cytology

pancreas
• EUS-FNA has rapidly become the diagnostic modality of choice in the evaluation of
pancreatic lesions.
• The sensitivity and specificity of EUS-FNA in the detection of pancreatic carcinoma
has been reported as up to 93% and 100%, respectively.

• EUS-FNA allows for highly sensitive and detailed ultrasound evaluation of pancreatic
lesions, which is more accurate in the staging of pancreatic cancer than computed
tomography (CT), magnetic resonance imaging (MRI), or transabdominal ultrasound

• In addition, during EUS evaluation of a pancreatic mass, FNA can be performed with
minimal risk of complications and allows definitive diagnosis for further treatment.

• EUS-FNA can be performed under light sedation rather than full anesthesia.

• The addition of rapid on-site evaluation by cytopathologists at the time of EUS-FNA

has made this modality even more sensitive and specific, and also can further reduce
the risk of complications by reducing the number of passes needed for a diagnosis.
• The diagnosis of serous cystadenoma of the pancreas requires correlation of cytologic, clinical,
and radiologic features.

• Aspirate smears of serous cystadenomas usually contain histiocytes and no or very little
epithelium, which, when present, appears as bland cuboidal cells with clear cytoplasm.
• Background debris and inflammation are not seen, unlike aspirates of chronic
pancreatitis.

• Mucin should be absent,

• carcinoembryonic antigen (CEA) testing of the cyst fluid will usually be extremely low, as
will enzyme levels (such as amylase).

• The radiologic appearance is characteristic, with a spongy appearance and a central scar or
fibrous area.

• Thankfully, nearly all serous cystadenomas of the pancreas are benign.

• Therefore, as the cytologic features of serous cystadenoma are so nonspecific, the primary role
of cytology in the evaluation of these tumors is to exclude a more significant neoplasm,
particularly a mucinous cystic neoplasm.
 Serous cystadenoma
carcinoembryonic antigen (CEA) and amylase are extremely low

Aspirate usually contain Mucin : absent debris and

histiocytes and no or very little inflammation are not
epithelium, which, when present, seen in Background
appears as bland cuboidal cells
with clear cytoplasm.
• Ancillary testing with carcinoembryonic antigen (CEA), amylase, mucin stains, and CA 19-9
has been used to improve the diagnosis of cystic pancreatic lesions on fine-needle aspiration
biopsy.
• This is because almost all mucinous cystic lesions are neoplastic, while the majority of
nonmucinous cystic lesions are benign.

• However, there can be significant cytomorphologic overlap between benign and neoplastic
cystic lesions on fine-needle aspiration biopsy.

• An elevated CEA level (over 192 ng/mL) is nearly always diagnostic of a mucinous
neoplasm, such as mucinous cystic neoplasm or intraductal papillary mucinous neoplasm
(answers C, D, and E).
• The aspirate smears of mucinous neoplasms also typically contain thick visible mucin, which
can be confirmed on mucin stains, and will have elevated CA 19-9 levels. Amylase in these
tumors can be high or low.

• In contrast, pancreatic pseudocysts will have very low CEA levels, and the destruction of
pancreatic tissue results in extremely high levels of amylase (answer A).
• Other tests, including mucin staining and CA 19-9, are usually negative.

• Serous cystadenomas of the pancreas will have very low CEA, amylase, and CA 19-9 levels and
a negative mucin stain (answer B).
• Well-differentiated pancreatic ductal adenocarcinomas can be difficult to distinguish from
reactive ductal atypia.

• Both reactive and neoplastic epithelium will appear cohesive, and can have mitotic figures.
• Reactive epithelium will also retain nuclear polarity and a low nuclear-to-cytoplasmic ratio,.

• but in well-differentiated adenocarcinomas, particularly mucinous adenocarcinomas, the

nuclear-tocytoplasmic ratio can remain low and only minimal loss of polarity may be seen.

• Prominent nucleoli are more typical of reactive changes than adenocarcinoma, which
usually has vesicular nuclei, irregular nuclear contours, and variably sized nucleoli.

