Letters to the Editors

IN answer to Mr. Meyer's letter on this subject, I can only say that the question of the dependence of Left-handedness on abnormality of the subclavian artery cannot be settled by the authority of even so eminent an anatomist as Professor Hyrtl, when it is adduced against the facts I mentioned in my last note. That there have been cases like that quoted from Dr. Buchanan of transposition of viscera and left-handedness occurring in the same individual, and that they will be observed again, I do not doubt. Otherwise the conclusion would be that such abnormalities prevent left-handedness, which no one pretends. What I venture to think the cases already on record prove is, that the one condition has no relation to the other in either causing or preventing it.


Disseminated Cryptococcosis Mimicking Metastatic Carcinoma: Diagnosis by Fine Needle Aspiration Cytology
To the Editors: Cryptococcosis is one of the first and most common opportunistic infections encountered in AIDS. 1 Meningeal symptoms related to central nervous system involvement represent the usual clinical presentation. A high rate of relapse (50-60%) after the initial infection is reported in HIV patients with low CD4 counts. 2 The atypical clinical scenario in recrudescence often hinders early diagnosis and prompt treatment. Fine needle aspiration (FNA) is increasingly becoming the initial diagnostic modality in unsuspected cases of opportunistic infections in immunocompromised individuals. 3,4 We present a case of relapsed and disseminated cryptococcosis with a dominant pancreatic mass clinically mimicking metastatic carcinoma. The diagnosis was established by FNA.
A 35-year-old woman with a history of HIV for nine years and a CD4 count of 38 cells/mm 3 presented with midepigastric pain of several weeks" duration. She had been treated for cryptococcal meningitis four months prior to her presentation and was on prophylactic antifungal and antiretroviral medications. Computed tomography (CT) scan of the abdomen revealed a mass in the head of the pancreas. Several smaller masses were identified in the splenic hilar region. CT of the chest showed bilateral multiple small lung nodules and hilar/mediastinal lymphadenopathy. The findings raised the clinical suspicion of metastatic carcinoma from a pancreatic primary. CT-guided percutaneous FNA of the pancreatic mass was performed using a 19-gauge needle. Three passes were made, smeared onto glass slides (Diff-Quik and Papanicolaou stained) and rinsed into RPMI for cell block sections (hematoxylin and eosin stained).
Smears and cell block sections showed numerous yeasts singly and in small aggregates. There was minimal accompanying inflammation. The yeast forms measured 4-6 µm in diameter and had thick walls with occasional single, narrow-based bud-

Giardia lamblia Presenting as a Right Iliac Fossa Mass
To the Editors: Giardia lamblia is the most common intestinal pathogen worldwide 5 and usually presents with nonspecific symptoms, like postprandial distress, nausea, cramping abdominal pain and diarrhea. 5 The diagnosis is most reliable on morphologic identification of the trophozoites in duodenal aspirates or biopsies or on cysts in stool rather than antibody detection by enzyme-linked immunosorbant assay or immunofluorescence. 5 The trophozoites characteristically localize in the proximal small intestine. 1 Localization at other sites, like stomach, 1,6 gallbladder, 2 terminal ileum 3,6 and colon, 4,6 has also been 280 Acta Cytologica Letters to the Editors ding. On Diff-Quik-stained slides, the organisms stained deep magenta, with a clear halo ( Figure 1). On Papanicolaou-stained smears the organisms were pale green to colorless, with refractile, thick walls and a peripheral, clear halo ( Figure 2). Mucicarmine highlighted the mucin capsule ( Figure 3). A diagnosis of pancreatic cryptococcoma was made.
Cryptococcus neoformans is a cause of self-limited pneumonitis in healthy individuals and potentially disseminated, life-threatening infection in immunocompromised patients. 2 Although the central nervous system and lungs are the sites involved most frequently in AIDS, virtually any organ can be infected, either alone or in combination with pulmonary or cerebral cryptococcosis. The advent of highly active antiretroviral therapy has modified the natural history of AIDS-related infections, leading to unusual clinical presentations of common pathogens seen in this group of patients. 5,6 C neoformans can be readily identified in smears with its typical morphology. The diagnostic challenge in this case was the clinical aspect, with the absence of active central nervous system disease and the perplexing imaging findings simulating metastatic carcinoma. Moreover, since the patient was on prophylactic antifungal agents, a clinical diagnosis of disseminated cryptococcosis was not entertained. All lesions regressed following therapy, confirming that the lymphadenopathy and lung lesions were also due to cryptococcosis.
