74
Correspondence
References 1. Kitchener HC. HPV primary cervical screening: time for a change. Cytopathology 2015;26:4–6. 2. Walboomers JMM, Jacobs MV, Manos MM et al. human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189:12–9. 3. Pirog EC, Lloveras B, Moljin A et al. HPV prevalence and genotypes in different histologic subtypes of cervical adenocarcinoma, a worldwide analysis of 780 cases. Mod Pathol 2014;27:1559–67. 4. Hopenhayn C, Christian A, Christian WJ et al. Prevalence of human papillomavirus subtypes in invasive cervical cancers from 7 US cancer registries before vaccination introduction. J Low Genit Tract Dis 2014;18: 182–9. 5. Wu Y, Chen Y, Li L et al. Association of high-risk HPV types and viral load with cervical cancer in China. J Clin Virol 2006;35:264–9. 6. Kang WD, Kim CH, Cho MK et al. Comparison of hybrid capture II assay with the human papillomavirus DNA chip test for the detection of high grade cervical lesions. Int J Gynecol Cancer 2009;19:924–8. 7. Moreira MAR, Longat0-Filhio A, Taromus E et al. Investigation of human papillomavirus by hybrid capture II in cervical carcinomas including 113 adenocarcinomas and related lesions. Int J Gynecol Cancer 2006;16:586–90. 8. Poljak M, Kovanda A, Kocjan BJ et al. The Abbott real Time High Risk HPV test: comparative evaluation of analytic specificity and clinical sensitivity for cervical carcinoma and CIN3 lesions with the Hybrid Capture 2 HPV DNA test. Acta Dermatovenerol Alp Pannonica Adriat 2009;18:94–103. 9. Zhao C, Li Z, Nayar R et al. Prior high-risk human papillomavirus testing and papanicolaou test results of 70 invasive cervical carcinomas diagnosed in 2012: results pf a retrospective multicenter study. Arch Pathol Lab Med 2015;139:184–8. 10. Katki HA, Kinney WK, Fetterman B et al. Cervical cancer risk for women undergoing concurrent testing for human papillomavirus and cervical cytology: a population-based study in routine clinical practice. Lancet Oncol 2011;12:663–72. 11. Ronco G, Dillner J, Efstrom KM et al. Efficacy of HPVbased screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet 2014;383:524–32. 12. Kinney W, Wright TC, Dinkelspiel HE et al. Increased cervical cancer risk associated with screening at longer intervals. Obstet Gynecol 2015;125:311–5. 13. McCredie MR, Sharples KJ, Paul C et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol 2008;9: 425–34.
14. Kinney W, Fetterman B, Poltras N, Lorey T. CIN3+ is not the right endpoint for evaluating screening algorithms, as it does refect cancer risk accurately. Gynecol Oncol 2014;133S:186.
A liver mass in a case of gastrointestinal stromal tumour of the stomach is not always a metastasis DOI:10.1111/cyt.12228
Dear Editor, Gastrointestinal stromal tumour (GIST) is a rare mesenchymal tumour of the gastrointestinal tract accounting for 0.1–0.3% of all such neoplasms.1 GISTs are believed to originate from the interstitial cells of Cajal or their precursors that regulate gut motility. Their biological behaviour is difficult to predict, ranging from clinically benign to malignant. Approximately 10–20% of patients with GIST develop other neoplasms, either synchronously or metachronously.1–3 The liver is the most common site of metastasis.4 The synchronous occurrence of GIST and hepatocellular carcinoma (HCC) is extremely uncommon and has only rarely been reported in the literature.5 Herein, we report the first such case to be diagnosed on cytology and later confirmed on histopathology and immunohistochemistry. Such cases always require meticulous diagnostic workup to differentiate them from metastatic GIST, which is the most common cause of a coexisting liver tumour. Fine needle aspiration (FNA) can prove to be useful in the diagnosis of these rare tumours. During the course of a master executive health check-up, a 62-year-old man was incidentally found to be anti-hepatitis C virus (HCV) reactive with a space-occupying lesion in the liver and a gastric mass on