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Four quadrant fine needle aspiration cytology for the detection of benign proliferative breast lesions accompanying breast carcinoma

Jayaram G, Gupta M, Lamba S

Malays J Pathol, 1993 Dec;15(2):137-42.
PMID: 8065175

Forty-eight patients with breast carcinoma were subjected to four quadrant fine needle aspiration (FNA) cytology examination of the ipsilateral and contralateral breast in an attempt to detect any accompanying benign proliferative lesion. Mastectomy of ipsilateral and open biopsy of contralateral breast provided material for histopathological study. Cytological evidence of epithelial proliferation was found in 8 (16.6%) cases which included atypical lobular hyperplasia (ALH), lobular neoplasia in-situ (LNIS), atypical ductal hyperplasia (ADH), and proliferative disease without atypia (PDWA). In lobular proliferative lesions, cytological smears showed configurations of cells that resembled filled up or expanded lobular units. The cytology was not distinctive enough to distinguish the sub-types of lobular proliferations. Likewise, the presence of ductal alterations could be suggested by cytological study but the distinction of proliferative disease without atypia (PDWA) from atypical ductal hyperplasia (ADH) was not possible on a cytological basis.
Four quadrant fine needle aspiration cytology of non-palpable benign proliferative breast lesions

Jayaram G, Lamba S, Kakar A

Malays J Pathol, 1993 Dec;15(2):131-6.
PMID: 8065174

Seventy-eight symptomatic females without palpable breast lumps were subjected to bilateral four quadrant fine needle aspiration cytology. Cytological evidence of an epithelial proliferative lesion was seen in 44 of these cases. Based on the cytological evidence of proliferation, the site for open biopsy was determined. Histopathological study of the breast biopsies in these patients showed proliferative disease without atypia (PDWA) in 40 cases, atypical ductal hyperplasia (ADH) in two, atypical lobular hyperplasia (ALH) in one and ADH with ALH in one case. Cytology was thus useful in establishing the presence of proliferative activity, commenting on the extent of proliferation, and thereby roughly mapping out the area of the breast most suitable for biopsy. On cytological grounds, it was not possible to distinguish the atypical hyperplastic lesions from the proliferative diseases without atypia.
Malignant rhabdoid tumour of the kidney: report of a case showing focal glomeruloid differentiation

Jayaram G, Looi LM

Malays J Pathol, 1994 Jun;16(1):83-7.
PMID: 16329582

A five-month-old male baby presented with an abdominal mass which was found on computerised tomography (CT) to be involving the left kidney. Nephrectomy and histopathological study showed morphological featues of a malignant rhabdoid tumour. The tumour cells stained strongly for cytokeratin and epithelial membrane antigen and less intensely for vimentin. Electron microscopy revealed concentric whorled arrays of intermediate filaments within the tumour cell cytoplasm. The child was put on post-operative chemotherapy and radiotherapy but developed bilateral lung metastases and died three months after surgery.
The value of cytology in granulomatous mastitis: a report of 16 cases from Malaysia

Yip CH, Jayaram G, Swain M

Aust N Z J Surg, 2000 Feb;70(2):103-5.
PMID: 10711470

BACKGROUND: Granulomatous mastitis is a rare condition of the breast that can mimic a carcinoma. There are characteristic histological features, the most important of which is a predominantly lobular inflammatory process. It must be differentiated from known causes of granulomatous inflammation, such as tuberculosis.
METHODS: In the present paper, the clinical and pathological features of 16 patients with granulomatous mastitis seen over a 3-year period in the University Hospital, Kuala Lumpur, are described.
RESULTS: A clinical suspicion of malignancy was present in 10 cases. One of the patients was nulliparous. One had an associated hyperprolactinaemia, while two had systemic lupus erythromatosis. One of the patients was pregnant at the time of presentation. Four patients had localized lumps excised, five were treated conservatively because the lesion was too extensive to resect, and seven patients required drainage procedures for abscess formation.
CONCLUSION: Awareness of this condition is important because it mimics a carcinoma, and surgery may not be the best treatment for recurrent disease.
Congenital esophageal stenosis: report of three cases, literature review, and a proposed classification