FNA has proven to be extremely useful in the diagnosis of opportunistic infections in immunocompromised individuals. 3,4,7 Diagnosis of cryptococcosis by FNA has been reported in various organs, including thyroid, lung and spleen. 8 Recently Yang described a case of Pneumocystis carinii infection presenting as a common bile duct mass in an HIVpositive patient with no pulmonary involvement. 3 As such, an infectious etiology should be strongly considered in the differential diagnosis of a mass lesion in immunocompromised patients. This case highlights that cryptococcal infection can recur at unusual sites with dissemination in HIV patients on prophylactic medications.  Letters to the Editors reported occasionally. Diagnosis in the terminal ileum and cecum in these reports was done on colonoscopic biopsies. In a study of 567 positive cases on histopathologic biopsies for Giardia trophozoites, Obserhuber 6 reported the following distribution: duodenal, 82.5%; jejunal, 2.1%; gastric antrum, 8.7%; and ileal mucosa, 12.1%; colon, 0.4%. The present case in an unusual manifestation of G lamblia infection presenting as a right iliac fossa lump diagnosed by fine needle aspiration cytology (FNAC).
A 39-year-old, multiparous female presented to the gynecologic outpatient department with a moderate fever associated with chills, moderate to severe abdominal pain in the right iliac fossa region and vomiting for three days. There was no history of loose stool, with or without blood and mucus, or of vaginal discharge. On examination there was diffuse tenderness in the right iliac fossa and lower abdomen. At vaginal examination the only positive finding was that the right fornix was full and tender. Laboratory investigations revealed mild polymorphonuclear leukocytosis and the presence of positive albumin and sugar in the urine, with no increase in pus cells. In Widal and other biochemical tests, no abnormality was detected.
With a clinical diagnosis of acute pelvic inflammatory disease, the patient was placed on broadspectrum antibiotics and tinidazole. Her pain and fever decreased, but a tender lump, 6 × 6 cm, developed in the right iliac fossa region three days later. Ultrasound showed a hypoechoic mass, 6 × 5 cm, with multiple cystic areas. The lower part of the mass was lying anterior to the right iliac vessels. The appendix and right ovary were not visualized properly. The patient was discharged on the same treatment for three more days.
On follow-up, a soft, mobile mass, 4 × 3 cm, persisted six weeks later. The mass was subjected to fine needle aspiration (FNA), which yielded scanty, fluidlike material with a few particles. Smears showed occasional intestinal epithelial cell clusters; scanty, mixed inflammatory cells; and numerous histiocytes. In addition, trophozoites of G lamblia were found scattered, particularly entangled in mucus ( Figure 1). No cyst was identified. Following FNA diagnosis, the patient underwent further laboratory investigation. Serum IgG and IgA levels were within normal limits. HIV serology was negative.
To our knowledge, this is the first case of its kind, where the patient presented with pain and fever followed by appearance of a right iliac fossa lump possibly due to G lamblia trophozoite infection and diagnosed by FNAC. The lump was mobile in the later part of the disease, suggesting that the disease had involved the terminal ileum rather than the ceccum. Stool examination showed numerous cysts of Giardia but no amebae. No trophozoites of either one were seen. Since the patient refused colonoscopy, it was not possible to pinpoint whether Giardia alone or with amebae had involved the cecum along with terminal ileum. The lump disappeared completely after a full course of metronidazole. Ultrasound 12 weeks later was normal. It is difficult to explain formation of the lump while the patient was on tinidazole.

Basement Membrane Substance in Adenomyoepithelioma of the Breast
To the Editors: Adenomyoepithelioma of the breast is a rare benign neoplasm characterized by a distinctive biphasic appearance composed of epithelial cells and myoepithelial cells. Recently we encountered a case of adenomyoepithelioma in which basement membrane substance was observed cytologically. The substance has been known as a feature of adenoid cystic carcinoma and collagenous spherulosis. To the best of our knowledge, there is no previous report describing the cytologic findings of the basement membrane substance in adenomyoepithelioma of the breast. A 61-year-old woman had a nodular lesion in the upper lateral area of the left breast measuring approximately 1.5 cm in diameter. Mammography showed a well-circumscribed, intracystic mass. Although fine needle aspiration was performed, a definitive diagnosis was not made because of insufficient material. Subsequently, extirpation of the mass was performed. We performed aspiration cytology on the resected mass before it was cut.
