Cytopathology

Cytopathology Dr Bijal Shah Specialty Trainee in Histopathology 31/01/2020

Gynae cytology

Age

When you're invited

under 25

up to 6 months before you turn 25

25 to 49

every 3 years

50 to 64

every 5 years

65 or older

only if 1 of your last 3 tests was abnormal

Question 8 You are delivering a course for nurses who are undertaking smear taker training for liquid based preparations. Following your presentation one of the nurses asks the age at which frequency of call for a routine smear changes from 3 yearly to 5 yearly.

Select the most appropriate answer.

■ A. 30 ■ B. 45 ■ C. 40 ■ D. 45 ■ E. 50

Answer ■

■ ■ ■ ■ ■

You are delivering a course for nurses who are undertaking smear taker training for liquid based preparations. Following your presentation one of the nurses asks the age at which frequency of call for a routine smear changes from 3 yearly to 5 yearly.

Select the most appropriate answer.

A. 30 B. 45 C. 40 D. 45 E. 50

Risk factors of cervical cancer • Viral infection • Sexual behaviour • Smoking • Immunosuppression • Non-attendance for cervical screening

Question 6 A cytoscreener brings a cervical screening sample to you for your opinion. The patient is a 37 year old woman who has had a previous cone biopsy for CIN3 6 months ago. There are crowded groups of hyperchromatic cells which you believe represent lower uterine segment sampling. The screener asks if testing for Human Papilloma Virus (HPV) may help to ascertain if residual CIN is present. What HPV type would you recommend testing for?

■ A. 1.

■ B. 3.

■ C. 6.

■ D. 8.

■ E. 16.

Answer A cytoscreener brings a cervical screening sample to you for your opinion. The patient is a 37 year old woman who has had a previous cone biopsy for CIN3 6 months ago. There are crowded groups of hyperchromatic cells which you believe represent lower uterine segment sampling. The screener asks if testing for Human Papilloma Virus (HPV) may help to ascertain if residual CIN is present. What HPV type would you recommend testing for?

■ A. 1.

■ B. 3.

■ C. 6.

■ D. 8.

■ E. 16.

• • • •

HPV vaccination programme Two types of vaccine in use in the UK 2008- Cervarix- Bivalent (HPV 16, 18) 2012- Gerdasil- quadrivalent (HPV 6, 11, 16, 18)

• In England, from September 2019, all boys and girls aged 12 to 13 will be routinely offered the first human papillomavirus (HPV) vaccination when they're in Year 8 at school. The second dose is usually offered 6 to 12 months after the first.

• HR HPV Testing in NHSCSP • HPV primary screening- December 2019 • Test of Cure for treated CIN & CGIN • Cervical sample taken in exactly same way • HPV test with reflex cytology • All samples HPV tested • If HR HPV positive, sample processed for cytology (10-15% screening population)

Implementation guide: primary HPV screening

Appendix 1: cervical screening protocol hrHPV Test

Baseline

hrHPV negative

hrHPV positive

Cytology negative

Cytology abnormal

Re-screen in 12 months

Colposcopy referral

Routine recall

12 months

hrHPV positive

hrHPV negative

Cytology negative

Cytology abnormal

Re-screen in 12 months

Colposcopy referral

Routine recall

24 months

hrHPV negative

hrHPV positive cytology negative, inadequate or abnormal

Routine recall Colposcopy referral

Cervical screening: cytology reporting failsafe

Appendix 2: cervical screening result and action codes Part 1 – Primary HPV screening result and action codes Cytology result codes

X 0 1 2 3 4 5 6 7 8 9

No cytology result ?glandular neoplasia (non-cervical) * inadequate negative low grade dyskaryosis high grade dyskaryosis (severe) high grade dyskaryosis ?invasive squamous carcinoma ?glandular neoplasia of endocervical type high grade dyskaryosis (moderate) borderline change in squamous cells borderline change in endocervical cells

* non-cervical neoplasia treated as negative for CSP management hrHPV result codes 0 (zero) 9 (nine) U Q

HPV negative HPV positive HPV result unavailable no HPV test carried out due to recent HPV positive result (pilot use only – code now retired, featured here in case noted in patient’s history)

Action codes A R S

routine recall early repeat in 3, 12 or 36 months according to protocol suspend from recall

