Cytomorphological Study of Articular and Periarticular Cystic Lesions Dr.Sneha Saini, Dr.Madhu Sinha , Dr

International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36

Original article: Cytomorphological study of articular and periarticular cystic lesions Dr.Sneha Saini, Dr.Madhu Sinha , Dr. Natasha S. Gulati , Dr. Abhijit Das, Dr. Man Mohan Mehndiratta

1. Dr.Sneha Saini- Senior Resident, Janakpuri Superspeciality Hospital (JSSH) 2. Dr.Madhu Sinha- Specialist(Pathology), Janakpuri Superspeciality Hospital (JSSH) 3. Dr. Natasha S. Gulati- Specialist(Cytology), Janakpuri Superspeciality Hospital (JSSH) 4. Dr. Abhijit Das- Assistant Professor, Janakpuri Superspeciality Hospital (JSSH) 5. Dr. Man Mohan Mehndiratta, Director, Janakpuri Superspeciality Hospital (JSSH) Corresponding Author: Dr.Sneha Saini , Senior Resident, Janakpuri Superspeciality Hospital (JSSH)

ABSTRACT: AIMS AND OBJECTIVES:- To study cytomorphology of articular and periarticular cystic lesions and to assess the efficacy of fine needle aspiration cytology (FNAC) in diagnosis and management of articular and periarticular cystic lesions. MATERIAL AND METHODS:- Our study was a retrospective study done over a period of 2 years from Jan 2015 to Jan 2017 in Cytology section of Pathology department of our hospital. Sixteen cases including ganglion cysts, synovial cysts and popliteal cysts from different articular and periarticular sites were studied. RESULTS:- In our study out of 16 cases, there were 10 (62.5%) cases of ganglion cysts, 3 (18.7%) cases of synovial cysts and 3 (18.7%) cases of popliteal cysts. The male to female ratio (M: F) for these lesions was 1:1.6 and were predominantly found in third decade (21-30 years). CONCLUSION:- FNAC offers a great diagnostic utility in articular and periarticular cystic lesions being an OPD procedure having low cost. It is minimally invasive and helpful in rapid diagnosis. Sometimes FNAC also has therapeutic implications in such lesions. Keywords:-Articular, periarticular, ganglion cyst, synovial cyst, popliteal cyst.

INTRODUCTION: Cysts and cyst-like lesions are common finding in articular and periarticular spaces. Most of these lesions can be diagnosed successfully with fine needle aspiration cytology (FNAC) which can help in proper management. Fine-needle aspiration cytology represents an excellent alternative to traditional cytologic (exfoliative cytology) or histologic methods for diagnosis of joint pathology. The advantages over open biopsy and other surgical procedures have made FNAC an increasingly popular procedure. (1) It is important to incorporate radiographic and clinical data when interpreting FNAC materials from such articular and peri-articular lesions. FNAC offers a great deal of diagnostic utility not only in early diagnosis but also in their treatment with minimal invasive means. Sometimes it also has therapeutic implications for such cystic lesions around joints. There are various cystic lesions around joints such as ganglion cysts (GC), synovial cysts (SC), bursal cyst , cystic inflammatory lesions, hematoma around joints or cystic tumours. Articular and periarticular cystic lesions can present with symptoms like pain, swelling, weakness, joint movement restrictions and compression of surrounding structures like blood vessels, nerves etc. Ganglion cysts are degenerative lesions, most often of the fibrous joint tissue or synovium. They occur commonly in the wrist, foot, or knee and present as firm, circumscribed masses of soft tissue. FNAC of ganglia has become more popular as a 23

