Color Atlas of Differential Diagnosis in Exfoliative and Aspiration Cytopathology 2nd Edition

COLOR ATLAS OF
DIFFERENTIAL DIAGNOSIS
IN EXFOLIATIVE AND ASPIRATION
CYTOPATHOLOGY
Second Edition
COLOR ATLAS OF
CYTOPATHOLOGY
Second Edition
SUDHA R. KINI
Division of Cytopathology
Department of Pathology
Henry Ford Hospital
Detroit, Michigan
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9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Kini, Sudha R.
Color atlas of differential diagnosis in exfoliative and aspiration cytopathology / Sudha R. Kini. – 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60831-275-7 (alk. paper)
1. Cytodiagnosis–Atlases. 2. Pathology, Cellular–Atlases. 3. Diagnosis, Differential–Atlases.
I. Kini, Sudha R. II. Title.
[DNLM: 1. Cytodiagnosis–methods–Atlases. 2. Diagnosis, Differential–Atlases. QY 17]
RB43.K54 2011
616.07⬘582–dc22
2011004727
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THIS BOOK IS DEDICATED TO
MAYA, RIA, RAHUL, AND RISHI
AND
TO THE LOVING MEMORIES
OF MY LATE HUSBAND RATNAKAR KINI, MD
Contributors
Dhananjay Chitale, MD Mariza de Peralta-Venturina, MD

Division Head, Molecular Pathology Department of Anatomic Pathology and
Department of Pathology Laboratory Medicine
Henry Ford Hospital Cedars-Sinai Medical Center
Detroit, Michigan Los Angeles, California
Chapter 1 Chapters 9 and 20
Kedar Inamdar, MD, PhD Aditya Raghunathan, MD, MPH

Division Head, Hematopathology Fellow, Neuropathology
Department of Pathology Department of Pathology
Henry Ford Hospital The Methodist Hospital
Detroit, Michigan Houston, Texas
Chapter 14 Chapter 23
vi
Preface
This long overdue second edition of the Differential Di- aspirates. Therefore, I felt it necessary to retain these top-
agnosis in Exfoliative and Aspiration Cytopathology is ics in the second edition.
presented 13 years following the publication of the first The overwhelming success of aspiration cytology in
edition in 1998. The last 13 years have witnessed an ex- the seventies and eighties established its dominance in the
plosion of advances in every fi eld of medicine, including field of cytopathology. However, to the disappointment of
our own speciality of cytopathology. The changes have many cytopathologists (including myself), the introduc-
been rapid, progressive, evolving, and have had consider- tion of newer core biopsy needles and techniques resulted
able impact on how we practice cytopathology. Incorpo- in a trend away from aspiration cytology as a diagnostic
rating these changes in this second edition was indeed a tool, for example, prostate, kidney, liver, and pancreas
very diffi cult task. Through the gracious help provided (until recently). Fine needle biopsies of the breast le-
by Drs. Dhananjay Chitale, Kedar Inamdar, Mariza de- sions followed the suit. The transition was more notable
Peralta Venturina, and Aditya Raghunathan, I was able to in large medical centers, as the surgeons preferred core
tackle this seemingly insurmountable task. needle biopsies, leading to the demise of breast fine nee-
I have followed the same format as before with an em- dle aspiration (FNA) specimens. Once again, this trend
phasis on differential diagnostic problems. The number of did not apply to clinicians in private practice setup who
chapters has remained the same; however, the text is ex- continue to perform aspiration biopsies of the breast
panded with more tables. I offer many thanks to the pub- lesions.
lisher, for allowing a substantial increase in the number of After a decline for several years, pancreatic FNA and
images. Also, this second edition now includes integration biliary tract brushings have made a comeback, thanks to
of images and explanatory legends with the text. Further- EUS-guided aspiration biopsy procedures. The pancre-
more, additional images are also available online. I would atic FNA under EUS guidance is now emerging as a new
have preferred to illustrate the histopathologic changes unique discipline with improved visualization, character-
for every diagnostic category in this atlas. However, it was ization, and sample acquisition. The same technology is
not a practical option. extended to endobronchial biopsies.