#

#It

is not necessary in the majority of cases for the laboratory to specify a recall interval, see Implementation guide for primary HPV screening. www.gov.uk/government/publications/cervical-screening-primary-hpv-screening-implementation By convention, results are referenced using the form [cytology result] [HPV result] [action] for example, X0A

Implementation guide: primary HPV screening

Appendix 2: cervical screening colposcopy management recommendations Colposcopy Examination

Adequate

Inadequate

No CIN on biopsy, no biopsy or no colposcopic impression of CIN Index hrHPV positive

*

Index hrHPV positive/cytology or borderline

Repeat colposcopy in 12 months

Index hrHPV positive/cytology *

Index hrHPV positive/cytology or borderline

Recall in 36 months LLETZ

Inadequate consider LLETZ patient choice *excludes borderline change in endocervical cells

Abnormal biopsy CIN1+ or colposcopic impression of CIN1 (no

Discussion at MDT

Manage according to ‘abnormal colposcopy examination’

Question 7 You are auditing a case of invasive carcinoma of the cervix. A cervical smear 3 years before she presented with cervical carcinoma was reported as borderline nuclear changes with a repeat smear requested in 6 months. Who is responsible for operating failsafe for this abnormal result?

■ A. The general practitioner.

■ B. The laboratory.

■ C. The colposcopy clinic.

■ D. The hospital based programme co-ordinator.

■ E. Central operations (call/recall) office.

Answer You are auditing a case of invasive carcinoma of the cervix. A cervical smear 3 years before she presented with cervical carcinoma was reported as borderline nuclear changes with a repeat smear requested in 6 months. Who is responsible for operating failsafe for this abnormal result?

■ A. The general practitioner.

■ B. The laboratory.

■ C. The colposcopy clinic.

■ D. The hospital based programme co-ordinator.

■ E. Central operations (call/recall) office.

Question 9 A trainee cytoscreener who is screening the days work notices simple, unbranched fungal hyphae and spores in a liquid based cervical screening sample. He asks you what the significance of this is. Select the most appropriate answer.

■ A. Artefactual overgrowth which should be discounted.

■ B. A harmless commensal which is of no clinical significance.

■ C. An invasive infection which is likely to lead to tubo-ovarian abscesses.

■ D. An unusual infection suggesting immunosuppression.

■ E. A notifiable disease which should be reported to the director of public health.

Answer A trainee cytoscreener who is screening the days work notices simple, unbranched fungal hyphae and spores in a liquid based cervical screening sample. He asks you what the significance of this is. Select the most appropriate answer.

■ A. Artefactual overgrowth which should be discounted.

■ B. A harmless commensal which is of no clinical significance.

■ C. An invasive infection which is likely to lead to tubo-ovarian abscesses.

■ D. An unusual infection suggesting immunosuppression.

■ E. A notifiable disease which should be reported to the director of public health.

Dyskaryosis Features• Abnormal chromatin pattern • Increased N:C ratio • Hyper or hypochromasia • Irregular nuclear membrane • Nuclear pleomorphism • Nucleoli • Evidence of HPV infection

Dyskaryosis Grading

References • https://www.gov.uk/government/publications/cervical-screening-primary-hpv-screeningimplementation • NHS Cervical Screening Programme Colposcopy and Programme Management NHSCSP Publication number 20 • Achievable standards, Benchmarks for reporting and criteria for evaluating cervical cytopathology, NHSCSP Publication No.1, 2013 • Guidelines on failsafe actions for the follow up of cervical cytology reports

• Audit of Invasive cervical cancers. Publication no 28.

• Denton K.J. et al. The revised BSCC terminology for abnormal cervical cytology. Cytopathology 2008, 19, 137-157.

Non-gynae cytology

Cytopathology samples• exfoliative (cells shed naturally or by direct sampling) • fine needle aspiration (FNA) The key principles with any cytological preparation are: • to enable accurate morphological assessment • to preserve adequate material for ancillary tests including immunocytochemistry, molecular analysis and others.

Minimum recommendations for sample preparation and staining Sample type

Sample preparation and staining

Urine tract samples

Papanicolaou stain

Bronchial samples

Papanicolaou stain

Serous effusions

• Papanicolaou stain • Romanowsky stain

Cerebrospinal fluid/cyst fluid

Romanowsky stain ± Papanicolaou stain

Synovial fluids

• Wet preparation • Romanowsky stain

Fine needle aspirations

Romanowsky stain ± Papanicolaou stain

Question 2.

