and its pitfalls in differentiating metastatic lesion of the breast from primary malignancy. Methodology: Retrospective analysis of 891 FNACs of the breast was performed for a time span of 3 years. A total of 12 cases were diagnosed on FNAC as secondary neoplasms to the breast. Clinical and radiological data, along with Pap and MGG stained smears of each case were examined and correlated with the histopathology of the primary tumor. Statistical analysis was carried out. All cases of primary breast malignancies were excluded from our study. Results: In 10 out of 12 cases, primary malignancies were identified as Plasma cell myeloma (one case), B-acute lymphoblastic leukemia (two cases), acute myeloid leukemia (one case); chronic myeloid leukemia (one case), Burkitt's lymphoma of the ovary (one case), Diffuse large B-cell lymphoma (one case), esophageal squamous cell carcinoma (one case), spindle cell sarcoma (one case) and squamous cell carcinoma of the cervix (one case). The remaining two cases in our study were misdiagnosed on cytology as metastasis and turned out to be breast primaries on histopathology. Conclusion: Our case series highlights the importance of FNAC to differentiate secondary lesions from primary breast malignancy and thus helps to avoid unnecessary surgery to the patient. It emphasizes on the need to keep in mind the possibility of metastatic breast neoplasms in the presence of unusual cytological features on FNAC.
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Cytomorphological evaluation of synovial lesions in a tertiary care centre in North India: A retrospective study p. 166
Poonam Sharma, Rajat Gupta, Subhash Bhardwaj, Manik Mahajan
DOI:10.4103/JOC.JOC_66_20  
Background: Numerous pathological processes involve synovium and periarticular tissues that are characteristic and in some cases specific to a particular disease. Synovial fluid is a thick, stringy fluid found in the cavity of synovial joint. Examination of the synovium plays a key role in the diagnosis of many joint diseases. Aims: The aim of this study was to study the spectrum of synovial lesions on fine needle aspiration cytology (FNAC) and to compare the cytological diagnosis with histopathological findings. Material and Methods: This retrospective diagnostic analytical study was carried out in the Department of Pathology. Sixty-six patients with suspected synovial lesions referred from other departments who underwent FNAC during 1 year from January 2017 to December 2017 were included in the study. The slides along with records of the patients were retrieved and findings recorded. Histopathological evaluation was performed wherever possible and compared with cytological diagnosis. Results: Non-neoplastic lesions accounted for 80.3% cases followed by benign tumors (15.2%). Ganglion cyst was the commonest non-neoplastic lesion (60.6%, 40/66), while tenosynovial giant cell tumor was the commonest neoplasm (12.1%, 8/66) observed in our study. Solitary case of synovial sarcoma was also observed. Histopathological evaluation was performed in 14 cases and FNAC had overall diagnostic accuracy of 85.7% in diagnosis of these lesions. Conclusions: FNAC is a useful tool with high diagnostic accuracy in the evaluation of synovial lesions.
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Rapid, Economic, Acetic Acid Papanicolaou Stain (REAP): An economical, rapid, and appropriate substitute to conventional pap stain for staining cervical smears p. 170
Garima Goel, Ajay Halder, Deepti Joshi, Abhijith C Anil, Neelkamal Kapoor
DOI:10.4103/JOC.JOC_89_20  
Background: The unanimous method of screening cervical cancer is a cervical smear stained with Papanicolaou stain. However, in spite of the various modifications, the staining procedure takes 20 min and uses substantial amount of alcohol which is highly priced. The aim of the study was to assess and analyze the quality of staining of cervical smears stained with Rapid Economical Acetic acid Papanicolaou (REAP) as compared to conventional pap stain in order to establish REAP as an alternative to conventional pap stain. Methods and Material: In this prospective study, a total of two smears each were collected from 50 females who visited the gynecology outpatient department. One of the smears was stained with conventional pap and the other with REAP. The conventional pap and REAP smears were evaluated and compared for the quality of staining. Results: The cervical smears stained with REAP showed optimal cytoplasmic and nuclear staining in 86% and 90% cases, respectively. The cytological findings and diagnosis of REAP stained smears correlated with their corresponding smears stained with conventional pap in 96% of cases. The turnaround time and cost per smear was much low for REAP as compared to conventional pap stain. Conclusion: The present study was able to establish REAP as an appropriate alternative to conventional pap stain. The staining by REAP was comparable to conventional pap stain.
