Fine-Needle Aspiration of the

Mediastinum:
A Clinical, Radiologic, Cytologic,
and Histologic Study of 42 Cases
Nina S. Shabb, M.D.,1* Mehieddine Fahl, M.D.,2 Basem Shabb, M.D.,3
Patrecia Haswani, M.D.,1 and Ghazi Zaatari, M.D.1

Forty-two fine-needle aspirates (FNA) of the mediastinum were

reviewed from 19841995. The clinical, radiologic, pathologic,
and cytologic material was studied. Twenty-five males and 17
females had an age range from 1072 yr and a mean of 41 yr.
Common complaints were chest pain, dyspnea, and cough. Thirtyeight tumors were in the anterior/superior mediastinum. Fiftyseven percent were primary neoplasms (Hodgkins lymphoma, 7;
non-Hodgkins lymphoma, 6; thymoma, 3; germ-cell tumor, 3;
thymic carcinoid and angiosarcoma, 1 each; and malignant not
otherwise specified, 3). Twenty-four percent were metastatic tumors (carcinoma, 9; and sarcoma, 1). Twelve percent were benign
conditions (granulomatous disease, 2; multinodular goiter, 1;
extramedullary hematopoesis, 1; and one thymic cyst). Seven
percent were inconclusive. FNA yielded adequate tissue for diagnosis in 83% and a correct diagnosis in 86%. There was one
false-negative and no false-positive diagnosis. FNA is a useful tool
for accurate tissue diagnosis of mediastinal masses. Diagn.
Cytopathol. 1998;19:428436. r 1998 Wiley-Liss, Inc.
Key words: aspiration biopsy; mediastinum; lymphoma; thymoma

The mediastinum is defined as the space between the pleura

laterally and limited by the sternum anteriorly, the vertebral
column posteriorly, the sternal notch superiorly, and the
diaphragm inferiorly. It is the site of a myriad of nonneoplastic and neoplastic conditions both benign and malignant,
primary and metastatic, many of which present as mediastinal masses. Although the clinical data, the location in the
mediastinum, and the radiologic findings all help in narrowing the differential diagnosis, a tissue diagnosis is very
helpful in proper guidance of management prior to definitive

1Department of Pathology, American University of Beirut, Beirut,

Lebanon
2Department of Radiology, American University of Beirut, Beirut,
Lebanon
3Department of Surgery, American University of Beirut, Beirut, Lebanon
*Correspondence to: Nina S. Shabb, M.D., Department of Pathology,
American University of Beirut, 850 Third Avenue, New York, NY 10022.
E-mail: NS04@aub.edu.lb
Received 27 December 1997; Accepted 3 June 1998

428

Diagnostic Cytopathology, Vol 19, No 6

treatment of these varied diseases. The role of fine-needle

aspiration (FNA) in the mediastinum has been controversial
due to the complexity and difficulty of diagnosing these
cases even on surgical biopsy material, and also due to the
danger incurred by the proximity of the heart and great
vessels.119 We reviewed our experience with FNA of the
mediastinum to assess its role in this setting.

Materials and Methods

All cases of FNA of the mediastinum were retrieved by
reviewing the cytology, radiology, and tumor registry files at
the American University of Beirut Medical Center from
January 1984October 1996. Patients charts were reviewed
and the clinical and demographic data were recorded. All
available radiologic studies were reviewed. Tumor size and
characteristics were recorded. The FNA cytology slides and
the surgical pathology slides were reviewed first by one
pathologist and then together with a second pathologist in a
blind fashion. All the aspirates except two were performed
by an interventional radiologist under CT or ultrasound
guidance. In 2 patients, the masses were in the superior
mediastinum and readily palpable. In these cases, the
pathologist performed the aspirate. Three to five passes per
lesion were performed. Cytologic material was immediately
smeared onto glass slides and air-dried for staining with
Diff-Quik (Harleco, Gibbstown, NJ) or fixed in Carnoys
solution (9:1 70% ethanol:glacial acetic acid) for staining
with the Papanicolaou stain. In some cases the needle and
syringe were rinsed in saline solution for cell-block preparation. The surgical specimens were formalin-fixed, routinely
processed, and stained with hematoxylin-eosin. In a few
cases, immunohistochemical stains were performed on the
cell blocks or the surgical specimens when indicated.

