Cytology

Breast
• Normal epithelial cells

• Small cohesive groups

• Monolayer sheets

• Occasional complete terminal duct-lobular units

• Nuclei are oval with regular outlines, 8-10μm diameter

• Inconspicuous nucleoli

• Evenly dispersed chromatin pattern

• Scanty delicate cytoplasm

• Oval myoepithelial cells with dense nuclei at periphery of sheets

• Naked bipolar (myoepithelial cells) in background of smears (when you see a mixture of ductal epithelial cells and myoepithelial cells)

Benign

Breast
• Cellular smears

• Poorly cohesive mainly dispersed epithelial cells of acinar type

• Cells have abundant fragile cytoplasm containing secreting vacuoles and frayed borders

• Round vesicular nuclei with central nucleoli

• Dirty/lipid background with stripped nuclei containing prominent nucleoli

• Single bipolar nuclei are difficult to find

Benign - Lactating

Breast
Dispersed acinar cells displaying abundant fragile cytoplasm, round nuclei with prominent central nucleoli, in a background demonstrating lipid secretions.

Corresponding Histology tissue section. Increased number of lobules, reduction in interlobular and intralobular stroma and myoepithelial cells are difficult to identify.

Benign - Lactating

Breast
• Cellular

• Epithelial fragments occur as large/flat/monolayered sheets

• Some ‘fingerlike’ projections (similar to that seen in FA)

• There is a bimodal pattern of single bare/bipolar nuclei in background.

• Adipose tissue may be present

• Moderate nuclear variation and atypia may be seen

Benign - Gynaecomastia

Breast
• Low to moderate cellularity

• Cohesive sheets of benign ductal cells arranged in flat honeycomb sheets, no loss of polarity with distinct cell borders

• Bare myoepithelial nuclei dispersed within the background or attached to sheets of epithelial cells

• Evidence of apocrine cells

• Presence of cystic/foamy macrophages

• Fat and stroma

• High cellularity or mild epithelial atypia may be present

Benign - Fibrocystic Change

Breast
• Cystic macrophages

• Apocrine cells

• Sheets of regular ductal epithelial cells

• In addition to the usual bimodal pattern of regular ductal epithelial cells and single bare bipolar nuclei

Benign - Fibrocystic Change

Breast

• Absence of altered blood or necrotic material

• ‘Cyst macrophages’- have abundant delicate vacuolated cytoplasm which may contain pigment.

• Apocrine epithelial cells – have abundant dense basophilic cytoplasm (MGG), nuclei are round, nuclear size may vary with prominent nucleoli.

• Nuclear outline is smooth, and the chromatin pattern is uniform.

• Inflammatory cells (polymorphs)

Benign - Cyst

Breast
• Benign bimodal component of non neoplastic epithelium.

• Inflammatory cells, chronic/acute.

• Regenerative epithelial atypia.

• Histiocytes, epithelioid cells, multinucleated giant cells and plasma cells (granulomatous reaction)

Benign - Inflammatory change c/w Mastitis

Breast
• Aspirate is usually scanty with a dirty background of granular debris

• Oily fluid texture

• Consisting mainly of fat

• Some foamy macrophages or vacuolated adipocytes

• Multinucleated histiocytic giant cells.

• Absence of epithelial cells

• Chronic inflammatory cells

Benign - Fat Necrosis

Breast
• Numerous foamy/cystic macrophages

• Multinucleated giant cells

• Fragments of normal and degenerating adipose tissue fragments.

• Sparse and variable numbers of inflammatory cells

• Free lipid droplets

• A granular amorphous cystic background debris

Benign Fat Necrosis

Breast

• Moderate to highly cellular smears

• Large cohesive sheets and papillary-like aggregates of ductal epithelial cells

• Branching antler horn/finger like projections of epithelial cells

• Moderate to increased numbers of bare bipolar nuclei

• Large fibromyxoid stromal fragments

• Few or no cystic macrophages or apocrine cells

Benign - Fibroadenoma

Breast
• Highly cellular with a bimodal pattern containing epithelial and stromal fragments.

• Epithelial component is regularly arranged in large sheets, may be elongated and branching aggregates, similar that seen in tissue sections.

• Variable nuclear crowding and overlapping, but nuclei are uniform with a bland chromatin pattern.