In keeping with the current trends in the practice of cy- I have chosen to expand “Diffuse Neuroendocrine
topathology and their utilization by our clinical colleagues, System and Neoplasia” and “Malignant Melanoma,”
the discipline of gynecologic cytopathology deserves spe- Chapters 10 and 11, respectively. The documentation of
cial note for the considerable changes it has undergone cytopathologic features of the vast spectrum of various
over the years: liquid-based cytology collection methods neuroendocrine tumors in the literature is very lean, let
and interpretation, human papilloma virus (HPV) detec- alone their illustrations. These tumors are considered in
tion, evolving guidelines for cervical cancer screening, and differential diagnosis at every site and deserve special at-
forms of automation in screening gynecologic specimens tention. Same holds true for malignant melanomas.
to name a few. Also, liquid-based cytopathology is fast I have devoted considerable attention to the “Central
becoming a popular processing technique in nongyne- Nervous System,” Chapter 23, for the benefit of those
cologic as well as aspiration cytopathology. Endoscopic pathologists/cytopathologists who do not have the luxury
ultrasound (EUS) guided biopsies and ancillary immunos- of working with neuropathologists. I have also expand-
taining and molecular/cytogenetic testings have had a sig- ed the Chapter on salivary gland lesions. This is a com-
nificant impact on the practice of cytopathology. plicated and diffi cult area that has been less effectively
There has been a gradual shift from certain diagnostic addressed and illustrated in the literature. I do hope the
procedures and application of cytopathology services. For improved and increased numbers of tables, comparisons,
example, over the last three decades, gastric and esopha- explanations, and illustrations will be helpful.
geal cytology brushings have been reduced in number or Finally, of special note, the cytopathology of thyroid
eliminated altogether in major medical centers. However, nodules has perpetually resulted in several problems,
these procedures are still being performed in the private many of which stem from inconsistencies in reporting
practice setting, and cytopathologic evaluation is still cytologic interpretations, and subsequent patient man-
being requested. I realized this when our health system agement problems. The new Bethesda system of report-
began to accept work from private physicians. Same ing thyroid aspirates, sponsored by the National Cancer
scenario can be described for specimens such as sputum, Institute (NCI), is aimed at simplifying the reporting for-
nipple discharges (secretions), and breast and ovarian cyst mat, which is discussed in details in Chapter 13.
vii
viii Preface
I reiterate my continued preference for the cytoprepa- compliment the cytopathology technical staff at Henry
ration with conventional methods, wet fixation with ethyl Ford Hospital for providing the excellent final products.
alcohol (spray fixative) and Papanicolaou stain. I have at- I was not quite prepared to illustrate the many diag-
tempted to present summaries of conventional cytoprepa- nostic entities in gynecologic cytopathology, processed
ratory techniques for specimens from body cavity fluids, with liquid-based technology, as the technique was
respiratory system, urinary system, and central nervous only recently introduced in our laboratory and I sorely
system. Training in gynecologic cytopathology, utilizing lacked the necessary images. I am indebted to Ms. Karen
actual glass slides, is the foundation for acquiring the Atkinson and Mr. Tim Collins of BD Diagnostics, Bur-
necessary skills required within the entire field of cytopa- lington, NC 27215, for allowing me to use many ex-
thology. Conventional cytopathology with Papanicolaou amples from their files.
staining is certainly a right way to master the discipline. All along I never let myself forget the fact that this atlas
The images in this book reflect my philosophy. of differential diagnosis is presented as a guide to all who
I have always said that the success of an atlas is very practice cytopathology while dealing with diagnostic dif-
much dependant on the quality of photographs. As in fi culties. It is not intended to be a comprehensive text in
the past, the principal photographer has been Ms. Jane cytopathology but to serve as a complement to the excel-
Smith Purslow BS, CT (ASCP), CMIAC, to whom I am lent texts available in the market today. I sincerely hope
heavily indebted. Her images are superb, clear, with ex- the second edition will receive the same welcome as the
cellent details. The images will not be of desirable qual- first edition.
