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REVIEW ARTICLE Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 3  |  Page : 395-402
Diagnostic dilemma: Diagnostic algorithm in fine needle aspiration cytology of mediastinal tumors


Department of Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication22-Oct-2010
 

   Abstract 

The mediastinum harbors a mixed bag of tumors, which may create significant diagnostic dilemmas. These tumors have widely variable therapeutic and prognostic implications. Correct pre-operative cytological diagnosis may obviate the need of surgical excision of many of these lesions. A stepwise algorithmic approach such as clinical history, radiological localization, salient cytomorphology and ancillary test helps in correct diagnosis of these tumors. This paper discusses the stepwise diagnostic algorithm for fine needle aspiration cytology diagnosis of mediastinal tumors.

Keywords: Cytology, diagnosis, fine needle aspiration cytology, mediastinum

How to cite this article:
Dey P. Diagnostic dilemma: Diagnostic algorithm in fine needle aspiration cytology of mediastinal tumors. Indian J Pathol Microbiol 2010;53:395-402

How to cite this URL:
Dey P. Diagnostic dilemma: Diagnostic algorithm in fine needle aspiration cytology of mediastinal tumors. Indian J Pathol Microbiol [serial online] 2010 [cited 2021 Oct 28];53:395-402. Available from: https://www.ijpmonline.org/text.asp?2010/53/3/395/68241



   Introduction Top


The mediastinum shows a wide variety of tumors with variable cytomorphology and this may lead to diagnostic problems. [1],[2],[3],[4],[5],[6],[7],[8] The diagnosis of the mediastinal tumors by fine needle aspiration cytology (FNAC) requires a combination of clinical, radiological, biochemical, and cytomorphological information. This paper discusses the diagnostic algorithmic approach of FNAC of mediastinal tumors.

There are essentially four steps in the approach for diagnosis of mediastinal tumors [Figure 1].
Figure 1: Flow diagram of step wise algorithmic approach to diagnosis

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   Step 1: Clinical History Top


The first step in the diagnostic approach of mediastinal FNAC is procuring relevant clinical history. Young patients may have germ cell tumors, thymomas or lymphomas. On the other hand, older patients may have more chances of metastatic tumors. Certain symptoms help indicate involvement of certain organs [9] [Figure 2]. Clinical history of myasthenia gravis is usually associated with thymoma. Past history of malignancy or the presence of malignant tumors in other parts of the body may be important for diagnosis of metastatic malignant tumors. Presence of generalized lymphadenopathy or hepatosplenomegaly on physical examination may indicate lymphoma or leukemic deposits. In germ cell tumors there may be associated abdominal mass in the pelvic region.
Figure 2: History and other relevant informati on for diagnosis

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   Step 2: Radiological Localization Top


The mediastinum is arbitrarily divided into many imaginary compartments on the basis of known anatomical landmarks. The preferential locations of the mediastinal tumors in one particular anatomical compartment have been highlighted in [Figure 2]. [10]


   Step 3: Cytomorphology Top


A thorough study of cytomorphology is extremely useful in reaching the correct diagnosis. The cytologic smears may be composed of predominantly round cells, spindle cells or pleomorphic bizarre cells. In certain situations no specific cell pattern may be noted [Figure 1]. We describe the algorithmic approach to diagnosis of mediastinal lesions on the basis of the predominant cell morphology below:

Predominant Round Cell Morphology

Smears with a predominant population of lymphoid cells

The cytology smears may show occasional groups of epithelial looking cells along with large number of discrete lymphoid cells. The differential diagnoses are thymoma, non-Hodgkin's lymphoma (NHL), Hodgkin's lymphoma (HL), and metastatic small cell carcinoma [Table 1].
Table 1: Differential diagnosis of predominant round cell morphology in mediastinal mass

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Cohesive clusters of cells are usually seen in thymoma and metastatic small cell carcinoma [Figure 1], whereas, the cells of lymphomas are always non-cohesive. FNAC smears of lymphocyte rich thymoma (Type B1) show abundant monomorphic population of small, mature lymphocytes with inconspicuous nucleoli. [11],[12],[13] In addition, clusters of epithelial cells surrounded by arborizing capillary networks are also noted. The epithelial cells have oval to plump shaped nuclei with pale homogenous chromatin, single prominent nucleoli and moderate amount of cytoplasm [14],[15],[16] [Figure 3].
Figure 3: High power view shows epithelial cells with pale cytoplasm and oval to elongated nuclei in a case of thymoma (May Grunwald Giemsa stain, ×480)