positron emission tomography-computed tomography (PET-CT) of the abdomen, which revealed an exophytic polypoidal multilobulated mass arising from the lesser curvature of the stomach and a solitary liver lesion in segment 4. Ultrasound (US)guided FNA was carried out from both the lesions. FNA smears from the gastric mass were moderately cellular, comprising loosely cohesive clusters of round to oval cells with mildly pleomorphic nuclei and coarsely granular chromatin against a haemorrhagic Correspondence: Dr R. Sachdev, A 803, Plot 7A, Navrattan Apartments, Sector 23, Dwarka, New Delhi 110075, India Tel.: +91-9811836806; Fax: +91-11-26182565; E-mail: [email protected] © 2015 John Wiley & Sons Ltd Cytopathology 2016, 27, 73–78
Correspondence
(a)
(a)
(b)
(b)
Figure 1. Gastric mass. (a) Ultrasound-guided fine needle aspirate showing cellular smears comprising loosely cohesive clusters of round to oval cells with mildly pleomorphic nuclei (Giemsa 9400, inset 91000). (b) Histopathology showing round to oval cells in sheets with pale eosinophilic vacuolated cytoplasm and multinucleated giant cells (haematoxylin and eosin 9400). Tumour cells are CD117 positive (inset 9400).
Figure 2. Liver space-occupying lesion. (a) Ultrasoundguided fine needle aspirate revealing polygonal cells arranged in loosely cohesive clusters with transgressing capillaries. Intranuclear inclusions are seen (Giemsa 9400). (b) Histopathology showing polygonal cells with prominent nucleoli arranged in a trabecular pattern with more than three cord cell thickness (haematoxylin and eosin 9400). Tumour cells are glypican-3 positive (inset 9400).
background (Figure 1a). A diagnosis of mesenchymal tumour suggestive of GIST was made. US-guided FNA smears obtained from the liver lesion were cellular and revealed polygonal cells arranged in loosely cohesive clusters and a trabecular pattern against a haemorrhagic background. Individual cells possessed abundant cytoplasm and central nuclei with prominent nucleoli. Transgressing capillaries and intranuclear inclusions were seen (Figure 2a). A diagnosis of HCC was suggested. The patient was scheduled for surgery and subsequently underwent a laparotomy and tumour resection. Intraoperatively, a tumour at the lesser curvature of the stomach (5.5 9 4.1 9 3.4 cm3) and a tumour in the liver (2.6 9 2.3 9 2 cm3) were detected and excised according to surgical protocols. Histopathology of the liver lesion confirmed the diagnosis of HCC (Figure 2b). The gastric lesion showed round to oval cells in sheets with pale eosinophilic and vacuolated cytoplasm. Many multinucleated giant cells were seen. Brisk mitotic activity was discernible (>5/50 per high-power field) (Figure 1b). The tumour cells were positive for CD117 (Figure 1b) and vimentin. They were negative for cytokeratin, smooth muscle actin, S100, glypican-3
and CD34. The diagnosis of GIST was confirmed on histopathology. The patient was discharged after 8 days without any surgical complications. In view of the malignant potential of GIST (high-risk category), the patient was prescribed imatinib, 400 mg once a day. The patient showed no signs of recurrent disease after 1.5 years of follow-up. Synchronous occurrence of GIST with other neoplasms has been reported in 10–20% of cases.1–3 The majority of GIST-associated tumours are gastrointestinal in origin, specifically gastric and colonic cancer.1 An extensive literature review performed by Agaimy and Wuensch6 found that lymphoma, leukaemia, carcinoma of the prostate, breast, kidney, lung and female genital tract, and carcinoid tumour were the tumour types most often seen in patients with GIST. GIST most commonly metastasizes to the liver (60%) or peritoneum,4 and may coexist with inflammatory pseudotumours of the liver, which also need to be excluded. This case is reported for its rarity and the fact that it is the first case to be diagnosed in cytology and later confirmed on histopathology and immunohistochemistry. The present case is also unique in the synchronous detection of a GIST and HCC in a healthy