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International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36 preoperative diagnostic or, in some instances, a therapeutic procedure.(2,3,4,5,6) They may affect any age group; however they are more common in the twenties to forties.(7) The aspirated material from ganglion cysts is thick, colourless & jelly- like. Microscopically, smears from the aspirated material show a small number of single cells with abundant cytoplasm and small oval nuclei over a background of abundant myxoid material which shows a peculiar drying artifact.(8) Synovial cysts are juxta-articular fluid- filled collections that are lined by synovial cells which cytologically as well as histologically distinguish them from other juxta-articular fluid collections, most importantly from ganglion cyst. It represents a focal extension of joint fluid due to herniation of synovial tissue into the surrounding soft tissue that can communicate with joint cavity. (9) Synovial cysts around knee joint are of two types on the basis of location i.e. popliteal (Baker’s cyst) and proximal tibiofibular cysts. (10) Other articular or periarticular cystic lesions include both benign and malignant lesions like meniscal cysts, bursitis, hematoma, abscess and synovial sarcoma etc. MATERIAL & METHODS: Our study was a two years retrospective study from Jan 2015 to Jan 2017 done in Cytology section of Pathology department of our hospital. After taking proper consent and clinical details of patients, FNAC was performed from the lesion sites mentioned on requisition forms and OPD slips. Skin overlying the lesions was cleaned by betadine and alcohol swab using a proper antiseptic method and aspiration was done using a 22-23 gauge needle attached to a 10 ml syringe with holder. The aspirated material was collected on to clean glass slides. The smears which were air-dried were stained with MGG (May Grunwald Giemsa) stain and those wet fixed were stained with Papanicolaou stain. Sometimes FNAC proved to be therapeutic due to partial or complete reduction in size of swelling. Cell block was also prepared from aspirated material of one case and stained with Haematoxylin and Eosin (H&E). Inclusion criteria:-All the cystic lesions around various joints. Exclusion criteria:-Non cystic lesions, clinically and radiologically malignant lesions. RESULTS AND DISCUSSION: A cyst adjacent to or in articular spaces is a frequent presentation. These lesions can be articular or periarticular which can present with symptoms like pain, swelling, weakness, joint movement restrictions and compression of surrounding structures (Fig no.1). FNAC offers a great deal of diagnostic utility not only in early diagnosis but also in their treatment with minimal invasive means. During retrospective study of two years from Jan 2015 to Jan 2017, total 16 cases of cystic lesions in joint spaces were studied. In our study, there were 10(62.5%) cases of ganglion cysts, 3(18.7%) cases of synovial cysts and 3(18.7%) cases of popliteal cysts. Most common lesion was ganglion cyst and found common in wrist joints (table no 1& fig no.2). Ganglion cysts are benign soft tissue tumors most commonly encountered in the wrist, but can occur in any joint. Sixty to seventy percent of ganglion cysts are found in the dorsal aspect of the wrist and communicate with the joint via a pedicle. (11)

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International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36

Fig no:-1 showing distribution of various type of bursal cysts and ganglion cyst of articular or periarticular region. In our study, age of presentation varied from 10 years to 63 years. These cystic lesions were more common in the age group of 21-30 years (table no.2). It is comparable with a study done by Meena S et al and Vijay PM et al. (7, 8)

Table no.1 :-Data of 16 cases of articular and periarticular cysts. S. No. Age/Sex Site of FNAC FNAC Impression Duration of Consistency of swelling fluid 1 30/M Swelling right wrist Ganglion cyst 1 year Thick,gelatinous 2 25/F Swelling left wrist Ganglion cyst 2 months Thick,gelatinous 3 35/F Swelling right wrist Ganglion cyst 5 months Clear,thin 4 63/M Swelling medial side of left knee Ganglion cyst 2 years Clear,thin 5 56/F Swelling medial side of left knee Synovial cyst 1 year Thick,gelatinous 6 29/F Swelling medial side of right knee Synovial cyst 1 year Thick,gelatinous 5 months 7 22/F Swelling lateral side of right wrist Ganglion cyst 4 months Thick,gelatinous 8 36/F Swelling lateral side of left wrist Ganglion cyst 3 months Thick,gelatinous 9 28/M Swelling lateral side of right wrist Ganglion cyst 1 year Blood tinged, thick gelatinous 10 10/F Swelling lateral side of right wrist Ganglion cyst 1 year Thick,gelatinous 2 months 11 24/M Swelling over right wrist Ganglion cyst 4 months Thick,gelatinous

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12 39/F Swelling over right elbow Ganglion cyst 8 months Thick,gelatinous 13 44/F Swelling over right elbow Ganglion cyst 3 years Thick,gelatinous 14 20/M Swelling over back of knee Baker’s cyst 1year Blood tinged, thick gelatinous 15 56/F Swelling in popliteal fossa Baker’s cyst 6 months Thick,gelatinous 16 17/M Swelling in popliteal fossa Baker’s cyst I year Thick,gelatinous 3 months

Fig no.2 :- Case distribution in our study.

10(62.5%) CASE DISTRIBUTION 10

6 N U 4 M 3(18.7%) B 3(18.7%) E 2 R 0 Gangion cyst Synovial cyst Popliteal cysts

TYPE OF CYST

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Table no.2 :- Age-wise incidence of articular and periarticular cysts.