• With 1 or 2 small indistinct nucleoli

• Numerous single bare oval nuclei scattered throughout the background

• Fragments of fibromyxoid stroma (stain magenta on MGG) are present within the background. These have a fibrillary structure with spindled, elongated fibroblastic

nuclei

Benign - Fibroadenoma

General Criteria for breast malignancy (13)

• Cellularity of the specimen

• Dispersal of single cells

• Biphasic pattern with bipolar cells

• Reduced cohesiveness of ductal cell population

• Nuclear size and pleomorphism

• Nucleolar size and pleomorphism

• Nuclear membrane irregularity and extranuclear chromatin

• Nuclear/Cytoplasmic ratio and cytoplasmic features

• Chromatin texture

• Nuclear fragility

• Relationship of nuclei to each other

• Mitosis

• Contents of background - necrosis

Histological subtypes of invasive breast carcinoma (7)

• Ductal NOS

• Lobular

• Medullary

• Tubular

• Mucinous

• Papillary

• Apocrine

Breast
• Moderate to highly cellular smears

• Single population of cells, no myoepithelial cells, no bare oval nuclei

• Variable loss of cell cohesion

• Single epithelial cells with intact cytoplasm

• Moderate to severe nuclear atypia

• Fibroblasts and fragments of collagen

• Necrosis is unusual

Malignant - Invasive Duct Carcinoma

Breast

• Varying cellularity from abundant to sparsely cellular

• Cells may present singly, in loose aggregates, cohesive groups, may have 3D appearance.

• Varying cellular and nuclear atypia according to histological grade.

• Cell may be vacuolated with occasional signet ring appearance.

• Microcalcification

• Mitoses are uncommon

• Necrosis

Malignant - Invasive Duct Carcinoma

Breast
• Low - moderately cellular smears

• Cells predominantly in cohesive clusters

• Epithelial fragments with angular or tubular shape, acinar structures and ‘fingerlike’ grps.

• Monolayered folded sheets

• Anatomical or rigid or palisaded borders (columnar arrays)

• Relatively uniform, mildly to moderately atypical epithelial cells

• Absence of bare bipolar nuclei, fibroblastic cells

• Nucleoli indistinct or small

• Evidence of stromal fragments

Malignant - Tubular Carcinoma

Breast

• Abundant background mucin

• Cellular smears with atypical cells in small solid aggregates and single intact epithelial

cells

• Mild to moderate nuclear atypia, bland chromatin

• Bare bipolar nuclei absent

• Chicken wire blood vessels

Malignant - Mucious (Colloid) Carcinoma

Breast
• Highly cellular smears

• Material is easy to obtain

• Poorly cohesive cells in clusters and singly

• Pale staining cytoplasm, syncytial aggregates

• Large pleomorphic obviously malignant nuclei with nucleoli and coarse chromatin

• Evidence of mitotic figures – bare malignant nuclei

• Background of lymphocytes and plasma cells

Malignant - Medullary carcinoma

Breast

• Often single cells and in small clusters

• Short single files ‘strips’ common/linear arrays

• Scanty/indistinct/delicate cytoplasm

• Small hyperchromatic nuclei, often uniform size

• Irregularity of nuclear shape, subtle

• Intracytoplasmic mucin vacuole (neolumina)

• Inconspicuous nucleolus

• Traumatised cell pattern

Lobular Carcinoma

Salivary Gland
MYB-NFIB fusion transcript is associated with which condition

Adenoid cystic carcinoma

Salivary Gland
CRTC1-MAML2 is associated with which condition

Mucoepidermoid carcinoma

Salivary Gland
ETV6-NTRK3 and ETV6-RET are associated with which condition

Secretory carcinoma, née Mammary analogue secretory carcinoma

Salivary Gland
Cystic aspirate is seen in which conditions? (6)

• Non-neoplastic

• Retention cysts

• Warthin’s

• Low grade mucoepidermoid carcinoma

• Acinic cell carcinoma

• Pleomorphic adenoma

• Metastasis

Salivary Gland
Clear Cells is seen in which conditions? (4)

• Pleomorphic adenoma

• Mucoepidermoid carcinoma

• Acinic cell carcinoma

• Metastatic

Salivary Gland
Squamoid morphology is seen in which conditions? (5)

• Squamous cell carcinoma

• Mucoepidermoid carcinoma

• Salivary duct carcinoma

• Pleomorphic adenoma

• Warthin’s tumour

Salivary Gland
Lymphoid rich is seen in which conditions? (5)

• Warthin’s tumour

• Acinic cell carcinoma

• Metastasis

• Normal lymph node

• Lymphoma

Salivary Gland
Granular debris is seen in which conditions? (3)

• Warthin’s tumour

• Tumour diathesis

• Sialadenitis

Salivary Gland
Mucinous aspirate is seen in which conditions? (4)

• Chronic obstructive sialadenitis

• Mucoepidermoid carcinoma

• Pleomorphic adenoma

• Warthin’s tumour

Salivary Gland
Hyaline globules is seen in which conditions? (5)

• Adenoid cystic ca

• Pleomorphic adenoma

• Basal cell adenoma/carcinoma

• Myoepithelioma – rare benign SG tumour arising from myoepithelial

cells found between the BM and basal lamina of acinar cells.

