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Cytopathology
Monday, February 28, 2005 - 7:30 PM
Rivercenter Salon H,K,L
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Moderator:
Celeste N. Powers
Medical College of Virginia
Richmond, VA
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Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Submitted by:
Martha Bishop Pitman
A 52-year-old female presents with a 1-month history of a deep cyst in the left cheek. The cyst was
anterior to the parotid gland and not associated with the salivary duct. The clinical impression was
a sebaceous cyst. An FNAB was performed.
Case 1 - Figure 1 - Scattered, large saw-toothed shaped groups of small bland basaloid cells were present (Medium power, Papanicoalou).
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Case 1 - Figure 2 - The basaloid cells were better evaluated in the smaller groups showing bland round to oval nuclei, no significant hyperchromasia, rare nucleoli, and no mitoses (High power, Papanicoalou).
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Case 1 - Figure 3 - Scattered within the cyst debris covering the slide were numerous "ghost" squamous cells" (Low power, Papanicolaou).
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Submitted by:
Sana O. Tabbara
A 62 year-old woman from Sierra Leone presented with a left-sided mass of her face that has been
progressively enlarging over the last 2 years. The patient complained of occasional pain, but no
dysphagia or mastication problems and no systemic symptoms. On physical examination, a firm 10 cm
mass extended from the left temporal area over the temporomandibular joint and covered the parotid and
jaw area. Her medical history was significant for a left mandibular mass excision with mandibular
reconstruction 25 years prior to presentation. The FNA of the mass is illustrated.
Case 2 - Figure 1 - Low to moderately cellular smears revealed an abundant mucoid/ proteinaceous material in the background and histiocytes compatible with the grossly cystic nature of the mass. A population of large polygonal or round squamous epithelial cells forming small sheets was present. Some of the squamous groups displayed variably sized large vacuoles with a double cytoplasmic membrane rim, containing bright eosinophilic /metachromatic granular material reminiscent of mucin. (Diff-Quik stain, medium power)
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Case 2 - Figure 2 - Groups of tightly packed basaloid cells were scattered. These groups consisted of cells with elongated, oval nuclei with scant or minimal amount of indistinct cytoplasm. The chromatin was dense and uniform and small nucleoli were discernable in some cells. In some of the three-dimensional groups, a well-defined border peripheral and peripheral palisading of the cells is noted. Focally in the background surrounding these clusters were single ovoid bland cells with a thin rim of cytoplasm (Diff-Quik stain, medium power)
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Case 2 - Figure 3 - Hyalinized metachromatic stromal fragments were identified within some of the basaloid cell groups. The stroma was dense and non-fibrillar, however it displayed no spherical or cylindrical shape and was closely apposed to the basaloid cells. Isolated squamous cells with rounded shapes or small groups of squamous epithelium are present in the vicinity of the basaloid group. A histiocyte is a reminder of the cystic nature of the lesion. (Diff-Quik stain, medium power)
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Submitted by:
Michael Henry
This 51-year-old woman presents with pneumonia. She had undergone a bone marrow transplant within the
recent past. Radiologic studies show bilateral diffuse pulmonary infiltrates. A bronchoalveolar
lavage was performed and Diff-Quik, Pap and GMS stains were prepared from cytospin preparations.
Case 3 - Figure 1 - Diff Quik, Low Power 20X: This Diff Quik stained cytospin is cellular with numerous neutrophils and occasional pulmonary macrophages and lymphocytes. From this power no organisms could be identified and no viral cytopathic effect was seen.
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Case 3 - Figure 2 - Diff Quik, High Power 100X: The oil immersion view at 100X shows the intracellular organisms.with in the cytoplasm of the neutrophils. The tachyzoites are about oval to round, 6 microns in size with blue cytoplasm and a central or eccentric nucleus.