Ramesh JC, Ramanujam TM, Jayaram G

Pediatr Surg Int, 2001 Mar;17(2-3):188-92.
PMID: 11315285

The aim of this paper is to report three cases of congenital esophageal stenosis (CES) of different anatomical varieties: (1) stenosis due to tracheobronchial remnants (TBR) involving the lower third of the esophagus; (2) fibromuscular stenosis (FMS) of the middle third; and (3) a membranous diaphragm (MD) involving the lower third. The first two patients were treated by segmental resection of the esophagus and end-to-end anastomosis with dramatic relief of symptoms. The third responded to dilatation. CES is a rare lesion, and about 500 cases are reported in the literature. CES due to TBR and fibromuscular hypertrophy is considered a segmental stenosis, as it involves a length of the esophageal wall, whereas the MD consists of mucosal folds and does not involve its muscular layer. The clinical presentation is varied, and a high index of suspicion is essential to arrive at an early diagnosis. Management depends on the type and severity of the stenosis. Stenosis due to TBR requires segmental resection. FMS may respond to dilatation, but severe degrees of stenosis require segmental excision. MDs usually respond to dilatation or may require endoscopic excision. Segmental stenosis can occur as an isolated lesion or in association with esophageal atresia or stenosis due to a MD. Based on this observation, a classification of CES is proposed.
Duplication of the rectum: report of four cases and review of the literature

Rajah S, Ramanujam TM, Anas SR, Jayaram G, Baskaran P, Ganesan J, et al.

Pediatr Surg Int, 1998 Jul;13(5-6):373-6.
PMID: 9639621

Rectal duplications are rare anomalies. Recently, we observed four cases of rectal duplication, each presenting with different clinical features including chronic constipation, a prolapsing rectal "polyp, " a "growth" from the vulva, and acute retention of urine. The variety of clinical presentations may lead to delay in diagnosis and multiple operations.
Fulltext Bilateral Carotid Body Tumours

Amran, A.R., Jayaram, G., Kumar, G.

International Medical Journal Malaysia, 2006;5(1):1-6.
MyJurnal

Paragangliomas are slow growing hypervascular tumour arising from neural crest cell derivatives throughout the body. In the head and neck region, the major paraganglial cells are located at the carotid bifurcation (carotid body), along the ganglia of the vagus nerve and along the nerves supplying the middle ear and jugular bulb. Less common locations include the larynx, orbit, nose and the aortic arch. Carotid body tumours are very rare neoplasms constituting less than 0.5% of all tumours. The true nature of the tumour is established at the time of attempted biopsy or surgical resection, sometimes with disastrous consequences. Only a few of the more than 500 cases reported in the literature have been studied and diagnosed preoperatively. These tumours must be considered in the evaluation of any lateral neck mass, even one located far from the carotid bifurcation. We report a case of bilateral carotid body tumours detected using 16-slice MDHCT in a patient who presented with pulsatile neck swelling for two years. This tumour is rarely malignant; however it produces serious problems by its progressive enlargement and impairment of adjacent structures in the neck. The treatment of choice is surgical resection; preferably to excise this lesion when it is small, because large, very vascular tumours are intimately attached to the carotid vessels and make surgical resection more hazardous. Pre-operative embolization can be performed in large tumours, as to facilitates surgery and reduce complication. In most of the cases, there is strong attachment of the tumour to the carotid arteries. When this is the situation, removal of the tumour means complete excision of both great arteries as well, and the mortality rate is 40 to 45 %. When surgical removal is not feasible, radiotherapy may help to control the tumour growth, although the results have not been encouraging. As it is very slow growing tumour with the growth rate of less than 5 mm per year tumours in old patients with significant risk factors for surgical intervention can be managed by observation alone.
Interdigitating dendritic reticulum cell sarcoma: cytologic, histologic and immunocytochemical features

