Fine needle aspiration biopsy of hepatocellular carcinoma and hepatocellular nodular lesions: role, controversies and approach to diagnosis.
- A Wee
- Cytopathology : official journal of the British…
Dear Editor, The recent article on fine needle aspiration (FNA) of hepatocellular carcinoma and hepatocellular nodular lesions: role, controversies and approach to diagnosis gave an extensive insight into hepatocellular lesions. There was a good discussion of the mimics of hepatocellular carcinoma (HCC). Extrahepatic spread of HCC is associated with a poor prognosis and poses a challenging diagnosis using FNA. Metastasis of HCC to the sinonasal area is very rare. We want to share our experience of a case of metastatic HCC to the maxillary sinus diagnosed using FNA cytology. The patient was a 72-year-old African-American female who presented with a history of left-sided facial pain for 1 month. She had a history of HCC diagnosed 1 year before. A computerized tomography (CT) scan showed a soft tissue mass originating in the left maxillary sinus with extension into and destruction of the inferior left orbital bone (Figure 1a). The differential diagnosis included a primary malignant tumour versus a metastatic lesion. Consideration was given to a metastatic HCC, given the patient s previous history. CT-guided FNA was done. Cytological smears were prepared including six Papanicolaou-stained slides, one Diff Quik-stained slide and one cell block preparation. Cytological evaluation showed a predominant population of cohesive cell clusters with mild nuclear atypia, prominent nucleoli and granular eosinophilic cytoplasm. No cytoplasmic bile was observed. A few individual cells with the same morphological features were also present (Figure 1b). Spindle-shaped endothelial cells were present around the edges of the cohesive groups (Figure 1c). Immunohistochemical stains were performed on the cell block with corresponding positive and negative controls. The neoplastic cells demonstrated a canalicular staining pattern (Figure 1d) with polyclonal carcinoembryonic antigen (1 : 200 dilutions; Dako Cytomation, Carpinteria CA, USA) and CD10 (56C6, prediluted; Novocastra Laboratories, Buffalo Grove IL, USA). There was focal positive staining with cytokeratin cam 5.2 (1 : 25 dilution; Becton Dickinson, Franklin Lakes NJ, USA). Alpha-fetoprotein (AFP) (Dako Cytomation) and Hepatocyte Paraffin 1(HepPar1) (prediluted; Dako,) were negative. The cytomorphological features and immunohistochemical staining patterns were virtually identical to those of the primary tumour. A diagnosis of metastatic hepatocellular carcinoma was rendered. Hepatocellular carcinoma is the most common primary malignant tumour of the liver. The major risk factor is cirrhosis and the majority of these patients also have a history of viral hepatitis. The clinical symptoms vary depending upon the stages of presentation. Metastasis from HCC has been reported in many different sites including the lung, kidney, bones, lymph nodes, adrenal glands, gastrointestinal tract, spleen, orbit, parotid gland and nasal septum. Involvement of the maxillary sinus is very rare. The overall prognosis of patients with metastatic HCC is poor. The typical symptoms of a sinonasal metastatic tumour include nasal obstruction, pain, local swelling, epistaxis and exophthalmos. Correlation with the past history and imaging studies are helpful in the identification of metastatic tumours in rare locations. Cytological evaluation shows highly cellular smears with cords, nests and sheets of cells. Spindle-shaped endothelial cells surrounding groups of hepatocytes is one of the characteristic features of this neoplasm. The cells are pleomorphic with a variable nuclear to cytoplasmic ratio and granular cytoplasm. Other features include a polygonal cell shape with centrally placed nuclei, sinusitis capillaries separating neoplastic cells and cytoplasmic bile. The differential diagnosis includes oncocytic neoplasms from the kidney or salivary gland, nasopharyngeal carcinoma, a granular cell tumour and Correspondence: S. M. Gilani, Department of Pathology, St. John Hospital & Medical Center, 22101 Moross road, CCB-SB, Detroit, MI 48236, USA Tel.: +1-313-343-3133; Fax: +1-313-881-4727; E-mail: firstname.lastname@example.org