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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 143-145

Fine-needle aspiration cytology of follicular dendritic cell sarcoma of cervical lymph node: A challenging diagnosis


Department of Pathology, Faculty of Medicine, Menoufia University, Shebein Elkom, Egypt

Date of Web Publication30-Aug-2019

Correspondence Address:
Dr. Asmaa Gaber Abdou
Department of Pathology, Faculty of Medicine, Menoufia University, Shebein Elkom
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JMAU.JMAU_57_18

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  Abstract 


Follicular dendritic cell sarcoma (FDCS) is a rare malignant tumor that could arise in both nodal and extranodal sites, with only nine previously reported cases demonstrating cytologic features. In this report, we describe a case of FDCS in a 60-year-old female who presented with neck mass. Fine-needle aspiration cytology and subsequent core biopsy were suggestive of metastatic carcinoma. The cytologic features were epithelioid-to-spindle cell morphology, vesicular nuclei, prominent nucleoli, intranuclear inclusions, and occasional binucleated and multinucleated forms. However, absence of cytokeratin expression was against the diagnosis of metastatic carcinoma. The definitive diagnosis was reached by the demonstration of CD21 and CD23 expression. The pathologist should be aware of this rare malignant tumor, especially its cytologic features in aspirated material. The differential diagnosis in the above case was metastatic carcinoma, melanoma, and malignant granular cell tumor. The demonstration of expression of one or more dendritic cell marker is the clue for the diagnosis, which could be applied on cytological preparations with sufficient material.

Keywords: CD21, CD23, follicular dendritic cell sarcoma, fine-needle aspiration cytology, neck swelling


How to cite this article:
Abdou AG, Asaad N, Aiad H, Shams A, Said A, Eldein MS. Fine-needle aspiration cytology of follicular dendritic cell sarcoma of cervical lymph node: A challenging diagnosis. J Microsc Ultrastruct 2019;7:143-5

How to cite this URL:
Abdou AG, Asaad N, Aiad H, Shams A, Said A, Eldein MS. Fine-needle aspiration cytology of follicular dendritic cell sarcoma of cervical lymph node: A challenging diagnosis. J Microsc Ultrastruct [serial online] 2019 [cited 2019 Nov 16];7:143-5. Available from: http://www.jmau.org/text.asp?2019/7/3/143/256309




  Introduction Top


Follicular dendritic cell sarcoma (FDCS) is a rare malignant tumor that could arise in both nodal and extranodal sites. It is a nonlymphoid primary nodal malignant tumor that has an indolent course.[1] Some studies demonstrated the liability for recurrence and metastasis of FDCS and therefore, it has been viewed as an intermediate-grade malignancy.[2] There are limited number of studies that investigated the cytologic features of FDCS in fine-needle aspiration cytology[3],[4],[5],[6],[7],[8],[9],[10] [Table 1]. In this report, we describe a case of FDCS in a female aged 60 years who presented with neck mass, demonstrating the common pitfalls and differential diagnosis.
Table 1: Summary of published articles concerning fine-needle aspiration cytology of follicular dendritic cell sarcoma

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  Case Report Top


A 60-year-old female patient presented with right lateral neck swelling before 5 years. Computed tomography and magnetic resonance imaging suggested a neoplasm with neurogenic features and recommended biopsy. Fine-needle aspiration cytology revealed cohesive clusters of malignant epithelioid cells that showed abundant eosinophilic cytoplasm and pleomorphic vesicular nuclei with prominent nucleoli and intranuclear inclusions [Figure 1]. Occasional binucleation and multinucleation forms were seen [Figure 1]. Positive for malignant epithelial cells, suggestive of metastatic carcinoma was the diagnosis of cytology specimen. The patient was further submitted to ultrasound-guided trucut biopsy that revealed rim of lymphocytes admixed with sheets of malignant ovoid-to-spindle-shaped cells that showed syncytial pattern with indistinct cell borders together with whorly pattern of arrangement, similar to that seen in meningioma [Figure 2]. The diagnosis was made as a metastatic carcinoma for clinical and radiological correlation. However, clinically and after extensive investigation, no primary origin was detected. The core was submitted to cytokeratin (CK) and S100 staining. The tumor cells were negative for CK and positive for S100 [Figure 2]d. At this time, the patient was submitted to complete excision of the mass and excision of two deep cervical lymph nodes. Again, the histological picture of the excised mass was similar to that seen in core biopsy with confirmation of lymph node architecture replaced by this type of malignancy. The other excised deep cervical lymph nodes showed picture of Castleman's disease. The latter attracts the attention for the possibility of primary lymph node malignancy which arises on the top of Castleman's disease; therefore, CD21 [Figure 3]a and CD23 [Figure 3]b were investigated which showed positive expression with a final diagnosis of FDCS. A written consent was taken from the patient to publish her case.
Figure 1: Cytology of aspirated cervical lymph node formed of cohesive sheets of epithelioid cells (a) that showed eosinophilic cytoplasm and occasional intranuclear inclusion (b, red circle) and binucleated or multinucleated forms (c and d, red circles) (H and E, ×100 for a and ×200 for b-d)