• Polymorphous low grade adenocarcinoma

Salivary Gland

Diagnostic considerations (7)

• Hyaline globules

• Mucinous material

• Granular debris

• Lymphoid rich

• Squamoid

• Clear cells

• Cystic

Salivary Gland
• Ciliated columnar cells

• Stone fragments

• Absence of mucus secreting and epidermoid cells

• Smears often scanty, with ductal cells and smaller nos of acinar cells

• Bg of bare oval nuclei of acinar epithelial cells

Chronic sialadenitis with mucinous metaplasia

Salivary Gland
- Cystic bg
- Crystals

Non-Neoplastic cyst with crystalloids

Salivary Gland
• Triphasic Pattern
• Background of stroma

• Classically magenta in colour, fibrillary and magenta in appearance on DQ

• May have mucin, basement membrane, hyaline globules

• Myoepithelial cells

• Plasmacytoid (common) – ovoid or spindle with abundant well defined cytoplasm

• Spindled

• Clear cell (rare)

• Ductal cells – regular ovoid nuclei with bland finely granular nuclear chromatin and smooth nuclear membranes

• May have metaplastic cells, oncocytic cells, goblet cells, sebaceous or squamoid appearance.

Pleomorphic Adenoma

Salivary Gland
• Uniform sheets of bland oncocytic cells, monolayered appearance

• Cystic debris

• Bg Mixed lymphoid cells, amorphous and granular debris

• Mast cells commonly assoc with oncocytic cells

Warthin’s tumour

Salivary Gland
• Honeycomb sheets of oncocytes and singly scattered columnar shaped cells
• Lymphoid Rich bg
• Keratinising cells

Warthin’s tumour

Salivary Gland
• Numerous monotonous small basaloid cells singly, in cohesive clusters with peripheral palisading

• Scanty cytoplasm

• Dispersed naked nuclei – regular round or oval nuclei, may appear dark but v bland, granular chromatin pattern.

• Small hyaline globules – scanty fibrous stroma

• Squamous whorls if present is a good diagnostic clue, frequent squamous metaplasia

Basal cell adenoma

Salivary Gland
• Smears present with a dirty background of mucus and debris

• Cohesive clumps and sheets of cells are present with small streams of cells

within mucus.

• Variation in cell type – intermediate, squamous, mucus secreting – most with abundant cytoplasm

• ‘Regular’ nuclei with prominent nucleoli and mitoses

• Well defined cell borders

• Occasional goblet cells may be seen with cytoplasmic mucin

Mucoepidermoid carcinoma

Salivary Gland
• Epithelial cells – cellular smears

• Small uniform, round to oval/some angulation

• Mild atypia: some variation in nuclear size, Hyperchromasia

• Cell fragments with finger-like or beaded cords or strands of hyaline stroma.

• Multilayered dense cell clusters of tumour cells

• Scanty cytoplasm, high NC ratio, nuclear molding, naked/stripped nuclei, nucleoli

• Relatively uniform round to oval hyperchromatic nuclei with coarse chromatin pattern

• Metachromatic hyaline stromal material

• Globules, cylindrical structures

• Metachromatic in DQ stain, pale blue in Pap

• Dense, homogenous, hard edges

• Epithelial cells characteristically cluster around stroma

Adenoid cystic cell carcinoma

Salivary Gland

Abundant cellular material - Epithelial cells – serous acinar cells, abundant cell yield

• Nuclei are round to medium size, uniform, pale, round, nucleoli variable

• Mild to moderate anisokaryosis

• Cells in clusters, scanty inconspicuous fibrovascular stroma

• Microacinar groups

• Many stripped nuclei in the background of smears

• Cytoplasm

• Typically, granular abundant-indistinct cytoplasm, occ oncocytic like

• Green/blue in Pap and Purple in DQ

• PAS positive

• Clear or foamy cytoplasm/stripped bare tumour nuclei

• Loose clusters, sheets or dispersed

• Can be cystic and can have a prominent lymphoid component.