Results
We had a total of 42 patients with an age range from 1072
yr and a mean of 41 yr (Table I). There were 25 males and 17
r 1998 WILEY-LISS, INC.

FNA OF THE MEDIASTINUM

Table I. Demographic, Clinical, Cytologic, and Pathologic Data: FNA of Mediastinal Lesionsa
Disease
categories

Age
and
sex

Lymphoma
Hodgkins
1

22 F

Symptoms

Location and
characteristics
of tumor

Size
(cm)

FNA
diagnosis

Pathology
diagnosis

Dyspnea and
cough
55 M None, routine
CXR

Ant. Solid, wellcircumscribed

Ant.

10

C/W Hodgkins

Hodgkins NS

C/W Hodgkins

1. Nondiagnostic
2. Hodgkins NS

32 F

C/W Hodgkins

Hodgkins NS

27 F

Ant. Solid,
invading chest
wall
Ant./superior,
solid
Ant. Solid,
invading chest
wall
Ant. Multiple,
invading chest
wall
Ant. Multiple,
invading chest
wall

C/W Hodgkins

Hodgkins NS

C/W Hodgkins

Ant. Solid,
invading chest
wall
Ant. Invading
chest wall

Dyspnea and
cough

Dyspnea and
cough
16 M Chest pain

38 M Chest pain

31 F

Chest pain

Non-Hodgkins,
LCL
8
56 F

Chest mass

10
11

30 M Dyspnea

17 M Shoulder pain
25 F Dyspnea and
cough

Non-Hodgkins,
lymphoblastic
12
13 M Cough

13

Thymoma
14
15
16
Germ-cell tumor
17

Surgical
procedure

Comments

Suprasternal
mediastinotomy
Both: mediastiFirst mediastinotomy
notomy; nondiagnostic
Mediastinotomy

FNA done without

X-ray guidance

Hodgkins NS

Cervical LN
biopsy
Mediastinotomy

S/O thymoma

1. Nondiagnostic
2. Hodgkins NS

Both: mediastinotomy

FNA misdiagnosed as S/O

thymoma

Nondiagnostic

Hodgkins NS

Mediastinotomy

LCL

LCL, diffuse

Cervical LN bx

LCL

No bx

None

Treated on FNA
result; surgery
avoided

Ant. Solid
Ant. Solid

8
LCL
No bx
Large 1. Malignant NOS 1. Hodgkins NS
2. Nondiagnostic 2. LCL

None
Both: mediastinotomy

Ant. Solid

Large Lymphoblastic
lymphoma

No bx

None

Lymphoblastic
lymphoma

No bx

None

Thymoma, noninvasive
Thymoma, invasive
Thymoma, noninvasive

Mediansternotomy
Mediansternotomy
Mediansternotomy

Surgical biopsy
avoided
Surgical biopsy
avoided
Surgical biopsy
avoided

10 M Cough

Ant. Solid

30 M Chest pain

Ant. Solid and

cystic
Ant./Superior,
solid
Ant. Solid

Thymoma

Thymoma

2.5

Thymoma

Ant. Solid,
invading chest
wall
Ant. Solid and
cystic

Undifferentiated
tumor, GCT?

GCT, embryonal
and yolk sac

Mediastinotomy

Multiple lung
nodules

Large Undifferentiated
tumor, GCT?

GCT, embryonal
and choriocarcinoma
No bx

Mediastinotomy

High serum
markers

None

Multiple lung
nodules, high
serum markers

51 M SVC syndrome
dyplopia
60 M None, routine
CXR
34 M Chest pain

18

24 M Cough

19

25 M Cough

Ant. Solid and

cystic

15

Treated on FNA
result; surgery
avoided
Treated on FNA
result; surgery
avoided

C/W GCT

Diagnostic Cytopathology, Vol 19, No 6

429

SHABB ET AL.
Table I. (continued)
Disease
categories

Age
and
sex

Thymic carcinoid
20

58 F

Angiosarcoma
21
Malignant neoplasm
NOS
22

23
24

Metastatic tumors
Oat cell
25

26
27

Adenocarcinoma
28
29
30

Symptoms

Location and
characteristics
of tumor

Chest pain and

dyspnea

Ant. Solid and

cystic

43 M Dyspnea and
hemoptysis

Ant. Solid and

cystic

50 F

Ant. Solid and

cystic

None, routine
CXR

FNA
diagnosis

Pathology
diagnosis

Surgical
procedure

10

Nondiagnostic,
scanty

Thymic carcinoid
(atypical)

