—  SPECIALTY CONFERENCE  — Cytopathology Wednesday, March 5, 2008, 7:30 PM Convention Center 108/110/112 Moderator: MARY K. SIDAWY Georgetown University Washington, DC Disclosure: The speakers have indicated they have nothing to disclose. Clinical Histories and Still Images are displayed below. Click on slide thumbnail images for an enlarged view. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Terence J. Colgan Clinical Summary: A 42 year old woman, G2 P2, had a routine screening Pap test taken. She was on the 9th day of her menstrual cycle. The cervix was visualized and appeared normal. No other clinical history was available. Case 1 - Figure 1 Four dense bodies/cellular clumps are noted on a cellular background consisting of squamous cells and rare endocervical fragment. Case 1 - Figure 2 An endocervical epithelial fragment is present (right), immediately adjacent to a dense, laminated body with a peripheral rim of cohesive cells. Case 1 - Figure 3 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 4 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 5 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 6 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 7 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 2 - Click here for Text and References Submitted by: Jennifer A. Brainard Clinical Summary: 82 year old man History of multiple bouts of pancreatitis Large duodenal polyp Endoscopic ultrasound showed: Diffuse changes of chronic pancreatitis Mass in the neck of the pancreas which obstructs the main duct and encases splenic vessels Stable appearing duodenal polyp Case 2 - Figure 1 The pancreatic aspirate sample is highly cellular with large fragments and numerous single cells. The large cohesive aggregates have a papillary architecture with central fibrovascular cores. Small groups and single cells appear to be falling off the large papillary structures. Case 2 - Figure 2 The pancreatic aspirate sample is highly cellular with large fragments and numerous single cells. The large cohesive aggregates have a papillary architecture with central fibrovascular cores. Small groups and single cells appear to be falling off the large papillary structures. Case 2 - Figure 3 The cell population is monotonous. Cohesive papillary fragments and syncytial aggregates are seen. Occasional tumor cells have a plasmacytoid appearance. Blood and occasional stripped nuclei are present in the background. Case 2 - Figure 4 The individual cells comprising the syncytial groups have high N/C ratios, fine chromatin and inconspicuous nucleoli. Histiocytes are seen here, suggestive of a cystic component. Case 2 - Figure 5 Overlapping nuclei with nuclear grooves and membrane irregularities are prominent in this aggregate. Still, many of the nuclear changes are subtle and not typical of pancreatic ductal adenocarcinoma. Case 2 - Figure 6 There is minimal variability in tumor cell morphology from field to field. Occasional tumor cells with intranuclear cytoplasmic inclusions are seen. Case 2 - Figure 7 The cell block highlights the uniformity and relative blandness of the cell population. The cells are arranged in strips. The major contribution of the cell block is to provide material for immunohistochemical staining. Case 3 - Click here for Text and References Submitted by: Zubair W. Baloch Clinical Summary: 55-year old woman with a 4.0 cm left parotid mass. The mass has been present for 10-years and has grown slowly to the present size. No complaints of pain or facial numbness and weakness. Case 3 - Figure 1 Diff-Quik® stained air-dried smear showing epithelial cells and magenta / eosinophilic stromal material. Case 3 - Figure 2 High power of the Diff-Quik® stained smear epithelial cells embedded within the stroma. Case 3 - Figure 3 High power of the Diff-Quik® stained smear showing a small tissue fragment containing cells with enlarged nuclei. Case 3 - Figure 4 Papanicolaou stained smear showing background stromal material with groups of epithelial cells arranged in "acinar" arrangement. Case 3 - Figure 5 High power of the Papanicolaou stained smear showing epithelial cells with granular cytoplasm arranged in cohesive groups. Case 3 - Figure 6 High power of the Papanicolaou stained smear showing epithelial cells with granular cytoplasm arranged in cohesive groups. Case 3 - Figure 7 Papanicolaou stained smear showing bi-nucleate atypical epithelial cell. Case 4 - Click here for Text and References Submitted by: Kristen Atkins Clinical Summary: A 35-year-old woman with morbid obesity presents with abdominal pain. An ultrasound demonstrates a 9 cm unilateral cyst with several internal loculations but no solid component. Ovarian cyst aspirate is performed. Case 4 - Figure 1A Ovarian cyst aspirate, Thin Prep slide, 400x (Papanicolou stains). Histiocytes and necrotic cells in the back ground. Case 4 - Figure 1B Ovarian cyst aspirate, Thin Prep slide, 400x (Papanicolou stains). Histiocytes and necrotic cells in the back ground. Case 4 - Figure 2 Ovarian cyst aspirate, Thin Prep slide, 200x (Papanicolaou stain). Papillary cluster of cells with variably sized cells with prominent nucleoli. Case 5 - Click here for Text and References Submitted by: Terence J. Colgan Clinical Summary: A 73 year old woman presented with post-menopausal vaginal bleeding. A pelvic ultrasound revealed a “polyp”. A subsequent polypectomy and endometrial curetting was reported as: “endometrioid adenocarcinoma, FIGO Grade 2/3 for an endometrial primary”. Four weeks later the patient underwent a hysterectomy and bilateral salpingo-oophorectomy. A peritoneal wash was undertaken upon entry into the peritoneal cavity. Case 5 - Figure 1 A mesothelial