ity if the cytologic preparations are substandard. I must Sudha R. Kini, MD
Preface to the First Edition
The concept of this atlas was born and fostered during criteria for “atypical squamous cells of undetermined sig-
my routine microscopy sessions with cytotechnologists, nificance” (ASCUS) as well as for “atypical glandular cells
pathology residents, and cytopathology fellows. After of undetermined signifi cance” (AGUS), including endo-
discussing the criteria for and against diagnoses, these cervical adenocarcinoma in situ. Our diagnostic schema
sessions would often end with encouraging comments, and criteria have produced consistent results in our own
“Dr. Kini, why don’t you put these criteria in a book laboratory and are well accepted by the gynecologists and
form?” What impressed these young minds was the sys- other clinicians in our system.
tematic approach I would use in arriving at a diagno- The diagnostic criteria described in this book are based
sis, the same one used by the late Dr. J.K. Frost, who on Papanicolaou-stained preparations, which I personally
had made a lasting impact on me when I had attended fi nd superior to other stains, especially for bringing out
his postgraduate institute some 20 years ago. I had just nuclear details. The choice of stain is a matter of personal
begun my career as a pathologist with major responsi- preference, based on how comfortable and confident the
bilities in cytopathology. With 2 months of training to pathologist feels in interpreting the cytologic prepara-
my credit during residency, I found the practice of cy- tions. There seems to be a tendency to look down on those
topathology very rough, and felt I lacked the direction who do not use Romanowsky stain for FNA biopsies, and
in handling difficult cases. Dr. Frost’s basic concepts this lack of use is translated as a drawback. The bottom
laid the foundation for my cytopathology practice. He line is to provide an accurate diagnostic impression in the
taught cytopathology as a science, using specific criteria best interest of the patient, regardless of the type of stain
for and against a diagnosis, thus systematically elimi- used. So, based on my own experiences, the majority of
nating all but one possibility. The practice of cytopa- the illustrations in the book are of Papanicolaou-stained
thology became a pleasant task from then on. Over the preparations.
years, the basic concepts helped me immensely when This atlas would not have been possible without the
confronted with problematic cases. I have since used the superb quality of the photomicrographs, for which I am
same teaching format as Dr. Frost, stressing the impor- forever indebted to M. Jane Purslow, Supervisor, Cytopa-
tance of differential diagnostic process and the diagnos- thology Laboratory. Her enthusiasm and relentless energy
tic pitfalls. encouraged me to keep going in times of frustration. The
Finally, when the decision was made to compile an atlas essence of any atlas is the quality of the illustrations, and
of differential diagnosis, the task seemed simple enough. for this the credit goes entirely to Jane.
However, as the work progressed, it mushroomed into a Scanning the images is not an easy task. Reproduction
gigantic project. of images to match the originals has been magnificently
Since differential diagnostic problems can stem from a achieved by my professional colleague Dr. Irving Dardick
wide array of causes, they can be approached from many of Pathology Image Inc., Toronto, Canada. Writing any
different angles which I have attempted to illustrate in kind of book on multiple systems is often a collabora-
this atlas. I have tried to include commonly encountered tive affair. I am grateful to my colleagues for reviewing
problems and I have been liberal with illustrations. How- chapters in the manuscript pertaining to their respective
ever, depicting each and every diagnostic entity is beyond specialties. My sincere thanks to Dr. Richard Zarbo for
the scope of this atlas. salivary gland; Dr. John Carey for lymph nodes; Dr. Usha
The main thrust of this atlas is comparison between Raju for breast; Dr. Mahual Amin for kidney, urinary
different diagnostic entities with cytopathologic findings system, and immunochemistry; Dr. Min Lee for electron
summarized in tabulated forms. It is hoped that this for- microscopy; and Dr. Amy Lynn for concepts in cytopa-
mat will offer valuable information at a glance and aid in thology. I am especially thankful to Dr. Dario Caccamo
problem solving. for contributing the chapter on the central nervous
My approach to gynecologic cytopathology is some- system.