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Pure cytological diagnosis of malignant thymoma is difficult. The presence of nuclear pleomorphism, mitotic activities and necrosis may indicate the possibility of thymic carcinoma. In FNAC smears it is almost impossible to differentiate benign thymoma from malignant thymoma. [17],[18] Occasionally, non-neoplastic thymic epithelial cells may be noted in FNAC smears in cases of thymic hyperplasia and these cases are difficult to diagnose on cytology alone. [19]

NHL is the most common neoplasm in the middle mediastinum and 15 to 25 % of peripheral lymphoma involves the mediastinal lymph node. [20] Dissociated population of immature lymphoid cells indicates the possibility of NHL. The presence of lympoglandular bodies in the background indicates the lymphoid origin of the cells. The dissociated lymphoid cells with convoluted nuclei, fine powdery chromatin and inconspicuous nucleoli are seen in lymphoblastic NHL. In large cell NHL, the smears show dissociated large lymphoid cells with fine chromatin and regular to convoluted nuclei [Figure 4]. [21] The cells are usually B-NHL. Extensive sclerosis in mediastinal sclerosing B-NHL may prevent to yield good diagnostic material. In fact extensive sclerosis may distort the cells to such an extent that NHL may be mistaken as soft tissue sarcoma, thymoma or metastatic spindle cell malignancy. [22],[23],[24]
Figure 4: Dissociated large lymphoid cells with fine chromatin and regular to convoluted nuclei in large cell non Hodgkin's lymphoma (May Grunwald Giemsa stain, ×480)

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Nodular sclerosis Hodgkin's lymphomas may not yield good diagnostic material due to fibrosis and there may be lack of diagnostic Reed Sternberg cells. [22] Rarely the other uncommon lesions such as Castleman's disease or extra- medullary haemopoiesis may be seen as mass lesions in the mediastinum. [25],[26] FNAC smears of the metastatic small cell carcinoma usually show dissociated cells with round to oval nuclei having minimal cytoplasm. Frequent crushing artifacts, nuclear molding and single rows of cells indicate the possibility of small cell carcinoma.

Predominant Population of Epithelial or Non-Lymphoid Cells

Predominant populations of non-lymphoid cells are present in thymoma, germ cell tumor, neuroblastoma, metastatic carcinomas, and nodular sclerosis Hodgkin's lymphoma. FNAC smears of germinoma show dual population of poorly cohesive cells consisting of malignant germ cells and reactive lymphoid cells in a tigroid (striped) background. Individual cells are large with prominent nuclei having clear cytoplasm due to glycogen accumulation. Small mature lymphocytes may be seen in the background. [27] Discrete large cells with prominent nucleoli, vacuolated foamy appearance of the background and fragile cells with chromatin threading may raise the suspicion of a germinoma. Single and clusters of moderately pleomorphic cells with multiple large prominent nucleoli along with background necrosis may raise the suspicion of embryonal carcinoma. Mediastinum is the most common extra gonadal site of primary germ cell tumor. [27] However, the possibility of metastasis must be excluded before the diagnosis of primary germ cell tumor in the mediastinum. It is important to note that the commonest primary germ cell tumor of the mediastinum is mature cystic teratoma. [27] FNAC of mature cystic teratoma yields pultaceous material and smears show discrete benign squamous cells on an acellular background.

FNAC smears of predominant epithelial subtypes of thymoma shows many clusters and also dissociated epithelial cells with plump round epithelial cells. Occasional cases of epithelial subtypes of thymoma may show atypical cytomorphology such as cellular overcrowding, dissociation and nuclear enlargement. [28] These cases should not be over diagnosed as thymic carcinoma.

