Cytopathology Challenge Weekly Cases

1. Cytopathology Challenge Weekly Cases July 21, 2008

2. 32 year old female. Thin prep pap A) Reactive endocervical cells B) HSIL C) LSIL D) Squamous metaplasia E) ASCUS 1

3. 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 • Normal lymphoid tissue • Metastatic squamous cell carcinoma • Metastatic papillary thyroid carcinoma • Lymphoma • Metastatic medullary carcinoma of the thyroid 2

4. 24 year old female. Thin prep pap A) Squamous metaplasia B) Negative for intraepithelial lesion C) HSIL D) ASCUS E) LSIL 3

5. 49 y/o male with corneal ulcer. History of “getting something in his eye” while doing yard work. Corneal scrape • Aspergillus • Candida • Mucormucosis • Fusarium • Pseudallescheria 4

6. 26 year old female. Thin Prep Pap • Leptothrix • Trichomonas • Candida • Actinomyces • No organisms present 5

7. 65 year old male with hematuria. Bladder washing A. BK virus effect B. High grade TCC C. Instrument effect D. Low grade TCC E. Squamous cell carcinoma 6

8. 36 year old female. Thin prep pap. • Squamous metaplasia • HSIL • Endocervical cells • LSIL • ASCUS 7

9. 50 year old male with neck mass. By examination the nodule felt like a lymph node. FNA aspirate – pap stain • Positive for tumor • Atypical • Reactive • Normal lymphocytes • Normal histiocytes 8

10. 55 year old male with LLL mass. Pleural fluid. • Non-small cell lung carcinoma • Bronchoalveolar carcinoma • CMV • Granulomatous changes • Benign mesothelial cells 9

11. 60 year old with pancreatic mass. FNA. • Reactive • Positive for tumor • Send for flow • Atypical • Artifact 10

12. Answers • B HSIL • 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! • C Metastatic papillary carcinoma • 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 your differential. • E LSIL (Low grade squamous intraepithelial lesion) • Cells with enlarged nuclei (> 3x that of a normal intermediate cell), coarsely granular chromatin and koilocytosis ( perinuclear halo). • D Fusarium • 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 common cause of keratomycosis. Remember you must be able to identify organisms from a fungal culture on the boards!! • B Trichomonas • Those tricky trich!! There are 4 of them around the cell on the left. • B High grade TCC • High NC ratio, irregular nuclei, clumpy chromatin • A Squamous metaplasia • 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 borders of these cells are sharply defined; their cytoplasm often looks “spidery” (especially on conventional paps)

13. 8. A Positive for tumor • Note the pleomorphism, high N:C ratio of some cells along with the clumpy chromatin. This was actually a metastatic melanoma. Melanin pigment is present in most of the cells. 9. E Benign mesothelial cells • Mesothelial cells can look like anything!! They can often look very ugly when they get reactive. These cells have classic features of the “ruffled skirt” (see in the left picture) and the mesothelial “window” seen in the right picture 10. B Positive for tumor • Once again, note the crowding of cells, different sizes/shapes of nuclei, irregular nuclear membranes. This is most likely a pancreatic ductal adenocarcinoma, especially with the mucin vacuoles present (though a mucinous cystadenocarcinoma cannot be ruled out if this was a cystic lesion)