Intraoperative consultations may pose considerable diagnostic challenge to the neuropathologist in diagnosing primary and metastatic neoplasms of the central nervous system (CNS). Cytological preparations in the form of squash, touch, imprint or smears are few of the available modalities in addition to the frozen section (FS). Although the latter is superior in providing both histologic patterns and cytomorphologic details yet smears are of vital importance when tissue available is limited (stereotactic biopsy), scrutinisation of intercellular matrix (astrocytoma versus oligodendroglioma) and evaluation of discohesive cells (lymphoma, pituitary adenoma) and in inflammatory lesions. This review is intended to emphasize the value, applicability and limitations of neurocytology aiming to expedite the intraoperative smear-based diagnoses of CNS neoplasia as per the World Health Organization (WHO) classification. We recommend that whenever possible, both smears and FS should be examined concomitantly and in a correlative manner. In the unlikely event of a mismatch between the findings on smear and FS, intraoperative diagnosis is primarily based on FS, if adequate tissue is available. However, each case must be evaluated on its own merit and in difficult cases relevant differential diagnoses should be offered to facilitate surgical decisions and optimally triage patient management.

Background: Human papillomavirus (HPV) infection as of now has been beyond doubt to be the causative agent for cervical carcinoma. Its morphological identification in Pap smear is important. Aim: To define the validity of classical and non-classical cellular changes indicative of low-grade squamous intraepithelial lesion (SIL) encompassing HPV infection in relation to positivity for 'high risk' HPV16 as well as for 'low risk' HPV6/11. Materials and Methods : A total of 3000 Papanicolaou smears were screened, of which 150 were reported as low grade-SIL encompassing HPV infection (LSIL-HPV). Subsequently cervical scrapes from these 150 subjects, along with equal number of normal women as controls, were collected and processed for HPV deoxy-ribonucleic acid testing by polymerase chain reaction (PCR). Results: On the basis of cytomorphological characteristics in Pap smears, HPV infection were categorized into the following two groups: Classical (koilocytic) changes (CC) encountered in 30 women and non-classical changes (NCC) encountered in 120 women. It was observed that 21 (70%) CC and 46 (38.3%) NCC of HPV infection were positive for HR-HPV16; however only 12 cases (10%) of NCC and two cases (6.6%) of CC were positive for LR-HPV 6/11. Majority (41.7%) of HPV positive cases were reported in the age group of 25 to 30 years and HPV positivity decreased with the increasing age. Conclusion: Classical cellular changes are not the only diagnostic features for HPV infection in Pap smear, non-classical diagnostic features also support the diagnosis of HPV infection and may be positive for HR-HPV16.

Objective: In the present study, oral brush cytology of premalignant and malignant lesions was performed using tooth brush. The cytopathological diagnosis of brush cytology was compared with that of punch biopsy. The reliability of oral brush cytology using tooth brush was assessed in terms of sensitivity and specificity. Materials and Methods: A total of 67 patients, 32 premalignant lesions and other 35 frank oral carcinomas, were included in the study. All patients underwent oral brush cytology using a toothbrush followed by punch biopsy. Sensitivity, specificity, positive and negative predictive values were calculated. Cytopathology and histopathology of premalignant and malignant lesions were compared using Mann-Whitney U test. Inter- and intra-examiner reliability was calculated using Rank-correlation coefficient. Results: Two in premalignant group and five in malignant group were marked insufficient. 18% of cases were false negatives. The sensitivity, specificity, positive predictive value and negative predictive value were 77%, 100%, 100% and 38%, respectively. Statistical analysis showed P>0.05, suggesting that there is no significant difference between histopathology and brush cytology in assessing both premalignant and malignant lesions. Inter- and intra-examiner reliability were 99.22% and 99.77%, respectively. Conclusion: Brush cytology using a tooth brush is reliable and can be easily performed with less cost and discomfort to the patient. It is useful in those situations when a patient refuses to have a biopsy performed or when medically compromised patients would be exposed to unnecessary surgical risks. It can be used for screening for suspicious oral lesions, and may have applications in resource-challenged areas.

