Liesegang Rings in Fine NeedleAspirate of Breast Cysts WithPredominance of Apocrine Cells:A Study of 14 CasesRaj K. Gupta, M.D., F.I.A.C.1,2*

Fine needle aspirate (FNA) from 14 cases (age range 17–84years), with Liesegang rings (LR’s) in breast cysts seen over aperiod of 26 years comprised the material of this study frommore than 38,000 FNA’s of the breast which had been done fora variety of breast lesions. In six of the 14 cases, the aspiratewas obtained under ultrasound guidance whereas in the remain-ing cases it was collected from a palpable lesion. The aspirationwas performed using a 22 gauge needle and the syringe andneedle contents were washed in a cytology container with 30%ethyl alcohol in physiologic saline. The cytologic preparationsfrom half of the sample were made on a 5 micron Schleicherand Schuell filter and stained by Papanicolaou method whereasfrom the remainder of the sample a cell block was made andsections cut, stained with hematoxylin-eosin (H&E) and used forimmunohistochemical study.

Filter preparations and cell blocks revealed cyanophilic,spherical, ring-like structures of various sizes and shape mostlywith double walls, and striations with amorphous material in thelumen and under polarized light were nonrefractile. Seen alsowere several apocrine cells and some macrophages and theLR’s were found to be negative on immunostains for EMA andCK, and a panel of other special stains (Table I). Since LR’scan be mistaken for ova, larvae, or parasites, it is important tobe aware of their potential presence in aspirate samples ofbreast cysts to avoid a misdiagnosis. The exact mechanism offormation of LR’s is not fully understood and certain views asproposed are discussed in this presentation. Diagn. Cytopathol.2008;36:701–704. ' 2008 Wiley-Liss, Inc.

Key Words: breast; fine needle aspirate; Liesegang rings; cyst

In a previous publication1 for the first time, we described

ring-like structures resembling Liesegang rings (LR’s) in

a fine needle aspirate (FNA) of a cystic lesion of the

female breast. Subsequently, in three patients a mammo-

graphic opacity was noted and an FNA sample in these

also showed a cystic lesion with many apocrine cells.2 In

a period of 26 years since FNA cytology became an inte-

gral part of investigation protocol in our practice, we

have examined more than 38,000 FNA’s of the breast and

have seen a total of 14 cases with ring-like structures in

breast aspirates. These are described in this communica-

tion. Four of the cases from the total (cases 1–4, Table I)

were briefly reported earlier by us.1,2

Materials and Methods

The aspiration was performed using a 22 gauge needle. For

cytologic study, the syringe and needle contents were im-

mediately washed in a cytology container with 30% ethyl

alcohol in physiologic saline and preparations were made

on Schleicher and Schuell filters (size 25 mm; pore size 5

microns), and staining was done with Papanicolaou

method. A cell block from the aspirated material was made

after centrifugation, fixed, processed, embedded, cut at 5

microns, and stained with hematoxylin-eosin. Additional

immunostains and special stains on cell blocks as listed

(Table I, Ancillary study findings) were done in 10 of the

14 cases. A summary of clinical findings, diagnosis, and

other pertinent data in all the cases is shown in Table I.

Results

Cytologic and Immunohistochemical Findings

The cytologic and cell block preparation in all the cases

and a biopsy in the cases with a mammographic opacity

(case 2–4; Table I) showed many apocrine cells, some

macrophages and several cyanophilic, spherical ring-like

structures of various sizes, mostly with double walls,

striations, and amorphous material in the lumen (Figs. 1–3).

Under polarized light, the rings were found to be nonre-

1Cytology Unit, Aotea Pathology (formerly Valley Diagnostic Labora-tories Ltd, Lower Hutt, New Zealand)

2Department of Pathology, School of Medicine, Wellington,New Zealand

*Correspondence to: Raj K. Gupta, M.D., F.I.A.C., Consultant Cytopa-thologist, Aotea Pathology, 6th Floor, CMC Building, 89 CourtenayPlace, Wellington, New Zealand. E-mail: raj.gupta@xtra.co.nz

Received 8 January 2008; Accepted 16 May 2008DOI 10.1002/dc.20902Published online in Wiley InterScience (www.interscience.wiley.com).

