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LETTER TO EDITOR
CytoJournal 2015,  12:12

Amylase crystalloids in fine needle aspiration cytology of parotid gland: A diagnostic challenge


Department of Pathology, Faculty of Medicine, Kocaeli University, Umuttepe, Izmit, Kocaeli, Turkey

Date of Submission02-Feb-2015
Date of Acceptance27-Apr-2015
Date of Web Publication23-Jun-2015

Correspondence Address:
Nadir Paksoy
Department of Pathology, Faculty of Medicine, Kocaeli University, Umuttepe, Izmit, Kocaeli
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1742-6413.159233

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How to cite this article:
Bayrak BY, Vural Ç, Paksoy N. Amylase crystalloids in fine needle aspiration cytology of parotid gland: A diagnostic challenge. CytoJournal 2015;12:12

How to cite this URL:
Bayrak BY, Vural Ç, Paksoy N. Amylase crystalloids in fine needle aspiration cytology of parotid gland: A diagnostic challenge. CytoJournal [serial online] 2015 [cited 2017 May 28];12:12. Available from: http://www.cytojournal.com/text.asp?2015/12/1/12/159233

Editorial/Peer Review Statement
To ensure the integrity and highest quality of CytoJournal publications, the review process of this manuscript was conducted under a double blind model (authors are blinded for reviewers and vice versa) through the automatic online system.


Sir,

Several types of crystalloids may be seen in fine needle aspiration cytology of benign or malignant lesions of the salivary gland. [1],[2] Due to their rarity, they may lead to confusion in diagnosis. Amylase type crystalloids (sometimes named nontyrosine crystals) are rarely found angular, nonbirefringent rectangular formed structures, with geometric shapes ranging between 5 μ and 500 μ in size and stained orange with Papanicolaou (PAP), dark blue with Diff-Quik® (DQ) and pink with Hematoxylin-Eosin (HE) stain.

They were first defined in salivary gland cysts in 1983 by Takeda and Ishikawa. [1],[3] Amylase crystalloids may also be observed in cystic sialadenitis as much as in cystic lesions. [1] We have presented here a case with cystic and chronic sialadenitis in the parotid gland, containing amylase crystalloids.

The ultrasonographic assessment performed on a 58-year-old female patient who had applied with a complaint of swelling in the frontal part of the left ear and on the left part of the neck resulted in the detection of a lesion at a size of 12.5 mm × 11 mm in the lower zone of the left parotid [Figure 1] and lymph node at a diameter of 1 cm in the left cervical area.
Figure 1: Ultrasonographic picture of the parotid mass

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Ultrasound-guided fine needle aspiration was performed by cytopathologist (N.P) with the preliminary diagnosis of the parotid tumor. About 0.2 cc of a mucoid fluid at an off-white color was aspirated. The slides were stained with DQ, PAP and HE.

Cytologic findings showed mixed-type inflammatory elements, proliferated salivary gland acinar cells, reactive atypical salivary gland ductal cells as well as square, cuboid, needle, rectangular, rhomboid or bar-shaped crystalloids [Figure 2]a-d. The crystalloids were stained bright orange with PAP; deep blue with DQ and eosinophilic with HE [Figure 3]a and b. Birefringence of the crystalloids was not observed by polarized light. The case was reported as cystic and chronic sialadenitis containing amylase crystalloids. The patient was monitored, and no growth was detected in the 2 years follow-up.
Figure 2: Various cytologic images of the amylase crystalloids on different power and stains. (a) Diff-Quik®, ×100. (b) Diff-Quik®, ×200. (c) Papanicolaou, ×200. (d) H and E, ×400

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Figure 3: Images of crystalloids at high power magnification with representative morphology. (a) Diff-Quik®, ×400. (b) H and E, ×400

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Many crystals such as amylase, tyrosine, collagenous crystalloids, oxalate and intraluminal crystals may be observed in the fine needle aspiration smears of salivary gland lesions. [1],[2],[4]

It is important to differentiate amylase crystalloids, which are geometric-shaped structures larger than 5 μm microscopically, from other crystalloids. Because, although crystalloids may be seen in malignant salivary gland tumors, amylase crystalloids accompany benign lesions. [1],[5]

The different types of crystals/crystalloids in relation to benign and malignant lesions and special stains/methods of detection are outlined below.