Age range (years) No. of cases 0-10 1 11-20 2 21-30 6 31-40 3 41-50 1 51-60 2 61-70 1 Total 16

In our study, cystic lesions were more common in females with 10 out of 16 cases (62.5%). The M: F ratio was 1:1.6 in our study which was comparable with study done by Meena S et al and Vijay PM et al (7,8). In a study done by Meena et al, incidence in males was 25/100,000 and in females 43/100,000. (7)

Ganglion cysts on aspiration revealed thick, colorless, jelly like aspirate. Microscopically, smears studied showed a small number (hypocellular) of single histiocyte –like cells with abundant cytoplasm and small oval nuclei over a background of abundant myxoid material which showed a peculiar drying artefact (Fig no.3). Similar observations were made by Dodd et al and Punia RS et al. (2, 12)

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Fig no.3 :-Smears from a ganglion cyst show single histiocyte like cells (yellow arrows) and peculiar drying artefact (green arrows) in a mucoid background and few distorted red blood cells(red arrows) [(Fig 1a & 2a: Giemsa, 100x) and (Fig 1b & 2b: Giemsa, 400x ]

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Fig no.4 :-Smears from synovial cysts show single histiocyte like cells (yellow arrows), synovial cells (green arrows) and peculiar drying artefact (red arrows) in a mucoid background [(Fig 3a & 4a: Giemsa, 100x) and (Fig 3b: Giemsa 1000x & 2b: Giemsa, 400x) ]

Ganglia are degenerative lesions, most often of the fibrous joint tissue or synovium. They occur commonly in the wrist, foot, or knee and present as firm, circumscribed masses of soft tissue. Treatment of these benign lesions range from rupturing the cyst with a sharp blow with a heavy book (preferably a bible) to surgical excision. Aspiration of ganglia has become more popular as a preoperative diagnostic or, in some instances, a therapeutic procedure. FNA usually recovers a thick, gelatinous fluid that is so viscous it may be difficult to expel from the syringe or aspiration needle. The mucoid material of the cyst usually forms thick folds on the slide, reminiscent of thick colloid or mucinous matrix. Some have referred to this distinctive appearance as a crinkled plastic food wrap pattern. The aspirates also are markedly hypocellular, usually containing very rare macrophages and some amorphous debris. (1, 2) Histologically, ganglion cysts are characterized by unilocular or multilocular cysts or clefts in supportive connective tissues. Areas of soft tissue myxoid degeneration usually are present adjacent to the cyst cavity. The cysts are filled with a mucinous substance that usually is not demonstrable in post-fixation, embedded, and sectioned histologic material. At times it is difficult or even impossible to distinguish from bursae or ganglion cyst which

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International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36 lack a true connection to the joint but at times can communicate to joint space. FNAC can complement in diagnosis because of some differences on cytology. (12) Herniation of synovium through a joint capsule or massive enlargement of bursa may produce a synovial cyst. Synovial cysts around knee joint are of two types on the basis of location i.e. popliteal (Baker’s cyst) and proximal tibiofibular cysts. On the other end, a SC is a juxta-articular fluid-filled collection that is lined by synovial cells which histologically distinguishes them from other juxta-articular fluid collections, most importantly from GC. It represents a focal extension of joint fluid that again may, or may not, communicate with the joint. Also, this fluid collection may extend in any anatomic direction, in opposition to a synovial effusion with its well-circumscribed anatomic boundary, the joint capsule, which guides its extension in a more predictable direction.(9) Aspirated material from synovial cysts can be thin or thick, straw colored or transparent depending on the underlying intraarticular disease. Cytologically, the smears prepared from aspirated material were hypocellular with abundant mucoid material with single histiocyte-like cells and distorted red blood cells (Fig no.4). Some cases showed pseudopapillary structures with ill-defined cell borders. Focal clusters of inflammatory cells may also be seen. Similar findings were observed in study by Punia RS et al, Meena S et al and Dodd et al. (12, 7, 2) A well -recognized example is the synovial cyst that forms in the popliteal space in the setting of rheumatoid arthritis (Baker cyst). The synovial lining may be hyperplastic and contain inflammatory cells and fibrin. (8) Ganglion cyst and synovial cyst have different origins. Ganglion cysts are a result of mucoid cystic degeneration in collagenous structures. (13) Synovial cysts connect to the joint space, since they represent herniation of synovial tissue into the surrounding soft tissues. (12) This can help in proper management of these cystic lesions also by determining the cause of the cysts like in case of synovial cyst these are mostly associated with joint diseases which need to be treated first otherwise cyst can reoccur while ganglion cysts are degenerative in nature. For ganglion cysts treatment is directed towards cyst only, smaller size cyst can be treated with enzymatic drugs like trypsin, chymotrypsin and FNAC and excision is advised in larger sized cysts. (9) Electroacupuncture may serve as a safe, cost-effective, and valuable alternative treatment for ganglion cyst. (14) An intra-articular ganglion cyst of the knee can be successfully treated by arthroscopic debridement, which means complete resection of the cyst and cyst walls. It is our opinion that open surgical excision should be reserved solely for large cysts arising from the infrapatellar fat pad after arthroscopic exploration of the knee. (15) Differential diagnosis of these articular or periarticular cystic lesions include a diverse list of lesions like meniscal cysts, bursitis, tumors like pigmented villonodular synovitis (PVNS), synovial sarcoma, myxoid liposarcoma, synovial chondromatosis, myxoma etc. and rheumatoid nodule, gouty tophi, hematoma, abscess. (1) The synovial cells themselves or primitive cells within the synovium giving rise to tumors which are peculiar to synovium e.g.,Synovial chondromatosis and the various types of nodular synovitis. These lesions are classified as synovial chondromatosis, Tenosynovial giant cell tumour (TGCT)” localized type” (nodular tenosynovitis), tenosynovial giant cell tumor “diffuse type” (Proliferative synovitis), florid synovitis, extraarticular pigmented villonodular synovitis, pigmented villonodular bursitis), Ganglion cyts, Baker’s cyst, synovial haemangioma, synovial lipomas. (16-21) Meniscal cysts are believed to form as a result of tears in the meniscal fibrocartilage, with extrusion of synovial fluid through the meniscal tear. Although lateral cysts are more common in the arthroscopic literature, medial parameniscal cysts are 2 times more common than lateral cysts in the radiologic literature. Medial meniscal cysts are typically associated with

