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8/10/2019 Introduction Cytology
http://slidepdf.com/reader/full/introduction-cytology 1/70
Introduction toCYTOLOGYThe 25 th Congress of the International Academy
of Pathology / Arab DivisionThe 5 th International Conference of the
Jordanian Society of Pathologists
Mousa Al-Abbadi, MD, FIAC, FCAPProfessor of Pathology & Cytopathology
King Fahad Specialist Hospital – DammamSaudi Arabia
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Fadi Abdul-Karim, MD
Professor of Pathology atCleveland Clinic1979 MD AUB
AP & Cytopathology certification >180 publications, chaptersGyn, bone and soft tissue
cytology
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ISAM-ELDIN ELTOUM, MD
- Professor of Pathology at UAB- School of Medicine University of
Khartoum, Sudan 1983
- CP residency, Assistant Professor atalma mater-Postdoctoral fellowship at NIH
- AP residency at GWU-Cytopathology & Surgical pathology
fellowship at UAB- > 100 publication, chapters
- Thyroid, EUS GI and Lung
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Outline
HistoryExfoliative vs FNAUtilization and advantages
Technical aspects…videos Cytology vs tissueMorphologic criteria
PitfallsReportExamples
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" My interest is in the futurebecause I am going to spend
the rest of my life there " Charles F. Kettering
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“A story lives onlywhen it is told”
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G. Papanicolaou 1883-1962
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Cytopathology
Exfoliative
Aspiration
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Exfoliative
Pap smear…anal smears Body fluids: Pl. F, Perit. F, Pericardial
F, FSF, Urine, Respiratory B&W&L,GIT, “Omayya reservoir”…. Scrape cytology…skin & eye
Nipple discharge Any other fluid collection
Pap smear…anal smears Body fluids: Pl. F, Perit. F, Pericardial
F, FSF, Urine, Respiratory B&W&L,GIT, “Omayya reservoir”…. Scrape cytology…skin & eye
Nipple discharge Any other fluid collection
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ASPIRATION
Any wherePalpable…non guided
Non- palpable or deep…Guided Fine Needle Aspiration = FNANeedle Aspiration Biopsy = NAB
Aspiration Biopsy Cytology = ABCFine Needle Aspiration Biopsy =FNAB
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UTILIZATION
REACH A DEFINITIVE DIAGNOSIS
ScreeningFollow upPrognostication
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ADVANTAGES
SAFESIMPLE
QUICK ACCURATECOST EFFECTIVE
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What do we need
Team work
Common language
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Technical
Smears: air-dried or fixedStains: Diff-Quik or Pap. +/- H & E
Preparation types: – Direct smears – Liquid-based: TP, SP, Cytospin – Membrane filter – Cell block “ mini biopsy “
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End result
Air dried, DQ stained smearsPap stained slides
Cell block slides stained by H&E+/- RPMI cellular solution: flowcytometry, cytogenetic analysis,
molecular studiesMicrobiology
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Diff Quik stain “ ModifiedRomanowsky”
Air dried…”hand held fan” Fast …< 1 minuteImmediate adequacy & triage
Advantages: – Triage - Mucin & colloid – Cytoplasmic details & vacuoles
– Pigments - Heme (LGB, Cyt basoph) – Matrix & background - B Membrane – Organisms
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Papanicolaou stain
Alcohol fixationLonger “ultrashort Pap”
Advantages: – Nuclear details: Chromatin pattern,outline and nucleoli
– Squamous differentiation – Cleaner background - Oncocytes – Psammoma bodies
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Features well-emphasized byDQ stain Pap
Cytoplasmic detailsStromaBackground
Nuclear detailsNucleoliOncocytosisPsammoma bodies
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ANCILLARY STUDIES
Simple special stainsImmunophenotypic: IMX, FCM, DIF
Cytogenetic analysisMolecular studies: PCREM: ?!
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““ Surgical BiopsySurgical Biopsy ”” vsvs ““ Cytology &Cytology &FNAFNA ””
AbsentPresentArchitecture
PossiblePossibleAncill. studies
S.t. LimitedWide expertisePathologistsNeverAlwaysScar
RareUncommonComplications
PossibleRarely an issueSampling error
MinimalExtensiveEquipment
UnnecessaryS.t. necessaryAnesthesia
MinimalMore expensiveCost
CellsTissueMaterial
Cytology & FNAExc. Biopsy
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Interpretation
THE GOOD
THE BAD
THE UGLY
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Cytopathological Featuresof malignancy
High cellularity Cellular enlargement
Increased N/C ratio Hyperchromasia Discohesiveness of cells
Prominent and large nucleoli
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Cytopathological Features ofmalignancy…. cont.,
Abnormal distribution of chromatinIncreased mitotic activity andspecially the presence of abnormalones.Cellular and nuclear pleomorphism
Background tumor necrosis/diathesis
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DIAGNOSIS
Negative or Positive for malignancy – more specific diagnosis
SuspiciousBenign cellular changesDescription
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Who is responsible about theprocess?