Mediastinotomy

12

Spindle-cell neoplasm

Large Malignant NOS

Multiple lung
nodules

Undifferentiated
carcinoma

Thoracotomy,
biopsy

Malignant NOS

Thoracotomy,
biopsy
LFU

Cytokeratin,
PLAP &
HCG
Cytokeratin, LCA,
PLAP, HCG
Cytokeratin,
PLAP, alpha
FP, LCA?

Ant. Solid

Large Malignant NOS,

favor lymphoma

Malignant, favor
lymphoma

50 M Cough

Ant.

Ca/lymphoma

No bx

None

65 F
47 F

Cough
Not available

Ant. Solid
Ant.

Large Oat cell

?
Ca/lymphoma

No bx
No bx

None
None

57 M Chest pain
32 F None, routine
CXR
56 M Cough and
hemoptisis

Ant. Solid
Ant. Solid

Adenocarcinoma No bx
Adeno C/W breast No bx

None
None

Ant. Solid

7
5

Malignant NOS

Mediastinotomy

Post. Solid

Ant. Solid

Large Adenocarcinoma

10

No bx

None

Ca/lymphoma

P.D. carcinoma,
nonoat cell

Thoracoscopy

32

50 M Dysphagia

Post. Solid

Large Ca/lymphoma

Metastatic ca to
LN

Mediastinoscopy

33

51 M Not available

Ant. Solid

Large P.D. carcinoma,

nonsmall cell

No bx

None

21 M Dyspnea

Ant./superior,
solid

No bx

None

Granulomas,
tuberculosis
Noncaseating
granulomas,
sarcoid

Mediastinotomy

Small roundcell sarcoma

34

Benign conditions
Granulomatous
disease
35
20 M Cough, shortness Ant. Cystic
of breath
36
40 F Cough
Ant. Cystic

Diagnostic Cytopathology, Vol 19, No 6

2.5

Metastatic small
round-cell sarcoma

Necrosis and a
few giant cells
Large Granulomas

Comments

Angiosarcoma

35 M Intercapsular
pain
35 M Cough

Poorly differentiated
nonoat cell
31
56 M Dyspnea and
chest pain

430

Size
(cm)

Mediastinotomy

Revised FNA
reading: oatcell ca
Revised FNA
reading: oatcell ca

History of breast
ca

2-cm lung mass.

Revised FNA
reading: PD ca
History of LCL 12
yr prior.
Revised FNA
reading: PD ca
Lung mass

History of small
round-cell sarcoma of flank, 9
mo prior

FU c/w sarcoid

FNA OF THE MEDIASTINUM

Table I. (continued)
Disease
categories
Multinodular
goiter
37

Age
and
sex

62 F

Extramedullary
hematopoeisis
38
39 F

Thymic cyst
39
Inconclusive
40
41
42

58 F

Symptoms

Location and
characteristics
of tumor

Size
(cm)

FNA
diagnosis

Pathology
diagnosis

Surgical
procedure

Dysphagia

Post. Solid

Multinodular
goiter

No bx

None

None, routine
CXR

Post. Solid

None, routine
CXR

Ant. Unilocular
cyst
Ant. Solid
Ant.
Ant.