Background: Cancer of the cervix has been considered as one of the preventable cancers. This study is the first published research addressing the screening of cancer of the cervix in the eastern region of Saudi Arabia. Aim: This study aims to detect the prevalence of abnormal epithelial changes and its types in the eastern region of Saudi Arabia. Settings and Study Design: A retrospective study was designed to evaluate all previously conducted cervical smears examined at a secondary care maternity hospital in Saudi Arabia, during the period from 2003 to 2010. During this period, a total of 1171 smears were reported. Materials and Methods: We analyzed the records of all patients who had undergone Papanicolaou (Pap) smear during this period. After data collection, all cases were recorded as per Bethesda nomenclature. Results: A total of 624 (53.3%) abnormal Pap smears were found, with only 58 cases reported to have squamous intraepithelial lesions (SIL). They represented 4.95% of total taken smears. A majority of the SIL diagnoses in our population were ASCUS, representing 60% of SIL cases. The prevalence of squamous cervical carcinoma was 0.34%. Conclusion: The study has shown a relatively high prevalence of epithelial abnormalities in cervical smears in the studied population. The squamous cell carcinoma represented a higher than the overall prevalence compared to World Health Organization (WHO) factsheets about Saudi Arabia. The mean age of epithelial abnormalities and squamous cell carcinoma was in the reproductive years.

Background: The evaluation and management of various hepatic lesions is a common clinical problem and their appropriate clinical management depends on accurate diagnoses. Aims: To study the cytomorphological features of distinctive non-neoplastic and neoplastic lesions of the liver and to evaluate the sensitivity, specificity and diagnostic accuracy of ultrasonography (USG)-guided fine needle aspiration cytology (FNAC) in the diagnosis of liver diseases. Materials and Methods: Seventy - two patients with evidence of liver diseases underwent USG-guided, percutaneous FNAC. Cytomorphological diagnoses were correlated with clinical, biochemical and radiological findings, histopathological diagnoses and follow-up information. Results: The age of the patients ranged from eight months to 90 years with 48 males (66.67%) and 24 females (33.33%). Of the 72 cases, the cytological diagnosis was rendered in 71 patients and smears were inadequate for interpretation in one case. Neoplastic lesions (68.06%) were more common than non-neoplastic lesions (30.56%). The majority of the neoplastic lesions were hepatocellular carcinomas (36.12%) followed by metastatic adenocarcinomas (19.45%). Among non-neoplastic lesions, cirrhosis was the commonest lesion (8.34%). The overall diagnostic accuracy of FNAC was 97.82% with a sensitivity and specificity of 96.87 and 100% respectively. Conclusion: USG-guided FNAC of the liver is a safe, simple, cost-effective and accurate method for cytological diagnosis of hepatic diffuse, focal/nodular and cystic lesions with good sensitivity and specificity.

Background: Current guidance recommends the use of fine needle aspiration cytology (FNAC) as an essential investigation in patients presenting with a thyroid lump. Current literature suggests that the sensitivity of FNAC in thyroid nodules ranges between 80-90%. However, only very few studies have looked specifically at the sensitivity of FNAC in solely thyroid cancer patients. Aims: The aim of our study was to investigate the value of FNAC as a first-line investigation in patients with thyroid cancer. We aimed specifically to assess the sensitivity of FNAC within this group. Materials and Methods: Patients diagnosed with thyroid cancer between 2000-08 were identified from a local histopathology database. Sixty-seven case notes were retrieved, retrospectively reviewed and analyzed. Analysis included results of FNAC, ultrasound scanning and final histopathological diagnosis. Results: Analysis of the 56 patients who underwent FNAC revealed that a cytological grading of thy3 or greater was only given to 31 cases (55.3%). Conclusion: In this study, FNAC findings of thy3 or greater were reported only in 55.3% of proven thyroid cancer cases. This study highlights the greater diagnostic difficulties of thyroid cancer compared to other thyroid nodules. Our findings suggest that clinicians must interpret the results of this initial investigation with caution and consider the routine use of ultrasound scanning to help guide FNAC.

Background: Cytological examination of effusions helps to differentiate between benign and malignant effusions, but fails a definitive diagnosis in a number of cases. The main problem here is to distinguish reactive mesothelial cells from neoplastic cells. Aim: In the present study, we used argyrophilic nucleolar organizer region (AgNOR) staining for diagnosis of benign and malignant effusions. Materials and Methods : In this study, 100 cases of effusion samples were taken and centrifuged. Four smears were prepared from sediment, one each for Leishman, hematoxylin and eosin (H and E) staining and two for AgNOR staining. AgNORs were counted as black dots in the nuclei of all abnormal cells using x100 oil immersion objective. Their dispersion and shape was compared in benign, malignant and atypical cases. Results: Out of 50 pleural effusion samples, 29 were benign, 10 were malignant and 11 atypical. Among the 47 peritoneal effusion samples, 27 were benign, 16 were malignant and 4 atypical. Out of three cases of pericardial effusion samples, one was benign and two were malignant. All effusions were subjected to AgNOR staining. The benign group consisted of cells showing 1 to 2 dots of regular size and shape. In malignant group, 3 to 5 dots of variable size, shape and irregular contours were observed per cell. In atypical group, the reactive mesothelial cells showed 1 to 2 dots, malignant cells showed 3 to 4 irregular dots. Thus, a differentiation was noted between activated mesothelial cells and malignant cells, which was not possible in Leishman and H and E-stained smears alone. Conclusion : Therefore, AgNOR can be branded as an extremely useful additional diagnostic tool for cytodiagnosis of effusions.