At times it is extremely difficult to differentiate thymic carcinoma from metastatic carcinoma on basis of cytomorphology. Lung is the commonest primary source of metastatic carcinoma followed by breast and prostrate, testis and skin [Figure 5]. Predominantly dissociated and occasional clusters of round to oval cells along with rosette formation are noted in neuroblastoma. Nuclei of the cells are round with fine chromatin and inconspicuous nucleoli. Background of the smear shows the striking absence of lymphoglandular bodies.
Figure 5: Round to oval cells with brownish melanin pigment in metastatic melanoma (H and E, ×480)

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Predominant Spindle Cell Morphology

FNAC smears of predominant spindle cell morphology could be categorized as

  • Lesions in which the spindle cell component represents reactive components such as the fibroblasts in solitary fibrous tumor of the mediastinum [29],[30] fibromatosis [31] and idiopathic fibrosing mediastinitis. [32]
  • Lesions in which the spindle cell components are the part of benign neoplasm, such as spindle cell thymoma, benign nerve sheath tumor etc.
  • Lesions consisted of malignant spindle cells such as, malignant schwannoma, squamous cell carcinoma, diffuse large cell NHL with sclerosis, metastatic malignant melanoma, pleomorphic liposarcoma and myxoid liposarcoma [Table 2]. [13],[33],[34],[35]
    Table 2: Differential diagnosis of predominant spindle cell lesions in mediastinum

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Oval to elongated spindle cells in small clusters along with mature lymphocytes in the background is usually noted in spindle cell variant of thymoma. The common neurogenic tumors in the mediastinum are neurofibromas, schwannomas, and malignant peripheral nerve sheath tumors. [36] The presence of large number of clusters and dissociated spindle cells with moderate nuclear pleomorphism and kinking nuclei indicate spindle cell tumors probably of nerve sheath origin. Cellular pleomorphism, bizarre cells and mitotic activities indicate the possibility of malignant tumor [Figure 6].
Figure 6: Bunch of spindle cells with moderately pleomorphic nuclei and bizarre cell in a malignant peripheral nerve sheath tumors. (May Grunwald Giemsa stain, ×480)

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In mediastinal sclerosing B-NHL the smears show discrete immature lymphoid cells with oval to spindle cells. Background shows lymphoglandular bodies. Extensive sclerosis in mediastinal sclerosing B-NHL may prevent yielding good diagnostic material. In fact extensive sclerosis may distort the cells to such an extent that NHL may be mistaken as soft tissue sarcoma, thymoma or metastatic malignancy with spindle cell morphology. [22],[23],[24]

Pleomorphic Cell Population

Predominant pleomorphic cell population may be noted in anaplastic large cell lymphoma (ALCL), lymphocytic depletion type of Hodgkin's lymphoma, metastatic poorly differentiated carcinoma and choriocarcinoma.

Large number of dissociated large pleomorphic cells, along with background lymphoglandular bodies, may raise the suspicion of anaplastic large cell lymphoma. In Hodgkin's lymphoma the large pleomorphic lobulated cells may be noted, however, the number of such cells is less. Metastatic poorly differentiated carcinoma may also show large number of pleomorphic cells. However, the malignant cells often show cohesive clusters. Choriocarcinoma often exhibits large pleomorphic bizarre cells and multinucleation. [37] These cells are admixed with smaller mononucleated cyto and intermediate trophoblasts. Background usually shows necrosis. The malignant syncytiotrophoblasts have abundant cytoplasm with frequent bi-nucleation.

No Specific Morphologic Pattern

There are many other lesions in the mediastinum which are difficult to put in a specific group. These lesions consist of intrathoracic goiter, parathyroid adenomas, lipoma, bronchogenic cyst, paravertebral abscess etc. [38],[39],[40]


   Step 4: Ancillary Techniques Top


A battery of ancillary investigations may be needed for diagnosis of mediastinal tumors [Figure 7].
Figure 7: Ancillary techniques in mediasti nal tumors

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Immunocytochemistry

It could be done either on alcohol fixed smears or cell block sections. Cell block is preferable for immunocytochemistry. [Figure 7] highlights the significance of positivity of different antibodies in the diagnosis of mediastinal tumors. [13],[41],[42],[43]

Flow Cytometric Immunophenotyping

This may be helpful in diagnosis and classification of non Hodgkin's lymphomas. [43] It is advisable to have a panel of immunostain on suspected case of NHL.