60 F Dyspnea
72 M Not available
65 F Not available

Extramedullary
hematopoeisis

No bx

None

Large 50 cc fluid, c/w

thymic cyst

No bx

None

Large Nondiagnostic
?
Nondiagnostic
?
Nondiagnostic

LFU
LFU
LFU

None
None
None

Comments

Iodine uptake confirmed thyroid

origin

History of congenital dyserythropoetic

anemia

aAnt.,

anterior; bx, biopsy; C/W, consistent with; Ca, cancer; CXR, chest X-ray; GCT, germ-cell tumor; LCL, large-cell lymphoma; LFU, lost to follow-up;
LN, lymph node; NOS, not otherwise specified; NS, nodular sclerosis; P.D., poorly differentiated; Post, posterior; S/O, suggestive of; SVC, superior vena
cava.

females. The most common symptoms were dyspnea, cough,

and chest pain. Six patients were asymptomatic from their
mediastinal lesion and were discovered by routine chest
X-rays. Thirty-eight of the aspirated tumors were in the
anterior or anterior/superior mediastinum, while only four
were in the posterior mediastinum. Tumor size ranged from
2.515 cm, with a mean of 7.5 cm. The majority of the
tumors were solid, some were mixed solid and cystic, and a
few cases were purely cystic. Seven tumors had invaded the
chest wall (mostly lymphomas and one germ-cell tumor).
The majority of cases (57%) were primary neoplasms of
the mediastinum (Table II). The second largest category was
of metastatic neoplasms (24%), mostly carcinomas. Benign
conditions accounted for 12%, while inconclusive cases
accounted for 7%.

Overall Performance of FNA

The fine-needle aspirate yielded adequate tissue for diagnosis in 35 of 42 cases (83%) (Table III). In 7 cases the
aspirates were scanty and hence inadequate for diagnosis.
This was related to dense fibrosis in the lesion in 2 cases of
lymphoma, and to extensive necrosis in one case of tuberculosis. In 4 cases the cause of the inadequate specimen was
not evident but may have been related to poor cooperation of
the patient, or poor aspirating technique.
Twenty-two patients (52%) had surgical intervention
either in the form of a limited surgical biopsy for diagnostic
purposes or a procedure such as thoracotomy or mediansternotomy for excision of the lesion. When compared to the
surgical pathology results when available, or compared to

Table II. Mediastinal Masses Divided According to Disease Categorya

Disease category
Primary neoplasms
Lymphoma
Thymoma
GCT
Thymic carcinoid
Angiosarcoma
Malignant NOS
Metastatic neoplasms
Carcinomas
Sarcoma
Benign conditions
Granulomas
MNG
EMH
Thymic cyst
Inconclusive
Total

No. of cases

Percent

24
13
3
3
1
1
3
10
9
1
5
2
1
1
1
3
42

57

24

12

7
100

aGCT,

germ-cell tumor; NOS, not otherwise specified; MNG, multinodular

goiter; EMH, extramedullary hematopoisis.

the final diagnosis reached by review of the FNA by the

pathologists in this study along with the clinical outcome,
the fine-needle aspirate was correctly diagnosed in 30 of the
35 cases with adequate cytology (86%). One case was
misdiagnosed: a case of Hodgkins lymphoma was called
suggestive of thymoma on FNA. Four cases were underdiagnosed: all of these were metastatic carcinomas to the
mediastinum where the FNAs were read as malignant
neoplasm, carcinoma vs. lymphoma.
Diagnostic Cytopathology, Vol 19, No 6

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SHABB ET AL.
Table III. Overall Performance of FNAa
Disease category
and no. of cases

Adequate

Inadequate

Correct

Incorrect

6
5
3
3
0
1
3

1
1
0
0
1
0
0

5
5
3
3

1
0
0
0

1
3

0
0

9
1

0
0

5
1

4b
0

1
1
1
1
0
35

1
0
0
0
3
7

1
1
1
1

0
0
0
0

30

Primary neoplasms
Hodgkins, 7
Non-Hodgkins, 6
Thymoma, 3
GCT, 3
Thymic carcinoid, 1
Angiosarcoma, 1
Malignant NOS
Metastatic neoplasms
Carcinoma, 9
Sarcoma, 1
Benign conditions
Granulomas, 2
MNG, 1
EMH, 1
Thymic cyst, 1
Inconclusive, 3
Total, 42

Fig. 1. Hodgkins lymphoma. A classic Reed-Sternberg (RS) cell (arrow)

seen in a mixed inflammatory background (Papanicolaou stain, 400).
Inset: RS variant.

aGCT,

germ-cell tumor; MNG, multinodular goiter; EMH, extramedullary

hematopoiesis.
bThese cases were initially diagnosed as carcinoma vs. lymphoma.