© 2015 John Wiley & Sons Ltd Cytopathology 2016, 27, 73–78
75
76
Correspondence
patient as an incidental finding during a routine check-up. Detection of a hepatic tumour in a patient with GIST should not prompt the diagnosis of metastatic GIST, even though it is the most common cause of a coexisting liver tumour. FNA can prove to be useful in the diagnosis of these tumours. R. K. Goel, B. Jha, I. Mohapatra, D. Gautam, A. Rana and R. Sachdev Department of Pathology and Laboratory Medicine, Medanta, The Medicity, Gurgaon, Delhi NCR, India References 1. Pandurengan RK, Dumont AG, Araujo DM et al. Survival of patients with multiple primary malignancies: a study of 783 patients with gastrointestinal stromal tumour. Ann Oncol 2010;21:2107–11. 2. Wronski M, Ziarkiewicz-Wroblewska B, Gornicka B et al. Synchronous occurrence of gastrointestinal stromal tumours and other primary gastrointestinal neoplasms. World J Gastroenterol 2006;12:5360–2. 3. Kalender ME, Sevinc A, Kucukdurmaz Z et al. Gastric and prostate adenocarcinoma in a patient with metastatic gastrointestinal stromal tumour. Onkologie 2007;30:568–70. 4. Connolly EM, Gaffney E, Reynolds JV. Gastrointestinal stromal tumours. Br J Surg 2003;90:1178–86. 5. Jaworski R, Jastrzebski T, Swierblewski M et al. Coexistence of hepatocellular carcinoma and gastrointestinal stromal tumour: a case report. World J Gastroenterol 2006;12:665–7. 6. Agaimy A, Wuensch PH. Gastrointestinal stromal tumours in patients with other-type cancer: a mere coincidence or an etiological association? A study of 97 GIST cases. Z Gastroenterol 2005;43:1025–30.
ogy. This case is reported because of the rarity of this subtype of melanoma and its uncommon location in the great toe. A 66-year-old man presented with a painless swelling on the right great toe of 1 year’s duration. The swelling was firm, nodular, non-tender, about 2 cm in diameter and located on the dorsum just proximal to the nail bed. Magnetic resonance imaging scan of the right foot revealed a focal, multiloculated, mixed-intensity, space-occupying lesion in the soft tissues, 1.3 9 1.7 9 2.0 cm3 in size, on the dorsal aspect of the proximal–mid part of the great toe. Imaging diagnosis of a malignant lesion was rendered. FNA was carried out. The FNA smears were cellular showing tumour cells as scattered cells, sheets and fascicles (Figure 1a). The cells were oval to spindle shaped with moderate nuclear pleomorphism and, in some cells, conspicuous nucleoli (Figure 1b). Intracytoplasmic brownish-black melanin pigment, confirmed on Masson–Fontana staining, was noted in some of the tumour cells (Figure 1c). Occasional tumour giant cells were seen (Figure 1d). A few mitotic figures were observed on extensive scrutiny. A diagnosis of spindle cell tumour with the possibility of desmoplastic melanoma was suggested after ruling out other malignant spindle cell tumours, such as
(a)
(b)
(c)
(d)
Cytological diagnosis of desmoplastic malignant melanoma of the great toe DOI:10.1111/cyt.12238
Dear Editor, Desmoplastic melanoma is a rare variant of malignant melanoma with a frequent chance of misdiagnosis on fine needle aspiration (FNA) cytolCorrespondence: U. Handa, Professor, Department of Pathology, Government Medical College & Hospital, Sector 32, Chandigarh, 160030, India Tel.: +919646121600; Fax: +911722608488; E-mail: [email protected]
Figure 1. Cytological findings. (a) Loosely structured tissue fragment and scattered tumour cells [May–Gr€ unwald– Giemsa (MGG) 9200]. (b) Cluster of oval- to spindleshaped tumour cells with subtle nuclear atypia (MGG 9400). (c) Sheet of tumour cells showing intracytoplasmic brownish-black melanin pigment in some of the tumour cells (haematoxylin and eosin 9400). (d) Occasional binucleate and multinucleate tumour giant cells (MGG 9600). © 2015 John Wiley & Sons Ltd Cytopathology 2016, 27, 73–78
