Cytology II MCQS

FINALS

Respiratory cytology

1. Roles

confirm clinical or radiological suspicion of lung cancer

assist in recognition of opportunistic infections (HSV, CMV, candida, aspergillus, cryptococcus, pneumocystis jiroveci) in immunocompromised patients

2. Sensitivity depends on

method of collection
no of samples submitted
tumor cell type
size and location of lesion

Specificity depends on

clinical history (adequate/inadequate)
preservation of the specimen
necrosis
inflammation

3. Types of cells

epithelial

alveolar epithelium

non epithelial cellular elements

macrophages
siderophages
neutrophils (PMN leukocytes)
lymphocytes
eosinophils

4. Sputum

5. Bronchial washing/Bronchial brushing/Bronchoalveolar lavage (BAL)

BW: bronchoscopy, saline wash over bronchi, bronchial trap

BB: bronchoscopy, brush, smear onto slide

BAL: lavaging the area with buffered saline solution

Diagnosis of: opportunistic infections, bronchoalveolar carcinoma, metastatic malignancies, Diffuse Interstitial Lung disease

Advantages

Localise lesion
Good for central and peripheral lesions
More accurate than sputum cytology
Diagnostic rate high
Diagnostic rate increases when biopsy is performed

Disadvantages

Day procedure with associated costs
Limited area sampled
Very peripheral lesions not diagnosed

6. FNA lung

transbronchial: distal, submucosal, mediastinal lesions

transthoracic: apical, mediastinal, intrapulmonary masses

Normal cells: squamous cells, squamous metaplasia, bronchial cells, macrophages

Opportunistic infections: HSV, CMV, Cryptococcus, Aspergillus

Non cellular entities: mucus, Curshman's spirals, ferruginous body

Contaminants: vegetable cells, meat fibers

5. Malignant

high death rate, high prevalence, high fatality 87%

etiology: tobacco smoking, industrial hazards, radiation

clinical presentation: cough, loss of weight, shortness of breath, hemoptysis, cervical lymphadenopathy, paraneoplastic syndromes

SCC 35~50%

Adenocarcinoma 15~35%

Small cell 20~25%

Large cell 10~15%

Effusions cytology

1. Definition

accumulation of fluid within the body cavity

excess of the normal amount

always due to the pathological process

indicates that a patient has disease

pleural, peritoneal (ascites), pericardial

2. Formation

increased vascular hydrostatic pressure （congestive heart failure)
decreased vascular osmotic pressure (hypoproteinemia)
increased vascular permeability (pneumonia)
decreased lymphatic absorption (tumor involvement)

3. Transudate & Exudate

Transudate:

increased hydrostatic
decreased osmotic
associated with systemic problems (congestive heart failure)

Exudate:

damage to capillaries in serosal CT
associated with local problems (infection, pulmonary infarction, GIT disease)

4. Collection

thoracentesis
pericardiocentesis
paracentesis

insert needle or catheter into space

aspirate out into collection bottle or bag

collect into sterile specimen containers + anticoagulant (heparin/EDTA)

delay specimen need refrigeration

5. Mesothelial cells

6. Mesothelioma

large clusters with scalloped edges

non cohesive

isolated cells

cytomegaly

round, central placed nucleus

prominent nucleolus

bi/multinucleation

dense cytoplasm with peripheral halo

normal N:C

windows

7. Metastatic adenocarcinoma

pleural: breast, lung

peritoneal: gastric, ovarian

acinar, papillary, sheet formations

high N:C

hyperchromatic

irregular, multiple nucleoli

pale cytoplasm

large secretory vacuole

8. Ancillary test

histochemical stains

immunocytochemical staining

electron microscopy

molecular biology

Thyroid cytology

1. FNA

main indication: thyroid nodule

quick, simple, inexpensive, accurate

palpation or ultrasound

needle is rinsed

resulting cell suspension used for cytocentrifuge, thin layer, cell block

adequate aspirate contain colloid (clear thin film of translucent material), follicular cells or inflammatory cells

6 well preserved and well stained follicular groups

> 10 cells/group

unsatisfactory: blood (can be reduced by thin layer)