Acinic cell carcinoma

Salivary Gland

• Cellular aspirate

• Large polygonal cells in crowded clusters, papillary groups, and single cells

• Rounded nuclei with distinct nucleoli

• Abundant finely vacuolated cytoplasm with occasional intracytoplasmic mucin-containing vacuoles

• Absence of cytoplasmic granules

• Extracellular mucoid material

• Variably described as filamentous, web-like, or “colloid-like”

Mammary analogue secretory carcinoma

Salivary Gland
• Overt malignant features – clearly malignant cells, present singly or in clusters

• Pleomorphic nuclei

• Necrotic debris

• Abundant cytoplasm, squamoid, oncocyte features

• No stromal component

• Low grade tumours with a cribriform pattern and uniform cells

Salivary duct carcinoma

If these IHC are positive, what are you expecting: TTF1, Napsin A, CK7

Pulmonary adenocarcinoma

If these IHC are positive, what are you expecting: Mammaglobin, GCDFP-15, ER, PR, CK7

Breast adenocarcinoma

If these IHC are positive, what are you expecting: PAX8, WT1, P53, CK7, ER, PR

Female genital tract carcinoma

If these IHC are positive, what are you expecting: WT1, CA125, MUC1, with neg GCDFP

Ovarian carcinoma

If these IHC are positive, what are you expecting: CDX2, CK7

GIT (oesophagus, stomach and small bowel)

If these IHC are positive, what are you expecting: CDX2, CK20

GIT (colo-rectum)

If these IHC are positive, what are you expecting: CDX2, CK7, CK19, S100P, MUC1, CEAm

Pancreatico-biliary

If these IHC are positive, what are you expecting: PAX8, RCC, CD10, Vimentin

Renal cell carcinoma

If these IHC are positive, what are you expecting: GATA3, Uroplakin, P63, CK7, CK20, HMWK

Urothelial carcinoma

If these IHC are positive, what are you expecting: PAX8, TTF1, Thyroglobulin

Thyroid carcinoma

If these IHC are positive, what are you expecting: PSA, PSAP

Prostate adenocarcinoma

If these IHC are positive, what are you expecting: HepPAR1, Glypican, CD34, P53, AFP

Hepatocellular carcinoma

If these IHC are positive, what are you expecting: P53, bcl-2, Ki-67, AE1, CK7, CK19, Cam5.2, with neg pCEA

Cholangiocarcinoma

If these IHC are positive, what are you expecting: P63, CK5/6, P40, P16

Squamous cell carcinoma

If these IHC are positive, what are you expecting: Sox-10, S100, Melan A, HMB45, MITF

Melanoma

If these IHC are positive, what are you expecting: Synaptophysin, Chromogranin, CD56, NSE

Neuroendocrine carcinoma

If these IHC are positive, what are you expecting: Cam 5.2, AE1/AE3, NSE, Chromogranin, Synaptophysin

Merkel cell carcinoma

Lymph Node
• Usually highly cellular

• Predominantly small lymphocytes

• Spectrum of medium and large lymphocytes

• Histiocytes

• Dendritic cells

• Tingible body macrophages

• Plasma cells, mast cells, eosinophils, neutrophils

Benign

5 Cells in the reactive germinal centre of the Lymph Node

• Centrocytes- Variable size cleaved cells with inconspicuous nucleoli

• Centroblasts- Large non-cleaved cells with vesicular nuclei and multiple distinct nucleoli

• Immunoblasts- Single nucleolus, basophilic cytoplasm

• Dendritic cells- bean shaped, fine nuclear membranes

• Tingible body macrophages

Lymph Node

• Syncytial aggregates of activated macrophages

• Epithelioid histiocytes

• Giant cells

Granulomatous Lymphadenitis

Lymph Node
• Classical appearance is (caseating) necrotizing granulomatous inflammation

• May see granulomas only, necrosis only or suppurative appearance

Tuberculosis

Lymph Node
• Suppurative granulomatous inflammation is the classical finding

• Neutrophils and dispersed macrophages may be only finding

Cat-Scratch Disease

Lymph Node

• Classical cases are seldom aspirated - the cases we see tend to have unusual Hx

• Cellular smears, with a follicular hyperplasia pattern/reactive lymph node of NS type

• Prominent population of plasmacytoid cells and a florid population of immunoblasts with prominent nucleoli and atypical lymphoid cells.

• In some cases cells with double nuclei may be seen and may mimic Reed Sternberg cells.