We all are
Problems can arise any time by anyoneCollection…….final report
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Pitfalls…why?
Poor collection techniqueImproper fixation
Changes of radiation andChemotherapyChanges of infarction, inflammation,necrosis…etc
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False negative
Desmoplasia (fibrosis)Geographic miss
Well differentiated tumorsInflammation, chemotherapy,radiation
Inexperience of interpreter
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False positive
PregnancyContamination
Hemorrhage and infarctionInflammation, chemotherapy,radiation
Inexperience of interpreter
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“ The adequacy of fineneedle aspirates is
operator dependent ”
Raul Braylan, MD
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Basic FNA rule…
DO YOUR OWN FNA
ORPERFORM IMMEDIATE
ADEQUACY EVALUATION(ROSE)
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Cameo (Swed) : Inrad (USA)
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Different FNA techniques
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67 year old male withsubmental lymph nodeenlargement for the last 4weeks. No response toantibiotics
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“ C R A T ” “ C R A T “
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CRAT Technique
Continuous Radial Aspiration Technique( CRAT)
Mirror image smears for air dried andethanol fixed
Air dried DQ stained smears for triagingDedicate a separate pass for cell block and
ancillary studiesCystic lesions
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What do we need to establishFNA service/clinic ? “ 101 FNA”
Convince your colleagues the pathologistsTeam workCommunications with the clinicians andthe RADIOLOGISTS ….develop anunderstandingThe FNA WAGON
The FNA Clinic
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FNA WAGON
Syringes, Needles (gauge: 21-25) &SlidesEthanol based fixative: SprayGun?!Ethanol based solution: Saccomanno
Ancillary studies solution: RPMICulture swabs and relatedQuick Stain: Diff-Quik
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Contraindications to FNA
The absolute are very rare: hydatidcyst ????, subcaspular hepaticadenoma, ParagangliomaWatch out for: – Anticoagulation (thyroid, liver, kidney)
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Baig & Al-Abbadi..et al Cytojournal. 2006 Apr 9;3:12
FCM MP CG
CB
RPMI
Saline
Formalin
Ethanol
C & S EM
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Good relationship with
ENTHeme/onc (tumor boards)
RadiologistsGeneral surgeonsGI (EUS-FNA)Prostate: NO
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Good relationship with
Pulmonary…(Fluoroscopy) OrthopedicsIDMelanomaBreast ??!!
BxFNA
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EUS-FNA
>>>> frequencyLearning curveTrans upper orlower GILiver, pancreas,L.nodes, B.ducts,perirectal masses? EUS-Core biopsy
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Tools to help:
LecturesCPC conferences
Tumor boards Announcements (local media, e-mail,flyers..etc)
Immediate dx. (Friday evening dx.)Word of mouth
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THE FINAL REPORT
AdequacyDiagnosisDescriptive diagnosisCommentRecommendation
We have to talk
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ADEQUACY
Pathologists don’t like to reportinadequate…but sometimes it isnecessaryInadequate no diagnosis
Adequate but suboptimal…notrecommendedDescriptive diagnosis withdifferential diagnosis
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DIAGNOSIS
Negative or Positive for malignancy – more specific diagnosis
SuspiciousBenign cellular changesDescription
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Cervix
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Breast
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Lung
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Esophagus
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Axill. Node, Hx. Of bladder and lungcarcinoma
CK 7 +
CK 20 -
Mets. Lung
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Neck mass: No Tenderness “ Cold abscess ”
DX: MycobacterialLymphadenitis
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71-year-F- cervical node
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Metastatic Small CellCarcinoma
Chromogranin CK+AE1/3
CG
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?Parotid mass FNA
Metastatic HCC to mandible
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B k f i h LCC NE
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Back soft tissue mass: hx. LCC-NEof lung and SQ.CC of neck
CK 7 –
CK 20 -TTF-1 -
P63
Mets. SQ
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Problems of the FNA:
Folllicular lesions/neoplasms ofthyroidWD epithelial neoplasms (HCC, PNC)Necrotic/cystic tumorsBasaloid salivary gland tumors
Low grade MEC of Saliv. GlandsInvasion in mammary carcinoma
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Problems of the FNA approach:
Papillary mammary neoplasmsBenign lymphoid lesions…no specificdiagnosis
Hodgkin’s lymphoma T-cell rich B-cell LymphomaT-cell lymphomasNecrotic/cystic tumorsGrading of some lymphomas
Young N 2006 Cancer Feb.
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+/- = DX
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DON’T BE A HERO
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DON’T BE A HERO