Electron Microscopy

Electron microscopy may be helpful in diagnosing the different mediastinal tumors. [44] It may be particularly helpful diagnosing metastatic squamous cell carcinoma, neuroblastoma or thymomas.

Biochemical Estimation

Raised level of alpha feto protein may be helpful in endodermal sinus tumors. Similarly, high level of HCG is helpful in diagnosis of choriocarcinomas.

Microbial Culture

A portion of the aspirate could be kept for microbial culture. Depending on the initial FNAC smear the sample should be processed.


   Discussions Top


Mediastinum is involved by a variety of primary and metastatic tumors. Majority of the mediastinal tumors are not unique in this region and can be found in other parts of the body, with the exception of thymic lesions. Tumors in this region have variable therapeutic management and prognosis and hence it is very important to reach the correct diagnosis by FNAC of mediastinal lesions. Shabb et al. [3] obtained adequate material in a study of 42 cases of FNAC of mediastinal lesions and were able to reach in correct diagnosis in 86% of cases. There was only one false negative case. Singh et al, [1] reported only 12 (6%) discordant cases out of 189 cases of mediastinal FNAC. There was no false positive case in that study. The errors were mainly due to misdiagnosis of small cell carcinoma for lymphoma, differentiating primary germ cell tumors from metastatic carcinoma, and misinterpretation of large cell lymphomas as mesenchymal tumor because of distortion of cells by the mesenchymal tissue.

In a recent study, Desai et al. [7] report the sensitivity and specificity of diagnosis of mediastinal lesions by FNAC as 88 and 82% respectively. They considered FNAC to be a highly effective technique in diagnosing mediastinal tumors. In a two-year period a total of 80 cases of mediastinal FNAC were encountered by us. In all these cases FNAC was done either under the guidance of USG or CT scan. In a total of 58 cases (72.5%) a conclusive diagnosis was offered on FNAC material. The commonest tumor diagnosed by FNAC was metastatic carcinoma (23), followed by thymomas (8), NHL (8), primary malignant germ cell tumor (2), HL (2), nerve sheath tumor (1) and miscellaneous group with variable diagnosis (13). We did not encounter any complications due to FNAC.

The mediastinum is surrounded by many vital structures such as heart and great vessels. Therefore many precautions are needed to perform FNAC of the mediastinal lesions. In fact, a team of experts consisting of radiologists, cytologists, physicians and surgeons is required to perform mediastinal FNAC. Rarely complications such as surgical emphysema, mediastinitis, and hemorrhage have been reported. [45],[46],[47] Usually ultrasonologically guided, CT or fluoroscopic guided FNAC are performed. However, the other techniques such as transesophageal or transbronchial endoscopic guided mediastinal FNAC are also popular. These techniques yield equally good material with low risk compared to the conventional CT or USG guided FNAC. [48],[49],[50]

Initial assessment of clinical features and radiological data narrows down the probable diagnostic categories of mediastinal tumors. This may help the cytologist to determine the future course of action during the time of FNAC procedure. Aspirated material should be collected for cell block, flow cytometry, electron microscopy and microbial culture. Sections from the cell block could be used for immunocytochemistry and this is one of the corner stones in ancillary technique. Material collected for flow cytometry could be processed after the initial diagnosis of NHL is confirmed on FNAC smears. This stepwise logistic approach is very helpful in major diagnostic categorization of mediastinal tumors. However, it is not free from pitfalls. On cytology smears, it is impossible to differentiate thymoma from malignant thymoma. [51] Malignant thymoma may not show significant nuclear enlargement and pleomorphism, however on histology section distinct capsular invasion may be evident. The demonstration of DNA aneuploidy may be helpful in distinguishing malignant thymoma from its benign counterpart. [52] In contrary, FNAC of thymic carcinoma shows significant nuclear enlargement, nuclear pleomorphism and background necrosis [18],[51] and therefore it is possible to suggest the diagnosis of thymic carcinoma on FNAC smears. Occasionally there may be difficulties in distinguishing thymic carcinoma from a metastatic poorly differentiated carcinoma purely on the basis of cytomorphology and immunocytochemistry. [18] Clinical history of primary malignancy is very helpful in this situation.