2. Benign follicular nodules

MNG (multinodular goiter)

Follicular adenoma (FA)

macro follicles

fragmented (flat sheets)

intact spheres

low to moderate cellularity

cohesive cells

uniform, evenly spaced follicular cells

coarse chromatin

colloid (abundant, watery)

macrophages

scant cytoplasm

3. HT

4. Papillary

5. Medullary

originates in parafollicular C cells

calcitonin

less common malignant:

poorly differentiated carcinoma
undifferentiated (anaplastic) carcinoma
medullary thyroid carcinoma
metastatic carcinoma

Breast cytology

1. FNA

evaluate palpable breast masses, breast cysts, non-palpable mammographic abnormalities

sensitivity 65~98%

specificity 34~100%

core needle biopsy (histology)

nipple discharge

open surgery

thin gauge 25~22G needle

applications:

palpable lesions
non-palpable deep seated lesions using radiological techniques
body organs (glands, thyroid, breast, lung)

indications:

preoperative confirmation of clinically suspected breast cancer
investigate palpable lump, benign or malignant
diagnosis of simple cyst
investigate recurrent or metastatic lesions
obtain material from tumors for special analysis and research

2. Benign

Cyst

90% benign
benign cyst: watery, yellow, clear to slightly opaque, few particles, no residual mass
atypical cyst: watery to viscous, brown to red, densely opaque, numerous particles, residual mass
ductal epithelial cells (apocrine cells in flat sheets, isolated cells are rare)
round central placed nuclei
prominent nucleoli
foam cells (macrophage) with abundant vacuolated cytoplasm

Fibroadenoma

most common in young women
freely movable, rubbery masses
hypercellular
large sheets
3D clusters with antler like configuration
fibrillar stromal fragments
bluish gray with pap stain
intensely red purple with Romanowsky
fine granular chromatin
small round nucleolus

3. Malignant

Invasive lobular

most common
50~75%
middle aged to elderly
risk factors:

early menarche
late menopause
nulliparity (no pregnant)
late first birth
first degree relative

hypercellular
isolated cells
poorly cohesive
comet cells (eccentric nucleus protruding from cytoplasm)
no bare bipolar nuclei
high N:C
hyperchromatic
pleomorphic nuclei
fine or coarse chromatin
irregular nucleoli
clean background but inflammation, blood, granular debris

Invasive ductal

5~15%
often sparsely cellular (marked stromal fibrosis)
isolated cells
linear, swirling fashion
small to medium sized uniform cells
infiltration pattern
high N:C
no bare bipolar nuclei
signet ring (large cytoplasmic vacuole)
eccentric kidney bean nucleus
hyperchromatic
nuclear molding
small nucleolus

Urine cytology

1. Benign

umbrella cells

urothelial cells

squamous cells

columnar cells

glandular cells

RBC, WBC

macrophages

seminal vesicle cells

contaminants

granular casts

hyaline casts

epithelial casts

crystals

calculi

fecal material

2. Infection

Candida

Polyoma virus

CMV

Trichomonads

Schistosoma haematobium (SCC)

3. CIS

very good cytological recognition
abundant abnormal urothelial cells
high N:C
hyperchromatic
pleomorphic nuclei
mitotic activity
single and sheets
clean background

4. SCC

5. TCC

Grade I

derived from epithelial hyperplasia
increased bland urothelial cells
papillary clusters with irregular edges
nuclear crowding
nuclear overlap
high N:C
poor cytological recognition

Grade II

irregular nuclear outlines and chromatin distribution
increased N:C
single cells > papillary

Grade III

derived from CIS
single bizarre cells
irregular nuclear borders
chromatin clearing
mitoses
blood, debris, inflammatory cells
very good cytological recognition

6. Ancillary techniques

NMP22

diagnosis and management of bladder cancer
elevated levels of NMP22 protein

UroVysion Multiprobe FISH

highly sensitive and specific
detect bladder cancer in voided urine and bladder washings
≥4 containing gain of >2 chromosomes of 3, 7or 17 and ≥12 cells with deletion of LSI p16 (9p21)

Reporting system in cytopathology

1. Paris system for reporting urinary tract cytopathology