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33 Cards in this Set
- Front
- Back
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Soft tissue lesions: what to report
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general category
-histologic subtype or description with differential diagnosis grade (low versus high only, only if tumour type is known) -mitoses (absent vs numerous) -necrosis ancillary study results notes and recommendations |
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Pancreas/biliary tract: how to report
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No standard.
Negative for malignant cells (with note re: possibility of false negative due to sampling) Neoplastic cells present (ie. MCN, IPMN, SPN, PEN), Atypical cells present, Suspicious for malignancy, positive for malignant cells nondiagnostic specimen (acellular or obscured by blood) |
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Indications for renal FNA
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10% of kidney lesions only.
-Radical nephrectomy is contraindicated: probable advanced-stage (unresectable) RCC, possible metastasis to the kidney (e.g., history of lung cancer), patient has coincident medical problems, patient desires an investigational treatment (lesion ablation in vivo) -Radiologic findings are equivocal: atypical cyst, small solid mass (“low-fat” angiomyolipoma versus oncocytoma versus RCC) -a partial nephrectomy is considered: small lesion or young patient, decreased renal function -an infection (pyelonephritis or abscess) is suspected |
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Indications for ovarian FNA
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Done in cases with low-pretest probability, not if any concerning features.
-Confirm benign nature of cyst discovered during pregnancy or infertility w/u -confirm malignancy in a patient with an inoperable pelvic mass -confirm recurrence of an ovarian tumor treated conservatively -drain a tubo-ovarian abscess Contraindication: acute abdominal/pelvic pain (mask tortion or PID/TOA) |
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Characteristics of normal hepatocytes
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-large polygonal cells
-isolated cells, thin ribbons (trabeculae), or tissue fragments -centrally placed, round to oval, and variably sized nucleus -commonly binucleated -prominent nucleolus -intranuclear pseudoinclusions -abundant granular cytoplasm pigments: lipofuscin (golden with the Papanicolaou stain and green-brown with a Romanowsky-type stain); hemosiderin (less common: when present in large quantities it suggests a disorder of iron metabolism): dark brown with the Papanicolaou stain and blue with a Romanowsky-type stain; bile (seen in cholestasis): dark green with both Papanicolaou and Romanowsky stains |
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Normal CSF elements
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common: lymphs, monocytes
rare: choroid plexus, ependymal cells, germinal matrix (usually only neonates), chondrocytes, bone marrow elements (<1%), brain fragments (ventricular sample only) contamination: pmns, rbcs, other lymphs |
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Differential for CSF macrophages, plasma cells, eosinophils and neutrophils
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Macrophages: meningitis, SAH, IVH, cerebral infarction, post-treatment inflammation, MS
Plasma cells: viral meningitis (ie. enterovirus, HIV), Lyme disease, TB, cysticercosis, syphilis, MS Neutrophils: contamination, acute bacterial meningitis, CMV radiculopathy (AIDS patient), toxoplasma meningoencephalitis, viral meningitis (early stage) Eosinophils: parasites (ex. Taenia solium, Angiostrongylus cantonensis), Coccidioides immitis, VP shunt, RMS fever |
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Causes of aseptic meningitis
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Viruses: HIV (Mollaret type), VZV, arboviruses, arenaviruses (lymphocytic choriomeningitis), enteroviruses
Bacteria: Borrelia (Lyme disease), syphillis, TB, ehrlichiosis, mycoplasma Fungi: crypto, histo, coccidiodes Systemic diseases: sarcoid, Behcet disease Other: drugs, vaccines, parainfectious syndrome, vasculitis |
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Most common source of malignant cells in CSF
Most common source for unknown primary presenting in CSF |
Most common: lung, breast, melanoma, lymphoma, leukaemia
Most common with unknown primary: lung>>stomach, melanoma, lymphoma, CNS (breast rarely occult) CNS tumours only 6% of +ve CSF |
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Sensitivity, specificity, adequacy: sputum
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42% sens to 91% (1 to 5 specimens); PPV 100% (specificity high), NPV 15%. 46-77% if central, 31-47% if peripheral.
Sensitivity independent of tumour stage/type DDT for homogenization increases sensitivity Tumour typing accuracy 75-80%. Adequate: multiple pulmonary macrophages |
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Fibrocystic changes
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Non-proliferative: apocrine cells, foam cells, small ductal cells
Proliferative FCC (no atypia): sheets and tight clusters of cells without significant nuclear overlap, regular cellular spacing, finely granular chromatin pattern, inconspicuous to small nucleus |
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Pleomorphic adenoma
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2/3rds of parotid tumours, 50% of salivary gland tumours. Painless aspiration.
Epithelial cells - groupings, honeycomb Myoepithelial cells - spindled (most common), epithelioid, clear cell, plasmacytoid. Fibrillary/ (frayed margins) chondromyxoid matrix material. 2/3rds of cases components easily recognized. Cylindromatous areas in 5% (if more think adenoid cystic). Mild atypia in 20% (if lots, necrosis, mitoses think carcinoma-ex). Squamous, mucinous metaplasia focal only (think mucoep if extensive) |
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Myoepithelioma
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Similar natural history to PA. Rare, monomorphic variant of PA. Clinically same as PA.