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Case 3 - Figure 3 - Diff Quik, High Power 100X: The oil immersion view at 100X shows the intracellular organisms.with in the cytoplasm of the neutrophils. The tachyzoites are about oval to round, 6 microns in size with blue cytoplasm and a central or eccentric nucleus.
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Submitted by:
Chris S. Jensen
The patient is a 24-year-old female with no significant past medical history. She presented with
sudden onset of upper abdominal pain, which was constant and severe but not associated with nausea or
vomiting. A CT scan of her abdomen showed multiple large low-density lesions scattered throughout the
liver. The patient had no history of prior liver disease and was not jaundiced. An initial fine
needle aspiration under ultrasound guidance was inconclusive due to low cellularity. A subsequent MRI
exam again revealed multiple liver lesions as well as a large mass between the liver and the anterior
wall of the stomach impinging upon the gastric orifice. A fine needle aspiration was performed of an
enlarged celiac lymph node under endoscopic ultrasound (EUS) guidance.
Case 4 - Figure 1 - Papanicolaou stain, low power (100X) - View shows larger tissue fragments which are composed of the mixture of fibrillar stroma and tumor cells. Tumor cells are present as epithelioid clusters as well as dispersed single cells. There is some tendency of small clusters of cells to group together in small gland-like structures.
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Case 4 - Figure 2 - Diff-Quik stain, high power (400X) - This high power view shows small cohesive groups of epithelioid cells. The cells have fairly abundant, slightly granular cytoplasm. Nuclei are round to slightly oval. Individual cell borders are not distinct. There are several stripped nuclei noted in the background. A rare intranuclear cytoplasmic inclusion is noted.
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Case 4 - Figure 3 - Papanicolaou stain, high power (600X) - This high power field shows a group of loosely cohesive cells. Several cells show prominent intranuclear cytoplasmic inclusion. The nuclei are somewhat ovoid with slight nuclear irregularities, chromatin is granular to slightly clumped. Cytoplasm is granular, with a suggestion of fibrillar cytoplasmic processes.
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Submitted by:
Martha Bishop Pitman
A 75-year-old alcoholic woman presented with abdominal pain. Ultrasound revealed a 4 cm
multiloculated cystic mass in the head of the pancreas connected with a dilated pancreatic duct. The
cyst had thick septations and there was no apparent wall mass. An endoscopic ultrasound guided biopsy
was performed. 30cc of viscous mucoid fluid was aspirated and sent for cytological evaluation and cyst
fluid analysis. A cytospin slide was prepared and stained with a Papanicolaou stain.
Case 5 - Figure 1 - The smear background displayed thick "colloid-type" mucin containing scattered epithelial cells, inflammatory cells and histiocytes (Low power, Papanicolaou stain).
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Case 5 - Figure 2 - Some of the epithelial cells were in small, cohesive sheets with small round uniform nuclei and ample clear to vacuolated cytoplasm consistent with "adenoma" type epithelium (Medium power, Papanicolaou stain).
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Case 5 - Figure 3 - Other epithelial cells were single and resembled high grade cervical dysplasia with atypical convoluted and hyperchromatic nuclei and a high nuclear to cytoplasmic ratio consistent with at least borderline malignancy(High power, Papanicolaou stain).
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Submitted by:
Sana O. Tabbara
A 56 year-old man presented with a history of intermittent fever, flushing, nausea, vomiting, and
abdominal pain and distention. A colonoscopic exam performed in the past year was reportedly normal.
An abdominal CT scan was performed and revealed a 12.0x5.0x 13.0 cm intra-abdominal mass involving the
small bowel. A core biopsy was obtained with ultrasound guidance but did not provide adequate tissue
for diagnosis. A PET scan confirmed the presence of a hypermetabolic, ill-defined soft tissue mass in
the lower abdomen arising from small bowel or mesenteric wall. Additional small coalescent masses or
adenopathy were also noted as well as increased marrow activity. An open biopsy with intraoperative
consultation was performed. Diff-Quik and H&E-stained smears were prepared.