Correspondence
References 1. Kitchener HC. HPV primary cervical screening: time for a change. Cytopathology 2015;26:4–6. 2. Walboomers JMM, Jacobs MV, Manos MM et al. human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189:12–9. 3. Pirog EC, Lloveras B, Moljin A et al. HPV prevalence and genotypes in different histologic subtypes of cervical adenocarcinoma, a worldwide analysis of 780 cases. Mod Pathol 2014;27:1559–67. 4. Hopenhayn C, Christian A, Christian WJ et al. Prevalence of human papillomavirus subtypes in invasive cervical cancers from 7 US cancer registries before vaccination introduction. J Low Genit Tract Dis 2014;18: 182–9. 5. Wu Y, Chen Y, Li L et al. Association of high-risk HPV types and viral load with cervical cancer in China. J Clin Virol 2006;35:264–9. 6. Kang WD, Kim CH, Cho MK et al. Comparison of hybrid capture II assay with the human papillomavirus DNA chip test for the detection of high grade cervical lesions. Int J Gynecol Cancer 2009;19:924–8. 7. Moreira MAR, Longat0-Filhio A, Taromus E et al. Investigation of human papillomavirus by hybrid capture II in cervical carcinomas including 113 adenocarcinomas and related lesions. Int J Gynecol Cancer 2006;16:586–90. 8. Poljak M, Kovanda A, Kocjan BJ et al. The Abbott real Time High Risk HPV test: comparative evaluation of analytic specificity and clinical sensitivity for cervical carcinoma and CIN3 lesions with the Hybrid Capture 2 HPV DNA test. Acta Dermatovenerol Alp Pannonica Adriat 2009;18:94–103. 9. Zhao C, Li Z, Nayar R et al. Prior high-risk human papillomavirus testing and papanicolaou test results of 70 invasive cervical carcinomas diagnosed in 2012: results pf a retrospective multicenter study. Arch Pathol Lab Med 2015;139:184–8. 10. Katki HA, Kinney WK, Fetterman B et al. Cervical cancer risk for women undergoing concurrent testing for human papillomavirus and cervical cytology: a population-based study in routine clinical practice. Lancet Oncol 2011;12:663–72. 11. Ronco G, Dillner J, Efstrom KM et al. Efficacy of HPVbased screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet 2014;383:524–32. 12. Kinney W, Wright TC, Dinkelspiel HE et al. Increased cervical cancer risk associated with screening at longer intervals. Obstet Gynecol 2015;125:311–5. 13. McCredie MR, Sharples KJ, Paul C et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol 2008;9: 425–34.
14. Kinney W, Fetterman B, Poltras N, Lorey T. CIN3+ is not the right endpoint for evaluating screening algorithms, as it does refect cancer risk accurately. Gynecol Oncol 2014;133S:186.
A liver mass in a case of gastrointestinal stromal tumour of the stomach is not always a metastasis DOI:10.1111/cyt.12228
Dear Editor, Gastrointestinal stromal tumour (GIST) is a rare mesenchymal tumour of the gastrointestinal tract accounting for 0.1–0.3% of all such neoplasms.1 GISTs are believed to originate from the interstitial cells of Cajal or their precursors that regulate gut motility. Their biological behaviour is difficult to predict, ranging from clinically benign to malignant. Approximately 10–20% of patients with GIST develop other neoplasms, either synchronously or metachronously.1–3 The liver is the most common site of metastasis.4 The synchronous occurrence of GIST and hepatocellular carcinoma (HCC) is extremely uncommon and has only rarely been reported in the literature.5 Herein, we report the first such case to be diagnosed on cytology and later confirmed on histopathology and immunohistochemistry. Such cases always require meticulous diagnostic workup to differentiate them from metastatic GIST, which is the most common cause of a coexisting liver tumour. Fine needle aspiration (FNA) can prove to be useful in the diagnosis of these rare tumours. During the course of a master executive health check-up, a 62-year-old man was incidentally found to be anti-hepatitis C virus (HCV) reactive with a space-occupying lesion in the liver and a gastric mass on