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Selected Problems in Fine Needle Aspiration of Head and Neck Masses Michael W

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Selected Problems in Fine Needle Aspiration of Head and Neck Masses Michael W Selected Problems in Fine Needle Aspiration of Head and Neck Masses Michael W. Stanley, M.D. Department of Pathology, Hennepin County Medical Center, Minneapolis, Minnesota the differential diagnosis of small blue cell epithe- A wide variety of masses in the head and neck, lial neoplasms; salivary gland aspirates that yield including those in the major salivary glands, can be mucinous cystic contents; neoplasms that consist approached by fine needle aspiration. In many in- of monotonous large cells with eosinophilic cyto- stances, a correct definitive diagnosis con be ren- plasm and low-grade nuclear features; and dered after examination of smears or cell block ma- squamous-lined cysts of the lateral neck. Finally, we terial. However, several significant but uncommon will briefly consider issues in thyroid aspiration. areas can lead to diagnostic difficulties, with the potential for clinically important diagnostic errors. Many of these occur in salivary gland lesions. The General Considerations in Fine Needle most frequent problems involve variations in the Aspiration of the Head and Neck expected cytology of pleomorphic adenoma. Then, The diversity of masses in the head and neck and there are several benign–malignant “look-alike” the differential diagnostic difficulties cited previ- pairs of lesions. The first of these is related to small- ously require that the best possible technique and cell epithelial neoplasms of low nuclear grade; the preparations be employed. In general, the tech- most frequent problem is between basal cell adeno- nique of needle aspiration is the same as that ap- mas and adenoid cystic carcinoma, particularly the plied to other areas. We use 25-gauge (0.5-mm) solid (anaplastic) type. The next area contrasts mu- needles exclusively. We have also found that a coepidermoid carcinoma with its cytologic mimic, 10-mL syringe is quite adequate and that larger benign salivary gland duct obstruction. The final syringes do not produce better specimens. It is our difficulty in salivary gland aspiration contrasts practice to use a syringe holder in the Swedish large-cell epithelial lesions of low nuclear grade: manner, although others prefer the French tech- oncocytic proliferations and acinic cell carcinoma. nique of puncture without syringe aspiration. We The clinical implications of cytologically benign have found that 25-gauge needles give adequate squamous cell–containing cyst aspirates from the samples, and all of the cytologic material illustrated lateral neck will be discussed. Finally, a brief con- in this presentation was obtained with these small sideration of methodological optimization for thy- instruments. roid aspirations will be offered. We regard the preparation of aspirated material as a key step in optimizing diagnosis. We have Mod Pathol 2002;15(3):342–350 found that the best results are obtained when the person performing the aspiration is also skilled in Masses in many head and neck sites are amenable preparation of smears and allocation of material to to diagnosis by fine needle aspiration (FNA) cytol- cell blocks, or other studies as needed. This hap- ogy. After a brief consideration of general clinical pens naturally in the type of practice in which a principles of the method, this discussion will focus pathologist sees the patient and performs the aspi- on areas in which significant diagnostic difficulties ration. It is also possible to train physicians or clinic may arise. Several of these involve salivary gland staff in these methods and thereby optimize the sites and include the following: uncommon varia- material that these individuals submit to the tions on the cytology of pleomorphic adenomas; laboratory. Most of our material is prepared as direct smears. Copyright © 2002 by The United States and Canadian Academy of This is in keeping with our literature’s most fre- Pathology, Inc. VOL. 15, NO. 3, P. 342, 2002 Printed in the U.S.A. quent descriptions of aspiration cytology. Both air- Date of acceptance: September 27, 2001. dried, Romanovsky-stained and fixed Papanico- Address reprint requests to: Michael W. Stanley, M.D., Department of Pathology—815, 701 Park Avenue, Minneapolis, MN 55415; e-mail: laou–stained preparations have an important role [email protected]; fax: 612-904-4282. in head and neck cytology. It is our goal to prepare 342 both types of smears on virtually all cases. Cell case into one of several categories. From this, more blocks can also be very useful and are suitable for detailed observation or extended investigation may all histochemical and immunohistochemical spe- lead to a more definitive classification. As discussed cial stains. The