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International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36 posterior horn tears, whereas lateral meniscal cysts arise from anterior horn and body tears. Lateral cysts are more symptomatic, with patients presenting with a painful palpable lump, which may account for its higher prevalence in the arthroscopic literature. Meniscal cysts can be classified into three types: intrameniscal, parameniscal, and synovial. (10,22) Bursae are cystic lesions containing synovial fluid that reduces friction between moving structures such as tendons, ligaments, bone, and skin.[23,24,25] Bursae are often not visible on imaging unless irritated or inflamed due to trauma, infection, or arthritis. In general, bursae do not connect to the joint space, which distinguishes them from synovial cysts and normal joint recesses; however, at times, they can connect to the joint, such as the iliopsoas bursa. There are numerous bursae in and around the knee. The prepatellar, superficial infrapatellar, and deep infrapatellar bursae are associated with the patella, whereas the pes anserine, iliotibial (IT), and medial (tibial) collateral ligament bursae are not.(23,24,26) Other classification systems categorize the suprapatellar, popliteal, and the gastrocnemius semimembranosus joint spaces as bursae, though they connect to the knee joint and, thus, are technically joint recesses. The prepatellar bursa is located anterior to the patella, deep to the subcutaneous soft tissues. Inflammation of the bursa, popularly referred to as “housemaid’s knee,” can result from direct trauma to the patella or repetitive injury, producing anterior knee pain which may be associated with a palpable mass. Infrapatellar bursitis can occur in the superficial (between the tibial tubercle and the overlying skin) or deep (between the posterior aspect of the patellar tendon and the tibia) bursae. (26)Often called “vicar’s” or “clergyman’s” knee, it is caused by repetitive knee flexion from deep knee bends or jumping. IT bursitis occurs secondary to friction of the IT band against the lateral femoral epicondylar prominence. It is common in patients who participate in intense physical activity, such as distance runners, cyclists, and football players. The pes anserine bursa is situated on the medial aspect of the knee, between the pes anserine tendons (gracilis, sartorius, and semitendinosus) and the tibial insertion of the tibial collateral ligament. Pes anserine bursitis affects both genders equally, classically occurring in older overweight women with knee osteoarthritis or in athletes in sports that require running and side to side movement. The medial collateral ligament bursa, which lies between the superficial and deep layers of the medial collateral ligament, infrequently becomes inflamed and filled with fluid. Physical activities that irritate the medial knee soft tissues, such as horseback and motorcycle riding, are potential causes. (24) Medial collateral ligament bursitis can at times be confused with a partial tear of the medial collateral ligament or a parameniscal cyst. (26) A hematoma represents a contained region of bleeding, which can be traumatic, iatrogenic, or spontaneous in origin.An abscess can form in the soft tissues of the knee due to hematogenous spread, from direct extension of infection from adjacent tissues, like in osteomyelitis, or when the skin barrier has been breached by surgery or trauma. (27) Focal enlargement of veins, arteries, and lymphatic structures around the knee can produce a “cystic” mass. These conditions include aneurysms, varices, hemangiomas, and lymphangiomas. (28,29) Rheumatoid arthritis is a chronic, disabling, systemic condition associated with circulating autoantibodies directed against native antigens. The disease involves the formation of inflammatory lesions in numerous organs, including the heart, lungs, vessels, and eyes as well as skin and soft tissue. The condition almost invariably involves the joints, with a predilection for joints of the hands and feet. FNAC of rheumatoid nodules are characterized by a background of necrotic debris and an admixture of lymphocytes, plasma cells, and elongated epithelioic type histiocytes. The composition of the aspirate will vary with the size of the lesion and the extent of necrosis. Cellular atypia may be so pronounced that it simulates a neoplastic process, representing a potential pitfall in diagnosis. (1, 30, 31)