• The features that are most specific for malignancy in a pancreatic aspirate sample include
1. irregular nuclear membranes,
2. single atypical cells,
3. anisonucleocytosis (variation in nuclear size), particularly fourfold or more variation in
nuclear size within a group.
• Distinction of an intraductal papillary mucinous neoplasm (IPMN) from a mucinous cystic neoplasm
(MCN) requires careful clinical and radiologic correlation in addition to cytologic examination of
cyst fluid.

• This is because aspirates of IPMN and MCN can be nearly indistinguishable by cytomorphologic features
alone.

• Both can show abundant extracellular mucin, cyst contents, and mucinous epithelium that can range from
normal appearing to overtly malignant.

• IPMNs will usually have more viscous, thick mucin than MCNs, but that distinction can be difficult to
make on aspirate smears.

• In addition, both IPMN and MCN can have highly elevated carcinoembryonic antigen (CEA) levels in the
cyst fluid.
• Elevated CEA levels are almost always present in IPMNs, but there is more variation in MCNs.

• The most common location of IPMNs is the head of the pancreas.

• The most common location of MCNs is the tail of the pancreas.

• Therefore, a pancreatic body tumor does not favor either tumor type.

• The most specific clinical and radiologic finding, which is required for the diagnosis of IPMN, is
connection of the lesion with the main pancreatic duct.

• During endoscopic ultrasound-guided evaluation, this connection (or lack thereof) can usually be
demonstrated.
Tumor cells have round nuclei and
scanty cytoplasm

No evidence of nucleoli
lung
 The major evidence for squamous
differentiation in cytology specimens is
orangeophilic cytoplasm in Pap smears

SQUAMOUS CELL CARCINOMA

Squamous metaplasia in a background of necrosis; pap
 SQUAMOUS CELL CARCINOMA
The major evidence for squamous
differentiation in cytology specimens is
orangeophilic cytoplasm in Pap smears
Minor cytomorphology features are dense
cytoplasm or pale-blue waxy appearance in
Diff-Quik smears

In a Pap smear, orangeophilic, keratinized, and squamous cells with blue waxy dense cytoplasm.
isolated squamous cells in a background of
necrosis
 Lung adenocarcinoma

Specific "drunken honeycomb"-like cell clusters and well-

defined intercellular boarder in Pap smears.
Lymph node
This is granuloma
Thyroid and parathyroid
PTC
If u see
lymphocytes , so this
is warthin
urin
‫مهم جدا‬
IHC
• Modified Ziehl-Neelsen Stain (Wade-Fite Stain): Mycobacterium leprae are much less acid- and
alcohol-fast as compared to mycobacterium tuberculosis.
• The image shows numerous mycobacterium leprae singly and in clusters (globi) with Wade-Fite
stain in skin biopsy of a patient with lepromatous leprosy
Past MCQ:
Special stain for
for TB in
fluorescent?
?
??
skin
Granular
cell tumor
Juvenile xanthogranuloma (JXG)
is a rare, benign proliferative
non-Langerhans cell histiocytic
proliferation.

Histologically characterized by
the presence of histiocytes,
foam cells and Touton giant
cells
Lafora disease:
an inherited, severe form of
progressive myoclonus epilepsy

Distinctive polyglucosans
(abnormal glycogen), also
called Lafora bodies
 Cutaneous mastocytosis

Positive stains
• Toluidine blue and Giemsa
(granules are purple red)

• CD117 / c-kit
 Seborrheic keratosis
• Common, benign keratinocyte proliferation of middle aged and elderly
• Seborrheic keratosis is a benign keratinocyte proliferation that lacks atypia
and dysplasia.

