LETTERS TO THE EDITOR

FNA of Pilomatrixoma: Smear vs. Cell Block

Dear Dr. Bedrossian: We have read the letter by Gupta and colleagues published in Diagnostic Cytopathology (DC) entitled Fineneedle aspiration cytology of pilomatrixoma of the arm and the role of cell block examination in the diagnosis.1 In their letter the authors comment that the application of neneedle aspiration cytology (FNAC) in the investigation of skin lesions has been less widely practiced than in other organs, and they justify such difference because of the need for surgical excision and biopsy for diagnosis. We agree with them on this issue, but it is appropriate to point out that FNAC has been successfully used for the study of dermal and subcutaneous skin nodules since the early years of FNAC. Almost every cytopathology textbook devotes one chapter to FNAC of cutaneous lesions.24 Over 18 yr, my colleagues and I have been steadily performing FNACs of skin nodules and we have published 13 articles, most of them in DC, referring to parasitic and inammatory conditions,5,6 benign and malignant tumors,716 and metastases.17 We believe that if thorough training in performing aspirations and interpreting smears is guaranteed and proper clinical data are available, FNAC can lead to an accurate diagnosis in specic pathological conditions, or can at least provide a tentative cytologic diagnosis that permits the cytopathologist to channel the patient for further studies. Concerning the processing techniques employed by Gupta and colleagues1 such as needle and syringe washings in 30% ethyl alcohol for liquid-based preparation, and cell block for histologic study, we believe that these are unnecessary if the cytopathologist is able to obtain a good yield that provides sufcient material for one or two smears suitable for DiffQuik and Papanicolaou stains. Fine needle aspiration is an art, and a great deal of its success is based on its simplicity, quickness, low cost, and diagnostic accuracy, although proper expertise is necessary to obtain a good yield. If we increase the cost of processing and we delay the diagnosis (a cytologic diagnosis can be available within 5 min on most occasions, whereas the turnaround of histologic diagnoses ranges between 24 and 48 hr), we are going against two of the cornerstones of this diagnostic procedure: low cost and rapidity. Concerning the cytologic diagnosis of pilomatrixoma (PMT), I would like to make again the observations that my colleagues and I published in DC in 1996.8 In our study, we collected nine PMT with cyto-histologic correlation (ve were correctly diagnosed, three were misdiagnosed, and one case yielded no aspirate; lack of clinical information, and overdiagnosis of basaloid cells, keratinized cells, and stromal fragments were responsible for the errors) and we focused our attention on the common ndings that might lead to misdiagnosis. We concluded our article with six recommendations that may be of help when a cytopathologist is faced by the yield taken from a PMT: (1) aspirations should be performed by the cytopathologist who is to interpret the slides; (2) clinical investigation is of paramount importance; (3) try to nd the coexistence of basaloid cells and shadow cells; if such coexistence is absent, search for shadow cells because these are seen only in PMT; (4) do not be overimpressed by the presence of naked nuclei with prominent nucleoli or by sheets of deeply stained nuclei; (5) use both Papanicolaou and DiffQuik stains; (6) think of PMT, especially when evaluating aspirates from subcutaneous growths and particularly, when these are located in the head and neck of a young person. In the case reported by Gupta and colleagues,1 the diagnosis of pilomatrixoma was suggested on cytologic grounds and the nal diagnosis was reached after cell block preparation and later conrmed on a subsequent surgical excision biopsy. However, we believe that Figure 1 is diagnostic of PMT and block preparation is unnecessary to arrive at the diagnosis. We agree with the authors that the differential diagnosis may not always be easy, particu#

rez-Guillermo, M.D., F.I.A.C., Department *Correspondence to: M. Pe a del Rosell, Paseo Alfonso XIII, 61, of Pathology, Hospital Santa Mar 30203 Cartagena, Spain. E-mail: miguel.perez-guillermo@carm.es Received 12 May 2005; Accepted 24 August 2005 DOI 10.1002/dc.20422 Published online in Wiley InterScience (www.interscience.wiley.com).

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FNA OF PILOMATRIXOMA

larly if the attention of the cytopathologist is attracted by the hyperchromatic basaloid cells and the rest of the cytologic details of the smears are neglected. Concerning the interpretation of shadow cells, we are of the opinion that they cannot lead to a mistaken diagnosis of an epidermal cyst. We have aspirated hundreds of cutaneous epidermal cysts and three testicular epidermal cysts, one of them published in DC,18 and the morphology of the squamous cells aspirated from these lesions is completely different from shadow cells, although we agree with the authors on the issue that the cells of epidermal cysts are singly dispersed, whereas shadow cells appear forming cohesive sheets. Finally, we would like to mention that Gupta and colleagues1 did not mention our article Mimics of pilomatrixomas in ne-needle aspirates8 in the references: we honestly believe that a careful reading of our article would have been of help in the interpretation of the liquid-based preparation of this aspirate. rez-Guillermo, M.D., F.I.A.C.* M. Pe a-Solano, M.D. J. Garc J. Acosta-Ortega, M.D. Department of Pathology a del Rosell Hospital Santa Mar Paseo Alfonso XIII, 61 30203 Cartagena, Spain