what different than the recommended “The Bethesda I am also very grateful to Susan Dingler, Education Co-
System” (TBS) format in some respects, especially in the ordinator, of the Henry Ford Hospital School of Cytotech-
use of “ungraded squamous intraepithelial lesion” and nology, for her invaluable suggestions in the best interest
ix
x Preface to the First Edition
of the cytotechnology students. The continuous support This atlas of differential diagnosis is presented as a
of the entire cytopathology staff has been overwhelming. guide to all who practice cytopathology. It is not intended
Typing the manuscript with more than 250 tables was to be a comprehensive text in this specialty but to serve
not an easy endeavor by any means. My secretary, Linda as a compliment to the excellent texts on cytopathology
Brandt, spent hour after hour at the computer, cheerfully available in the market today. I sincerely hope it will be a
making revision after revision. To her I offer my heartfelt very useful addition.
and sincere thanks. Sudha R. Kini, MD
Acknowledgments
My sincere thanks to the following professional colleagues Dr. Nina Durandher, formerly from the Department
from within the United States and internationally, for gra- of Pathology, Tulane University Medical Center, New
ciously providing the images at my request: Orleans, LA, for Figures 15.66A–D.
Dr. Catherine S. Abendroth, Hershey Medical Center, Dr. Henry F. Frierson, University of Virginia Medical Cen-
Hershey, Pennsylvania, for Figures 15.55A and B; Figures ter, Charlottesville, Virginia, for Figures 15.171A–C.
24.2A and B.
Reně Gerhard, MD, Department of Pathology, Hospital
Dr. Syed Z. Ali, Department of Pathology, Johns Hopkins das Clinicas, University of Sao Paulo, SP, Brazil, for Figure
Hospital, Baltimore, Maryland, for Figure 15.149C. 13.100B.
Ms. Karen Atkinson, MPA, CT(ASCP), CMIAC, Director Michael Glant, MD, Director, Diagnostic Cytology Clinic,
of Education and Training, BD Diagnostics—Women’s Indianapolis, Indiana, for Figures 13.140A–C.
Health and Cancer, and Mr. Tim Collins, BS, CT(ASCP),
Senior Scientist, Research and Development, BD Diag- John F. Goellner, MD, Previously of Department of Pa-
nostics—Women’s Health and Cancer, Burlington, North thology, Mayo Clinic Rochester, Minnesota, for Figure
Carolina, for the following figures: 13.117.
Figures 2.4, 2.6C, 2.7C, 2.9E, 2.11A, and 2.11B;
Dr. Prabodh Gupta, Director, Cytopathology, University
e-Figures 2.2B, 2.4B, 2.5B and C; Figures 2.8B, 2.9B,
of Pennsylvania, Philadelphia, Pennsylvania, for Figures
2.15B, 2.17, 2.18, 2.20A, and 2.20B; Figures 3.3A,
6.10A and B, 6.39A and B, e-Figure 6.15.
3.5A, 3.6, 3.10, 3.15A–C, 3.19A–C, 3.23, 3.28,
3.29, 3.32, 3.41B, 3.42A and B, 3.44A–C, 3.45A and
Hitoshi Hara, Pathology Division, Yamanashi Central
B, 3.48A and B, 3.53, 3.64D–F, 3.71, 3.89A and B,
Hospital, 1-1-1 Fujimi, Kofu, Yamanashi, 400 Japan, for
3.98A–G; Figures 4.3A and B, 4.4A and B, 4.6B, 4.8,
Figure 15.43.
4.9, 4.14, 4.21, 4.23C, 4.40C, 4.40D, 4.45A–C, 4.46A
and B, 4.49A and B, 4.50, 4.51A–D, 4.65, 4.67, 4.70A
Dr. Eiji Katsuyama, The Department of Pathology Medi-
and B; e-Figures 4.2A, 4.2B; e-Figures 4.4A and B, 4.6;
cine, Kyoto City Hospital, Kyoto, Japan, for Figures 15.53A
e-Figure 5.9C.
and B.
Mithra Baliga, MD, University of Mississippi, Jackson,
Mississippi, for Figures 13.16A; 13.91A–E; 13.36A; Fig- Dr. Y.T. Kaw, Quest Laboratories, Providence, Rhode
ures 15.149A and B; Figure 21.11A–E. Island, for Figures 7.44A, B, and D.
Dr. B. Chandralekha, Regional Cancer Center, Trivan- Dr. E. Kawhara, Department of Pathology, Kanazawa
drum, Kerala, India, for Figure 7.50. University School of Medicine, Kanazawa, Japan, for Fig-
ures 7.51A and B.