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Gout is a disorder of uric acid metabolism that causes deposition of monosodium urate crystals in joint spaces, which, in turn, elicits an acute inflammatory reaction. With either untreated hyperuricemia or longstanding gout characterized by multiple episodic bouts of arthritis, gouty tophi will form in the soft tissues. These typically occur in and around joint spaces but may present in other sites as well, particularly the pinna of the ear. Although gout is recognized and treated easily, occasionally, gout may present as a soft tissue tophus without antecedent hyperuricemia.16 Reports of patients with gouty tophi who were diagnosed by FNA describe features consistent with the histology-Small flecks of whitish material often are visible macroscopically in the aspirated material. On microscopic examination, the aspirate is comprised of aggregates of the crystalline material as well as occasional histiocytes. Multinucleate giant cells are associated with the lesion but are a less common feature in aspirates, because the acellular crystalline material accounts for the largest portion of the tophus volume. Careful attention to the smear background will reveal the slender, rod-shaped crystals. Crystals also are present in aggregates of dense, amorphous material that has a dark grayish appearance on Giemsa-based stain. One potential pitfall in aspiration cytology is distinguishing the contents of a gouty tophus from a deposit of pseudogout. (1, 32, 33) PVNS is the intra-articular form of tenosynovial giant cell tumor (localised type). Once identified as a reactive lesion, it is now believed that PVNS is a neoplasm-based demonstration of monoclonality (27) and cytogenetics. (1, 28–30) In addition, there are rare documented instances of me tastases. (1, 31–34) PVNS occurs in both localized and diffuse forms, with the latter more likely to be associated with large, weight-bearing joints, such as the knee or ankle. PVNS first may manifest as a joint effusion, in which case exfoliative cytology may demonstrate the characteristic findings. (1, 35) More commonly, however, it will present as a periarticular extremity mass susceptible to FNA. PVNS can have a destructive appearance on imaging studies.The neoplasm may erode local bone and mimic a more aggressive lesion, such as sarcoma. Fortunately, the cytologic features of PVNS/tenosynovial giant cell tumor are very straightforward and distinctive: histiocytoid cells (xanthoma), giant cells, and pigment, both intracellular and extracellular. Mild cytologic atypia may be noted, particularly in the histiocytoid component. To date, it has not been proven that cytologic atypia has any correlation with aggressive behavior (1, 34, 35, 36) Xanthoma cells are also frequent, tend to be located geographically in these tumors, and often contain fine hemosiderin granules. Cartilaginous and osseous metaplasia is a rare focal finding in these tumors. (20) Diffuse tensoynovial giant cell tumor can be regarded as the soft tissue counterpart of pigmented villonodular synovitis of the joint space. In most instances the lesion probably represents extraarticular extension of a primary intraarticular process, a contention supported by the similarity in age, location, clinical presentation, and symptoms of the two processes. In rare instances this disease resides completely outside a joint, in which case its origin must be ascribed to the synovium of the bursa or tendon sheath. (1, 35) FNAC yielded pale yellow to pale brown coloured fluid aspirate, smears from the centrifuged sediment from fluid showed sheets of synovial cells with occasional papillary clusters and macrophages containing brown cytoplasmic granules of hemosiderin, occasional tuton type of multinucleated giant cells were seen. Similar observations were reported by chhieng et al. (1, 37) Diffuse type of TGCT shows a female preponderance and Interphalangeal joints of hand & knee are the common joints that involves.(8) Synovial chondromatosis is a lesion characterized by multiple nodules of benign cartilage forming in the synovium. The process most commonly effects large joints, and patients present with swelling, pain, and limited range of motion. The etiology of this lesion is unknown, but it is believed that chondromatosis is a metaplastic process rather than a neoplastic process. On radiographic studies, the appearance of chondromatosis is fairly characteristic. Partially calcified, nodular masses