Background: Secretions are seen in a range of breast cancer that includes invasive ductal carcinoma, mucinous carcinoma and secretory carcinoma. Evaluation of the quantity and location of secretions and the contours of the cell clusters complement cell morphology could improve diagnostic cytopathological criteria. Aim: To identify the range of breast carcinomas with secretions on fine-needle aspiration. Materials and Methods: A retrospective study of 160 patients with breast carcinoma was carried out. The tumors were typed by evaluating the quantity and location of secretions, cellularity and nuclear grade. Results: Secretions were seen in 16 of 160 breast carcinomas. Eleven were invasive ductal carcinoma (IDC), three were mucinous and two were secretory carcinomas. In IDC, minimal intracytoplasmic secretions were seen in 10, nuclear grades of 2 and 3 in 9, cell clusters with irregular margins in 6, and necrosis in 4. All mucinous and secretory carcinomas were nuclear grade 1. Extensive extracellular secretions and cell clusters with rounded contours were seen in mucinous carcinomas. In secretory carcinomas, the secretions were predominantly intracellular; stringy vasculature was a unique feature. Conclusion: Secretions in breast cancer are seen in a range of lesions that include IDC, mucinous, and secretory carcinomas. The quantity and location of secretions in breast cancer offer clues to differentiating these.

Adenoid cystic carcinoma (ACC) of the lacrimal gland is a rarely encountered orbital tumor. It invades intracranially more frequently than carcinomas of other glands in the head and neck. A 61-year-old man underwent right orbital exenteration for a tumor in the supraorbital region. He had lost all records and presented to us with a diffuse swelling in the right forehead, six years later. Fine-needle aspiration cytology of the right frontal swelling revealed monomorphic population of small, slightly atypical cells, arranged in multilayered groups with abundant fine intercellular metachromatic substance between cell groups. There were hyaline globules of varying size with attached tumor cells. Cytological diagnosis of metastatic intracranial ACC with a lacrimal gland primary was suggested. Biopsy of the swelling confirmed our cytological diagnosis of ACC with perineural, vascular and lymphatic invasion. Thus, the authors report this case of intracranial metastasis of ACC of the lacrimal gland to remind neurosurgeons planning intervention that this disease shows a tendency to invade intracranially.

Basal-cell adenoma and basal-cell adenocarcinoma of the salivary gland are rare tumors. Fine-needle aspiration cytology of these tumors, particularly those of basal-cell adenocarcinoma, has rarely been described in the literature. In this report, we describe the clinical, cytomorphologic and histopathologic features of basal cell adenocarcinoma in a 48-year-old male patient. Fine-needle aspiration specimen showed abundant cohesive groups of basaloid cells revealing focal anisonucleosis and nuclear atypia. The tumor cells also showed rosette-like arrangement around central eosinophilic globule. Pertinent literature is reviewed and differential diagnosis are discussed.

Adult granulosa cell tumor is often a hormonally active stromal cell neoplasm of the ovary with malignant potential. Intra-operative pathological assessment is a valuable tool in guiding optimal surgical treatment in patients. Of the various intra-operative cytological diagnostic modalities, scrape smear cytology is an effective, economical, simple, fast and reliable method with results comparable with frozen section diagnosis. We describe a case of adult granulosa cell tumor in a 30-years-old lady diagnosed on intra-operative scrape cytology, and further reconfirmed on frozen section and histopathology.

Hashimoto's thyroiditis is the second most common thyroid lesion next to goiter diagnosed on fine needle aspiration cytology (FNAC). It is also an important cause for hypothyroidism. FNAC plays a significant role in the diagnosis of thyroid lesions due to its simplicity and low cost. It can accurately diagnose Hashimoto's thyroidits in most patients. However, a small percentage of cases may be missed due to the inherent limitations of this procedure and the varied cytomorphology of this lesion. Therefore thorough cytological evaluation and an integrated approach are necessary to pick up correct diagnosis and to avoid unnecessary surgery. We present a 56-year-old female with solitary thyroid nodule diagnosed as Hurthle cell neoplasm on FNAC, but subsequent histopathological diagnosis following resection revealed Hashimoto's thyroiditis with marked Hurthle cell change.

