they originate either in bone ( osseous plasmacytoma ) or in soft tissues ( extramedullary plasmacytoma ) . it can occur as the sole manifestation of plasma cell neoplasm , as a metastasis from another extramedullary plasmacytoma or as a consequence of multiple myeloma . it has no characteristics of multiple myeloma , but the development of multiple myeloma has been observed in 836% of patients months or years later . these plasma cell tumors can occur anywhere and have to be differentiated from other neoplasms , infectious processes and chloromas . the head and neck region has been reported as a frequent site for amyloid deposits . one of the most common forms of amyloid proteins are amyloid light chain ( al - type ) , which is derived from plasma cells , contains immunoglobulin light chains and is associated with plasma cell dyscrasias . fine needle aspiration smears of a 50-year - old female patient with cervical lymphadenopathy were sent to the department of pathology without any clinical details . cytology smears ( giemsa stain ) showed sparse cellular aspirate with amorphous granular basophilic material , predominantly scattered lymphocytes , plasma cells and occasional epithelioid cells [ figure 1 ] . this amorphous material was interpreted as caseous necrosis and the possibility of tuberculous lymphadenitis was suggested . subsequently , patient 's clinical findings were provided with the request for review of slides as the patient had not responded to antituberculous treatment . in the details provided , a nasal growth was also mentioned to be present in the lateral wall of the nasal cavity , which was globular , firm and pink in colour and measured 3  2  2 cm . lymph node aspirate showing amorphous granular basophilic material which mimicked caseous necrosis ( giemsa ,  400 ) repeat aspiration from the cervical lymph node , imprint smears and biopsy from the growth were performed . repeat aspiration and imprint smears revealed high cellularity with amorphous basophilic material , large number of plasma cells with varying degree of maturity , myeloma cells and occasional scattered epithelioid cells . an occasional foreign body type , multinucleated giant cell with intracytoplasmic amorphous basophilic material was also seen . plasma cells had prominent eccentric nuclei , coarse chromatin , perinuclear halo and basophilic cytoplasm and myeloma cells had fine chromatin , prominent nucleoli and little or no halo . presence of numerous plasma cells and myeloma cells raised the possibility of plasmacytoma [ figure 2 ] . the amorphous extracellular material and similar intracytoplasmic material within giant cells raised the possibility of amyloid within the cells . subsequent congo red staining of the cytology and histopathology slides , showed the amorphous material to be orange - red in color . it gave an apple - green birefringence when viewed under polarized light , confirming it to be amyloid . thus , the diagnosis of plasmacytoma with amyloidosis was suggested and confirmed by a histopathology study of the biopsy tissue . there was no clinical , radiological or laboratory evidence of plasma cell dyscrasias or systemic amyloidosis . repeat lymph node aspirate showing plasma cells ( uninucleate and binucleate ) , myeloma cells , scattered lymphocytes and amorphous basophilic material ( giemsa ,  400 ) extramedullary plasmacytoma is a soft tissue neoplastic lesion that is made up of monoclonal plasma cells ( plasma cell dyscrasias ) . it can be primary , without evidence of disease in other foci , or part of a systemic process during the course of multiple myeloma . thus , these patients should be carefully evaluated for the presence of disseminated disease / multiple myeloma before arriving at a diagnosis of extramedullary plasmacytoma . studies should include complete blood cell count , serum calcium levels , radiologic skeletal survey , magnetic resonance imaging ( mri ) of the spine , pelvis , humeri and femurs , immunoelectrophoretic examination of serum and urine , 2 microglobulin assay and bone marrow biopsies . diagnosis should be made only if all studies for disseminated disease are negative , as was seen in our case . these tumors can occur anywhere in the body , but nearly 8090% of all extramedullary plasmacytoma occur in the head and neck region . most of these cases arise in the aerodigestive tract , probably because of the abundance of lymphatic tissue in this area . in one study the frequently affected sites in decreasing order of frequency included nasal cavity or paranasal sinuses , nasopharynx , oropharynx and larynx . extramedullary plasmacytoma occurs in patients between 50 and 60 years of age , and is more common in men ( 4:1 ) . plasmacytomas arising in the nasal cavity or nasopharynx usually present as a soft bleeding mass or