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International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36 are present in the joint space and extend into the surrounding soft tissue (loose bodies). Occasionally, there may be radiographically detectable pressure erosion of adjacent bone. (1, 37) Synovial chondromatosis may be seen in a wide variety of disturbances of synovial membrane of joints and bursae like infection, trauma and metaplastic transformation of synovial tissues. (19) Histologically, synovial chondromatosis is characterized by well-formed nodules. Nodules typically vary in size from millimeters to several centimeters and are comprised of cartilage arising within synovium. The nodules usually are modestly cellular and may show mild cytologic atypia of chondrocytes. Binucleate chondrocytes are seen commonly in chondromatosis. (1, 38) A number of patients with malignant degeneration of synovial chondromatosis to chondrosarcoma have been documented. Once it was believed that this was an extremely rare event; however, the incidence of malignant transformation is estimated now at approximately 5%. (1, 38).Histologic features that would indicate a potential malignancy or malignant transformation include the presence of necrosis, myxoid change, mitoses, and replacement of the nodular pattern with a more indistinct, sheet-like arrangement. (1, 39) Cytologic descriptions of synovial chondromatosis have been relatively rare and confined to a few case reports of aspirate findings. Aspirates are dominated by the presence of matrix material. Cartilaginous matrix stains metachromatically on Giemsa based stain and presents as blue-green extracellular material on Papanicolaou stain .Chondrocytes are a relatively rare finding and may be clustered together in small groups. Nuclei are large, and cytoplasm is abundant but often indistinct. Cytologic atypia, as mentioned previously, may be present and should be interpreted with caution. Binucleate or multinucleate chondrocytes are a not-infrequent finding. Mitoses in a cartilaginous aspirate should always raise the possibility of malignancy or secondary malignant transformation. The cytologic features of synovial chondromatosis would be difficult to separate from a well-differentiated chondrosarcoma on FNA alone. Likewise, malignant transformation of a pre-existing, benign chondromatosis represents a potential cytologic pitfall for either over-estimation or under-estimation of malignancy based on subtle cytologic atypia. Like other cartilaginous lesions, synovial chondromatosis is one that should be approached with extreme caution on aspiration cytology. (1, 39) Synovial sarcoma is a malignant neoplasm that occurs classically in the periarticular regions of the extremities, particularly the knee. Despite its name, it does not arise from the synovium. Initial investigators mistook the tumor cells for synovial cells, leading to this misnomer. Despite a strong predilection for the joint region like kmee, ankle & foot, it has occurred in a variety of sites without an obvious synovium, including the larynx, pharynx, and abdominal wall. Synovial sarcoma is a lesion of young adults and adolescents: The majority of patients are age less than 40 years. Imaging studies can be immensely valuable in establishing a diagnosis. They often appear as well defined, non infiltrative masses. (1,41) Synovial sarcoma occurs as either a biphasic tumor with spindled and epithelioid regions or as a monophasic lesion, usually of the spindled component. The latter may be difficult to distinguish from malignant peripheral nerve sheath tumor, fibro sarcoma, or malignant hemangiopericytoma. There also has been a poorly differentiated or small cell variant described. (1, 40) This variant may be impossible to distinguish from the peripheral neuroectodermal/Ewing sarcoma group without benefit of ancillary studies. Demonstration of the translocation of (X; 18) with generation of fusion product SYT-SSX represents the state of the art in molecular tumor diagnosis. (1, 41) The cytology of synovial sarcoma has been well described. Aspirates are characteristically very cellular. The smears contain an evenly distributed population of cells, either singly or loosely aggregated. In the monophasic variant, the cells are small,

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International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36 spindled, and relatively homogenous. The nuclei usually are elongated with rounded ends and have a dense, hyperchromatic nucleoplasm. Nucleoli are small and inconspicuous. Cytoplasm is sparse and indistinct. Numerous mitoses and apoptotic degenerating cells usually are present. (1,42-45). Other “cystic” mass involving joints include peripheral nerve sheath tumor (PNST) and myxomatous tumor, PNST (schwannomas and neurofibromas) appears as a fusiform mass arising from a nerve, occasionally producing a “tail” on both ends where the nerve enters and exits the mass, accounts for 10% of all primary soft tissue malignant tumors. Malignant peripheral nerve sheath tumors (MPNSTs) are rare, but should be considered if there is a rapid change in size of the lesion or the development of pain in a previously painless mass. (27, 46) Myxomatous neoplasms, which may be benign or malignant, are associated with an overproduction of mucopolysaccharide substances. (46) These neoplasms include benign intramuscular and juxtaarticular myxomas, as well such malignant sarcomas with myxoid components such as myxoid liposarcomas and myxoid fibrosarcomas. FNAC has both diagnostic and therapeutic role. It distinguishes between malignant and benign articular and periarticular lesions for some extent. In most instances, mass-producing lesions of the joint space or the periarticular soft tissues can be diagnosed successfully by FNAC. The common lesions are easily recognizable and are cytologically distinctive. (1) CONCLUSION: FNAC offers a great diagnostic utility in articular and periarticular cystic lesions with low cost, rapid diagnosis, minimal invasiveness, therapeutic implications and advantages over traditional methods (exfoliative cytology). FNAC also contributes in differentiating ganglion cysts from other bursal cysts which is important for management.