most frequent method of cell block below, some differential diagnostic problems remain preparation in our laboratory involves allowing insoluble by cytologic means. hemorrhagic material to clot. This is then placed in neutral buffered formalin and handled as any small histologic specimen. Furthermore, we regard the Normal Salivary Gland Tissue need for cell block material as an indication for Our first category is normal salivary gland tissue. repeat FNA. This process is facilitated by immediate In most instances, given the clinical impression of a on-site review of rapidly stained smears. mass, aspiration of only normal salivary gland ele- FNA of head and neck sites has been studied ments indicates that the lesion has not been tar- extensively for several decades. The complication geted accurately or has not given up material to the rate is extraordinarily low. Even after addressing large aspirating needle. However, in the proper clinical numbers of lesions in variably immunosuppressed setting, it may be reasonable to consider a diagno- individuals, we have seen no incidence of local aspi- sis of sialosis. The most important factor in making ration site infection and have had no problems re- this diagnosis a reasonable consideration is the skill lated to hemorrhage. Furthermore, the literature gives level and thoroughness of whomever has per- no instance of facial nerve damage in the case of formed the aspiration. To say that a salivary gland parotid aspiration, despite the fact that this nerve enlargement does not represent a tumor based on courses through the substance of the gland. aspiration of normal tissue elements requires a very Some have expressed fear of unknowingly en- high level of confidence in the procedure that has countering carotid body tumors in aspiration of been performed. neck masses. We have aspirated such lesions on a The typical case of sialosis is bilateral and often number of occasions and have experienced no associated with one of a variety of clinical consid- complications. It seems that if one engages in as- erations, including malnutrition, diabetes mellitus, piration of head and neck masses, eventually an or alcoholism. However, some cases are probably unsuspected carotid body tumor will be encoun- unilateral and idiopathic. Ultimate consideration of tered. At this point, it is useful to underscore the this diagnosis must rest in clinical hands. safety of performing this procedure with 25-gauge The second type of aspiration is one that shows needles. inflammation. In our experience, most aspirations yielding purulent material represent a secondary infection superimposed on sialolithiasis. Granulo- Difficult Differential Diagnoses in Salivary mas can be encountered in a variety of conditions. Gland Cytology When chronic inflammatory cells are aspirated, one Masses that appear clinically to be seated in the may consider an inflammatory process, aspiration parotid gland may represent the gland itself, an of a regional lymph node, or hematopoietic neo- intraparotid lymph node, a high cervical lymph plasm. In this setting, rapid interpretation of the node, or a cyst of the neck, or a soft tissue mass. smear material is very useful if one wishes to insti- Thus, given the clinical description of a parotid tute cultures or immunophenotypic investigation mass, one’s differential diagnosis must be ex- of lymphoid cells. However, it is important to recall tremely broad. Complicating this clinical issue is that several salivary gland neoplasms can show the fact that secondary alterations of several types prominent superimposed chronic inflammation. can be superimposed on a wide variety of salivary When normal salivary gland tissue is aspirated, gland neoplasms. These include prominent lym- one can see both ductal and acinar elements. These phoid stroma, cystic change, clear cell change, on- are frequently present as large tissue particles con- cocytic alterations, sebaceous differentiation, and taining both types of tissue and may be associated mucin production. Thus, although the characteris- with adipose tissue. Ducts are tubular and may tic cytologic presentation of most common lesions show branching. They are lined by a benign glan- is usually predictable, several confounding clinical dular epithelium similar to that in many other body and cytologic issues combine to make some frac- sites. Acinar tissue shows basketlike arrangements tion of aspirated cases very difficult to interpret. of uniform cells with abundant granular or vacuo- Our classification of salivary gland aspirates is lated cytoplasm and basally located, banal- summarized in a detailed fashion in Table 1. This appearing nuclei. Many acinar cells will be dam- approach is based on one’s first impression of an aged in the smearing process so that the slide aspirate and the differential diagnostic considerations background
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