Intravascular papillary endothelial hyperplasia diagnosed by fine needle aspiration: Report of a case and cytology literature review
A 55-year-old female patient presented with a progressively increasing swelling, of six months duration, on her left jaw. She also complained of left-sided otalgia. Past medical history was significant for thyroidectomy for papillary carcinoma diagnosed 2½ years ago. On examination, a tender oval mass measuring 1.5 × 1.3 × 1.2 cm was noted just anterior to the left parotid gland, overlying the inferior aspect of the masseter muscle. Patient was administered a course of oral antibiotics following which the tenderness subsided; however, the swelling persisted. Patient was referred for an ultrasound-guided FNA of the jaw swelling. Ultrasound revealed a dominant soft tissue mass in the left submandibular area, measuring 2.2 × 1.3 × 1 cm. Preliminary onsite cytological diagnosis of suspicious for malignancy was rendered. Final cytology was signed out as consistent with IVPEH. Patient underwent complete excision of the mass and final pathology revealed IVPEH.\nFNA was performed with a 23-gauge needle. Aspirate smears were stained with Diff Quik and Papanicolaou stains. Cell block material was also obtained. Immunohistochemical stains were performed on the cell block material using the Ventana BenchMark Ultra automated immunohistochemistry slide staining system.\nThe smears revealed isolated clusters of pleomorphic polygonal cells and sheets of spindle cells in a hemorrhagic background. Polygonal cells with abundant pale cytoplasm exhibited anisonucleosis, increased nuclear cytoplasmic ratio, overlapping nuclei and irregular nuclear contours []. Spindle cells with elongated oval nuclei and scant cytoplasm surrounded metachromatic hyaline globules and hyaline stalks [Figures and ]. No necrosis or atypical mitoses were seen. Due to patient's prior history of papillary carcinoma, we considered the cytological findings suspicious for malignancy at the time of onsite evaluation and also raised the possibility of recurrence of papillary carcinoma with anaplastic features at the time of onsite evaluation. Subsequent cell block showed characteristic features of IVPEH characterized by papillary cores lined by plump endothelial cells, adjacent to small delicate papillae []. The papillae were composed of attenuated endothelial cells overlying hyalinized cores. The endothelial cells maintained the polygonal or spindle shape noted in the aspirate smears. Abundant cytoplasm and large, pleomorphic nuclei were occasionally identified. No mitotic activity was noted. Immunohistochemical stains for factor VIII and CD34 performed on the cell block material outlined the endothelial cells []. Final cytology was reported as consistent with IVPEH.\nThe resected specimen measured 1.5 × 1.3 × 0.7 cm and revealed a hemorrhagic cut surface. The sections showed intravascular lesion with a blood clot. The characteristic features of IVPEH with numerous areas of endothelial ingrowths and delicate papillae with hyalinized cores covered by attenuated endothelial cells as noted in cell block sections were seen []. Loosely arranged bands of fibrous tissue were identified at the periphery of the specimen. No mitotic activity was noted. A CD34 immunohistochemical stain was performed, and it outlined the papillary structures, as well as some of the fibrous tissue at the periphery of the specimen.