REFERENCES: 1. Dodd LG, Major NM. Fine needle aspiration cytology of articular and periarticular lesions. Cancer (Cancer cytopathol).2002; 96 (3):157-65. 2. Dodd LG, Layfield LJ. Fine-needle aspiration cytology of ganglion cysts. Diagn Cytopathol. 1996; 15:377–381. 3. Oertel YC, Beckner ME, Engler WF. Cytologic diagnosis and ultrastructure of fine-needle aspirates of ganglion cysts. Arch Pathol Lab Med. 1986; 110:938–942. 4. Nield DV, Evans DM. Aspiration of ganglia. J Hand Surg (Br). 1986; 11:264. 5. Muddlu BN, Morris MA, Fahmy NRM. The treatment of ganglia. J Bone Joint Surg (B). 1990; 72:147. 6. Nokes SR, Koonce TW, Mantanez J. Ganglion cysts of the cruciate ligaments of the knee: recognition on MR images and CT-guided aspiration. Am J Roentgenol. 1994; 162:1503. 7. Meena S, Gupta A. Dorsal wrist ganglion: Current review of literature. J clin ortho and trauma.2014;5:59-64. 8. Vijay PM, Sudha VM, Doddikoppad MM. Diagnostic utility of fine needle aspiration cytology versus conventional histopathological study and immunohistochemistry of benign tumors and tumor-like growths of the synovium. Int J Biol & Med Res. 2015; 6(4):5316-5321. 9. Giard MC, Pineda C. Ganglion cyst versus synovial cyst? Ultrasound characteristics through a review of the literature. Rheumatol Int.2015; 35(4):597-605. doi: 10.1007/s00296-014-3120-1 10. Telischak NA, Wu JS, Eisenberg RL. Cysts and cystic-appearing lesions of the knee: A pictorial essay. Indian J Radiol Imaging.2014; 24(2):182-91.

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11. Angelides AC, Wallace PF. The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg. 1976; 1(3):228–35. 12. Punia RS, Gupta S, Handa U et al. Fine needle aspiration cytology of bursal cyst. Acta Cytol 2002; 46:690-692. 13. Chhabra A, Cerniglia CA. Bursae, cysts and cyst-like lesions about knee. J Am Osteopath Coll Radiol.2013; 2(4):2- 13. 14. Kissel JA, Wong C. Ganglion cyst of the wrist treated with electroacupuncture: a case report. The Journal of the Canadian Chiropractic Association. 2017; 61(3):269-276. 15. Bojani ć I, Dimnjakovi ć D, Smoljanovi ć T. Ganglion cyst of the knee: a retrospective review of a consecutive case series. Acta Clin Croat. 2017; 56:359-368. 16. Rosenberg A. Bones, joints and soft tissue tumours. In” Ramzi CS, Kumar V, Collins T, ed(s). Robbins pathologic basis of disease.6th Edn. Philadelphia: W.B. Saunders Co; 1999: 1246pp. 17. Lichtenstein L. Diseases of bone and joints. 2nd Edn. St. Louis: C.V. Mosby; 1975. Chapter-15: Disorder of synovial joint; 265pp. 18. Hough A J. Joints. In: Damjanov I & Lindu J, ed(s).Anderson's pathology, Vol.2. 10th Edn. St.Louis: Mosby; 1996. 2615pp. 19. Hajdu S I. Pathology of soft tissue tumours. Philadelphia: Lea and Febiger; 1979. Chapter-3: Tumours of tendosynovial tissue; 165pp. 20. Weiss WS, John RG. Soft tissue tumours. 4th Edn. St.Lous: Mosby; 2001. Chapter-28: Benign tumours and tumour like lesions of synovial tissue; 1037-1062pp. 21. Revell PA. “The synovial biopsy”. Recent advances in histopathology. 1987; 13: 79-89. 22. Campbell SE, Sanders TG, Morrison WB. MR imaging of meniscal cysts: Incidence, location, and clinical significance. Am J Roentgenol 2001; 177:409 13. 23. Francesca D, Beaman MD, Jeffrey J, Peterson MD. MR imaging of cysts, ganglia, and bursae about the knee. Radiol Clin North Am 2007; 45:969 82. 24. De Maeseneer M, Shahabpour M, Van Roy F, Goossens A, De Ridder F, Clarijs J, et al. MR imaging of the medial collateral ligament bursa: Findings in patients and anatomic data derived from cadavers. Am J Roentgenol 2001; 177:911 7. 25. Chatra PS. Bursae around the knee joints. Indian J Radiol Imaging 2012; 22: 27 30. 26. Marra MD, Crema MD, Chung M, Roemer FW, Hunter DJ, Zaim S, et al. MRI features of cystic lesions around the knee. Knee 2008; 15:423 38. 27. Butler MG, Fuchigami KD, Chako A. MRI of posterior knee masses. Skeletal Radiol 1996; 25:309 17. 28. Beall DP, Ly JQ, Wolff JD, Sweet CF, Kirby AB, Murphy MP, et al. Cystic masses of the knee: Magnetic resonance imaging findings. Curr Probl Diagn Radiol 2005; 34:143 59. 29. Jans L, Ditchfield M, Jaremko JL, Stephens N, Verstraete K. MRI demonstrates the extension of juxta articular venous malformation of the knee and correlates with joint changes. Eur Radiol.2010; 20:1792 8. 30. Vass L, Limjoco JM, Gupta PK. Fine needle aspiration of a rheumatoid nodule. Acta Cytol. 1992;36:107–108