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Molecular testing for BRAFV600E and RAS mutations from cytoscrapes of thyroid fine needle aspirates: A single-center pilot study p. 174
Ojas Gupta, Upasana Gautam, Muralidaran Chandrasekhar, Arvind Rajwanshi, Bishan Dass Radotra, Roshan Verma, Radhika Srinivasan
DOI:10.4103/JOC.JOC_45_20  
Context and Aim: Molecular testing of thyroid FNA has been advocated in the indeterminate categories of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) 2018. The utility of cytoscrapes of thyroid FNA samples for BRAF V600E and RAS mutations was evaluated in this pilot study. Methods and Materials: Thyroid FNA samples between 2015 and 2018 from TBSRTC categories 3–6 were included. DNA was extracted from one to two representative smears (cytoscrape). Real-time PCR for BRAF V600E and RAS(KRAS, NRAS, and HRAS) gene mutations was performed. Histopathology correlation was available in 44 cases. Statistical Methods: Chi-square test and calculation of sensitivity, specificity, and positive/negative predictive values were performed. Results: A total of 73 thyroid FNA cases and 11 nodal metastases of papillary thyroid carcinoma (PTC) were evaluated. The DNA yield ranged from 1.9 to 666 ng/μl (mean 128 ng/μl) in 80 cases and was insufficient in four cases. Overall, mutations were seen in 45 (56.25%) cases with BRAF V600E, NRAS, HRAS, and KRAS in 21 (46.7%), 19 (42.2%), 4, and 1 cases, respectively. BRAF V600E mutation was seen in PTC (11/18, 61%), nodal PTC metastases (5/10, 50%), and occasionally in TBSRTC category 3 (1/18, 5.5%). NRAS mutations were seen across all categories and were maximum in the AUS/FLUS group (6/18, 33%). BRAF V600E /RAS testing had an overall sensitivity, specificity, and positive and negative predictive values of 61.7%, 80%, 91.3%, and 38%, respectively, for the detection of malignancy. In indeterminate thyroid nodules, the sensitivity, specificity, PPV, and NPV were 56.2%, 80%, 81.8%, and 53.3%, respectively. Conclusion:BRAF V600E/RAS mutation testing from cytoscrapes are useful as a rule-in test for indeterminate thyroid nodules and provide molecular confirmation in nodal metastases of PTC.
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Wuchereria bancrofti and cytology: A retrospective analysis of 110 cases from an endemic area p. 182
Dev Prasoon, Parimal Agrawal
DOI:10.4103/JOC.JOC_59_20  
Background: Wuchereriasis is a significant cause of chronic morbidity. It can affect any organ/tissue in the body. Fine-needle aspiration cytology (FNAC) is an easy method for its detection. A comprehensive analysis of the various facets involved has not been discussed in detail in any publication. Materials and Methods: A twenty-six year (February 1994 to January 2020) retrospective audit of all patients who were cytologically diagnosed with wuchereriasis was performed. Data regarding age, sex, organ/tissue involved, and presence of co-existing disease were noted. Hematoxylin and eosin (H and E) and May-Grünwald-Giemsa (MGG) stained slides were screened for microfilaria, adult worm, larval forms, microfilaria ghosts, epithelioid cell granuloma, and eosinophils. Results: Audit yielded 19,323 cases of which 110 had wuchereriasis giving an incidence of 0.57%. The 11–30 year age group accounted for 41.8% cases. Male: female ratio was 1.04:1. Duration of disease at presentation ranged from 3 days to 24 years. Lymph node was the commonest site involved (40%), followed by soft tissue (23.6%) and female breast (14.5%). Highest parasitic load was encountered in female breast aspirates. Microfilaria bancrofti was seen in 105 (95.4%) cases. In the five cases where microfilaria bancrofti was not encountered, diagnosis was established by the presence of adult gravid female worm (2 cases), coiled larvae (2 cases), and both adult gravid female worm and coiled larvae (1 case). Microfilaria ghosts were seen in 18.2% cases. Coexisting benign and malignant diseases were encountered in 17.3% and 13.6% cases, respectively. Conclusion: FNAC provides a simple and inexpensive means of detecting wuchereriasis and is preferred over histopathology. All stages of development of this nematode in human beings are identified in cytology. Microfilaria ghost is a useful clue in screening. The presence of granuloma and eosinophilic infiltrate indicates tissue reaction only. Patients with asymptomatic microfilaraemia should be reported in cytology as they merit treatment.