Jayaram G, Mun KS, Elsayed EM, Sangkar JV

Diagn Cytopathol, 2005 Jul;33(1):43-8.
PMID: 15945093

Tumors of dendritic reticulum cells are rare neoplasms that exhibit significant morphologic overlap with other malignancies. Fine-needle aspiration cytologic appearances of this neoplasm are not well understood. A 33-yr-old woman presented with a rapidly growing nodular mass in the right upper cervical region and right-sided ptosis. Fine-needle aspiration cytology of the mass showed dissociated as well as clustered, large, polygonal cells that showed high nuclear-cytoplasmic ratio. Nuclei were round, oval, or irregular in shape. Large and small blastoid forms with prominent nucleoli and chromatin clumping as well as binucleated cells and cells with lobulated nuclei were seen. Numerous mitoses were observed. The tumor cells expressed focal immunocytochemical reactivity to CD45 and CD68, but were negative for CD2, CD3, CD4, CD8, CD20, CD30, CD45RO, epithelial membrane antigen (EMA), cytokeratin, and HMB45. Histologic sections of the biopsy from the growth showed nodal tissue effaced by a tumor composed of large, pleomorphic neoplastic cells with some binucleate and multinucleate forms resembling Reed-Sternberg cells. The intervening stroma contained numerous small lymphocytes. Tumor cells expressed vimentin, S-100 protein, CD68, and MAC387, but were negative for LCA, CD1a, CD3, CD15, CD20, CD21, CD23, CD30, CD35, carcino-embryonic antigen, HMB45, cytokeratin AE1/3, EMA, myeloperoxidase, lysozyme, smooth-muscle actin, and desmin. The combined histologic and immunohistologic features suggested a histiocytic/dendritic reticulum cell neoplasm and a diagnosis of interdigitating dendritic reticulum cell sarcoma was made.
Cytopathology in malaysia

Jayaram G, Yahya H

Diagn Cytopathol, 2002 Nov;27(5):322-4.
PMID: 12412003
Fine-needle aspiration cytology of phyllodes tumors

Jayaram G, Sthaneshwar P

Diagn Cytopathol, 2002 Apr;26(4):222-7.
PMID: 11933267

Breast lesions with a significant spindle cell or mesenchymal component are not commonly encountered in fine-needle aspiration (FNA) cytologic material and include a heterologous variety of benign and malignant conditions, with phyllodes tumors (PTs) being the foremost differential diagnostic consideration. This study comprises 28 tumors diagnosed histologically as PT in which FNAC material was available for review. Histological sections and cytological smears from these cases were retrieved and subjected to detailed morphological review. Cytological parameters assessed included ratio of stroma to epithelium, pattern characteristics and cytological characteristics of the stromal, and epithelial components and the background cells. Large and hypercellular stroma fragments, dissociated spindle and plump stromal cells, often accompanied by large, folded sheets of epithelium were cytological features that characterized PT. Smears from malignant PT showed predominantly or solely mesenchymal components. FNAC was a highly reliable procedure for the diagnosis of PT, giving an accuracy rate of 92.8%.
Cytology of columnar-cell variant of papillary thyroid carcinoma

Jayaram G

Diagn Cytopathol, 2000 Apr;22(4):227-9.
PMID: 10787142

Columnar cell variant of papillary carcinoma (CCV-PC) thyroid is a rare and aggressive tumor composed of tall columnar cells that form papillae, glands and solid structures. This paper describes fine needle aspiration (FNA) cytologic features in a case of CCV-PC occurring in the right thyroid lobe of a 27-year-old female. Smears showed tall columnar cells in monolayered, three-dimensional, acinar and occasional papillary clusters. Nuclei were oval or elongated and monomorphic. Nuclear pseudostratification, resembling that seen in respiratory epithelial cells, was present in some of the cell clusters. Occasional cells showed squamous or Hurthle cell metaplasia. Nuclear grooves and intranuclear cytoplasmic inclusions were not seen. Sections of the right lobectomy specimen showed an well-encapsulated CCV-PC with capsular and vascular permeation. Tall cell variant of papillary carcinoma (TCV-PC) can be distinguished from CCV-PC by the oxyphilia of the tumor cells and the absence of nuclear pseudostratification. Colorectal and endometrial adenocarcinomas metastatic to the thyroid may be difficult to distinguish from CCV-PC.
Fine-needle aspiration cytology in Kimura's disease