There was one false-negative diagnosis where a Hodgkins

lymphoma was misdiagnosed as a thymoma; there was no
false-positive diagnosis.
Only one complication was documented in the clinical
charts, which was a pneumothorax necessitating chest tube
insertion and a 2-day hospital stay.
The common and interesting lesions will be discussed,
while the rare lesions are described in Tables IIII.

Primary Neoplasms
Lymphoma
Hodgkins lymphoma. There were 7 cases of Hodgkins
lymphoma (HL). The mean age was younger than that
of the group, i.e., 31 yr compared to 41 yr. There were 4
females and 3 males. All the tumors were solid, and
4 had invaded the anterior chest wall. FNA was consistent
with Hodgkins disease in 5 of the 7 cases where ReedSternberg cells, a few classic ones but mostly variants,
were seen in a background of a mixture of inflammatory
cells; mature lymphocytes, a few eosinophils, plasma
cells, and histiocytes (Fig. 1). In case 6, the FNA was
misinterpreted as suggestive of thymoma. Review of the
slides showed that in reality the tumor was not sampled,
but the aspirate consisted of sheets of mesothelial cells,
a few groups of bronchial epithelial cells, and clusters of
histiocytes, along with scattered lymphocytes. The overall
cellularity was moderate to scant. The sheets of mesothelial cells, along with the clustered histiocytes, were
misinterpreted as the epithelial component of a thymoma
(Fig. 2).
A limited surgical biopsy in the form of a mediastinotomy
was performed in all 7 cases. In one case where the FNA was
432

Diagnostic Cytopathology, Vol 19, No 6

Fig. 2. Sheets of histiocytes intermixed with a few lymphocytes, misinterpreted as thymoma (Papanicolaou stain, 400).

consistent with HD, the first mediastinotomy was nondiagnostic, yielding only fibrous tissue, fat, and a mixture of
inflammatory cells. The second mediastinotomy yielded
diagnostic material.
In all 7 cases the surgical biopsies revealed nodular
sclerosis HD.
Non-Hodgkins lymphoma. There were 6 cases of nonHodgkins lymphoma (NHL), 4 of large-cell lymphoma
(LCL), and 2 of lymphoblastic lymphoma (LL). The mean
age was younger than that of the group: 25 yr compared to
41 yr. The 2 patients with lymphoblastic lymphoma were
age 10 and 13 yr. There were 4 males and 2 females. All
tumors were solid, and two had invaded the anterior chest
wall. The FNA was consistent with NHL in 5 of the 6 cases
with proper subclassification. The aspirates were cellular,
showing mostly discohesive lymphoid cells with lymphoglandular bodies in the background. In the LCL cases the cells
were predominantly large with irregular nuclei, with or

FNA OF THE MEDIASTINUM

Fig. 3. Lymphoblastic lymphoma. Discohesive lymphoid cells of intermediate size with bland, even chromatin and convoluted nuclear contours.
Lymphoglandular bodies are evident (arrowhead) (Papanicolaou stain,
400).

Fig. 4. Thymoma. Biphasic lesion composed of round to oval and spindled

epithelial cells, intermixed with mature lymphocytes (Papanicolaou stain,
400).

without nucleoli. In the cases of LL, the cells were intermediate in size with irregular nuclear contours, and bland,
even chromatin without conspicuous nucleoli (Fig. 3).
Mitotic figures and tingible body macrophages were also
seen. Immunophenotyping of these lymphomas was not
done.
Three patients were treated on the bases of the FNA
results. Two patients underwent surgical biopsy, confirming
the FNA diagnosis in both cases. One patient was lost to
follow-up.