A medical student undertaking a pathology study module is assigned to cytology. He notices that alcohol is put on the slide before a Papanicolaou stain is applied. He asks you to explain the purpose of this alcohol.

■ Choose the most appropriate response.

■ (a). To ‘glue’ the cells onto the slide so that the cells are not lost during staining.

■ (b). To fix the cells so that cellular detail is preserved.

■ (c). To ensure the cells take up orange G allowing easy recognition of squamous cells.

■ (d). To remove water from the cells so that the mountant remains transparent.

■ (e). To lyse red blood cells.

Answer A medical student undertaking a pathology study module is assigned to cytology. He notices that alcohol is put on the slide before a Papanicolaou stain is applied. He asks you to explain the purpose of this alcohol.

■ Choose the most appropriate response.

■ (a). To ‘glue’ the cells onto the slide so that the cells are not lost during staining.

■ (b). To fix the cells so that cellular detail is preserved.

■ (c). To ensure the cells take up orange G allowing easy recognition of squamous cells.

■ (d). To remove water from the cells so that the mountant remains transparent.

■ (e). To lyse red blood cells.

• RCPath endorses the adoption and use of the following cytopathology reporting systems: • urine cytopathology – Paris system • respiratory cytopathology – RCPath Dataset for histopathological reporting of lung • cancer • pancreas and biliary cytopathology – Papanicolaou Society of Cytopathology System • salivary cytopathology – Milan system • thyroid cytopathology – RCPath Guidance on the reporting of thyroid cytology specimens • Breast Screening Programme (BSP) classification for breast FNA. 5

4

25

4

4

• Breast cytology

Question 3 A 48 year old female is discussed at the breast MDT meeting. She presented with a firm, mobile mass in the left breast which had been present for 8 weeks. Mammography revealed a well defined, ovoid mass considered to be benign (M2) and ultrasound revealed a slightly lobulated, well defined hypoechoic mass again considered to be benign (U2). A fine needle aspirate was reported as carcinoma (C5). A core biopsy was performed due to the discrepancy. A single palpable core was taken.

This revealed fat necrosis and scattered breast lobules with no evidence of malignancy (B2).

■ The most appropriate conclusion is: ■ (a). The correct diagnosis is fat necrosis.

■ (b). The correct diagnosis is a fibroadenoma.

■ (c). The correct diagnosis has not been established.

■ (d). The correct diagnosis is carcinoma.

■ (e). The correct diagnosis is an abscess.

Answer A 48 year old female is discussed at the breast MDT meeting. She presented with a firm, mobile mass in the left breast which had been present for 8 weeks. Mammography revealed a well defined, ovoid mass considered to be benign (M2) and ultrasound revealed a slightly lobulated, well defined hypoechoic mass again considered to be benign (U2). A fine needle aspirate was reported as carcinoma (C5). A core biopsy was performed due to the discrepancy. A single palpable core was taken.

This revealed fat necrosis and scattered breast lobules with no evidence of malignancy (B2).

■ The most appropriate conclusion is: ■ (a). The correct diagnosis is fat necrosis.

■ (b). The correct diagnosis is a fibroadenoma.

■ (c). The correct diagnosis has not been established.

■ (d). The correct diagnosis is carcinoma.

■ (e). The correct diagnosis is an abscess.

Outline of breast FNA reporting categories C1

Inadequate for cytological diagnosis

C2

Benign breast tissue

C3

Atypia, probably benign

C4

Suspicious, probably malignant

C5

Malignant

Table 1: General diagnostic criteria for the recognition of benign and malignant conditions Criterion

Benign

Malignant

Cellularity

Usually poor or moderate

Usually high

Cell-to-cell cohesion

Good with large defined clusters of cells

Poor with cell separation resulting in dissociated cells with cytoplasm or small groups of intact cells

Cell arrangement

Even, usually in flat sheets (monolayers)

Irregular with overlapping and three-dimensional arrangement

Cell types

Mixtures of epithelial, myoepithelial and other cells with fragments of stroma

Usually uniform cell population

Bipolar (elliptical) bare nuclei

Present, often in high numbers

Not conspicuous

Background

Generally clean except in inflammatory conditions

Occasionally with necrotic debris and sometimes inflammatory cells including macrophages