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The genotoxic and cytotoxic effects of CT scan on buccal epithelial cells p. 189
Santosh Palla, Vishwanath Rangdhol, AN Uma, Santha A Devy, Vandana Shekar
DOI:10.4103/JOC.JOC_120_19  
Background: Diagnostic radiation is reported to cause significant damage in buccal cells, while the same effects after natural cell turn over cycle were not checked for in previous studies. The buccal cells were studied in patients exposed to computed tomography (CT) scans for evaluating the cells with micronuclei and cytotoxic changes, namely, pyknotic cells, karyorrhectic cells and karyolytic cells. The pre-exposure counts were compared with postexposure counts on 10 and 20 days corresponding to first and second cell turnover cycles. Aim: The aim of this study is to estimate the counts of micronucleus and cytotoxic changes in buccal cells post-exposure to CT scans and report on variance of the same with first and second buccal cell turnover cycles. Materials and Methods: This is an observational study, wherein the buccal smears of patients undergoing CT scans were made before and after CT scan exposures as needed. Papanicolaou (PAP) staining and analysis were performed as per standard criteria for micronuclear and cytotoxic changes, respectively. Statistical test used was paired t-tests. Results: The micronuclear counts revealed 0.4% positive cells before exposure and 1.4% positive cells post 10 days and 20 days of exposure were significant (P < 0.005). The cytotoxic changes showed around 2.5% positive cells before and 5.7% positive cells 10 days after CT exposure (P < 0.005). The cytotoxic cell values from baseline to 20th day were not significant (P < 0.25). Conclusion: CT scans have caused genotoxic effects notable after two cell turnover cycles but the cytotoxic changes have significantly decreased naturally after 2nd cell turnover as per our study.
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Correlation between thyroid imaging reporting and data system and bethesda system of reporting of thyroid cytopathology of thyroid nodule: A single center experience p. 193
Ananya Biswas, Keya Basu, Suparna De, Subhrajyoti Karmakar, Debanu De, Moumita Sengupta, Sujoy Ghosh
DOI:10.4103/JOC.JOC_57_19  
Background: The incidence of thyroid cancer has been increasing worldwide. Thyroid imaging reporting and data system (TIRADS) has been proposed for risk stratification of thyroid nodules to improve categorical management. Fine needle aspiration cytology based on Bethesda system for reporting of thyroid cytopathology (BSRTC) plays a fundamental role in the evaluation of thyroid nodule microscopically. Both the systems, the TIRADS and the latest revised BSRTC 2017, are widely recommended and practiced all over the world, but the correlation between the two systems has not been established. Aims and Objectives: This study was conducted to assess the risk of malignancy (ROM) in the intermediate Bethesda categories of thyroid lesions and their correlation with the corresponding TIRADS categories. Materials and Method: It was a prospective cross-sectional study over 1 year including 69 patients aged 18 years or older having solitary thyroid nodules. All cases were triaged using both TIRADS and BSRTC 2017 and the diagnostic performances were compared with subsequent paraffin sections to evaluate ROM. Correlation between TIRADS and BSRTC systems was expressed as kappa value. Result: Good concordance was observed between TIRADS and BSRTC systems in the evaluation of benign thyroid nodule lesions (category 2-II). There was discordance in follicular lesions (category 4-IV). The kappa value generated (0.411) revealed moderate agreement between the two risk stratification systems. Conclusion: Careful application of both grading systems is essential for the proper segregation of thyroid nodules to facilitate effective clinical and surgical management. However, universally acceptable protocols need to be developed to avoid the heterogeneous approach.