Case 6 - Figure 1 - Highly cellular smears show a monotonous population of polygonal cells organized in loose clusters, sheets and numerous single cells. The cells have large, round, or slightly irregular centrally placed nuclei and macronucleoli as well as abundant dense cytoplasm. Although monotonous some nuclear size variability is easily observed and intercellular gaps are evident. Scattered cells show single large cytoplasmic vacuoles containing eosinophilic material. (Diff-Quik stain, medium power)
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Case 6 - Figure 2 - Numerous cells with abundant cytoplasm and large round vesicular nuclei with prominent nucleoli are present in flat sheets and singly. Intercellular spaces or windows are apparent. Despite some degree of monotony, nuclear pleomorphism is present with some larger, hyperchromatic nuclei. Bi-and multinucleation is illustrated as well as the presence of mitotic figures. (H&E stain, medium power)
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Case 6 - Figure 3 - In addition to the cytologic features described above, some cells show small punched out vacuoles in a perinuclear location and sometimes overlapping the nucleus. The abundant dense cytoplasm appears more delicate at the periphery in some cells and intercellular spaces or windows are also seen. (Diff-Quik stain, high power)
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Submitted by:
Michael Henry
This 41-year-old para 0, gravida 0 woman presented with a history of vaginal bleeding. She has no
history of cervical disease or malignancy. On exam she is an obese Caucasian female in no evident
distress. Pelvic examination shows an enlarged friable cervix. A SurePath cervical sample was taken
as well as a biopsy.
Case 7 - Figure 1 - SurePath™ Papanicolaou stain, high power: This image shows the spindle shaped malignant cells in a SurePath cervical preparation. The cells are quite variable in shape and size. The nuclei have an open chromatin pattern with a prominent nucleolus.
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Case 7 - Figure 2 - SurePath™ Papanicolaou stain, high power: A tumor diathesis is seen here. On SurePath preparations necrotic material is generally seen as clumps of amorphous material mixed with blood and neutrophils.
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Case 7 - Figure 3 - SurePath™ Papanicolaou stain, high power: A mitotic figure is seen here and the image again demonstrates the marked pleomorphism of the malignant cells.
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Submitted by:
Chris S. Jensen
The patient is a 55-year-old female with a several year history of recurrent urinary tract infections
and recurrent gross hematuria. Her past medical history is remarkable for a TAH/BSO five years
previously. Physical exam revealed a 2-3 cm smooth mass palpable at the mid urethra consistent with a
diverticulum. There was no palpable mass or stone in diverticulum and no urethral discharge on
palpation. The remainder of the exam was unremarkable. A catheterized urine cytology was collected.
MRI revealed a large (3.7 x 2.1 x 2.1 cm) complex left periurethral diverticulum with thick nodular
enhancing walls, (radiologic differential diagnosis includes malignancy in the diverticulum and an
infected diverticulum). Cystoscopy revealed no mucosal lesion and no discernable diverticular opening
associated with the previously noted submucosal mass lesion.
Case 8 - Figure 1 - Papanicolaou stain, medium power (200X) - Scattered small three dimensional clusters, as are seen in this field, are noted in a background of granular acellular debris. There is not significant inflammatory cells in the background. The three dimensional clusters have a scalloped border.
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Case 8 - Figure 2 - Papanicolaou stain, high power (600X) - High power examination of the three dimensional clusters show that the cells have a high nuclear to cytoplasmic ratio. Nuclei are round with somewhat irregular nuclear contours. Nucleoli are prominent. The cytoplasm that is present is dense and granular with a few small cytoplasmic vacuoles.
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Case 8 - Figure 3 - Papanicolaou stain, high power (600X) - Rare clusters of cells were less three dimensional and had a sheet-like appearance. These cells had more abundant granular to vacuolated cytoplasm. Nuclear irregularities and nucleoli were again quite prominent. Cytoplasmic borders were focally distinct.
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