Size (in relation to RBC diameter)

Small

Variable, often large, depending on tumour type

Pleomorphism

Rare

Common

Nuclear membranes (PAP stain)

Smooth

Irregular with indentations

Nucleoli (PAP stain)

Indistinct or small and single

Variable but may be prominent, large and multiple

Chromatin (PAP stain)

Smooth or fine

Clumped and may be irregular

Additional features

Apocrine metaplasia, foamy macrophages

Mucin, intracytoplasmic lumina

Nuclear characteristics

Breast Cytology Coding • Guidelines for non-operative diagnostic procedures and reporting in breast cancer screening. June 2016

C1- inadequate

• Urine cytology

Outline of the Paris urinary cytopathology reporting system

I

Non-diagnostic or unsatisfactory

II

Negative for high grade urothelial carcinoma

III

Atypia

IV

Suspicious for high grade urothelial carcinoma

V

Low grade urothelial neoplasia (LGUN)

VI

High grade urothelial carcinoma (HGUC)

VII

Other malignancies, primary and metastatic

• 88-year-old man with a history of T1 HGUC previously treated by local excision. F/U bx negative. Cystoscopy – negative.

Question 4 A 79 year old male is referred to the urology department with microscopic haematuria. He has a past history of ischaemic heart disease and diabetes mellitus. Investigations performed in the clinic confirm haematuria on dipstick testing, and ultrasound reveals a mass measuring 5x3cm in the left kidney. A sample of urine is submitted for cytological evaluation. This contains mature and anucleate squamous cells, variably degenerate urothelial cells, macrophages, neutrophils and corpora amylacea.

• The most likely diagnosis is: • (a). Renal calculus.

• (b). Prostatic adenocarcinoma.

• (c). Renal cell carcinoma.

• (d). Transitional cell carcinoma.

• (e). Malakoplakia.

Answer A 79 year old male is referred to the urology department with microscopic haematuria. He has a past history of ischaemic heart disease and diabetes mellitus. Investigations performed in the clinic confirm haematuria on dipstick testing, and ultrasound reveals a mass measuring 5x3cm in the left kidney. A sample of urine is submitted for cytological evaluation. This contains mature and anucleate squamous cells, variably degenerate urothelial cells, macrophages, neutrophils and corpora amylacea.

• The most likely diagnosis is: • (a). Renal calculus.

• (b). Prostatic adenocarcinoma.

• (c). Renal cell carcinoma.

• (d). Transitional cell carcinoma.

• (e). Malakoplakia.

• Thyroid cytology

Outline of Thyroid FNA RCPath reporting categories Thy 1/ Thy 1c

Non-diagnostic for cytological diagnosis

Thy 2/ Thy 2c

Non-neoplastic

Thy 3 Thy 3a Thy 3f

Neoplasm possible Atypia- architectural or cytological atypia Follicular

Thy 4

Suspicious of malignancy

Thy 5

Malignant

Thy 1- Non-diagnostic

http://www.british-thyroidassociation.org/Guidelines/Docs/BTA_DTC_gui dlines.pdf

Thy 2- Non-neoplastic

Thy 3- Neoplasm possible

Thy 4- Suspicious of malignancy

Thy 5- Diagnostic of malignancy

Question 5 A 24 year old male presents with a mass in the right side of the neck, which has been growing for the previous 3 months. Ultrasound scan of the neck reveals a solitary mass in the right thyroid which is of high vascularity. Enlarged lymph nodes are also present in the right carotid chain.

Fine needle aspiration of the thyroid mass includes numerous cells with moderate amounts of slightly granular cytoplasm and eccentric nuclei. The nuclei are round and oval with finely granular chromatin and inconspicuous nucleoli. Immunocytochemistry reveals strong expression of cytokeratins and calcitonin.

• The most appropriate classification for this aspirate is: • (a). Thy1.

• (b). Thy2.

• (c). Thy3f.

• (d). Thy4.

• (e). Thy5.

Answer A 24 year old male presents with a mass in the right side of the neck, which has been growing for the previous 3 months. Ultrasound scan of the neck reveals a solitary mass in the right thyroid which is of high vascularity. Enlarged lymph nodes are also present in the right carotid chain.