Jayaram G, Peh KB

Diagn Cytopathol, 1995 Nov;13(4):295-9.
PMID: 8599911

Three patients presenting with parotid, submandibular, and/or lymph node masses were subjected to fine-needle aspiration cytology. Smears showed dissociated and clustered endothelial cells, eosinophils, lymphocytes, and Warthin Finkeldey giant cells. In two cases a diagnosis of Kimura's disease was suggested from the FNA cytologic smears. In the third case the presence of mononucleate cells with prominent nucleoli led to a suspicion of Hodgkin's disease. Excision biopsy and histopathologic study established a diagnosis of Kimura's disease in all three cases.
Fine-needle aspiration cytology of metastatic nasopharyngeal carcinoma

Jayaram G, Swain M, Khanijow V, Jalaludin MA

Diagn Cytopathol, 1998 Sep;19(3):168-72.
PMID: 9740988 DOI: 10.1002/(sici)1097-0339(199809)19:3<168::aid-dc2>3

Over a 32-month period at the University Hospital, Kuala Lumpur, we were able to study the cytological appearance of metastatic nasopharyngeal carcinoma (NPC) in 17 cases. This comprised 14 males and three females of which 13 were Chinese, three were Malay, and one was Indian. Their ages ranged from 27 to 64 years. Histological correlation was available in all the patients in the form of nasopharyngeal biopsies, and they were classified as per the World Health Organization classification into types I, II, and III NPC. Smears from type II NPC showed good cellularity with mainly clustered and occasionally dissociated cells, with focal columnar appearance, vesicular nuclei, prominent nucleoli, and variable amounts of cytoplasm. Clusters of malignant cell closely associated with lymphoid cells and dissociation of malignant cells were more characteristic of type III NPC. FNA cytology is now applied extensively to the diagnosis of head and neck tumours and knowledge of the cytomorphology of NPC would greatly aid in pinpointing the primary of this tumour which is notorious for presenting with early nodal metastasis.
A case report of primary hyperparathyroidism with severe bony involvement and nephrolithiasis

Chan SP, Hew FL, Jayaram G, Kumar G, Chang KW, Tay A

Ann Acad Med Singap, 2001 Jan;30(1):66-70.
PMID: 11242630

INTRODUCTION: Although the majority of patients with primary hyperparathyroidism have a relatively asymptomatic benign disorder, there are patients who have a more aggressive disorder.
CLINICAL PICTURE: We report a case of primary hyperparathyroidism presenting during pregnancy complicated by antepartum haemorrhage and severe prematurity. The diagnosis was made postpartum, when her problems rapidly progressed to result in severe neuromuscular weakness, bilateral pathological hip fractures as well as nephrolithiasis.
TREATMENT: Surgical parathyroidectomy was performed. The underlying lesion was a large solitary parathyroid adenoma with cystic elements.
CONCLUSION: Primary hyperparathyroidism is not an innocuous disease and can result in severe morbidity if left untreated.
Papillary breast lesions diagnosed on cytology. Profile of 65 cases

Jayaram G, Elsayed EM, Yaccob RB

Acta Cytol., 2007 Jan-Feb;51(1):3-8.
PMID: 17328487

OBJECTIVE: To analyze the cytologic features of nipple discharge and fine needle aspiration (FNA) cytologic smears from breast lesions reported as showing papillary features and to correlate them with histopathologic features.

STUDY DESIGN: The study group consisted of FNA smears and/or nipple discharge smears from 65 breast lesions diagnosed on cytology as duct papilloma, papillary lesion, fibrocystic condition, fibroadenoma, papillary neoplasm or papillary carcinoma. Cytomorphologic features assessed included cellularity, cell pattern (clusters, papillary, 3-dimensionality, etc.) and cell characteristics (monomorphism, pleomorphism, apocrine change, plasmacytoid features). Histological material was available for review and cytohistologic correlation in all cases.

RESULTS: Forty-six specimens were FNA smears, and 16 were nipple discharge smears; in 3 cases FNA and nipple discharge cytologic smears were available for review. Cytologic study could predict the presence of a papillary pattern in all neoplasms with pure or focal papillary differentiation. There was an overlap in cytomorphologic features between papillary and nonpapillary benign lesions as well as between benign and malignant papillary neoplasms. Frank blood in the aspirate, cell dissociation and atypia, however, were more frequent in the last.

