Upper New York State Society of Cytology,Inc.

Interesting Case 2

Submitted by: Sharon Leo, MS, CT(ASCP), CMIAC

University of Rochester Medical Center, Rochester, NY

History

A 57 year old man presented with fever and anemia. A CT scan showed a 4 x 6 cm adrenal mass. A CT-guided fine-needle aspiration biopsy was performed.

Cellular Findings

The specimen was hypercellular with single cells, stripped nuclei, and various sized sheets of cells. The sheets were either loose aggregates or tightly packed nuclei with little cytoplasm. The granular cytoplasm ranged from esosinophilic to indeterminate. Cytoplasmic borders were indistinct. The nuclei were round to oval with regular nuclear membranes. The nuclear size range is best seen on the air dry/Strong Fast stained picture. The hyperchromasia varied from slight to marked. The chromatin was finely granular with a tiny off-center nucleolus present in every nucleus. The biopsy from the iliac crest shows the "trabecular pattern" seen in neuroendocrine tumors.

Diagnosis/Discussion

Cytology - Cellular evidence suggestive but not diagnostic of origin from pheochromocytoma.

Histology- Right iliac crest, biopsy: Metastatic malignant neuroendocrine tumor. The tumor cells are positive for PGP 9.5 and LEU 7. Tumor cells are negative for synaptophysin, NSE, S-100, leukocyte common antigen, cytokeratin, vimentin, chromogranin and CD99.

Pheochromocytoma is the most common tumor occuring in the adrenal medulla and is seen in the fourth to fifth decade of life(1). Care should be taken when doing FNA on a patient suspected of having pheochromocytoma because of the potential of a hypertension crisis or hemorrhage. If a pheochromocytoma is suspected, the staff should be prepared to manage the possible crisis. The tissue for benign and malignant pheochromocytoma can be similar and not until there is a metastasis is it considered to be malignant. The malignant variant accounts for about 10% of cases and is considered aggressive with a poor prognosis(1). When a pheochromocytoma is extra-adrenal, it is called a paraganglioma, i.e., carotid body tumor.

The cellular patterns can range from a neuroendocrine-like cells to pleomorphic, anaplastic, and bizarre cells. DeMay notes that the cellular picture cannot be used to determine the benign or malignant nature of the pheochromocytoma and sometimes the less innocuous looking patterns turn out to be the malignant ones(1).

References

1. DeMay RM. The Art & Science of Cytopathology: Volume II. Aspiration Cytology. Chicago: ASCP Press, 1996,S pp 1124-1126.