' 2008 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 36, No 10 701

Table

I.SummaryofFindingsin

14Fem

aleBreastCyst

FNA’s

withBenignApocrineChanges

andLiesegangRings

Case

Age

(years)

Clinicalfin

ding

sClinicaldiag

nosis

FNAdiag

nosis

Histologic

confi

rmation

Ancillary

stud

yfin

dings

(case

1to

10)

171

3.5

32.5

cmcystic

massonleftside

Cyst

Apocrinecystwith

LR’s

CCytokeratin

–N

EMA

–N

Periodic

acid-Schiffwithand

withoutdiastase–N

Bestcarm

ine–N

Alcianblue(pH

2.5

and1)–N

Mucicarm

ine–N

VonKossa–N

Perlsironstain–N

Congored–N

Birefringence

(congored)–N

Polarizedlight(findings)

-nonrefractile

243

23

1.5

cmmam

mographic

opacityin

rightupper

inner

quadrantwith

microcalcification

Suspiciousforcarcinoma

Asabove

C&B

Asabove

345

23

1cm

mam

mographic

opacityin

leftupper

inner

quadrant

Suspiciousforcarcinoma

Asabove

C&B

Asabove

465

3.5

32.5

cmmassin

leftlower

outer

quadrantwithmicrocalcificationand

opacity

Suspiciousforcarcinoma

Asabove

C&B

Asabove

573

2.5

32cm

massin

rightlower

quadrant

Cyst

Asabove

CAsabove

661

1.5

31cm

cystic

massonleftside

Cyst

Asabove

CAsabove

729

23

1cm

partially

cystic

massin

rightupper

outerquadrant

Cystfibroadenoma?

Asabove

CAsabove

828

2.5

32cm

cystic

massin

leftupper

inner

quadrant

Cystfibroadenoma?

Asabove

CAsabove

945

33

2cm

painfulcystic

massin

leftupper

outerquadrant

Duct

ectasia

Inflam

edapocrine

cyst

withLR’s

CAsabove

10

84

2.5

32.5

cmpainfulmassonrightside

Infected

cyst

Inflam

edapocrine

cyst

withLR’s

CAsabove

11

17

1.5

31cm

massonleftside

Firbroadenoma

Apocrinecystwith

LR’s

CNotdone

12

48

2.5

32cm

cystic

massin

rightupper

outerquadrant

Fibrocystic

process

Asabove

CNotdone

13

51

33

2.5

cmcystic

painfulmassin

left

upper

outerquadrant

Infected

cyst

Asabove

CNotdone

14

59

3.5

32cm

cystic

massin

rightlower

outerquadrant

Cyst

Asabove

CNotdone

N,negative;

C,cellblock;B,biopsy;LR’s,Liesegangrings.

GUPTA

702 Diagnostic Cytopathology, Vol 36, No 10

Diagnostic Cytopathology DOI 10.1002/dc

fractile, and no birefringence was noted in congo-red

stained preparations. On immunostaining for CK and

EMA in the 10 cases (Table I), the ring-like structures

showed a negative reaction and in view of a negative

finding on staining in these cases, four of the most

recently seen cases were not studied with any of the im-

munohistochemical stains (case 11–14; Table I).

