Respiratory cytology (continued…)

October 2007

Summary Slide

Benign proliferationsTherapeutic agents InflammationMalignant diseaseMetastases

Reserve cell hyperplasia

Resemble lymphocytes or histiocytes

Tightly cohesive groups Small uniform cells Dark round nuclei Basophilic cytoplasm High N/C Ciliated Columnar along surface Ddx: small cell carcinoma

Malignant disease

Older than 40, peak incidence at 60 More aggressive in younger patients Male > female (3-6:1) Signs and symptoms appear late Weight loss and cough (presenting sx)

Dyspnea, weakness, chest pain, hemoptysis. Acute respiratory distress or cardiac failure

Metastases to mediastinum Effects on vital structures

Bad stuff that happens

Pancoast syndromePain or tingling in shoulder, arm or ulnar

nerve distribution Horner’s sign: ptosis, myosis, anhidrosisDensity on CXR at extreme apex of lung

(superior sulcus tumor)Usually SCC

Squamous cell carcinoma Small cell carcinoma Adenocarcinoma Large cell carcinoma Adenosquamous carcinoma Carcinoid tumor Carcinomas of salivary gland type Unclassified carcinoma

1999 WHO classification of invasive malignant epithelial lung tumors

Adenocarcinoma

Bronchogenic AdenocarcinomaCrowded sheets, cell balls, papillae,

microaciniNuclei

PolarLobulated borderVesicular chromatinProminent nucleoli

CytoplasmFoamy granular or secretory+/- mucin

Bronchioalveolar Carcinoma

Cellular 3D groups Differentiation Resemble:

GobletMesothelialAlveolar macrophages

Squamous cell carcinoma

Keratinizing / well differentiatedFrequent clustersPoor cohesionOdd shapes, central nuclei, prominent nucleoliCytoplasm sharply demarcatedKeratin formation

Foreign body reactionLeukocytes are frequently present

Non keratinizing DDX: Metastases

Large cell undifferentiated carcinoma

Lacks features of glandular, squamous, or neuroendocrune

Cellular, large cells singly and clustersNuclear abnormalities Intense mitotic activityNecrosis commonDDX: Poorly differentiated

adenocarcinoma, metastases.

Small cell carcinoma

Oat cell/Intermediate typeHigh cellularityCytoplasm scantyNuclei are stripped of cytoplasmWell preserved nuclei are 2x lymphocytesMitoses rareCrush nuclear material

Ddx: atypical carcinoid, malignant lymphoma (nuclear molding)

Carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements

Carcinomas with spindle and/or giant cells Pleomorphic carcinoma Spindle cell carcinoma Giant cell carcinoma Carcinosarcoma Blastoma (Pulmonary blastoma)

Carcinoids

Kulchitsky cells Sheets of cuboidal or polygonal cells Basophilici cytoplasm Regular, round, and centrally or peripherally

located nuclei Regularly distributed chromatin granules. Small nucleoli No necrosis Single population (unlike small cell)

Salivary gland analogs

Adenoid-cystic carcinomaMucoepidermoid carcinomaOncocytoma

Metastases

Three times more common than primary adenocarcinoma

Common origins are GI, breast, lymphoma/leukemia.

Multiple nodules favor metastatic Review the primary if you can. Cohesive clusters in a clean background

(20% invade locally diathesis)

References:

Demay. The art and science of cytopathology www.cytologystuff.com Cytotechnology online course

http://www.upstate.edu/courseware/cytotech/atlas/

Pulmonary pathology. Leslie, Wick. www.Uptodate.com