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Figure 2: Core biopsy showing peripheral lymphocytic infiltrate adjacent to the malignant sheets of cells (a) that were arranged in syncytial sheets with whorly pattern (b) and formed of epithelioid cells with occasional spindling (c) (H and E ×100 for a and ×200 for b and c). Nuclear and cytoplasmic immunoreactivity for S100 (immunohistochemical, ×400)

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Figure 3: The malignant cells showing focal faint expression for CD21 (a) and strong expression for CD23 (b) (immunohistochemical, ×400 for a and ×200 for b)

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  Discussion Top


FDCS is commonly presented as neck mass similar to that reported in the present case. The cytologic features seen in the present case simulate that described in the previous studies[3],[4],[5],[6],[7],[8],[9],[10] including syncytial and discohesive large epithelioid-to-spindled malignant cells with intranuclear inclusions and presence of binucleated and multinucleated forms. The cytology of FDCS represents a true challenge to reach a proper diagnosis, and it could be easily misdiagnosed as metastatic carcinoma as in the present study and in others.[1],[5] We agreed with others that the diagnosis of FDCS is made after the demonstration of positivity for dendritic cell markers such as CD21, CD23, and CD35. We demonstrated positive expression for CD21 and CD23, which could be focal and not necessarily diffuse, agreeing with Yin et al., 2010.[11] We agreed with the latter study[11] in demonstrating S100 expression. The main differential diagnosis is from metastatic carcinoma, melanoma, and malignant granular cell tumor which are excluded by negativity for CK and HMB45, and although the present case showed S100 expression, it also showed positivity for dendritic cell markers. The latter positivity differentiates it from malignant granular cell tumor. FDCS could arise on the top of Castleman's disease, similar to that seen in the present case.[12] The etiology is unknown in most cases; however, some authors have found an association with Epstein–Barr virus by its detection by in situ hybridization.[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wang XI, Zhang S, Thomas JO, Adegboyega PA. Cytomorphology, ultrastructural, and cytogenetic findings in follicular dendritic cell sarcoma: A case report. Acta Cytol 2010;54:759-63.  Back to cited text no. 1
    
2.
Pisani F, Marino M, Sentinelli S, Petti MC. Follicular dendritic cell sarcoma of the neck: Report of a case treated by surgical excision and COP plus (PEG)-liposomal doxorubicin. J Exp Clin Cancer Res 2008;27:33.  Back to cited text no. 2
    
3.
Gaffney RL, Feddersen RM, Bocklage TJ, Joste NE. Fine needle aspiration cytology of follicular dendritic cell sarcoma. Report of a case with cytologic detection in an extranodal site. Acta Cytol 2000;44:809-14.  Back to cited text no. 3
    
4.
Vicandi B, Jiménez-Heffernan JA, López-Ferrer P, Viguer JM. Fine needle aspiration cytology of follicular dendritic cell sarcoma. A case report. Acta Cytol 2000;44:1106-10.  Back to cited text no. 4
    
5.
Loo CK, Henderson C, Rogan K. Intraabdominal follicular dendritic cell sarcoma: Report of a case with fine needle aspiration findings. Acta Cytol 2001;45:999-1004.  Back to cited text no. 5
    
6.
Ren R, Sun X, Staerkel G, Sneige N, Gong Y. Fine-needle aspiration cytology of a liver metastasis of follicular dendritic cell sarcoma. Diagn Cytopathol 2005;32:38-43.  Back to cited text no. 6
    
7.
Fan YS, Ng WK, Chan A, Chan GS, Tsang J, Chim CS, et al. Fine needle aspiration cytology in follicular dendritic cell sarcoma: A report of two cases. Acta Cytol 2007;51:642-7.  Back to cited text no. 7
    
8.
Granados R, Aramburu JA, Rodríguez JM, Nieto MA. Cytopathology of a primary follicular dendritic cell sarcoma of the liver of the inflammatory pseudotumor-like type. Diagn Cytopathol 2008;36:42-6.  Back to cited text no. 8
    
9.
Tokyol C1, Yilmaz MD, Ekici O, Aktepe F. Follicular dendritic cell sarcoma: A case report. Acta Cytol 2008;52:235-9.  Back to cited text no. 9
    
10.
Kure K, Khader SN, Suhrland MJ, Ratech H, Grossberg R, Oktay MH, et al. Fine needle aspiration of follicular dendritic cell sarcoma in an HIV-positive man: A case report. Acta Cytol 2010;54:707-11.  Back to cited text no. 10
    
11.
Yin WH, Yu GY, Ma Y, Rao HL, Lin SX, Shao CK, et al. Follicular dendritic cell sarcoma: A clinicopathologic analysis of ten cases. Zhonghua Bing Li Xue Za Zhi 2010;39:522-7.  Back to cited text no. 11
    
12.
Amin Z, Suhaimi Y, Ahmad R. Head and neck follicular dendritic cell sarcoma: Disease associations and treatment review. Med J Malaysia 2010;65:77-9.  Back to cited text no. 12
    


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