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Cytopathological diagnosis of herpes simplex viral mastitis: Three rare cases and a review of the literature p. 200
Ping Gong
DOI:10.4103/JOC.JOC_139_19  
Context: Virus infection has a unique morphological change in cell pathology. It is also of great significance in the diagnosis of herpes simplex mastitis. Aims: To evaluate the practicability and feasibility of cytological diagnosis of herpes simplex virus mastitis. Materials and Methods: Three cases of HSV mastitis diagnosed by cytology smears were collected. The papules were stained with Wright-Giemsa to observe the morphological characteristics of the cells. Statistical Analysis: The cytological characteristics of 3 cases were summarized and compared with the literature. Results: In the background of inflammatory cells in the smear, the cells with characteristic changes can be seen in the mass and scattered distribution. The nuclear size increased significantly, and mononuclear, binuclear, trinuclear and multinuclear nuclei appeared. The nuclei of multinuclear were crowded and mosaic. The chromatin of nucleus changed like frosted glass, and the chromatin became thicker at the edge of nucleus. Inclusion bodies were found in the nucleus, eosinophilic, with different sizes and irregular shapes. These characteristics are helpful to distinguish from other lesions. Conclusion: Scraper cytology is a diagnostic tool with simple operation, small trauma and pain, and it has important application value in the differential diagnosis of HSV infection, which deserves the attention of clinicians.
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Is subdivision of Atypia of Undetermined Significance AUS/Follicular lesion of undetermined significance cases according to detailed nuclear features vital for assessing the risk of malignancy? p. 204
Esin Kaymaz, Banu Dogan Gun, Ilhan Tasdoven, Furuzan Kokturk
DOI:10.4103/JOC.JOC_5_20  
Background: It has been known that the “atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS)” category is the most problematic category in Bethesda system due to its highly heterogeneous morphological features. Recently, it has been reported that aspirates including nuclear atypia in the AUS/FLUS category have a higher risk of malignancy. Aims: This study aimed to assess each nuclear property in aspirates with cytological atypia and also to determine the relationship with the risk of malignancy. Material and Methods: We reviewed 980 AUS/FLUS fine-needle aspirations (FNAs) performed between '2012 and 2019' at a single institution. We classified these aspirates into four groups: AUS-N (nuclear atypia), AUS-A (architectural atypia), AUS-H (Hurthle cell change), and AUS-O (other). Nuclear features were detailed sub-classified; size and shape (enlargement, elongation, and overlapping), membrane irregularities (irregular contours, grooves, pseudoinclusion), and chromatin characteristics (pale chromatin). The estimated risk of malignancy (ROM) was calculated for each subgroup. Results: Of 980 AUS/FLUS cases, follow-up histological outcome data were available for 209 cases. Among these cases, the estimated ROM was 27.8%. The ROM were 26.4%, 15.4%, and 22.5% for AUS-N, A, and H, respectively. The most common nuclear findings associated with ROM were nuclear groove (67.9%); irregular contours (76.9%) suspected pseudoinclusion (100%) and overlapping (56%) (P < 0,001). But nuclear findings such as nuclear enlargement, mild pleomorphism, or pale chromatin have a similar ROM as architectural atypia. Conclusion: Although it is known that the presence of cytological atypia in an AUS/FLUS nodule increases the estimated risk of malignancy, all nuclear properties are not equally effective in predicting malignancy risk. Emphasizing nuclear atypia details in reports of AUS case may be a more sensitive way to identify nodules with a high risk of malignancy.
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IMAGES IN CYTOPATHOLOGY Top

Hamartomas of the breast: A mimic of fibroadenoma and cytological pitfall p. 210
Akanksha Bhatia, Ravi Hari Phulware, Arvind Ahuja, Manju Kaushal
DOI:10.4103/JOC.JOC_138_20  
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Low-grade chondrosarcoma of petrous apex diagnosed by intraoperative crush smear cytology p. 212
Yookarin Khonglah, Darilin Shangpliang, Biswajit Dey, Vandana Raphael, Pranjal Phukan
DOI:10.4103/JOC.JOC_96_20  
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LETTER TO EDITOR Top

Cytological clues to the diagnosis of solid variant of papillary thyroid carcinoma p. 214
Himanshi Diwan, Nadeem Tanveer, Sushma Kashyap
DOI:10.4103/JOC.JOC_84_20  
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ERRATUM Top

Erratum: Indian academy of cytologists national guidelines for cytopathology laboratories for handling suspected and positive COVID-19 (SARS-CoV-2) patient samples p. 216

DOI:10.4103/0970-9371.300381  
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