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International J. of Healthcare and Biomedical Research, Volume: 06, Issue: 04, July 2018, 23- 36

31. Youngberg GA, Farnum JB. Cellular atypia in a rheumatoid nodule: a diagnostic pitfall of aspiration biopsy. J Dermatol Surg Oncol. 1984; 10: 128–132. 32. Agudelo CA, Wise CM. Gout and hyperuricemia. Curr Opinion Rheum. 1991; 3: 684–691. 33. Wernick R, Winkler C, Campbell S. Tophi as the initial manifestation of gout. Report of six cases and review of the literature. Arch Intern Med. 1992; 152: 873–876. 34. Fletcher JA, Henkle C, Atkins L, Rosenberg AE, Morton CC. Trisomy 5 and trisomy 7 are nonrandom aberrations in pigmented villonodular synovitis: confirmation of trisomy 7 in uncultured cells. Genes Chromosomes Cancer. 1992; 3: 264–266. 35. Somerhausen NS, Fletcher CD. Diffuse-type giant cell tumor: clinicopathologic and immunohistochemical analysis of 50 cases with extraarticular disease. Am J Surg Pathol. 2000; 24: 479–492. 36. Chhieng DC, Boguniewicz A, Mckenna BJ. Pigmented villonodular synovitis. Report of a case with diagnostic synovial fluid cytological features”. Acta cytol.1997; 41: 1811-1814. 37. Davis RI, Hamilton A, Biggart JD. Primary synovial chondromatosis: a clinicopathologic review and assessment of malignant potential. Hum Pathol. 1998; 29:683–688. 38. Bertoni F, Unni KK, Beabout JW, Sim FH. Chondrosarcoma of the synovium. Cancer. 1991;67: 155–162. 39. Batheja NO, Wang BY, Springfield HG, et al. Fine-needle aspiration diagnosis of synovial chondromatosis of the tibiofibular joint. Ann Diagn Pathol. 2000;4: 77–80. 40. Silverman JF, Landreneau RJ, Sturgis CD, et al. Small-cell variant of synovial sarcoma: fine-needle aspiration with ancillary features and potential diagnostic pitfalls. Diagn Cytopathol. 2000;23: 118–123. 41. Akerman M, Willen H, Carlen B, Mandahl N, Mertens F. Fine needle aspiration (FNA) of synovial sarcoma—a comparative histological-cytological study of 15 cases, including immunohistochemical, electron microscopic and cytogenetic examination and DNA-ploidy analysis. Cytopathology. 1996; 7:187–20. 42. Kilpatrick SE, Teot LA, Stanley MW, Ward WG, Savage PD, Geisinger KR. Fine-needle aspiration biopsy of synovial sarcoma. A cytomorphologic analysis of primary, recurrent and metastatic tumors. Am J Clin Pathol. 1996; 106:769–775. 43. Bakri A, Shinagare AB, Krajewski KM, Howard SA, Jagannathan JP, Hornick JL, et al. Synovial sarcoma: imaging features of common and uncommon primary sites, metastatic patterns, and treatment response. Am J Roentgenol 2012;199:208 15. 44. Viguer JM, Jimenez-Heffernan JA, Vicandi B, Lopez-Ferrer P, Gamallo C. Cytologic features of synovial sarcoma with emphasis of the monophasic fibrous variant: a morphologic and immunocytochemical analysis of bcl-2 protein expression. Cancer. 1998; 84:50–56. 45. Wu JS, Hochman MG. Soft tissue tumors and tumorlike lesions: A systematic imaging approach. Radiology 2009; 253:297 316. 46. Daluiski A, Seeger LL, Doberneck SA, Finerman GA, Eckardt JJ. A case of juxta ‑articular myxoma of the knee. Skeletal Radiol 1995;24:389 ‑91.

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