The Department of Pathology, Ottawa Civic Hospital,
Ottawa, Ontario, Canada, for Figures 15.175A and B, Dr. Lzler Kern, Lijiebijana, Slovenia, for e-Figures
Figures 15.178A–C. 7.34A–C.
The Department of Pathology, Ottawa General Hospital, Dr. Claire W. Michael, University of Michigan Health
Ottawa, Ontario, Canada, for Figures 15.62A and B; Fig- System, Ann Arbor, Michigan, for Figures 13.2D; 13.4C;
ures 15.63A and B; Figures 15.64A and B. 13.16B and C; 13.22B; 13.33C; 13.36B; 13.49C; 13.91F.
Dr. Mariza de Peralta-Venturina, Cedar-Sinai Hospital, Dr. Bernard Naylor, Emeritus Professor of Pathology, Uni-
Los Angeles, California, for Figures 2.18A–D; e-Figures versity of Michigan Medical School, Ann Arbor, Michi-
4.13A–D; e-Figures 7.35A and B; Figures 13.2C; 13.6A gan, for Figures 7.98, e-Figures 7.6B; 7.37A and B; 7.38A
and B; 13.19; 13.31A–D; 13.45I; 13.50F; 13.70A–70C. and B; 7.39A and B.
xi
xii Acknowledgments
WK Ng, MD, Department of Pathology, Queen Mary Special thanks are due to Ms. Riva Sayegh-McCullen for
Hospital, Hong Kong, for Figure 13.100A. her expertise and patience.
Dr. Roberta Nieberg, Midway Hospital Medical Center, Acknowledgements are due for the following copyrighted
Los Angeles, California, for Figures 7.43A, B, and D. material:
Lippincott William & Wilkins, for Figure 9.1
Dr. Lata Pishrodi, Department of Pathology and Labo-
ratory Medicine, Brown University, Providence, Rhode Figure 3.4; Relationship of WHO 1973 to WHO/ISUP
Island, for Figures 15.65A–D. 2004 classifi cation of papillary urothelial tumors.
Epstein JI, Amin M, Reuter V. Bladder Biopsy Interpre-
Dr. William Rafferty, Department of Pathology, Cooper tation, Lippincott Williams & Wilkins, 2004, page 40.
University Hospital, Camden, New Jersey, for Figures
Lippincott William & Wilkins, for Figure 15.38A
15.18A and B.
Martinez-Madrigal F, Bosq J, Casiraghi O. Table
Dr. Michael Stanley, Chief of Pathology, Hennepin County 17.14, Morphology and histologic markers of the
Medical Center, Minneapolis, Minnesota, for e-Figures normal and modifi ed myoepithelial cells, Chapter 17,
7.54A–7.54C. Major Salivary Glands. In: Mills SE, ed. Histology for
Pathologists.
Dr. Kazuo Watanabe, Division of Pathology, Fukushima
Irving Dardick, MD, of Pathology Images, Inc, Ot-
Medical University School of Medicine Hospital, Fuku-
tawa, Ontario, Canada, for majority of the images in
shima City, Japan, for Figures 15.174A–D.
Chapter 15.
Dr. Bigit Waynand, Louvain Medical School, Saint Luc I thank Dr. Dardick for his generosity in granting me
University, Brussels, Belgium, for Figure 7.43C. an unlimited access to all the images from Kini, SR,
Dardick, I. Atlas of Salivary Gland Tumor Cytopathol-
Dr. Shigeo Yokoyarma, Department of Pathology, Oita ogy. CD-ROM-1. Ottawa, Canada, Pathology Images
Medical University, Oita, Japan, for Figures 7.52A–D. Inc, 2006.
Dr. Ghazi Zaafari, Beirut Lebanon, for Figures 7.54A To Springer Science ⫹ Business Media, New York, for
and B. their kind permission to reproduce the following Tables
from Kini SR, Color Atlas of Pulmonary Cytopathology,
I am appreciative of many of my past pathology residents New York, Springer, 2002.
and cytopathology fellows for the digital photography.
Table 4.7: Differential diagnosis of foamy macrophages
I am especially thankful to Drs. Songling Liang, Osama
in respiratory specimens.