fragment is evident (center) on a background of mononuclear cells. A dense cellular fragment with a distinctly different morphology is evident to the right of the mesothelial fragment. Case 5 - Figure 2 In contrast to the mesothelial fragment with its regular appearance and low nuclear to cytoplasmic ratio (top), the dense cellular fragment exhibits overlapping of cells (architectural disarray) and an increased nuclear to cytoplasmic ratio. Case 5 - Figure 3 In addition to architectural disorganization, these fragments show a smooth peripheral contour. The nuclei show significant variability in size and chromatin abnormalities. The outline of some of the nuclei is irregular and notched. Cytoplasmic vacuolation is evident. Case 5 - Figure 4 In addition to architectural disorganization, these fragments show a smooth peripheral contour. The nuclei show significant variability in size and chromatin abnormalities. The outline of some of the nuclei is irregular and notched. Cytoplasmic vacuolation is evident. Case 5 - Figure 5 In addition to architectural disorganization, these fragments show a smooth peripheral contour. The nuclei show significant variability in size and chromatin abnormalities. The outline of some of the nuclei is irregular and notched. Cytoplasmic vacuolation is evident. Case 5 - Figure 6 In addition to architectural disorganization, these fragments show a smooth peripheral contour. The nuclei show significant variability in size and chromatin abnormalities. The outline of some of the nuclei is irregular and notched. Cytoplasmic vacuolation is evident. Case 5 - Figure 7 In addition to architectural disorganization, these fragments show a smooth peripheral contour. The nuclei show significant variability in size and chromatin abnormalities. The outline of some of the nuclei is irregular and notched. Cytoplasmic vacuolation is evident. Case 6 - Click here for Text and References Submitted by: Jennifer A. Brainard Clinical Summary: 36 year old woman 4x5x2.3 cm liver lesion Adjacent to vena cava Multiple lung nodules Case 6 - Figure 1 Case 6 - Figure 2 The liver aspirate is highly cellular. Large, cohesive cell fragments in a bloody background are seen at low magnification. Case 6 - Figure 3 In addition to large aggregates, small groups and single cells are seen. Capillaries are seen within the larger cell groups. The individual cells do not resemble normal hepatocytes. The cell population is relatively uniform and no bile duct epithelium is seen, consistent with a neoplasm involving liver. Case 6 - Figure 4 Numerous thick-walled capillaries with adherent tumor cells, termed "transgressing capillaries" are prominent in this image. Case 6 - Figure 5 A large cohesive cluster with transgressing capillaries is also seen in this Pap stained slide. Case 6 - Figure 6 A higher magnification view of thick walled capillaries associated with a large tumor cell aggregate. Capillaries traverse the cell groups but endothelial wrapping is not seen. Hemosiderin pigment is present. Case 6 - Figure 7 The individual tumor cells have moderate to abundant amounts of cytoplasm. The cytoplasm of the tumor cells is vacuolated. In some cells, the vacuoles are single and appear "punched out". In others, multiple variably sized vacuoles are seen. There is a hint of some eosinophilic fibrillar material within this cell group. Case 6 - Figure 8 The Pap stain highlights eccentric nuclei with vesicular chromatin, slight nuclear membrane irregularities and prominent nucleoli. Case 6 - Figure 9 A similar Diff Quik image shows a small cluster of multivacuolated tumor cells with relatively uniform nuclei, low N/C ratios and indistinct cell borders. Case 7 - Click here for Text and References Submitted by: Zubair W. Baloch Clinical Summary: 35-year old woman with 3.0 cm right thyroid nodule. The ultrasound examination showed a hypoechoic solid and cystic thyroid nodule with few calcification and increased vascularity. Case 7 - Figure 1 Low power of Diff-Quik® stained air-dried smear showing follicular cells arranged in loosely cohesive papillary fragment and small follicular groups. Case 7 - Figure 2 Medium power of Diff-Quik® stained air-dried smear a monotonous population of follicular cells arranged in cohesive papillary group. Case 7 - Figure 3 High power showing follicular cells with ample oncocytic cytoplasm and round to oval nuclei. Case 7 - Figure 4 Papanicolaou stained smear showing a papillary group with spindle cell proliferation. Case 7 - Figure 5 Papanicolaou stained smear showing oncocytic cells (medium power) with round to oval nuclei with prominent nucleoli, intranuclear grooves and small intranuclear inclusions (high power). Case 7 - Figure 6 Papanicolaou stained smear showing oncocytic cells (medium power) with round to oval nuclei with prominent nucleoli, intranuclear grooves and small intranuclear inclusions (high power). Case 7 - Figure 7 Papanicolaou stained smear showing oncocytic cells (medium power) with round to oval nuclei with prominent nucleoli, intranuclear grooves and small intranuclear inclusions (high power). Case 8 - Click here for Text and References Submitted by: Kristen Atkins Clinical Summary: A 38-year-old woman presents for her annual exam. She has no significant history. Physical exam is normal. The images are from all the screening dots. Case 8 - Figure 1 Thin Prep slide from the pap test. Mature squamous cells and single cell with a high N:C. Case 8 - Figure 2 Single cell with an eccentrically placed nucleus and squamoid cytoplasm. Case 8 - Figure 3 Cluster of cells with high N:C. Case 8 - Figure 4 Cluster of cells with some nuclear enlargement and irregular nuclear contours.