CONCLUSION: Overlap of cytologic features in nonneoplastic and neoplastic benign papillary lesions and between benign and malignant papillary neoplasms necessitates histologic evaluation in all cases diagnosed as papillary on cytology. Since 49.2% of lesions showing papillary features on cytology prove to be malignant, all cases reported as papillary on cytology should be excised urgently for histologic assessment.
Carcinosarcoma of the palate: report of a case with a diagnosis of sarcomatoid metastasis by fine needle aspiration cytology

Jayaram G, Elsayed EM

Acta Cytol., 2005 Sep-Oct;49(5):520-4.
PMID: 16334029

BACKGROUND: Carcinosarcoma (sarcomatoid carcinoma) is a rare tumor with a high predilection for the aerodigestive tract. Cytologic diagnosis of metastatic carcinosarcoma has been reported in very few cases.

CASE: An 84-year-old woman presented with a 2-cm-diameter, right cervical lymph node that was referred for fine needle aspiration cytology (FNAC). She had received radiotherapy for a palatal squamous cell carcinoma 2 years earlier. The FNAC smears had a sarcomatoid appearance. Repeat fine needle aspiration was performed, with cytologic and immunocytochemical staining. Careful consideration of the cytologic and immunophenotypic features led to an impression of carcinosarcoma. Histologic sections of the palatal biopsy that had been previously diagnosed as squamous cell carcinoma were reviewed, and a final diagnosis of carcinosarcoma was established.

CONCLUSION: Metastasis of rare lesions, such as carcinosarcoma may be confusing and difficult to diagnose on FNAC, especially when the cytologic sample shows a predominantly sarcomatoid component. The difficulty is compounded when the sarcomatoid component happens to have been overlooked on the initial histologic assessment. With representative cytologic sampling, immunocytochemical staining and review of the histologic material, the correct diagnosis was achieved in this case.
Cytologic evaluation of prognostic markers in breast carcinoma

Jayaram G, Elsayed EM

Acta Cytol., 2005 Nov-Dec;49(6):605-10.
PMID: 16450899

To type breast carcinomaon on fine needle aspiration cytology (FNAC) material and correlate the results with histologic typing, to grade breast carcinoma on FNAC material and correlate the findings with Bloom-Richardson histologic grading, and to determine the estrogen receptor (ER) status in cases of breast carcinoma by immunocytochemical (ICC) staining of FNA cytologic material and correlate the findings with ER status, as determined by immunohistochemical (IHC) staining of tissue sections.

STUDY DESIGN: Seventy-seven cases of breast carcinoma diagnosed on FNAC formed the basis of this study. Typing was done in all cases on the basis of cytologic features and grading in 62. (Fifteen cases were special types of breast carcinoma). In all cases, ER status was determined by immunostaining of cytologic smears. Results of tumor typing, grading and ER status on cytologic material were compared with the results of histologic typing, grading and immunostaining of histologic material obtained from mastectomy or wide excision specimens.

RESULTS: Tumor typing was accurate in 73 of 77 cases (94.8%). Fifteen of 18 cases that were cytologically grade 3 were confirmed on histology, while 3 proved to be grade 2. Of 40 cytologic grade 2 cases, 26 were confirmed on histology, while 14 cases were grade 3. Three of 4 cytologically grade 1 cases were confirmed on histology while 1 was grade 2. The overall accuracy for cytologic grading was 71% (44 of 62 cases). Thirty-seven of 40 ER-positive cases (92.5%) were labeled ER positive on ICC. One case was ER negative on cytology, while in 2 cases the cellularity of the cytologic smear was insufficient to assess ER expression. Thirty-seven cases were negativefor ER on IHC. Nine of these showed ER positivity on ICC, 26 were negative, and 2 had cellularity that was inadequate for assessment of ER. Sensitivity and specificity rates for ER detection on ICC were 97.4% and 74.3%, respectively.

CONCLUSION: Tumor typing, grading and evaluation of ER status on FNA C material in breast carcinomas are simple, quick and moderately reliable techniques that compare and correlate favorably with histologic typing, grading and ER status on IHC.
Leiomyosarcoma of the breast: report of a case with fine needle aspiration cytologic, histologic and immunohistochemical features

Jayaram G, Jayalakshmi P, Yip CH

Acta Cytol., 2005 Nov-Dec;49(6):656-60.
PMID: 16450908

BACKGROUND: Leiomyosarcoma of the breast is a rare neoplasm. We present a case of primary leiomyosarcoma of the breast in a middle-aged female in whom fine needle aspiration cytologic features suggested sarcoma.