Alassi, Kedar Inamdar, Dongping Shi, Ziying Zhang, Oslin
Seglam, Leo Newman, Aditya Raghunathan, Gaurav Table 6.3: Differential diagnosis of well-differentiated
Sharma, Chaksu Gupta, and Shweta Mehera. squamous carcinoma.
Table 7.9: Differential diagnosis of well-to-moderately
I offer my heartfelt gratitude to the following contribu-
differentiated adenocarcinoma and bronchioloalveo-
tors: Dr. Dhananjay Chitale for Chapter 1 and his com-
lar carcinoma.
mentaries on immunohistochemistry and molecular test-
ings in Chapters 7, 10, 13, and 16; Dr. Kedar Inamdar Table 8.8: Differential diagnosis of small cell carcinoma.
for Chapter 14; Dr. Mariza de-Peralta-Venturina for
Table 8.10: Differential diagnosis of small cell carcinoma.
Chapters 9 and 20; and Dr. Aditya Raghunathan for
Chapter 23. Table 9.3: Differential diagnosis of large cell undiffer-
entiated carcinoma.
I am indebted to Ms. Linda Brandt and Ms. Laure Gratopp
To the Armed Forces Institute of Pathology for
for their secretarial assistance and great patience in for-
matting the large numbers of tables. Table 10.1: Lloyd RV, Douglas BR, Young WF. Diffuse
Neuroendocrine System. In: Endocrine Diseases. Atlas
I am grateful to the members of the Department of Art of Nontumor Pathology. Washington, DC. AFIP 2002.
and Photography at Henry Ford Hospital for preparation Reproduced with permission from American Registry
of the image files, including scanning and color correction. of Pathology.
Contents
Contributors vi
Preface vii
Preface to the First Edition ix
Acknowledgments xi
Abbreviations xv
Explanatory Notes xvii
CHAPTER 1 Overview 1
Dhananjay Chitale, Sudha R. Kini
SECTION I: GYNECOLOGIC CYTOPATHOLOGY
CHAPTER 2 General Aspects of Gynecologic Cytopathology, Reporting System,

and Benign Cellular Changes 31
CHAPTER 3 Squamous Lesions 48
CHAPTER 4 Endometrium and Endocervix 94
CHAPTER 5 Miscellaneous 138
SECTION II: NONGYNECOLOGIC CYTOPATHOLOGY
CHAPTER 6 Serous Effusions 149

CHAPTER 7 Respiratory Tract: Exfoliative and Aspiration Cytopathology 191
CHAPTER 8 Alimentary Tract: Esophagus, Gastrointestinal, Gall Bladder
and Extrahepatic Biliary Tract (Exfoliative and Aspiration Cytology) 294
CHAPTER 9 Urinary System 325
Mariza de Peralta-Venturina, Sudha R. Kini
SECTION III: FINE-NEEDLE ASPIRATION CYTOPATHOLOGY
CHAPTER 10 Neuroendocrine System and Neuroendocrine Neoplasia 349

CHAPTER 11 Malignant Melanoma 370
CHAPTER 12 Head and Neck (Miscellaneous) 380
CHAPTER 13 Thyroid and Parathyroid 401
CHAPTER 14 Reactive and Malignant Lymphadenopathies 543
Kedar V. Inamdar, Sudha R. Kini
CHAPTER 15 Salivary Glands 571
xiii
xiv Contents
CHAPTER 16 Breast 688

CHAPTER 17 Mediastinum 731
CHAPTER 18 Liver 749
CHAPTER 19 Pancreas (Exfoliative and Aspiration) 769
CHAPTER 20 Kidney 812
Mariza de Peralta-Venturina, Sudha R. Kini
CHAPTER 21 Adrenal Glands and Retroperitoneum 832
CHAPTER 22 Gonads (Ovaries and Testes) 852
CHAPTER 23 Central Nervous System 870
Aditya Raghunathan, Sudha R. Kini
CHAPTER 24 Soft Tissues and Bones 919
CHAPTER 25 Neoplasms in the Pediatric and Adolescent Age Groups 965
INDEX 989
Abbreviations
ACOG American College of Obstetrics and EM Electron microscopy

Gynecology
ER Estrogen receptor
AFP Alpha fetoprotein
ERCP Endoscopic retrograde
AGC Atypical glandular cells cholangiopancreatography
AIDS Auto immune deficiency syndrome EUS Endoscopic ultrasound
AIS Adenocarcinoma in situ FIGO International Federation of Gynecology and

Obstetrics