The smears revealed a biphasic pattern composed of cohesive epithelial clusters and numerous isolated naked cells (Figure 1). The clusters were composed of small cells with a high nuclear/cytoplasmic ratio. The nuclei were round or oval, and the chromatin was finely granular. Some clusters revealed a tubular structure containing inspissated proteinaceous material within the lumen. The nuclei of the isolated naked cells were round, oval, indented or bipolar and had distinct nucleoli. Rarely did the tumor cells represent faintly stained cytoplasm. In the background, dense hyaline material consistent with basement membrane substance was observed ( Figure 2). The material showed a variety  nosis of adenomyoepithelioma with basement membrane substance is adenoid cystic carcinoma and collagenous spherulosis. Adenoid cystic carcinoma shows a more-monotonous cell population and less-cohesive pattern in comparison with adenomyoepithelioma. Collagenous spherulosis is generally a nonpalpable mass, and hyaline material may have a fibrillar appearance, which was not seen in our case.
In cytology of the breast, basement membrane substance is seen not only in collagenous spherulosis and adenoid cystic carcinoma but may also be observed in adenomyoepithelioma. Letters to the Editors of shapes, such as round, cylindrical and membranous. Intranuclear cytoplasmic inclusions and mitotic figures were not observed. After the smears were destained by ethyl alcohol, they were immunocytochemically stained using anti-type IV collagen antibody (1 : 50, Dako, Glostrup, Denmark). All the dense hyaline material was positive for the antibody.
Histologically, the mass showed lobular structures composed of glandular epithelial cells and large, polygonal, clear cells located on the outside of the glandular epithelial cells. Biphasic tumor cell nests were surrounded by thick basement membrane substance (Figure 3). Immunohistochemically, the tumor cells forming glands were positive for high-molecular-weight keratin (34 β E12). The polygonal, clear cells were positive for S-100 protein and α-smooth muscle actin and negative for 34 β E12. The basement membrane substance was immunopositive for type IV collagen and laminin (1 : 50, Bio-Science, Emmenbrücke, Switzerland).
So far, few reports on the cytologic findings of adenomyoepithelioma of the breast have been published. [1][2][3][4] According to their descriptions, the cytologic features of the tumor include tubular clusters composed of two kinds of tumor cells, mild cell atypia, a clean background and intranuclear inclusion bodies. The cytologic findings in our case were essentially consistent with those of adenomyoepithelioma mentioned above except for the presence of the basement membrane substance. Although basement membrane substance has been observed histologically in adenomyoepithelioma, there is no report of cytologic observation.
The major consideration in the differential diag-

Melanin Pigment in Aspirates from Epidermal Cysts
To the Editors: Epidermal cysts are frequently subjected to fine needle aspiration (FNA), mainly to confirm the clinical opinion. The cytologic findings in epidermal cysts are rarely discussed, mostly because epidermal cysts are very common, innocuous lesions. Needless to say, though not discussed frequently, epidermal cysts are often cause for concern and may show worrisome epithelial atypia on FNA. 5 This letter discusses the finding of melanin pigment in an epidermal cyst. This may cause unnecessary worry unless the cytologist is aware that pigmented epidermal cysts are commonly found in darkskinned people. Both our patients were female, aged 35 and 40 years, with similar histories and clinical findings. Both presented with a swelling near the knee joint that had been present for three to four years. On clinical examination the swellings were 1.5-2 cm, round, soft and cystic. The clinical diagnosis in both patients was epidermal cyst. The patients, on inquiry, gave histories of repeated trauma to the cyst. They were referred for fine needle aspiration cytology (FNAC).
Aspiration was carried out using a 23-gauge nee-dle and 10-mL syringe in both patients. Two to three Giemsa-and Papanicolaou-stained smears from both patients were analyzed. Aspirates in both cases showed similar cytologic features. The smears revealed a background of keratin mixed with nucleate and anucleate squames. Also seen were a few fragments of squamous epithelium with foreign body giant cells and macrophages. Fine, brown, rodlike pigment was seen in the macrophages and a few epithelial cells (Figure 1). There were no other significant findings, and the nuclei of all cells were bland. The presence of foamy macrophages and giant cells indicated ruptured epidermal cysts. As the cytologist was aware that pigmentation occurs in epidermal cysts, the diagnosis of pigmented epidermal cyst was offered. Histology confirmed the diagnosis of epidermal cyst with rupture and melanin accumulation as part of the degenerative process. The pigment was melanin because it was Masson-Fontana positive and could be bleached with potassium permanganate.