EBV

Lymph Node
monotonous small cell pattern

Non-Hodgkins Lymphoma (CLL, mantle)

Lymph Node
mixed cell pattern

Non-Hodgekins (FL, PTCL NOS)

Lymph Node
Scattered large cell pattern

Hodgkins Lymphoma

CD45+

CD45+ Lymphocytes

CD19+

CD19+ B-cells

CD3+

CD3+ T cells

No questions, It was just stared so I wanted it here

Lymph Node
• Small round lymphoid cells with clumped chromatin

• Population of slightly larger cells with vesicular chromatin and nucleoli

• Generally, less nuclear irregularity

NH Lymphoma - CLL/SLL

Lymph Node
• Monotonous population of small lymphocytes

• Slight but distinctive nuclear irregularity

• Scant/absent mitotic activity

• Scattered histiocytes

NH Lymphoma - Mantle Cell

Mantle Cell Lymphoma flow results

CD23- CD20 bright

Small Lymphocytic Lymphoma flow results

CD23+, CD20 dim

Lymph Node
Identification of t(11;14)(q13;q32) would suggest what condition

Mantle cell lymphoma

Lymph Node
• Reed Sternberg cell

• Atypical mononuclear cells

• BG eosinophils, plasma cells and histiocytes

• Lymphocytes dispersed within the background

Hodgekin Lymphoma

Lymph Node
Aspirates show a monotonous population of large lymphoid cells which typically make up 50%-80% of cells with a variable mixture of small round lymphocytes and histiocytes.

Diffuse large B-cell lymphoma

Lymph Node
• Highly cellular smears

• Monotonous population of medium sized cells, round oval nuclei, with several small nucleoli

• Moderate amount of cytoplasm with lipid vacuoles on DQ

• Dirty background – numerous apoptotic bodies

• Mitoses, TBMs

Burkitt lymphoma

Intra-abdominal
• May have sheets or aggregates
• May have Trabecular arrangements
• Cells with single (binucleated), central, round nucleus with even chromatin and a single nucleolus
• ^ Cells can have lipidic cytoplasm
• Sheets of honeycomb arranged sheets and tubules (ductal cells)

Benign

Intra-abdominal
• Large fragments and dispersed cells
• Widened trabeculae
• Necrosis
• Well defined capillaries traversing fragments
• Endothelial rimming of islands
• Polygonal cells with central nuclei
• Increased nuclear size
• Increased N:C ratio
• Nuclear atypia - Hyperchromasia and irregular nuclear membranes, macronucleoli
• Multinucleation & Intranuclear inclusions
• Stripped atypical nuclei
• Frequent mitoses
• Fat and glycogen & Bile as coarse plugs

Hepatacellular Carcinoma

Intra-abdominal
• Aggregates/tubules with gland formation
• Cohesive groups: nuclear enlargement and pleomorphism
• Cuboidal/columnar cells with eccentric, round to oval nuclei and abundant cytoplasm. Nuclear enlargement with prominent nucleoli

Cholangiocarcinoma

Intra-abdominal
• Characterised by tightly or loosely cohesive clusters of spindle-shaped cells.
• Elongated blunt ended uniform nuclei and scant eosinophilic cytoplasm with occasional cytoplasmic vacuoles indenting nucleus.
• Cell may be embedded in a delicate fibrillary background.
• In epithelioid cell types, the cells are loosely cohesive, round or polygonal with a coarsely granular chromatin and slightly irregular nuclear membrane.
• Req IHC for dx, and >5 mitoses/50 hpf.
• Presence of necrosis is helpful.

GIST - Gastro-Intestinal Stromal Tumours

Intra-abdominal
• Duct epithelium - uniform, regular, can be honeycomb
• Acinar cells - delicate cytoplasm

Pancreas

Intra-abdominal
• Large cell within a complex structure with lots of elongated neuclei and vessles
• epithelial histiocytes
• Necrotic background

Tuberculosis

Intra-abdominal
• Large cell within a complex structure with lots of elongated neuclei and vessles
• epithelial histiocytes
• Clean background

Sarcoidosis

Intra-abdominal
• Large cell within a complex structure with lots of elongated neuclei and vessles
• epithelial histiocytes

Granuloma

Intra-abdominal
• Necrotic debris - “dirty”
• Granular calcific debris, lipid droplets
• Inflammatory cells esp. macrophages
• degenerative and reactive atypia

Pancreatitis

Intra-abdominal
• High cellularity with large aggregates, clusters, dispersed cells
• Monolayered sheets with marked nuclear enlargement and pleomorphism
• Gland formation
• Crowding, disorganization, disturbed polarity
• N:C ratio normal or increased, Cell enlargement, Mitoses
• Apoptotic debris in tumour cell sheets
• Enlarged, irregular nuclei with coarse chromatin, hyperchromasia
• Large irregular nucleoli, Multinucleation
• Disorganised sheets
• Small acinar groups
• Loose aggregates and single pleomorphic cells
• Background of necrotic debris

Adenocarcinoma