References
1. Gupta RK, Phang T, Lallu S, Naran S. Fine-needle aspiration cytology of pilomatrixoma of the arm and the role of cell block examination in the diagnosis. Diagn Cytopathol 2005;32:6162. n S. Melanomas and skin nodules. In: Clinical 2. Linsk JA, Franze Aspiration Cytology. 2nd edition. Philadelphia: JB Lippincott Co; 1983. p 319336. 3. Orell SR, Sterret GF, Walters MN-I, Whitaker D. Supporting tissues. In: Manual and atlas of ne needle aspiration cytology. Edinburgh: Churchill Livingstone; 1986. p 205232. 4. Curling M, Oomen R. Skin. In: Gray W, editor. Diagnostic Cytopathology. Edinburgh: Churchill Livingstone; 1995. p 827840. rez-Guillermo M, Herna ndez-Gil A, Bonmat Limorte C. Diagno5. Pe sis of cutaneous leishmaniasis by means of ne-needle aspiration cytology (FNAC). Acta Cytol 1988;32:485488.

a Solano J, Garc a Rojo B, Sa nchez Sa nchez C, Montalba n 6. Garc rez-Guillermo M. Utility of ne-neeRomero S, Acosta Ortega J, Pe dle aspiration in the diagnosis of panniculitis. Diagn Cytopathol 1998;18:425430. rez-Guillermo M, Sola Pe rez J, Garc a Rojo B, Herna ndez Gil A. 7. Pe Fine-needle aspiration cytology of cutaneous vascular tumours. Cytopathology 1992;3:231244. nchez Sa nchez C, Gime nez Bascun ana A, Pastor Quirante F, et 8. Sa al. Mimics of Pilomatrixomas in Fine-Needle Aspirates. Diagn Cytopathol 1996;14:7583. a Rojo B, Garc a Solano J, Sa nchez Sa nchez C, Montalba n 9. Garc rez-Guillermo M. On the limited Romero S, Vicente Ortega V, Pe value of ne-needle aspiration for the diagnosis of benign melanocytic proliferations of the skin. Diagn Cytopathol 1998;19:441445. a Rojo B, Garc a Solano J, Sa nchez Sa nchez C, Montalba n 10. Garc nez Parra D, Pe rez-Guillermo M. On the utility of Romero S, Mart ne-needle aspiration in the diagnosis of primary scalp lesions. Diagn Cytopathol 2001;24:104111. rez-Guillermo M, Garc a-Solano J, Acosta Ortega J. Fine needle 11. Pe aspiration of apocrine hidrocystoma. A potencial mimic of papillary neoplasms metastatizing to the skin. Diagn Cytopathol 2004;30: 275279. rez-Guillermo M, Bonmat -Limorte C, Garc a Rojo B, Her12. Pe ndez Gil A. Infantile cutaneous rhabdomyosarcoma (Li-Frauna meni syndrome): cytological presentation of ne-needle aspirate biopsy. Report of a case. Diagn Cytopathol 1992;8:621 626. rez-Guillermo M, Sola Pe rez J, Abad Montan n o C, Montalba 13. Pe Romero S, Pastor Quirante F. Merkel cell tumor of the eyelid. Diagnosis by means of ne-needle aspiration cytology. Diagn Cytopathol 1994;10:146151. a Solano J, Garc a Rojo B, Sa nchez Sa nchez C, Montalba n 14. Garc rez-Guillermo M. Basal-cell carcinoma: cytologic and Romero S, Pe immunocytochemical ndings in ne-needle aspirates. Diagn Cytopathol 1998;18:403408. a Solano J, Garc a Rojo B, Sa nchez-Sa nchez C, Montalba n 15. Garc nez Parra D, Pe rez-Guillermo M. On the utility and Romero S, Mart limitations of ne-needle aspiration of palpable lesions located in the hand. Diagn Cytopathol 2000;23:284291. rez-Guillermo M, Sola Pe rez J, Abad Montan n o C, Montalba 16. Pe Romero S, Pastor Quirante F. Merkel cell tumor of the eyelid. Diagnosis by means of ne-needle aspiration cytology. Diagn Cytopathol 1994;10:146151. nez Parra D, Garc a Rojo B, Nevado H, et al. Puncio n aspira17. Mart n con aguja na de no dulos cuta neos y subcuta neos metasta ticos. cio Rev Esp Patol 2000;33:3140. rez-Guillermo M, Garc a-Solano J. Diagnostic limitations in tes18. Pe ticular cytopathology. To what extent is ne needle aspiration reliable for the diagnosis of epidermal cyst of the testis? Diagn Cytopathol 2004;31:8386.

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