APUD Amine precursor uptake and decarboxylation
FISH Florescent in situ hybridization
ARDS Adult respiratory distress syndrome
FNA Fine needle aspiration
ASCCP American Society for Colposcopy and
Cervical Pathology GBM Glioblastoma multiforme
ASC-H Atypical squamous cells, cannot exclude GCT Granulosa cell tumor
high-grade squamous intraepithelial lesion
GI Gastrointestinal
ASC-US Atypical squamous cells of undetermined
significance GIST Gastrointestinal stromal tumor
ASR Arias-Stella reaction H&E Hematoxylin and Eosin
BAC Bronchioloalveolar carcinoma HCC Hepatocellular carcinoma
BAL Bronchoalveolar lavage HIV Human immunodeficiency virus
BCG Bacillus Calmette-Guérin HPV Human papilloma virus
CIN Cervical intraepithelial neoplasia HRT Hormone replacement therapy
CIS Carcinoma in situ HSIL High-grade intraepithelial lesion
CK Cytokeratin IUD Intrauterine device
CNS Central nervous system ISUP International Society of Urologic Pathologists
CSF Cerebrospinal fluid LBP Liquid-bases preparation
CT Computed tomography LCA Leukocyte common antigen
DES Diethylstilbestrol LGNEC Large cell neuroendocrine carcinoma
DSRCT Desmoplastic round mall cell tumor LMP Low malignant potential
EBUS Endoscopic bronchial ultrasound LSIL Low-grade squamous intraepithelial lesion
xv
xvi Abbreviations
LUS Lower uterine segment PTC Papillary thyroid carcinoma
MALT Mucosa-associated lymphoid tissue PUN-LMP Papillary urothelial neoplasm of low

malignant potential
MFH Malignant fibrous histiocytoma
SBT Serous borderline tumor
MGH Microglandular hyperplasia
SCC Squamous cell carcinoma
MI Microinvasive
SD Severe dysplasia
ML Malignant lymphoma
SFT Solitary fibrous tumor
MMMT Malignant mixed Müllerian tumor
SIL Squamous intraepithelial lesion
MPNST Malignant peripheral nerve sheath tumor
SP SurePath
MRI Magnetic resonance imaging
TBS The Bethesda system
NA Not applicable
TCC Transitional cell carcinoma
NHL Non-Hodgkin lymphoma
TIS Transitional cell carcinoma in situ
NOS Not otherwise specified
TM Tubal metaplasia
PAP Papanicolaou
TP Thin-Prep
PAS Periodic acid-Schiff
UPSC Uterine papillary serous carcinoma
PCR Polymerase chain reaction
VAIN Vaginal intraepithelial neoplasia
PET Positron emission tomography
VMA Vanillylmandelic acid
PNET Peripheral neuroectodermal tumor
WHO World Health Organization
PR Progesterone receptor
Explanatory Notes
STAINS MAGNIFICATIONS
Unless otherwise specifi ed, all cytologic preparations are Unless specified, all images are taken at 40⫻ or high power
wet-fi xed by spray fi xative and stained by Papanicolaou (magnification 640⫻). All other magnifications are noted
method. in the legends (low power 4⫻, medium power 10⫻).
Any other stain used is so indicated. All electron photomicrographs are taken on uranyl ac-
etate and lead citrate preparation.
xvii
COLOR ATLAS OF
CYTOPATHOLOGY
Second Edition
1 OVERVIEW
Dhananjay
h j Chi
Chitale
l • SSudha
dh R. Kini
i i
Working up a diffi cult case is very challenging and

INTRODUCTION TO DIFFERENTIAL intellectually stimulating. It is intensely gratifying when
DIAGNOSIS a correct diagnosis is made and humbling when it is
incorrect. Misinterpretations in cytopathologic diagnoses
The term “differential diagnosis” is used when one or are brought to the attention of the cytopathologist via a
more diseases are considered to be diagnostic possibilities cytohistologic correlation—an indispensable exercise that
because of similar or overlapping features that preclude must never be ignored.