Intraluminal crystalloids show a structure with geometrical shapes like amylase crystalloids. However, intraluminal crystalloids are dense, amorphous, filled with eosinophilic substance and at a size of 100 μ. Intraluminal crystalloid are reported to be seen in malignant salivary gland tumors. [6]

Amylase crystalloids have more translucent appearance and are generally at a size of 500 μ. They are stained orange with PAP, dark blue with DQ® and pink with HE. Both intraluminal and amylase crstalloids are nonbirefringent.

Amylase crystalloids are so far encountered with only in benign lesions including chronic sialadenitis, unilocular cysts, lymphoepithelial cysts and Warthin's tumor. [1],[7]

Collagenous crystalloids are seen as radial and fusiform fibers of eosinophilic collagen on HE stain. These crystalloids stain bright blue on trichrome stain, indicating the presence of Type I collagen and are also positive on Snook Reticulin Stain, indicating the presence of Type III collagen. They are birefringent. Collagenous crystalloids are reported to be seen in pleomorphic adenomas, myoepitheliomas and also myoepithelial carcinomas. [5],[6]

Tyrosine crystals appear in an eosinophilic, refractile, flower-like shape with blunt ends (petal shaped) on HE stain. Tyrosine crystalloids are reactive with Millon reagent and are positive with diazotization-coupling reaction. They are nonbirefringent. Tyrosine crystals are mainly identified in pleomorphic adenomas and also rarely encountered in malignant salivary gland neoplasms such as carcinoma ex pleomorphic adenoma, adenoid cystic carcinoma, low-grade adenocarcinoma. [1],[2],[5],[6]

In conclusion, amylase crystalloids are not substances that may appear very frequently in parotid fine needle aspiration. They may accompany especially nonmalignant benign, chronic inflammatory lesions. They are rarely observed.

We wanted to present our case in the light of literature for the purpose of highlighting the fact that crystalloids may lead to diagnostic challenges in parotid fine needle aspiration. We also focused on the representative cytomorphology of the crystalloids.


 » Acknowlegment Top


Presented in part in form of a poster at the 24 th National Pathology Congress in Trabzon. Turkey in 19-23 November 2014.


 » Competing interests statement by all authors Top


The authors declare that they have no competing interests.


 » Authorship statement by all authors Top


Each author has participated sufficiently in the work and takes public responsibility for appropriate portions of the content of this article. Each author acknowledges that this final version was read and approved.


 » Ethics statement by all authors Top


This manuscript is a case description in form of a letter. Therefore, institutional ethical approval is not mandatory.


 » List of abbreviations Top


PAP = Papanicolaou

HE = Hematoxylin-Eosin

 
 » References Top

1.
Paker I, Anlar M, Genel N, Alper M. Amylase crystalloids on fine-needle aspiration of salivary gland. Turk Patoloji Derg 2010;26:153-5.  Back to cited text no. 1
    
2.
Kuwabara H, Ishizaki S, Akashi S, Yuki M, Shibayama Y. A-amylase crystalloid granuloma in the parotid gland. Diagn Cytopathol 2015;43:114-6.  Back to cited text no. 2
    
3.
Takeda Y, Ishikawa G. Crystalloids in salivary duct cysts of the human parotid gland. Scanning electron microscopical study with electron probe X-ray microanalysis. Virchows Arch A Pathol Anat Histopathol 1983;399:41-8.  Back to cited text no. 3
    
4.
Sáenz-Santamaría J, Catalina-Fernandéz I, Fernandez-Mera JJ. Sialadenitis with crystalloid formation. Fine needle aspiration cytodiagnosis of 15 cases. Acta Cytol 2003;47:1-4.  Back to cited text no. 4
    
5.
Bellizzi AM, Mills SE. Collagenous crystalloids in myoepithelial carcinoma: Report of a case and review of the literature. Am J Clin Pathol 2008;130:355-62.  Back to cited text no. 5
    
6.
Ro JY, Mackay B, Batsakis JG, Cartwright J Jr. Intraluminal crystalloids in malignant salivary gland tumors (electron microscopic and X-ray microanalytic studies). J Laryngol Otol 1987;101:1175-81.  Back to cited text no. 6
    
7.
Issac RM, Oommen AM, Mathai JM. Crystalloids in salivary gland lesions. J Cytol 2014;31:194-5.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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