Fine needle aspiration of the thyroid mass includes numerous cells with moderate amounts of slightly granular cytoplasm and eccentric nuclei. The nuclei are round and oval with finely granular chromatin and inconspicuous nucleoli. Immunocytochemistry reveals strong expression of cytokeratins and calcitonin.

• The most appropriate classification for this aspirate is: • (a). Thy1.

• (b). Thy2.

• (c). Thy3f.

• (d). Thy4.

• (e). Thy5.

• Cytological features of medullary thyroid carcinoma • Uniform population of dispersed plasmacytoid, granular or spindle cells • Salt and pepper nuclear chromatin • Intranuclear cytoplasmic inclusion (>50%) • Amyloid • MEN syndrome

• Cytologic features of PTC Major criteria Intranuclear cytoplasmic inclusions, nuclear grooves, pale powdery nuclear chromatin, oval nucleus with eccentric nucleolus Minor criteria Dense waxy cytoplasm, bubble gum colloid, psammoma bodies, giant cells, papillary groups

IHC

Medullary thyroid carcinoma

Papillary thyroid carcinoma

Thyroglobulin

-

+

TTF1

+

+

CK19

-

+

NE markers

+

-

Calcitonin

+

-

CEA

+

-

• Salivary gland cytology

Outline of the Milan Salivary Cytopathology reporting system 1

Non-diagnostic

2

Non-neoplastic

3

Atypia of undetermined significance (AUS)

4– a b

Neoplastic: Benign Uncertain malignant potential (SUMP)

5

Suspicious for malignancy

6

Malignant

Question 10 • You are assessing a fine needle aspirate from a parotid mass in a 68 year old female. The aspirate contains mucoid material, plentiful lymphoid cells of mixed type and papillary groups of epithelial cells with copious, granular cytoplasm and round nuclei with prominent nucleoli. Select the most likely diagnosis.

• A. Pleomorphic adenoma.

• B. Muco-epidermoid carcinoma.

• C. Warthin’s tumour.

• D. Non-Hodgkin’s lymphoma.

• E. Low grade polymorphous carcinoma.

Answer • You are assessing a fine needle aspirate from a parotid mass in a 68 year old female. The aspirate contains mucoid material, plentiful lymphoid cells of mixed type and papillary groups of epithelial cells with copious, granular cytoplasm and round nuclei with prominent nucleoli. Select the most likely diagnosis.

• A. Pleomorphic adenoma.

• B. Muco-epidermoid carcinoma.

• C. Warthin’s tumour.

• D. Non-Hodgkin’s lymphoma.

• E. Low grade polymorphous carcinoma.

Warthin’s tumour www.forpath.org

Warthin’s Tumourhistology imgarcade.com

• Serous Fluid cytology

The International System for Reporting Serous Fluid Cytopathology Diagnostic category

% Risk of malignancy

Non-Diagnostic (ND)

17% (+/- 8.9%)

Negative for Malignancy (NFM)

21% (+/- 0.3%)

Atypia of Undetermined significance (AUS)

66% (+/- 10.6%)

Suspicious for Malignancy (SFM)

82% (+/- 4.8%)

Malignant (MAL)

99% (+/-0.1%

• Metastatic lung adenocarcinoma • Positive for BerEP4/MOC-31, CK7, TTF-1 and Napsin A; Negative for Calretinin/D2-40 and CK20 • EGFR/ALK/ROS1/PD-L1

Confirm with IHC to determine the primary site of tumour • Breast: ER/PR, GATA3, GCDFP15 • Ovary: WT1, p53 • Thyroid: TTF1, TG • Lung: Adenocarcinoma: TTF1, Napsin A, CK7 and then molecular studies • Squamous cell carcinoma: CK5/6, p40, p63, PDL1 • Small cell carcinoma: TTF1, AE1/3, NE markers, Ki-67

• • • • •

Colorectal: CK7, CK20 cdx2 Pancreas & Upper GI: CK7, CK20 cdx2 Melanoma: Melan A, HMB45, SOX10 Kidney: CD10, RCC, CAIX Prostate: PSA, PAP

• Neoplasm in keeping with mesothelioma • WT1, Calretinin, CK5/6- +ve • BerEP4, CEA- Neg • Correlate with radiology and check for asbestos exposure

NFM (benign mesothelial proliferation) Mesothelioma

Desmin (cytoplasmic)

+

-

EMA (membranous)

-

+

BAP1 (nuclear)

+

-

P16/CDKN2A (FISH)

No deletion

Deletion detected

IHC

Adenocarcinoma

Mesothelioma

BerEP4

+

-

MOC31

+

-

Calretinin

-

+

CK5/6

-

+

Question 1.