Essential features
• Benign
• Clinical: waxy, brown slow growing papule
• Histologic:
– Proliferation of basaloid keratinocytes without atypia
– Acanthosis and hyperkeratosis most often with horn pseudocys

Q: Sudden eruption of seborrheic keratosis on the trunk should prompt which clinical
response?
Evaluation for underlying colonic carcinoma
Vacuolar degeneration of the
basal cell laye

dyskeratotic keratinocytes
Microscopic features of discoid
lupus erythematous include :

epidermal atrophy,

effacement of rete ridges,

hyperparakeratosis,

follicular keratotic plugging and

basement membrane thickening
with

vacuolar interface change and

keratinocyte apoptosis
Essential features:

•Numerous stromal eosinophils and

lymphoid reaction with follicles in most
cases

•Most frequent sites are head and distal

extremities

•All cases show diffuse strong

expression of vascular markers
 CK20: (classic dot-like
paranuclear pattern)

CM2B4 is a monoclonal antibody that detects Merkel

cell polyomavirus (MCPyV) large T antigen expression
in MCC
Merkel cell carcinoma (MCC)
is an uncommon and highly
aggressive primary cutaneous
neuroendocrine carcinoma

TX:Emergence of immune
checkpoint blockade therapy,
targeting PDL1 / PD1
pathway, for advanced disease

CM2B4 is a monoclonal
antibody that detects Merkel
cell polyomavirus (MCPyV)
large T antigen expression
in Merkel cell carcinoma

Nuclear pattern of CM2B4

immunoreactivity in MCC
indicates MCPyV large T
antigen expression (virus
positivity)
‫سؤال مهم و مكرر‬
‫سؤال مهم و مكرر‬
‫سؤال مهم و مكرر‬
 Balloon cell melanoma
• Balloon cell melanoma (BCM) is a rare variant of melanoma in which the tumor
cells have abundant clear or eosinophilic granular cytoplasm causing ballooning of
cells.

• The tumor cells contain PAS+ diastase-resistant granules which are composed
of ribonucleoprotein.

• They result either from abnormal metabolism of melanosomes or due to

melanosome degeneration.

• HMB-45 and S-100 protein are generally positive.

• The poor prognosis usually seen with BCM is related to tumor depth at the time of
presentation.
Balloon cell melanoma
This is angiofibroma
Heart
 PAST MCQs:
• Case of rheumatic fever in child, death 3 days after the onset of the
disease, systolic murmur is heard in examination, what is the cause of
death?
Rupture of chorda tinda

• A case of right side valve and right sub-endocardial plaques?

Carcinoid heart syndrome

• Young age , sudden death , biopsy show replacement of right ventricle

by fat , what is the cause?
genetic
Soft tissue
CNS
 cerebral malaria

Histology of a brain from a patient with cerebral malaria showing sequestration of

parasites, pigmentation and obstruction of blood vessels

Microscopically, the cerebral capillaries are dilated and congested with pale-stained red blood
cells which contain discrete tiny dark brown pigments .
 Key words:
African man + Febrile illness
= Malaria
 The fat embolism syndrome

Oil Red O stain showing lipid

Microhemorrhages around
globules in capillaries
occluded capillaries
 Subarachnoid Hemorrhage

Subarachnoid Hemorrhage Related to Ruptured Berry

Aneurysm
large pontine hemorrhage with extensio
n into ventricle
.
Hemorrhage within the brain parenchyma-

In hemorrhage, the primary event is the disruption of the integrity of the wall of a blood vessel, followed by bleeding into the brain.
This is in contrast to hemorrhagic infarction, in which the primary event is infarction of neural tissue, followed by hemorrhage into the
infarcted tissue.

Hypertensive hemorrhage is by far the most common cause of spontaneous hemorrhage within the brain parenchyma and
follows the distribution of hypertensive arteriopathy (changes in the blood vessels due to hypertension), occurring most frequently in
the basal ganglia, pons and cerebellum.

Here are examples of hypertensive hemorrhages:

putamenal hemorrhage extending into thalamus with midline shift,
acute basal ganglia hemorrhage with rupture into the ventricular system,
acute pontine hemorrhage with rupture into fourth ventricle,
large pontine hemorrhage with extension into ventricle.
Cerebral hemorrhage is usually caused by rupture of a small vessel in the
parenchyma.
Hyaline changes in the vessel wall predispose to rupture in the
hypertensive patient.
 Cerebral
contusion
Focal demyelination in a patient with multiple sclerosis
(MS)
systemic amyloidosis
 Associated with
infantile
polycystic kidney
disease