positron emission tomography-computed tomography (PET-CT) of the abdomen, which revealed an exophytic polypoidal multilobulated mass arising from the lesser curvature of the stomach and a solitary liver lesion in segment 4. Ultrasound (US)guided FNA was carried out from both the lesions. FNA smears from the gastric mass were moderately cellular, comprising loosely cohesive clusters of round to oval cells with mildly pleomorphic nuclei and coarsely granular chromatin against a haemorrhagic Correspondence: Dr R. Sachdev, A 803, Plot 7A, Navrattan Apartments, Sector 23, Dwarka, New Delhi 110075, India Tel.: +91-9811836806; Fax: +91-11-26182565; E-mail: [email protected] © 2015 John Wiley & Sons Ltd Cytopathology 2016, 27, 73–78
Correspondence
(a)
(a)
(b)
(b)
Figure 1. Gastric mass. (a) Ultrasound-guided fine needle aspirate showing cellular smears comprising loosely cohesive clusters of round to oval cells with mildly pleomorphic nuclei (Giemsa 9400, inset 91000). (b) Histopathology showing round to oval cells in sheets with pale eosinophilic vacuolated cytoplasm and multinucleated giant cells (haematoxylin and eosin 9400). Tumour cells are CD117 positive (inset 9400).
Figure 2. Liver space-occupying lesion. (a) Ultrasoundguided fine needle aspirate revealing polygonal cells arranged in loosely cohesive clusters with transgressing capillaries. Intranuclear inclusions are seen (Giemsa 9400). (b) Histopathology showing polygonal cells with prominent nucleoli arranged in a trabecular pattern with more than three cord cell thickness (haematoxylin and eosin 9400). Tumour cells are glypican-3 positive (inset 9400).
background (Figure 1a). A diagnosis of mesenchymal tumour suggestive of GIST was made. US-guided FNA smears obtained from the liver lesion were cellular and revealed polygonal cells arranged in loosely cohesive clusters and a trabecular pattern against a haemorrhagic background. Individual cells possessed abundant cytoplasm and central nuclei with prominent nucleoli. Transgressing capillaries and intranuclear inclusions were seen (Figure 2a). A diagnosis of HCC was suggested. The patient was scheduled for surgery and subsequently underwent a laparotomy and tumour resection. Intraoperatively, a tumour at the lesser curvature of the stomach (5.5 9 4.1 9 3.4 cm3) and a tumour in the liver (2.6 9 2.3 9 2 cm3) were detected and excised according to surgical protocols. Histopathology of the liver lesion confirmed the diagnosis of HCC (Figure 2b). The gastric lesion showed round to oval cells in sheets with pale eosinophilic and vacuolated cytoplasm. Many multinucleated giant cells were seen. Brisk mitotic activity was discernible (>5/50 per high-power field) (Figure 1b). The tumour cells were positive for CD117 (Figure 1b) and vimentin. They were negative for cytokeratin, smooth muscle actin, S100, glypican-3
and CD34. The diagnosis of GIST was confirmed on histopathology. The patient was discharged after 8 days without any surgical complications. In view of the malignant potential of GIST (high-risk category), the patient was prescribed imatinib, 400 mg once a day. The patient showed no signs of recurrent disease after 1.5 years of follow-up. Synchronous occurrence of GIST with other neoplasms has been reported in 10–20% of cases.1–3 The majority of GIST-associated tumours are gastrointestinal in origin, specifically gastric and colonic cancer.1 An extensive literature review performed by Agaimy and Wuensch6 found that lymphoma, leukaemia, carcinoma of the prostate, breast, kidney, lung and female genital tract, and carcinoid tumour were the tumour types most often seen in patients with GIST. GIST most commonly metastasizes to the liver (60%) or peritoneum,4 and may coexist with inflammatory pseudotumours of the liver, which also need to be excluded. This case is reported for its rarity and the fact that it is the first case to be diagnosed in cytology and later confirmed on histopathology and immunohistochemistry. The present case is also unique in the synchronous detection of a GIST and HCC in a healthy
