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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

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THANK YOU