Pigmentation of epidermal cysts is a rarely discussed issue in dermatopathology. 1,3,4 It was initially reported to herald the onset of a systemic disease, like hemochromatoses. 3 However, it is now recognized that epidermal cysts are usually pigmented in dark-skinned people. 1 In an analysis in African American patients, 37% of epidermal cysts were pigmented. 1 Melanin pigment was seen in 63% of epidermal cysts in our (Indian) patients. Cysts in the thigh, forehead and sacrogluteal area accumulated more pigment and melanophages. This possibly was a degenerative change.
It is not surprising that one may worry if one sees melanin pigment in an aspirate from an otherwiseinnocuous epidermal cyst. The cytologist may then entertain the possibility of a melanocytic lesion. This may be especially so because many times the macrophages have atypical nuclei. However, though melanin is seen in these cysts, the cells do not have features of malignancy. Melanocytic cells with the classical cytologic features described for nevi and melanomas 2 are never seen.
Thus, the finding of melanin is a variation in the cytology of epidermal cysts, and awareness of this feature will help to avoid unnecessary concern.

Periurethral Vaginal Melanoma: Urine Cytologic Findings
To the Editors: The finding of melanoma on urine cytology is a rare occurrence. 1,2 We recently encountered such a case.
A 74-year-old African American female was referred to our institution after a periurethral biopsy performed elsewhere was diagnosed as malignant. On examination, a 2.5 × 2.0-cm, pink-tan, polypoid mass arising in the periurethral area was noted, with deviation of the urethral meatus laterally. Multiple darkly pigmented nodules were also noted in the vagina. Specimens submitted included urine for cytology and biopsies of the periurethral mass and of two of the nodules in the lateral vaginal wall, measuring 1 × 0.6 and 0.7 × 0.5 cm. Microscopically, urine cytology showed a poorly differentiated malignant neoplasm. The malignant cells occurred singly and in occasional loose clusters. The cells were large, with coarsely clumped chromatin. Multinucleation was noted, and occasional macronucleoli were seen. Pigmentation was not noted (Figures 1 and 2). Biopsy of the nodules in the lateral vaginal wall showed typical pigmented melanoma measuring 0.35 cm in depth. Biopsy of the right periurethral mass showed similar histology to that of the vaginal wall lesions but with more anaplasia and minimal pigment. The lesions stained for HMB45 and S-100.
The detection of melanoma, either primary or metastatic, on urine cytology is rare. 1 In the largest reported series, Zogno et al reported melanoma cells in the urine of three males, two with cutaneous melanoma and one with primary melanoma of the gallbladder. 1 Primary vaginal malignant melanoma is an uncommon disease with a poor prognosis. As compared with malignant melanoma of the skin, vaginal melanoma early on infiltrates deep into the underlying tissue, with its abundant lymphatics and blood vascularization. It represents < 3-5% of malignant neoplasms of the vagina, is mainly a disease of postmenopausal women and is usually diagnosed at a late stage, with resulting poor outcomes. This is probably related to the less frequent gynecologic examinations elderly women receive as well as to insufficiently liberal biopsy practice. 3 Since Clark's levels are inappropriate for mucosal sites of melanoma, a modification described by Chung is utilized. 4 The system is as follows: level 1, tumor confined to the surface epithelium; level 2, invasion of ≤ 1 mm; level 3, invasion of 1-2 mm; and level 4, invasion > 2 mm. Depth of invasion is measured in millimeters as the thickness from the tumor surface to the deepest portion using Breslow microstaging, 5 divided into: < 0.76, 0.76-1.50, 1.51-3.0 and > 3.0 mm. A high mitotic rate, advanced age, aneuploidy, lymphovascular space in- volvement, ulceration and central location of the tumor are also indicators of a poor prognosis. 6 Malignant melanoma rarely originates in the vagina and is thought to arise from the malignant transformation of ectopic melanocytes. 7,8 The lesions can show a variable degree of pigmentation and usually occur on the anterior aspect of the vagina. In our case, the periurethral mass was not pigmented, and the vaginal nodules were-hence the lack of pigmentation on cytology. Vaginal bleeding, discharge and a tumor mass are the chief signs and symptoms. Because of the rarity of these cases and the aggressiveness of the disease, optimal management is still evolving. This case illustrates the need to consider melanoma in the differential diagnosis of a high grade malignant neoplasm of nonurothelial origin presenting in a urine specimen.