as a polypoid mass , covered mostly by an intact overlying mucosa . cervical lymphadenopathy and nasal discharge may be the associated presenting symptoms in an occasional patient . microscopic examination of cytological smears show numerous plasma cells , including binucleate , multinucleate and pleomorphic forms . on histopathological examination , plasmacytomas are very vascular tumors with minimal stromal component and sheets of plasma cells with varying degrees of differentiation and immature plasma cells . differential diagnosis of plasmacytoma includes plasma cell granuloma , plasmacytoid lymphoma and large cell lymphoma of immunoblastic type . immunocytochemical study with antibody to kappa and lambda light chains is an important approach to differentiate these conditions . kappa or lambda light chain - restricted population confirms the diagnosis of plasmacytoma and suggests a pathogenetic relationship between plasmacytoma and amyloid deposition . sakai et al . diagnosed extramedullary plasmacytoma of the tonsil by demonstrating diffuse immunoreactivity for lambda light chains within plasmacytoid cells . immunoblastic lymphomas usually involve lymph nodes and show cytoplasmic igm heavy chain ( igg and iga heavy chains in plasmacytomas ) and express pan b cell surface antigens . eilam et al . reported a case of plasmacytoma of the nasal cavity that involved the palate , ethmoidal and maxillary sinuses and contained deposits of amyloid . reported a case of extramedullary plasmacytoma of the parotid gland with extensive amyloid deposition masking the cytologic and histopathologic picture . amyloid refers to the extracellular fibrillar proteinaceous substance deposited in various tissues and organs of the body in a wide variety of clinical settings clinically , the symptoms depend on the magnitude of the deposits and on the particular sites or the organs affected . regarding its imaging appearance , affected bony conchae and sinus walls show a fluffy appearance adjacent to amyloid deposit on computed tomography scan ; calcification has been mentioned as a nonspecific finding . foreign body giant cell reaction may be evoked about the amyloid deposits , as was also seen in our case . it can be seen on mri as a peripheral enhancement in the region of amyloid deposits with contrast material administration . differential diagnosis of this material on lymph node cytology smears include caseous necrosis , tumor necrosis and colloid . completely amorphous granular material without identifiable cell remnants suggest caseous necrosis , seen predominantly in tuberculosis caused by mycobacteria and other bacterial diseases and fungal infections . the type of granulomatous reaction , clinical details and bacteriological data are necessary to differentiate these conditions . neoplastic conditions , specially the lymphomas ( non - hodgkin 's and hodgkin 's ) and metastatic carcinomas , show tumor necrosis and therefore should be excluded . tumor necrosis appears as numerous cell shadows with pyknotic nuclei it may be homogenous or granular , resembling caseous necrosis . colloid appears as a dense , blob - like material with sharp outlines on cytology smears from the thyroid . rectal / bone marrow biopsy and fine needle aspiration of abdominal subcutaneous fat is suggested to rule out systemic amyloidosis . the diagnosis of amyloid is based almost entirely on its staining characteristics . with light microscope and standard tissue stains differentiation between amyloid and other amorphous eosinphilic substances , such as hyaline material , collagen and fibrin , is impossible . thioflavin t and other fluorescent dyes offer greater sensitivity in detection of amyloid but both hyaline and fibrin give positive results . thus , the gold standard for diagnosis of amyloid is congo red staining , which stains the tissue pink or red in color by light microscopy and gives green birefringence by polarized microscopy due to a -pleated sheet conformation of amyloid fibrils .
amyloid material on lymph node cytology smears can mimic caseous necrosis . 
 we report one such case where a 50-year - old lady presented with a nasal mass and cervical lymphadenopathy . 
 fine needle aspiration cytology smears of the cervical lymph node were interpreted as tuberculous lymphadenitis based on the presence of an occasional epithelioid cell and caseous material . 
 the patient did not respond to antituberculous therapy and was revaluated . 
 repeat aspiration from the lymph node showed numerous plasma cells and myeloma cells in addition to the amorphous material which was confirmed to be amyloid on staining with congo red . 
 a diagnosis of plasmacytoma with amyloidosis was rendered . 
 imprint smears from nasal mass , detailed hematology workup and subsequent histology confirmed the diagnosis .