•

• • • • •

A 56 year old female with a history of cirrhosis of unknown aetiology presents with increasing lethargy and abdominal distension. Clinical examination reveals tense ascites which is drained and a sample submitted for cytological examination. The consultant asks for a cell count on the specimen. The count of which type of cell provides the most diagnostic information? (a). Eosinophil. (b). Macrophage. (c). Lymphocyte. (d). Neutrophil. (e). Basophil.

Answer •

• • • • •

A 56 year old female with a history of cirrhosis of unknown aetiology presents with increasing lethargy and abdominal distension. Clinical examination reveals tense ascites which is drained and a sample submitted for cytological examination. The consultant asks for a cell count on the specimen. The count of which type of cell provides the most diagnostic information? (a). Eosinophil. (b). Macrophage. (c). Lymphocyte. (d). Neutrophil. (e). Basophil.

• Spontaneous bacterial peritonitis • No malignant cells seen

Question 11 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

A. CD45 B. CD9 C. CD38 D. CD29 E. CD3 F. CD30 G. CD56 H. CD82 I. CD20 J. CD99

A 73 year old male presents with increasing shortness of breath. He has smoked cigarettes for many years and has a history of chronic obstructive pulmonary disease.

Investigations reveal a left sided pleural effusion. A sample of this is submitted for cytological examination which reveals large numbers of mature, small lymphocytes with scattered macrophages and reactive mesothelial cells. There are also medium sized cells with scanty cytoplasm, hyperchromatic nuclei and stippled chromatin. Nuclear moulding is present. Which antibody, from the list given above, would you expect to be expressed by the medium sized cells?

Answer ■

A 73 year old male presents with increasing shortness of breath. He has smoked cigarettes for many years and has a history of chronic obstructive pulmonary disease.

Investigations reveal a left sided pleural effusion. A sample of this is submitted for cytological examination which reveals large numbers of mature, small lymphocytes with scattered macrophages and reactive mesothelial cells. There are also medium sized cells with scanty cytoplasm, hyperchromatic nuclei and stippled chromatin. Nuclear moulding is present.

Which antibody, from the list given above, would you expect to be expressed by the medium sized cells?

■

G. CD56

Question 12.

■ ■ ■ ■ ■ ■ ■ ■ ■ ■

A. CD45 B. CD9 C. CD38 D. CD29 E. CD3 F. CD30 G. CD56 H. CD82 I. CD20 J. CD99

A 68 year old male presents with increasing shortness of breath and cervical lymphadenopathy. He has smoked cigarettes for many years and has a history of chronic obstructive pulmonary disease. Investigations reveal a left sided pleural effusion. A fine needle aspiration of the palpable neck lymph nodes is performed. This contains abundant material composed of cells with scanty cytoplasm with many of the cells being disrupted with streaking of the DNA. Small nucleoli are present. A colleague suggests these are from a poorly differentiated carcinoma, but you believe them to be lymphoid cells. Which antibody, from the list given above, is most likely to be expressed in this case if you are correct?

Answer ■

A 68 year old male presents with increasing shortness of breath and cervical lymphadenopathy. He has smoked cigarettes for many years and has a history of chronic obstructive pulmonary disease. Investigations reveal a left sided pleural effusion. A fine needle aspiration of the palpable neck lymph nodes is performed. This contains abundant material composed of cells with scanty cytoplasm with many of the cells being disrupted with streaking of the DNA. Small nucleoli are present. A colleague suggests these are from a poorly differentiated carcinoma, but you believe them to be lymphoid cells. Which antibody, from the list given above, is most likely to be expressed in this case if you are correct?