Thymoma
There were 3 cases of thymoma. All were adult males with a
mean age of 47 yr. One patient had symptoms of myasthenia
gravis. Two tumors were solid, and one was solid and cystic.
The FNAs of all 3 cases were consistent with thymoma. The
smears were biphasic and composed of epithelial cells and
lymphocytes (Fig. 4). The epithelial cells were in large,
cohesive, mostly two-dimensional fragments, with some
smaller fragments and rare single cells. The cells had
abundant cytoplasm which was poorly defined. The nuclei
were round to oval, and occasionally spindled, and were
regular and small with bland chromatin. They were evenly
spaced within the fragments and did not overlap. Anaplasia
and mitosis were absent. The number of lymphocytes
intermingled with these epithelial fragments varied from
area to area in the same case and from case to case. The
lymphocytes were abundant and either lay on top of the
epithelial fragments or were scattered throughout the slide.
The lymphocytes were small and round, and appeared
mature. No other elements were seen.
A limited surgical biopsy was avoided in all 3 cases, and
the surgeon went directly to mediansternotomy and excision
of the tumor. In one case, however, the thymoma was
invasive and deemed inoperable; only a biopsy was taken.

Fig. 5. Germ-cell tumor. High-grade epithelial-type tumor cells (Papanicolaou stain, 400).

The surgical specimens showed thymoma in all 3 cases (type

I in 2 cases and type II in one case).

Germ-Cell Tumors
There were 3 cases of germ-cell tumors (GCT). All were in
adult males with a mean age of 28 yr. Two of the tumors
were mixed solid and cystic, while the other was purely
solid. In addition to the mediastinal masses, 2 patients had
multiple lung nodules. Serum markers (alpha-fetoprotein
and HCG) were elevated in 2 patients. FNA showed a
high-grade epithelial-type neoplasm in all 3 cases, which in
conjunction with the serum markers and the young age of the
patients made the diagnosis of GCT most likely on FNA
(Fig. 5). In one case, syncytiotrophoblasts were seen on the
FNA slide.
One patient was treated on the basis of the FNA. Two
patients had a limited surgical biopsy. In these cases the
biopsy showed mixed, nonseminomatous GCT.
Diagnostic Cytopathology, Vol 19, No 6

433

SHABB ET AL.

Angiosarcoma
This patient presented with a mixed solid and cystic anterior
mediastinum mass with multiple lung nodules. FNA showed
a monotonous population of spindle cells. The cells were in
densely cellular fragments composed of a single population
of monomorphic hyperchromatic spindle cells which lacked
cytologic atypia, pleomorphism, and mitotic figures. The
diagnosis was spindle-cell neoplasm; differential diagnoses
included spindle-cell thymoma (although a lymphoid component was lacking) and monomorphic sarcoma. Mediastinotomy and biopsy revealed an angiosarcoma. The tumor
cells were positive for factor VIII.

Malignant Neoplasms, Not Otherwise Specified

There were 3 cases in this category where the FNAs and the
surgical biopsies showed an undifferentiated malignant
neoplasm. Two of the patients were young adult males.
Immunohistochemical markers for germ-cell tumors were
negative in all three. Cytokeratin was positive in one,
favoring a poorly differentiated carcinoma of undetermined
origin, while LCA was weakly positive in another, favoring
a lymphoma. Two patients were lost to follow-up immediately after the biopsies, and the third patient had disseminated malignancy in his abdomen and chest while on
chemotherapy and passed away 2 mo after diagnosis.

Fig. 6. Noncaseating granuloma. An aggregate of epithelioid histiocytes

(left), a giant cell (arrow), and mature lymphocytes (Papanicolaou stain,
400).

Metastatic Neoplasms
There were 9 metastatic carcinomas and one metastatic
sarcoma.
Six cases were of lung primary. In these cases the
mediastinal mass was so large as to obscure the origin from
the lung, or the mediastinal mass was dominant with a small
mass in the lung. FNA in 3 cases were small-cell undifferentiated (oat-cell) carcinoma, 2 were poorly differentiated
nonsmall-cell carcinoma, and one was adenocarcinoma.
One metastatic adenocarcinoma was from a breast primary. In 2 cases, the primary lesion was unknown. The
original reading on four of these FNAs was malignant
neoplasm, carcinoma vs. lymphoma. Review of these aspirates revealed features of carcinoma in all four.