© 2015 John Wiley & Sons Ltd Cytopathology 2016, 27, 73–78
75
76
Correspondence
patient as an incidental finding during a routine check-up. Detection of a hepatic tumour in a patient with GIST should not prompt the diagnosis of metastatic GIST, even though it is the most common cause of a coexisting liver tumour. FNA can prove to be useful in the diagnosis of these tumours. R. K. Goel, B. Jha, I. Mohapatra, D. Gautam, A. Rana and R. Sachdev Department of Pathology and Laboratory Medicine, Medanta, The Medicity, Gurgaon, Delhi NCR, India References 1. Pandurengan RK, Dumont AG, Araujo DM et al. Survival of patients with multiple primary malignancies: a study of 783 patients with gastrointestinal stromal tumour. Ann Oncol 2010;21:2107–11. 2. Wronski M, Ziarkiewicz-Wroblewska B, Gornicka B et al. Synchronous occurrence of gastrointestinal stromal tumours and other primary gastrointestinal neoplasms. World J Gastroenterol 2006;12:5360–2. 3. Kalender ME, Sevinc A, Kucukdurmaz Z et al. Gastric and prostate adenocarcinoma in a patient with metastatic gastrointestinal stromal tumour. Onkologie 2007;30:568–70. 4. Connolly EM, Gaffney E, Reynolds JV. Gastrointestinal stromal tumours. Br J Surg 2003;90:1178–86. 5. Jaworski R, Jastrzebski T, Swierblewski M et al. Coexistence of hepatocellular carcinoma and gastrointestinal stromal tumour: a case report. World J Gastroenterol 2006;12:665–7. 6. Agaimy A, Wuensch PH. Gastrointestinal stromal tumours in patients with other-type cancer: a mere coincidence or an etiological association? A study of 97 GIST cases. Z Gastroenterol 2005;43:1025–30.
ogy. This case is reported because of the rarity of this subtype of melanoma and its uncommon location in the great toe. A 66-year-old man presented with a painless swelling on the right great toe of 1 year’s duration. The swelling was firm, nodular, non-tender, about 2 cm in diameter and located on the dorsum just proximal to the nail bed. Magnetic resonance imaging scan of the right foot revealed a focal, multiloculated, mixed-intensity, space-occupying lesion in the soft tissues, 1.3 9 1.7 9 2.0 cm3 in size, on the dorsal aspect of the proximal–mid part of the great toe. Imaging diagnosis of a malignant lesion was rendered. FNA was carried out. The FNA smears were cellular showing tumour cells as scattered cells, sheets and fascicles (Figure 1a). The cells were oval to spindle shaped with moderate nuclear pleomorphism and, in some cells, conspicuous nucleoli (Figure 1b). Intracytoplasmic brownish-black melanin pigment, confirmed on Masson–Fontana staining, was noted in some of the tumour cells (Figure 1c). Occasional tumour giant cells were seen (Figure 1d). A few mitotic figures were observed on extensive scrutiny. A diagnosis of spindle cell tumour with the possibility of desmoplastic melanoma was suggested after ruling out other malignant spindle cell tumours, such as
(a)
(b)
(c)
(d)
Cytological diagnosis of desmoplastic malignant melanoma of the great toe DOI:10.1111/cyt.12238
Dear Editor, Desmoplastic melanoma is a rare variant of malignant melanoma with a frequent chance of misdiagnosis on fine needle aspiration (FNA) cytolCorrespondence: U. Handa, Professor, Department of Pathology, Government Medical College & Hospital, Sector 32, Chandigarh, 160030, India Tel.: +919646121600; Fax: +911722608488; E-mail: [email protected]
Figure 1. Cytological findings. (a) Loosely structured tissue fragment and scattered tumour cells [May–Gr€ unwald– Giemsa (MGG) 9200]. (b) Cluster of oval- to spindleshaped tumour cells with subtle nuclear atypia (MGG 9400). (c) Sheet of tumour cells showing intracytoplasmic brownish-black melanin pigment in some of the tumour cells (haematoxylin and eosin 9400). (d) Occasional binucleate and multinucleate tumour giant cells (MGG 9600). © 2015 John Wiley & Sons Ltd Cytopathology 2016, 27, 73–78