■

A – CD45

Question 13 ■ ■ ■

■ ■ ■

■ ■ ■ ■

A. CD45 B. CD9 C. CD38 D. CD29 E. CD3 F. CD30 G. CD56 H. CD82 I. CD20 J. CD99

■

A 17 year old male presents with night sweats and weight loss. Enlarged cervical lymph nodes are noted on clinical examination. Fine needle aspiration of the lymph nodes is performed. The aspirate includes abundant material composed of a dispersed mixture of cells of varying type including eosinophils. There are several large cells with pale staining cytoplasm, large nuclei and prominent nucleoli. Some of the large cells are binucleate. Which antigen, from the list given above, is most likely to be expressed by the large cells?

Answer ■

A 17 year old male presents with night sweats and weight loss. Enlarged cervical lymph nodes are noted on clinical examination. Fine needle aspiration of the lymph nodes is performed. The aspirate includes abundant material composed of a dispersed mixture of cells of varying type including eosinophils. There are several large cells with pale staining cytoplasm, large nuclei and prominent nucleoli.

Some of the large cells are binucleate. Which antibody, from the list given above, is most likely to be expressed by the large cells?

■

F – CD30

Question 14 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

A. CD45 B. CD9 C. CD38 D. CD29 E. CD3 F. CD30 G. CD56 H. CD82 I. CD20 J. CD99

■

A 63 year old female presents with a rapidly enlarging mass in the left side of the neck. An ultrasound scan of the neck reveals the mass to be formed of several large, rounded lymph nodes which lack a fatty hilum.

Fine needle aspiration of this is performed. The aspirate includes numerous large cells with plentiful cytoplasm, irregular nuclei, irregular chromatin and multiple nucleoli. Several mitotic figures are noted many of which are morphologically abnormal.

Plentiful tingible body macrophages are present giving a ‘starry sky’ appearance. Which antibody, from the list given above, is most likely to be of diagnostic value in this case?

Answer ■

A 63 year old female presents with a rapidly enlarging mass in the left side of the neck. An ultrasound scan of the neck reveals the mass to be formed of several large, rounded lymph nodes which lack a fatty hilum. Fine needle aspiration of this is performed. The aspirate includes numerous large cells with plentiful cytoplasm, irregular nuclei, irregular chromatin and multiple nucleoli. Several mitotic figures are noted many of which are morphologically abnormal. Plentiful tingible body macrophages are present giving a ‘starry sky’ appearance.

Which antibody, from the list given above, is most likely to be of diagnostic value in this case?

■

I – CD20

Question 15 ■ ■ ■

■ ■ ■

■ ■ ■ ■

A. CD45 B. CD9 C. CD38 D. CD29 E. CD3 F. CD30 G. CD56 H. CD82 I. CD20 J. CD99

■

A 17 year old male presents with a mass on the left chest wall. A chest X-ray reveals a mass expanding the 7th rib with an ‘onion skin’ appearance. Fine needle aspiration of the mass is performed.

Numerous cells with scanty cytoplasm and round, hyperchromatic nuclei are present. Frequent mitotic figures are noted. Which antigen, from the list given above, is most likely to be expressed by the cells?

Answer ■

A 17 year old male presents with a mass on the left chest wall. A chest X-ray reveals a mass expanding the 7th rib with an ‘onion skin’ appearance. Fine needle aspiration of the mass is performed.

Numerous cells with scanty cytoplasm and round, hyperchromatic nuclei are present. Frequent mitotic figures are noted. Which antibody, from the list given above, is most likely to be expressed by the cells?

■

J – CD99

• Pancreas cytology

Outline of the Papanicolaou Society approach to reporting pancreatobiliary cytopathology

I

Non-diagnostic

II

Negative (for malignancy)

III

Atypical

IV

Neoplastic: benign or other

V

Suspicious (for malignancy)

VI

Positive (malignant)

• All laboratories should participate in technical EQA schemes relevant to cytopathology, such as that run by UKNEQAS. All laboratory reporting staff should participate in any relevant interpretative EQA schemes as and when they are developed. Currently, no such national scheme exists in the UK, but one is under active development.

References • The Royal College of Pathologists- Tissue pathways for diagnostic cytopathology. May 2019.

• Chandra A, Crothers B, Kurtycz D, Schmitt FS.Announcement:the international system for reporting serous fluid cytopathology. Acta Cytol.2019;24:1-3.

• Google images

• Acknowledgement • Dr Durgesh N Rana • Dr Mickhaiel Barrow • Dr Neil Anderson

Thank you