No epithelial cells or matrix material. Only myoepithelial cells. (may be sampling error) DDx Schwannoma. Ancillary: p63 (also stains epidermoid cells of mucoep) S100 often+ in myoepithelioma Clear cell change, plasmacytoid Myoepithelial carcinoma general malignant features. |
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Basal cell adenoma
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Most often in parotid. Clinically mimicks PA.
Small and medium sized basaloid cells (2 distinct populations) with palisading. Dense non-fibrillary matrix at edge of groups. Bare nuclei can be abundant. Small globules/cylinders of hyaline material (non-specific) Histologic patterns are variable: solid, cystic, membranous (dermal analog tumour), trabecular and mixed |
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Dermal analogue tumour (membranous basal cell adenoma)
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Distinct clinically/cytologically. Dense peripheral band of hyaline material around cell groups. Sparse intercellular hyaline material. Not fibrillary like PA.
Coalescing spheres of matrix material prominent. Identical to dermal cylindroma. Looks like basaloid SCC (but this has more high grade features, often HPV+) |
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Differential for basaloid salivary gland lesions
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Chronic sialadenitis (sparsely cellular, chronic inflammation, diffuse process)
Basal cell adenoma (?squamous whorls) Basal cell adenocarcinoma Adenoid cystic carcinoma (solid variant) - never have squamous differentiation Cellular PA Small cell carcinoma metastatic basal-like SCC, basal cell carcinoma Frozen section can help guide extent of surgery |
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Warthin tumour
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Mostly in parotid/periparotid regions. Thought to be salivary gland remnants trapped within intraparotid lymph nodes. Second most common salivary tumour, 5-10% of all salivary gland tumours. Most often in 50-79 age range. M>F. Doughy on palpation, thick brown-green "dirty motor oil" fluid on aspiration.
Lymphocytes (most), oncocytes, granular debris. Also mast cells (giemsa) Infrequently papillary groups Nuclear enlargement/nucleoli ok in these lesions DDx: oncocytoma, acinic cell carcinoma, metastatic RCC. Can see squamous/mucinous metaplasia if inflammed. |
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Oncocytoma
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Rare, benign 1-3% of salivary tumours. Discrete, clinically detectable nodule. At least partial fibrous capsule, well demarcated. Most in parotid. Rare<50 years.
Cellular, clean background, oncocytes, no lymphocytes. No mitoses. Oncocytes have small, centrally placed, round nuclei. |
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Differential diagnosis of oncocytic lesion, salivary gland
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Oncocytoma, Warthin tumour, oncocytosis, PA, mucoepidermoid carcinoma (oncocytic variant), acinic cell carcinoma, oncocytic carcinoma, metastatic RCC
DDX ancillary: PAS-D (+acinic cell), PTAH (+oncocytoma) |
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Acute sialadenitis
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Rarely aspirated, usually clinically suspected, infection secondary to second impaction. Ill-defined, not discrete mass.
Neutrophils, necrotic debris, stone fragments, scant ductal cells. Hypocellularity and no atypia rules out neoplasm. Send portion for microbiology |
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Chronic sialadenitis
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Often submandibular gland, discrete mass. Etiologies radiation or stone.
Scant cellularity, Small sheets and tubules of basaloid ductal cells with sharp borders, paucity of acinar elements, blood, proteinaceous debris, mature lymphocytes, Fragments of fibrous tissue Kuttner tumour (chronic sclerosing sialadenitis) looks the same. DDx: normal (more acinar), lymphoepithelial sialadenitis (LE islands, germinal center fragments), Warthin tumour (has cohesive groups of oncocytes), basaloid tumours, mucoepidermoid carcinoma (mature squamous, mucocytes absent), SCC (more cellular, atypical, isolated epithelial cells) |
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Sialadenosis
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Bilateral, non-inflammatory enlargement. Causes: endocrine abnormalities (DM), nutritional deficiencies, alcoholism, cirrhosis, drugs (anti-hypertensives).
Hypertrophy of acinar cells (upto 100um in size). Exclude mass lesion clinically. |
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Lymphoepithelial sialadenitis
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MESA, BLEL, Mikulicz disease all names for it preferred term is lymphoepithelial sialadenitis (LESA). Women, bilateral diffuse enlargement, usually parotid. All patients with Sjogrens, but only 50% of LESA is in patients with Sjogrens.
Cellular, mixed lymphoid population lymphocytes, plasma cells, tingible body macrophages, germinal center fragments, LE islands. Acinar cells rarely present. Often reactive and squamous metaplastic changes. DDx: chronic sialadenitis, (less cellular, no LE islands), simple lymphoepithelial cyst, HIV-associated cystic lesions (similar), Warthin tumour (oncocytes), MALT lymphoma - monomorphic/atypical lymphoid population (flow/PCR) |
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Non-neoplastic salivary cysts: squamous lined
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5% of salivary FNAs. squamous lined (simple LE cyst (unilateral/solitary), HIV (multiple/bilateral)/sjogrens-associated, congenital branchial cleft or dermoid cysts).