Discussion

Although the exact reasons of LR formation are not

known, a belief based on precipitation phenomenon from

supersaturated colloidal systems is suggested. Also, their

occurrence in nature as calcium carbonate in oolitic lime-

stone, crystals of various monosacchrides, calcium, iron,

silicone, and sulfur have been known, along with certain in

vivo examples like pulmonary and central nervous system

corpora amylacea.3–8 Some studies have also indicated that

LR’s may be found in inflamed, fibrotic and cystic lesions

(renal and perirenal cysts) and in some of these processes,

an environment similar to colloidal gels may be created

because of high molecular weight polymers.3,5,6

LR’s can be of variable size and shape and in cytohis-

tological material may be mistaken for eggs, larvae, or

any other helminth, and LR’s in renal cysts have been

mistaken for giant kidney worm, Dioctophyma

renale.3,5,6,8 In 14 cases presented in this study, an inter-

esting finding in all the cystic lesions with LR’s was the

presence of several apocrine cells and whether these cells

had any role in the formation of LR’s was unclear, since

on review of several hundreds of such cystic lesions, no

such structures were found. However, the possibility of

high molecular weight polymers as being a possible rea-

son for LR formation with numerous apocrine cells could

not be totally excluded since such polymers have been

suggested to be a likely cause for LR formation in rare

cases of cystic and inflamed tissue.1,8

In the three cases with a mammographic opacity (case

2–4; Table I) and subsequent finding of LR’s in FNA was

of interest. However, the reason for such a finding could

not be conclusively explained, since in none of the other

eleven cases with LR’s in breast FNA samples were such

opacities noted. Neither any calcific material in aspirate

sample was found in any of the cases. Also, the negative

findings on immunohistochemical study in the cases were

inconclusive of LR composition. In conclusion, and as

stressed previously1,2 it is suggested that LR’s in cytohis-

tologic material should be reported and not over diag-

nosed for nonexistent conditions.

Acknowledgments

The author acknowledges the excellent technical help of

several cytotechnologists at Wellington Hospital and Valley

Diagnostic Laboratory during the course of this study. The

cooperation and professional exchange of information from

various breast clinicians is acknowledged. The photo-

graphic assistance of Abed Kader and Dinesh Gupta, and

Fig. 1. Filter preparation from a breast aspirate showing Leisegang ringsand apocrine cells (Papanicolaou stain 3450).

Fig. 2. Filter preparation from a breast aspirate showing Leisegang ringsand apocrine cells (Papanicolaou stain 3450).

Fig. 3. Cell block from a breast aspirate showing Leisegang rings alongwith apocrine cells (Hematoxylin-eosin stain 3450).

LIESEGANG RINGS IN BREAST CYST

Diagnostic Cytopathology, Vol 36, No 10 703

Diagnostic Cytopathology DOI 10.1002/dc

assistance of Suvira Gupta in transcribing and review is

gratefully acknowledged. The findings presented include

some of the observations which were made by the author

while at Wellington Hospital, Wellington, New Zealand

between May 1981 and December 2003 as Head of

Cytology Unit.

References

1. Gupta RK, McHutchison AGR, Fauck R. Liesegang rings in a needleaspirate from a breast cyst. Acta Cytol 1991;35:700–702.

2. Gupta RK, Panwar NK. Fine needle aspiration cytodiagnosis of Lei-segang rings in women presenting with a mammographic opacity.Diagn Cytopath 1997;17:213–215.

3. Katz LBK, Ehya H. Liesegang rings in renal cyst fluid. Diagn Cyto-pathol 1990;6:197–200.

4. Liesegang RE. Uber einige Eigenschaften von Gallerten. Naturwis-senchaften 1896;11:353–362.

5. Sneige N, Dekmezian RH, Silva EG, Cartwright J, Jr., Ayala AG.Pseudoparasitic Liesegang structures in perirenal hemorrhagic cyst.Am J Clin Pathol 1988;89:148–153.

6. Sneige N, Dekmezian R, Zaatari GS. Liesegang-like rings in fineneedle aspirates of renal/perirenal hemorrhage cysts. Acta Cytol1988;32:547–551.

7. Siverman JF. Guides to clinical aspiration biopsy: Infectious andinflammatory diseases and other non neoplastic disorders. New York:Igaku-Shoin; 1991. p 266–267.

8. Tuur SM, Nelson AM, Gibson DW, et al. Liesegang rings in tissue:How to distinguish Liesegang rings from the giant kidney worm.Dioctophyma renale. Am J Surg Pathol 1987;11:598–605.

GUPTA

704 Diagnostic Cytopathology, Vol 36, No 10

Diagnostic Cytopathology DOI 10.1002/dc