Benign Conditions
Granulomatous Disease
There were 2 cases in this category. The first (case 35) was a
20-yr-old man who had by radiologic and clinical impression an aggressive invasive lesion in the anterior mediastinum. FNA yielded necrotic material and a few giant cells. At
surgical exploration the lesion was found to be poorly
circumscribed, with invasive margins. Frozen section revealed caseating granulomas. Tissue culture later grew
Mycobacterium tuberculosis. The second case (case 36) was
a 40-yr-old woman who had enlarged anterior mediastinal
lymph nodes. FNA showed well-formed, noncaseating granu434

Diagnostic Cytopathology, Vol 19, No 6

Fig. 7. Multinodular goiter. A sheet of follicular thyroid epithelium in a

honeycombed pattern (Papanicolaou stain, 400).

lomas with giant cells (Fig. 6). A limited surgical biopsy

revealed noncaseating granulomas. Stains for tuberculosis
and fungi were negative. Cultures were also negative. A
diagnosis of sarcoidosis was favored.

Multinodular Goiter
This 62-yr-old woman (case 37) presented with dysphagia.
Her past medical history was significant for partial thyroidectomy 10 yr prior to her presentation. A CT scan showed a
well-defined solid mass in the posterior mediastinum, 3 cm
in size. FNA showed many large open sheets of follicular
epithelium in honeycombed arrangement, with smaller colloid-containing follicles, a few histiocytes, and colloid
material in the background (Fig. 7). Further radiologic
studies showed a thin band of tissue connecting this mass to
the anterior neck. Iodine uptake studies were positive,
proving the true thyroid nature of the lesion.

FNA OF THE MEDIASTINUM

Fig. 8. Extramedullary hematopoeisis. Two megakaryocytes in a background of erythroid and granulocytic precursors (Papanicolaou stain,
400).

Extramedullary Hematopoesis
This 39-yr-old woman, already diagnosed with congenital
dyserythropoetic anemia, presented with complaints related
to severe anemia. In addition to low hematocrit and heart
failure, she had a well-defined, solid, 3-cm mass in the
paravertebral area in the posterior mediastinum. FNA revealed a mixture of hematopoetic elements, including many
megakaryocytes, granulocytes, and erythrocytes (Fig. 8). A
diagnosis of extramedullary hematopoeisis was made, and
the patient was saved a surgical procedure.

Thymic Cyst
In this case, the FNA yielded 50 cc of clear fluid. The cyst
disappeared after the aspirate. The FNA in this case was both
diagnostic and therapeutic.

Discussion
Although the role of FNA in the mediastinum remains
controversial,14,6,8,9 our results have shown that despite the
cystic, necrotic, and fibrotic nature of many of these lesions,
the tissue adequacy by FNA was remarkably good (83%),
and that despite the varied pathologic entities and the
difficulty in reaching a correct diagnosis even in open
surgical biopsies, our diagnostic accuracy by FNA was 86%.
The patient demographics in this study are similar to those
in previously reported series,1,4,14 with a wide age range
(1072 yr) and a male predominance (60%).
In contrast to similar previously reported data,1,4 our study
had a predominance of primary mediastinal lesions (57%),
while metastatic tumors accounted for only 24%. Other
similar reports have a predominance of metastatic tumors in
their series. This discrepancy is explained by our study
design. The aim of the study was to assess the dignostic
accuracy of FNA in primary mediastinal lesions; hence,