Sampling error is a major hurdle in the diagnosis of mediastinal lesions. [1],[3] Tumors of the mediastinum may show necrosis, inflammation and fibrosis on FNAC smears. Needle may hit in the non-viable area and the quality of the material may be sub-optimal. Tumor heterogeneity particularly in case of mixed germ cell tumors may also pose diagnostic challenge. [3]


   Conclusions Top


In summary, mediastinum is the site of a large variety of primary and metastatic tumors. Many of the lesions are unique with clinical features, radiological localization, and cytomorphology. Additional investigations such as immunocytochemistry, flow cytometric immunophenotyping, and tumor markers may help in further confirmation in diagnosis. Stepwise algorithmic approach provides more definitive diagnosis in majority of the cases.

 
   References Top

1.Singh HK, Silverman JF, Powers CN, Geisinger KR, Frable WJ. Diagnostic pitfalls in fine -needle aspiration biopsy to the mediastinum. Diagn cytopathol 1997;17:121-6.  Back to cited text no. 1      
2.Linder J, Olsen GA, Johnston WW. Fine needle aspiration biopsy of the mediastinum. Ann Intern Med 1986;81:1005-8.  Back to cited text no. 2      
3.Shabb NS, Fahl M, Shabb B, Haswani P, Zaatari G. Fine-needle aspiration of the mediastinum: A clinical, radiologic, cytologic, and histologic study of 42 cases. Diagn Cytopathol 1998;19:428-36.  Back to cited text no. 3      
4.Wakely PE Jr. Cytopathology-histopathology of the mediastinum: Epithelial, lymphoproliferative, and germ cell neoplasms. Ann Diagn Pathol 2002;6:30-43.   Back to cited text no. 4      
5.Geisinger KR. Differential diagnostic considerations and potential pitfalls in fine-needle aspiration biopsies of the mediastinum. Diagn Cytopathol 1995;13:436-42.  Back to cited text no. 5      
6.Assaad MW, Pantanowitz L, Otis CN. Diagnostic accuracy of image-guided percutaneous fine needle aspiration biopsy of the mediastinum. Diagn Cytopathol 2007;35:705-9.  Back to cited text no. 6      
7.Desai F, Shah M, Patel S, Shukla SN. Fine needle aspiration cytology of anterior mediastinal masses. Indian J Pathol Microbiol 2008;51:88-90.  Back to cited text no. 7  [PUBMED]  Medknow Journal  
8.Goel D, Prayaga AK, Sundaram C, Raghunadharao D, Rajappa SJ, Rammurti S, et al. Utility of fine needle aspiration cytology in mediastinal lesions: A clinicopathologic study of 1617 cases from a single institution. Acta Cytol 2008;52:404-11.  Back to cited text no. 8      
9.Crapo JD, Glassroth J, Karlinsky J. Baum's textbook of pulmonary diseases. Philadelphia, PA: Lippincott Williams and Wilkins 2004. p. 883-912.  Back to cited text no. 9      
10.Duwe BV, Sterman DH, Musani AI. Tumors of the mediastinum. Chest 2005;128:2893-909.  Back to cited text no. 10      
11.Engels EA, Pfeiffer RM. Malignant thymoma in the united states: Demographic patterns in incidence and associations with subsequent malignancies. Int J Cancer 2003;105:546-51.  Back to cited text no. 11      
12.Rosai J. Histological typing of tumours of the thymus. Berlin: Springer; 1999.   Back to cited text no. 12      
13.Ali SZ, Erozan YS. Thymoma. Cytopathologic features and differential diagnosis on fine needle aspiration. Acta Cytol 1998;42:845-54.  Back to cited text no. 13      
14.Chhieng DC, Rose D, Ludwig ME, Zakowski MF. Cytology of thymomas: Emphasis on morphology and correlation with histologic subtypes. Cancer 2000;90:24-32.  Back to cited text no. 14      
15.Tao LC, Pearson FG, Cooper JD, Sanders DE, Weisbrod G, Donat EE. Cytopathology of thymoma. Acta Cytol 1984;28:165-70.  Back to cited text no. 15      