-cellular, histiocytes, keratin debris and anucleate squamous, small clusters of squamous cells, mixed population of lymphocytes, +/-germinal center fragments, no LE islands (unless cystic LESA or HIV-cystic lesion). Ddx: pure lymphoid lesions, cystic salivary neoplasms, cystic metastatic SCC |
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Non-neoplastic salivary cysts: mucin-containing
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Included mucocele/mucous retension cyst (submandibular/sublingual > parotid) - both from obstruction, mucocele is pseudocyst.
Sparsely cellular, extracellular mucin, histiocytes, amylase crystalloids, scattered lymphocytes. Occasional metaplastic epithelial cells, normal elements. Also includes mucoepidermoid ca (residual mass after aspiration, greater cellularity, atypia, occasional clusters of intermediate and epidermoid cells), chronic sialadenitis with metaplasia (ciliated columnar cells). |
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Amyloidosis - salivary
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CR + extracellular homogenous material. Hypocellular, scant or absent acinar cells and scattered groups of ductal cells. Focal or diffuse gland enlargement.
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Radiation effects - salivary gland
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Usually effects submandibular gland (radiation for oral SCC). Hard, firm mass-like lesion. Acinar atrophy, squamous metaplasia, chronic inflammation.
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Mucoepidermoid carcinoma
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Most common salivary malignancy. Low grade more cystic, high grade more solid. Treatment much different depending on grade.
Mucus cells (more in low-grade), epidermoid cells, intermiediate cells (like immature squamous metaplastic cells), extracellular mucin, overt malignant (in high-grade). Often clear cells present. Oncocytic change possible. Combined mucous and squamous features in one cell diagnostic. DDX (low grade): acquired mucin cyst, chronic sialadenitis with mucinous metaplasia of ducts, Warthin tumour, PA DDX (high grade): ca. ex-PA, salivary duct carcinoma (necrosis, papillary), oncocytic ca., metastatic ca (history, lots of keratinization). (mucicarmine helpful). |
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Acinic cell carcinoma
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Second most common salivary malignancy. Upto 17% of malignant tumours. 4-6% of neoplasms. Low-grade, recur locally. Most in parotid, women. Broad age, mean 44. Circumscribed, mobile, slowly growing.
cellular smear with serous-type acinar cells: -sheets, crowded clusters, isolated cells -large polygonal cells, abundant vacuolated cytoplasm -PAS-positive diastase-resistant cytoplasmic zymogen granules -indistinct cell borders -bland nuclei -naked nuclei with or without lymphocytes (10%) DDx: normal salivary gland, sialadenosis, oncocytoma, Warthin tumor, mucoepidermoid carcinoma, sebaceous neoplasms, clear cell neoplasms On cell block, PAS-D+. Richly vascular - often capillaries seen |
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Adenoid cystic carcinoma
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Less common than MEC and acinic cell carcinoma, more common in submandibular gland. Long-term survival 10-20years is poor, due to recurrences. Pain during FNA (invasion of nerves).
Variably sized, often large, three-dimensional, acellular hyaline matrix globules and linear branching structures matrix is acellular with sharp borders basaloid cells numerous basaloid cells (± atypia) and scant matrix (solid variant) DDx: pleomorphic adenoma, other basaloid neoplasms, polymorphous low-grade adenocarcinoma, epithelial-myoepithelial carcinoma, eccrine cylindroma of the skin |
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Clear cell sarcoma (malignant melanoma of soft parts)
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<1% of soft tissue neoplasms. melanocytic differentiation. 20-40year olds. deep extremities, slow growing often painful. Fascia, tendons or aponeuroses. Usually <5cm, Recurrences common if no amputation.
-dispersed round, polygonal, or spindle-shaped cells -prominent nucleolus -moderate to highly cellular, clean background -binucleation -no necrosis -“wreath-like” multinucleated giant cells -intranuclear cytoplasmic pseudoinclusions -clear to pale staining cytoplasm |
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Gastrointestinal stromal tumour (GIST)
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generallly cellular
irregularly outlined clusters of cells spindle-shaped or epithelioid wispy cytoplasm with long extensions, often loose cytoplasm mitoses, necrosis (occasionally). FNA preferred method of sampling. **not finished. |
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Bethesda system: thyroid (2009)
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1. ND/UNS (incl CFO)
2. Benign (consistent with BFN, Hashimotos, granulomatous thyroiditis, other) 3. AUS/FLUS (<7% of results, see book for scenarios) 4. Suspicious for follicular neoplasm (specify if Hurthle cell type) 5. Suspicious for malignancy (PTC, medullary, lymphoma, etc.) 6. Malignant |