those cases that were obviously metastatic to the mediastinum were not included.
Many reports in the literature attest to the difficulty in
diagnosing and accurately distinguishing between thymomas and lymphomas by FNA alone, and recommend the use
of core-needle biopsy in these cases.2,4,8,15 In our study, these
cases were readily diagnosed by FNA alone. Ten of the 13
lymphomas and all 3 of the thymomas were correctly
diagnosed. Hodgkins disease of the mediastinum is usually
of the nodular sclerosis subtype, where dense fibrosis may
interfere with good cellular yield, and the paucity of classic
Reed-Sternberg cells may make the diagnosis by FNA
difficult. Despite the above-mentioned difficulties, 5 of the 7
cases of Hodgkins lymphoma yielded good cellularity, and
the diagnosis was suspected not on finding classic ReedSternberg cells, but on finding Reed-Sternberg variants in
the appropriate cellular background of inflammatory cells.
As is well-known, a definitive diagnosis of HL should not be
made on FNA alone. Confirmation needs to be obtained by
surgical biopsy. The advantage of FNA in these cases is that
the surgeon would know that he or she is dealing with a
lymphoma and can plan for a limited surgical procedure.
Non-Hodgkins lymphoma of the mediastinum is most
often diffuse large-cell or lymphoblastic.19,20 Smears are
usually cellular and composed of dispersed single cells with
lymphoglandular bodies in the background. The distinction
between the two subtypes is made on the cytologic details of
the cells, taking into account cell size, nuclear contours,
shape, and chromatin pattern. Tingible body macrophages
and many mitotic figures are seen more often in high-grade
lymphoblastic lymphoma.20
In this study, all cases of thymoma had the classic
biphasic pattern of bland epithelial cells in a background of
mature lymphocytes, and hence did not raise diagnostic
difficulties. This may not always be the case, since spindlecell thymomas and heavily lymphocytic thymomas may
indeed be problematic by FNA. In this study, one case (a
Hodgkins lymphoma) was incorrectly suspected of being a
thymoma. The aspirate was scanty and was not representative. Sheets of benign mesothelial cells and aggregates of
histiocytes were misinterpreted as the epithelial component
of a thymoma, while a few lymphocytes were interpreted as
the lymphocytic component. Similar difficulties have been
reported in the literature.1 The diagnosis of thymoma should
only be made when there is adequate cellularity in addition
to the typical biphasic pattern.
The distinction between poorly differentiated carcinoma
and lymphoma was not made in 4 of our cases. These were
called malignant neoplasms, lymphoma vs. carcinoma.
These cases were from the early part of the study, where the
limited expertise and confidence of the pathologist may have
played a role. Review of these cases showed typical cell
clustering, nuclear molding, nuclear variability, and hyperchromasia typical of carcinoma. The absence of lymphoglanDiagnostic Cytopathology, Vol 19, No 6

435

SHABB ET AL.
2. Rosenberger A, Adler O. Fine-needle aspiration biopsy in the diagnosis
of mediastinal lesions. AJR 1978;131:239242.

dular bodies was also a helpful feature. In difficult cases the

use of immunohistochemical markers may help in resolving
the issue. Small-cell carcinoma is distinguished from nonsmall-cell carcinoma by the small size of the cells, minimal to
absent cytoplasm, evenly hyperchromatic nuclei, absence of
prominent nucleoli, and nuclear molding.
When the FNA yields undifferentiated malignant cells,
particularly in young adult males, then the diagnosis of
germ-cell tumor needs to be seriously considered. Material
for cell-block and immuhistochemical stains should be
obtained in addition to serum markers. Elevated serum
markers in conjunction with undifferentiated malignant cells
on FNA in this setting may be adequate to diagnose
germ-cell tumor. In some cases, despite surgical biopsy and
a battery of immunohistochemical stains, a definite subclassification of the neoplasm cannot be achieved.
Although benign conditions are reported to be difficult to
diagnose by FNA,1416 4 of the 5 cases in this study yielded
good cellularity and accurate diagnosis. Two of these cases
(a nodule of goiter extending to the posterior mediastinum
and a mass of extramedullary hematopoeisis also in the
posterior medistinum) were accurately diagnosed by FNA,
avoiding surgical intervention.
We conclude that FNA is a good diagnostic tool in lesions
of the mediastinum, as a first attempt at tissue diagnosis. It
may result in a definitive diagnosis avoiding surgical
intervention, such as in some cases of non-Hodgkins
lymphoma, GCTs, or metastatic tumors. If a definitive
diagnosis cannot be reached, then a preliminary diagnosis
would help to guide the surgeon in his or her surgical
approach. Nonsurgical conditions (such as lymphomas and
GCTs) could be approached with a mediastinotomy and
limited surgical biopsy, while surgical diseases such as
thymomas would be approached with a thoracotomy or
mediansternotomy for total surgical removal of the lesion.

10. Linder J, Olsen G, Johnston WW. Fine-needle aspiration of the

mediastinum. Am J Med 1996;81:10051008.

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