16.Wakely PE Jr. Cytopathology of thymic epithelial neoplasms. Semin Diagn Pathol 2005;22:213-22.  Back to cited text no. 16      
17.Kuo TT, Chan JK. Thymic carcinoma arising in thymoma is associated with alterations in immunohistochemical profile. Am J Surg Pathol 1998;22:1474-81.  Back to cited text no. 17      
18.Shin HJ, Katz RL. Thymic neoplasia as represented by needle aspiration biopsy of anterior mediastinal masses: A practical approach to the differential diagnosis. Acta Cytol 1998;42:855-64.  Back to cited text no. 18      
19.Bangerter M, Behnisch W, Griesshammer M. Mediastinal masses diagnosed as thymus hyperplasia by fine needle aspiration cytology. Acta Cytol 2000;44:743-7.  Back to cited text no. 19      
20.Strickler JG, Kurtin PJ. Mediastinal lymphoma. Semin Diagn Pathol 1991;8:2-13.  Back to cited text no. 20      
21.Hughes JH, Katz RL, Fonseca GA, Cabanillas FF. Fine-needle aspiration cytology of mediastinal non-Hodgkin's nonlymphoblastic lymphoma. Cancer 1998;84:26-35.  Back to cited text no. 21      
22.Silverman JF. Raab SS, Park HK. Fine needle aspiration cytology of primary large-cell lymphoma of the mediastinum: Cytomorphologic findings with potential pitfalls in diagnosis. Diagn Cytopathol 1993;9:209-15.  Back to cited text no. 22      
23.Sterrett G, Whitaker D, Shiilkin KB, Walters NI. The fine needle aspiration cytology of mediastinal lesions. Cancer 1983;51:127-35.  Back to cited text no. 23      
24.Yu GH, Salhany KE, Gokaslan ST, Cajulis RS, De Frias DV. Thymic epithelial cells as a diagnostic pitfall in the fine-needle aspiration diagnosis of primary mediastinal lymphoma. Diagn Cytopathol 1997;5:460-5.  Back to cited text no. 24      
25.Meyer L, Gibbons D, Ashfaq R, Vuitch F, Saboorian MH. Fine-needle aspiration findings in Castleman's disease. Diagn Cytopathol 1999;21:57-60.  Back to cited text no. 25      
26.Sαenz-Santamarνa J, Catalina-Fernandez I. Fine needle aspiration diagnosis of extramedullary hematopoiesis resembling mediastinal and paravesical tumors: A report of 2 cases. Acta Cytol 2004;48:95-8.  Back to cited text no. 26      
27.Dehner LP. Germ cell tumors of the mediastinum. Semin Diagn Pathol 1990;7:266-84.  Back to cited text no. 27      
28.Riazmontazer N, Bedyat G, Izadi B. Epithelial cytologic atypia in a fine needle aspirate of an invasive thymoma: A case report. Acta Cytol 1992;36:387-90.  Back to cited text no. 28      
29.Witkin GB, Rosai J. Solitary fibrous tumor of the mediastinum: A report of 14 cases. Am J Surg Pathol 1989;13:547-57.  Back to cited text no. 29      
30.England DM, Hochholzer L, McCarthy MJ. Localized benign and malignant fibrous tumors of the pleura: A cliniopathologic review of 223 cases. Am J Surg Pathol 1989;13:640-58.  Back to cited text no. 30      
31.Pachter MR, Latters R. Mesenchymaltumors of the mediastinum: I, Tumors of fibrous tissue, adipose tissue, smooth muscle and striated muscle. Cancer 1963;16:95-107.  Back to cited text no. 31      
32.Light AM. Idiopathic fibrosis of mediastinum: A discussion of three cases and review of the literature. J Clin Pathol 1978;31:78-88.  Back to cited text no. 32      
33.Suster S, Moran CA. Spindle cell thymic carcinoma: Clinicopathologic and immunohistochemical study of a distinctive variant of primary thymic epithelial neoplasm. Am J Surg Pathol 1999;6:691-700.  Back to cited text no. 33      
34.Slagel DD, Powers CN, Melaragno MJ, Frable WJ, Silverman JF. Spindle-cell lesions of the mediastinum: Diagnosis by fine needle aspiration biopsy. Diagn Cytopathol 1997;17:167-76.  Back to cited text no. 34      