CASE: A 55-year-old female presented with a rapidly growing breast lump of 1 month's duration. On examination, an ulcerating, 12 x 10 cm tumor was seen involving the lower medial and lateral quadrants of the right breast. Fine needle aspiration cytology showed variably sized, dissociated and loosely clustered polygonal, plump and spindle cells with pale blue cytoplasm and vesicular nuclei that were round, oval or irregular. Occasional giant forms and nucleolated and mitotic cells were present. A single cluster of benign ductal cells was seen. The tumor cells did not express immunocytologic reactivity to estrogen receptor protein. A cytologic diagnosis of sarcoma was given with differential diagnoses of metaplastic carcinoma and malignant phyllodes tumor. Histologic study established the diagnosis of leiomyosarcoma. Leiomyosarcoma of the breast shows fine needle aspiration cytologic features of sarcoma, but specific tumor typing may not be possible, especially when the cytologic material is inadequate for ancillary staining required to distinguish leiomyosarcoma from metaplastic carcinoma and malignant phyllodes tumor.
Malignant teratoma of the thyroid with predominantly neuroepithelial differentiation. Fine needle aspiration cytologic, histologic and immunocytochemical features of a case

Jayaram G, Cheah PL, Yip CH

Acta Cytol., 2000 May-Jun;44(3):375-9.
PMID: 10833994

BACKGROUND: Teratoma of the thyroid in adults is extremely rare, and most are malignant. Only nine cases have been adequately documented in the English-language literature, and there are no reports detailing the fine needle aspiration (FNA) cytologic characteristics.

CASE: A 32-year-old female presented with a left-sided nodular thyroid mass with left cervical lymphadenopathy. FNA cytology of the thyroid and lymph nodes was done. The cytologic and immunocytochemical features were that of a small round cell tumor with neuroepithelial (NE) differentiation, metastasizing to the cervical nodes. Microscopic study of the thyroidectomy specimen showed a tumor showing an NE pattern with occasional islands of squamous and cuboidal epithelium, leading to a diagnosis of malignant teratoma.

CONCLUSION: Knowledge of FNA cytologic features of rare but highly malignant lesions like thyroid teratomas allow early recognition so that suitable and possibly aggressive treatment protocols can be adopted in the hope of prolonging survival.
Fine needle aspiration cytology of lymph nodes in HIV-infected individuals

Jayaram G, Chew MT

Acta Cytol., 2000 Nov-Dec;44(6):960-6.
PMID: 11127753

OBJECTIVE: To assess the role of fine needle aspiration cytology (FNAC) in lymphadenopathy in human immunodeficiency virus-infected individuals (HIVII).

STUDY DESIGN: Thirty-nine HIVII presenting with lymphadenopathy at University Hospital, Kuala Lumpur, were subjected to FNAC. Cytologic smears were routinely stained with May-Grünwald-Giemsa stain. Special stains and immunostains were used when necessary.

RESULTS: In nine cases, the cytologic appearance was compatible with HIV type A and in one case with HIV type C lymphadenopathy. In 21 cases, acid-fast bacilli (AFB) were demonstrated in the cytologic smears, enabling a diagnosis of mycobacterial lymphadenitis. In one of these cases there was a concomitant infection with Penicillium marneffei that was overlooked on initial cytologic examination. The cause of granulomatous lymphadenitis could not be ascertained in one case, where neither AFB nor any other organisms were demonstrable. Two cases of histoplasma and one of cryptococcal lymphadenitis were diagnosed, as was one high grade non-Hodgkin's lymphoma that could be immunophenotyped on cytologic material. In three cases the aspirates were inadequate for a cytologic diagnosis.

CONCLUSION: Lymph node FNAC is a valuable investigative modality in HIVII. Most opportunistic infections (bacterial and fungal) can be correctly identified, and high grade lymphoma can be diagnosed and phenotyped.

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