Primary (spontaneous) umbilical endometriosis is very rare with an estimated incidence of 0.5-1% of all patients with endometrial ectopia. Endometriosis is a common gynecological condition, the pelvis being the most common site of the disease. Extrapelvic site is less common and even more difficult to diagnose due to the extreme variability in presentation. A 38-year-old woman presented with a blackish nodule over the umbilicus of 3 years duration. Fine needle aspiration cytology of the lesion showed cells in clusters and sheets with background of scant stromal fragment, hemosiderin laden macrophages and RBCs, leading to a suggestion of umbilical endometriosis. Histopathological examination of the excised lesion confirmed the same.

Juvenile xanthogranuloma (JXG) is a rare cutaneous lesion with paucity of literature on its cytological features. We report one such case which on fine-needle aspiration cytology yielded a mixed population of foamy histiocytes, multinucleated giant cells and variable admixture of lymphocytes and eosinophils causing diagnostic dilemma with other differentials, especially Langerhans cell histiocytosis. However, clinical correlation followed by histopathology confirmed the diagnosis. Hence, JXG has characteristic and diagnostic cytologic features.

Central neurocytomas (CNs) are uncommon tumors of the central nervous system. These tumors have a predilection for the lateral ventricles of young adults and are known to display characteristic neuroimaging and histomorphologic features. Typically, CNs are associated with a favorable outcome, although cases with more aggressive clinical course with recurrences are not unknown. Most descriptions of this tumor are available in the form of isolated histopathology-based case reports and small series. Cytology-based publications of CN are rare. Here, we report a case of CN in a 22-year-old girl. Intra-operative squash cytology and subsequent histopathology of the tumor simulated an oligodendroglioma and a clear cell ependydoma. Final confirmation was obtained on immunohistochemistry. This paper discusses the salient cytological, histomorphological and immunohistochemical features of CN that are useful in distinguishing from its mimickers.

Parathyroid carcinoma is a very rare cause of primary hyperparathyroidism. Pre-operative diagnosis remains a challenge. We report a case referred for a suspicious goiter with a poor general condition associated with hypercalcemia. Cytological findings attributed it to a possible parathyroid neoplasm that must be considered in the differential diagnosis of a nodular thyroid mass by the cytopathologist. Serum parathormone levels were correlated and the patient underwent surgery. Histopathology confirmed the diagnosis of parathyroid carcinoma. There can be a major pitfall, as it may appear indistinguishable from a benign adenoma.

Small cell lung carcinoma represents a group of highly malignant tumors giving rise to early and widespread metastasis at the time of diagnosis. However, the pancreas is a relatively infrequent site of metastasis by this neoplasm, and there are only occasional reports on its fine needle aspiration (FNA) cytology diagnosis. A 66-year-old man presented with extensive mediastinal lymphadenopathy and a mass in the pancreatic tail. Ultrasound-guided FNA smears from the pancreatic mass contained small, round tumor cells with extensive nuclear molding. The cytodiagnosis was metastatic small cell carcinoma. Immunocytochemical staining showed that a variable number of neoplastic cell were positive for cytokeratin, chromogranin A, neurone-specific enolase and synaptophysin but negative for leukocyte common antigen. The trans-bronchial needle aspiration was non-diagnostic, but biopsy was suspicious of a small cell carcinoma. This case represents a rare metastatic lesion in the pancreas from small cell lung carcinoma, diagnosed by FNA cytology.

Anaplastic lymphoma kinase protein (ALK)-negative anaplastic large cell lymphoma (ALCL) has a vast morphologic spectrum and may mimic many other types of malignancies both cytologically and histologically. There are only a few published case reports/series describing the cytomorphologic features of ALCL on fine-needle aspiration (FNA) biopsy specimens. We describe a case of ALK-negative ALCL mimicking a high-grade soft tissue sarcoma of the thigh in a 62-year-old man. The characteristic morphologic findings on FNA and core biopsy along with the immunophenotypic profile are described and reviewed. The diagnosis of ALCL on FNA biopsy may be difficult, but can be done successfully with the use of ancillary tests. Therefore, it must be considered in the differential diagnosis of lesions with pleomorphism, anaplasia, and wreath-like or horseshoe-shaped nuclei to ensure that adequate material is obtained for ancillary studies.

Nodular hidradenoma is an established entity as a skin adnexal tumor arising from eccrine sweat glands. A skin adnexal tumor located in the breast is unusual and is one of the differential diagnoses for subareolar breast nodules. With the exception of gynecomastia, other lesions of the male breast are not very common. The review of literature showed only 25 reported cases till date. The rarity of this neoplasm and failure to identify its morphologic features may lead to misdiagnosis. Being itself rare, cytological features of this lesion are hardly encountered in case reports. We report a case of an 18-year-old male who presented with a left breast lump and underwent fine needle aspiration and was diagnosed as having a benign skin adnexal tumor. Later it was confirmed by histopathology to be a nodular hidradenoma.