35.Bavi P, Shet T, Gujral S. Malignant melanoma of mediastinum misdiagnosed as a spindle cell thymoma in a fine needle aspirate: A case report. Acta Cytol 2005;49:424-6.  Back to cited text no. 35      
36.Reeder LB. Neurogenic tumors of the mediastinum. Semin Thorac Cardiovasc Surg 2000;12:261-7.  Back to cited text no. 36      
37.Collins KA, Giesinger KR, Wakely P Jr, Olympia GA, Silverman JF. Extragonadal germ cell tumors: A fine-needle aspiration biopsy study. Diagn Cytopathol 1995;12:223-9.  Back to cited text no. 37      
38.Strollo DC, Rosado-de- Christenson ML, Jett JR. Primary mediastinal tumors: Part I, Tumors of the anterior mediastinum. Chest 1997;112:511-22.  Back to cited text no. 38      
39.Clark O. Medastinal parathyroid tumors. Arch Surg 1988;123:1096-100.  Back to cited text no. 39      
40.Wong NA, Mihai R, Sheffield EA, Calder CJ, Farndon JR. Imprint cytology of parathyroid tissue in relation to other tissues of the neck and mediastinum. Acta Cytol 2000;44:109-13.   Back to cited text no. 40      
41.Beckstead JH, Alkaline phosphatase histochemistry in human germ cell neoplasm. Am J Surg Pathol 1983;7:341-9.  Back to cited text no. 41      
42.Yatabe Y, Mitsudomi T, Takahashi T. TTF-1 expression in pulmonary adenocarcinomas. Am J Surg Pathol 2002;26:767-73.  Back to cited text no. 42      
43.Dey P, Amir T, Jassar AI, Shemmari AI, Jogai S, Bhat G, et al. Combined applications of fine needle aspiration cytology and Flow cytometric immunphenotyping for diagnosis and classification of non Hodgkin Lymphoma. Cyto Journal 2006;3:24.  Back to cited text no. 43      
44.Neill JS, Silverman JF. Electron microscopy of fine-needle aspiration biopsies of the mediastinum. Diagn Cytopathol 1992;8:272-7.  Back to cited text no. 44      
45.Adler OB, Rosenberger A, Peleg H. Fine-needle aspiration biopsy of mediastinal masses: Evaluation of 136 experiences. AJR Am J Roentgenol 1983;140:893-6.  Back to cited text no. 45      
46.Sinner WN. Directed fine needle biopsy of anterior and middle mediastinal masses. Oncology 1985;42:92-6.   Back to cited text no. 46      
47.Westcott JL. Percutaneous needle aspiration of hilar and mediastinal masses. Radiology 1981;141:323-9.  Back to cited text no. 47      
48.Panelli F, Erickson RA, Prasad VM. Evaluation of mediastinal masses by endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol 2001;96:401-8.  Back to cited text no. 48      
49.Kramer H, Sanders J, Post WJ, Groen HJ, Suurmeijer AJ. Analysis of cytological specimens from mediastinal lesions obtained by endoscopic ultrasound-guided fine-needle aspiration. Cancer 2006;108:206-11.  Back to cited text no. 49      
50.Giovannini M, Seitz JF, Monges G, Perrier H, Rabbia I. Fine-needle aspiration cytology guided by endoscopic ultrasonography: Results in 141 patients. Enoscopy 1995;27:171-7.  Back to cited text no. 50      
51.Finley JL, Silverman JF, Strausbauch PH, Dobbs DJ, West RL, Weaver MD, et al. Malignant thymic neoplasm: Diagnosis by fine needle aspiration biopsy with histological, immunocytochemical, and ultrastructural confirmation. Diagn Cytopathol 1986;2:118-25.  Back to cited text no. 51      
52.Kuo TT, Lo SK. DNA flow cytometric study of thymic epithelial tumors with evaluation of its usefulness in the pathologic classification. Hum Pathol 1993;24:746-9.  Back to cited text no. 52      

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Correspondence Address:
Pranab Dey
Department of Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh-160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.68241

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