July 21, 2008

32 year old female. Thin prep pap

A) Reactive endocervical cells

B) HSIL

C) LSIL

D) Squamous metaplasia

E) ASCUS

1

45 year old female with previous history of a thyroid lesion which was resected. She now presents with an enlarged lymph node. This is an FNA specimen of the lymph node

A) Normal lymphoid tissue

B) Metastatic squamous cell carcinoma

C) Metastatic papillary thyroid carcinoma

D) Lymphoma

E) Metastatic medullary carcinoma of the thyroid

2

3

24 year old female. Thin prep pap

A) Squamous metaplasiaB) Negative for intraepithelial lesionC) HSILD) ASCUSE) LSIL

49 y/o male with corneal ulcer. History of “getting something in his eye” while doing yard work. Corneal scrape

A. Aspergillus

B. Candida

C. Mucormucosis

D. Fusarium

E. Pseudallescheria

4

5

26 year old female. Thin Prep Pap

A) Leptothrix

B) Trichomonas

C) Candida

D) Actinomyces

E) No organisms present

6

65 year old male with hematuria. Bladder washing

A. BK virus effectB. High grade TCCC. Instrument effectD. Low grade TCCE. Squamous cell carcinoma

7

36 year old female. Thin prep pap.

A) Squamous metaplasia

B) HSIL

C) Endocervical cells

D) LSIL

E) ASCUS

50 year old male with neck mass. By examination the nodule felt like a lymph node. FNA aspirate – pap stain

A) Positive for tumor

B) Atypical

C) Reactive

D) Normal lymphocytes

E) Normal histiocytes

8

55 year old male with LLL mass. Pleural fluid.

A) Non-small cell lung carcinoma

B) Bronchoalveolar carcinoma

C) CMV

D) Granulomatous changes

E) Benign mesothelial cells

9

60 year old with pancreatic mass. FNA.

A) Reactive

B) Positive for tumor

C) Send for flow

D) Atypical

E) Artifact 10

AnswersAnswers1.1. B HSIL B HSIL

• Single hyperchromatic atypical cells with high N:C ratio, irregular nuclear membrane, and clumpy Single hyperchromatic atypical cells with high N:C ratio, irregular nuclear membrane, and clumpy chromatin. These single cells are sometimes missed on pap smears so beware!chromatin. These single cells are sometimes missed on pap smears so beware!

2.2. C Metastatic papillary carcinomaC Metastatic papillary carcinoma• Cells are in papillary clusters with grooves and an intranuclear inclusion. In a patient with a previous Cells are in papillary clusters with grooves and an intranuclear inclusion. In a patient with a previous

history of a “thyroid lesion” and these characteristics, papillary thyroid carcinoma should be at the top of history of a “thyroid lesion” and these characteristics, papillary thyroid carcinoma should be at the top of your differential.your differential.

3.3. E LSIL (Low grade squamous intraepithelial lesion)E LSIL (Low grade squamous intraepithelial lesion)• Cells with enlarged nuclei (> 3x that of a normal intermediate cell), coarsely granular chromatin and Cells with enlarged nuclei (> 3x that of a normal intermediate cell), coarsely granular chromatin and

koilocytosis ( perinuclear halo).koilocytosis ( perinuclear halo).

4.4. D FusariumD Fusarium• The corneal scrape just shows septated fungal organisms. That is as far as you can go with that The corneal scrape just shows septated fungal organisms. That is as far as you can go with that

diagnosis. The slide of the culture shows classic “banana shaped” macroconidia. Fusarium is a diagnosis. The slide of the culture shows classic “banana shaped” macroconidia. Fusarium is a common cause of keratomycosis. Remember you must be able to identify organisms from a fungal common cause of keratomycosis. Remember you must be able to identify organisms from a fungal culture on the boards!!culture on the boards!!

5.5. B TrichomonasB Trichomonas• Those tricky trich!! There are 4 of them around the cell on the left.Those tricky trich!! There are 4 of them around the cell on the left.

6.6. B High grade TCCB High grade TCC• High NC ratio, irregular nuclei, clumpy chromatinHigh NC ratio, irregular nuclei, clumpy chromatin

7.7. A Squamous metaplasiaA Squamous metaplasia• Squamous metaplastic cells have a cyanophilic (blue-green) cytoplasm with a slightly increased N:C Squamous metaplastic cells have a cyanophilic (blue-green) cytoplasm with a slightly increased N:C

ratio (but always <50%). The nuclear contours are smooth and the chromatin is evenly distributed. The ratio (but always <50%). The nuclear contours are smooth and the chromatin is evenly distributed. The borders of these cells are sharply defined; their cytoplasm often looks “spidery” (especially on borders of these cells are sharply defined; their cytoplasm often looks “spidery” (especially on conventional paps)conventional paps)

8. A Positive for tumor8. A Positive for tumor• Note the pleomorphism, high N:C ratio of some cells along Note the pleomorphism, high N:C ratio of some cells along

with the clumpy chromatin. This was actually a metastatic with the clumpy chromatin. This was actually a metastatic melanoma. Melanin pigment is present in most of the cells.melanoma. Melanin pigment is present in most of the cells.

9. E Benign mesothelial cells9. E Benign mesothelial cells• Mesothelial cells can look like anything!! They can often look Mesothelial cells can look like anything!! They can often look

very ugly when they get reactive. These cells have classic very ugly when they get reactive. These cells have classic features of the “ruffled skirt” (see in the left picture) and the features of the “ruffled skirt” (see in the left picture) and the mesothelial “window” seen in the right picturemesothelial “window” seen in the right picture

10. B Positive for tumor10. B Positive for tumor• Once again, note the crowding of cells, different sizes/shapes Once again, note the crowding of cells, different sizes/shapes

of nuclei, irregular nuclear membranes. This is most likely a of nuclei, irregular nuclear membranes. This is most likely a pancreatic ductal adenocarcinoma, especially with the mucin pancreatic ductal adenocarcinoma, especially with the mucin vacuoles present (though a mucinous cystadenocarcinoma vacuoles present (though a mucinous cystadenocarcinoma cannot be ruled out if this was a cystic lesion)cannot be ruled out if this was a cystic lesion)