a precise diagnosis. The diagnostic process includes the Misinterpreted cases must be reviewed to avoid repeti-
evaluation of pertinent clinical and laboratory data and tions of errors. Such a review is an excellent learning expe-
signifi cant radiologic fi ndings, a review of cytohistologic rience. No one has expressed these sentiments as succinctly
material, and the application of the results of ancillary as Dr. J.G. Azzopardi: “One must be willing, even anxious,
tests to cytohistologic material. A fi nal diagnosis is then to learn from one’s errors. This requires a degree of humil-
rendered by systematically eliminating all possibilities but ity, a readiness to listen to the arguments of others, includ-
one, based on fi ndings that best fi t the diagnostic entity. ing those of one’s juniors and inclination to re-examine
Overlapping features may involve clinical presentation, cases in which a mistaken diagnosis has been made and
laboratory data, radiologic fi ndings, or the morphologic to analyze the reasons for the original mistake, otherwise
characteristics of pathologic material. This atlas particu- there is a grave danger of repeating that same mistake.”
larly focuses on differential diagnoses in cytopathology. Pathologists and cytotechnologists must be familiar
Most of the commonly encountered lesions present typi- with the basic concepts of cytopathology as well as the
cal cytopathologic features that can be easily recognized from common presentations of commonly encountered lesions.
routine preparations. Diagnostic difficulties are faced in situ- A preliminary diagnosis should be made on routinely
ations such as the uncommon presentation of a common le- stained preparations. Ancillary tests should be performed
sion (and vice versa), an inadequate specimen that lacks key only when applicable and with discretion. Most ancil-
criteria, suboptimal cytopreparation, degenerative changes lary tests are performed to type a neoplasm. It is impera-
that alter morphology and simulate neoplasia, overlapping tive that a cellular sample be first diagnosed as benign or
cytologic features, or a lack of differentiating features. The cli- malignant on a routinely stained preparation since neither
nician’s level of experience certainly plays an important role. immunohistochemical stains nor ultrastructural studies
The process of differential diagnosis with regard to will differentiate benign lesions from malignant ones.
a diffi cult diagnostic problem can be grouped into two
broad categories. The fi rst comprises benign lesions that
may be misinterpreted as malignant and malignant lesions
CONCEPTS BASIC TO CYTOPATHOLOGY
that may be misinterpreted as benign; the second involves
the accurate typing of neoplasms. The situations in the
former category are commonly referred to as a false posi- Understanding certain concepts that are basic to cytopa-
tive diagnosis and a false negative diagnosis, respectively, thology is a prerequisite for practicing cytotechnology
and may have considerable therapeutic implications. The and cytopathology (at least in this author’s [SRK] view).
familiar term “diagnostic pitfalls” also refers to the pro- These concepts are of great aid in cytologic evaluations to
cess of differential diagnosis but implies the necessity for arrive at an accurate interpretation. They are fundamen-
caution while rendering the final diagnosis, particularly in tal to learning the science of cytopathology and will lay
cases where a false diagnosis may result in an unnecessary a strong foundation. Misinterpretations (errors) in cyto-
surgical procedure, or in some cases, a mutilating surgery. logic evaluations often occur when basic concepts have
The second category is equally important since accurate not been understood or taught during training programs.
typing of the neoplasm is often mandated by clinicians be- The basic concepts summarized in Table 1.1 are
cause the treatment modalities differ among neoplasms. adapted from the late Dr. J.K. Frost’s classic monograph
1
2 Chapter 1: Overview
TABLE 1.1 MORPHOLOGIC CHARACTERISTICS OF DIFFERENT TYPES OF GENERAL ACTIVITY OF CELLS
Hyperplasia/Hypertrophy
Repair/Regeneration Degeneration/Necrosis
Normal Resting Invasive Cancer (Metaplasia/Dysplasia) Retrogressive Changes
Phase Euplasia Malignant Neoplasia Proplasia Retroplasia
Cellular Activity Normal baseline Markedly increased above Increased above the base Decreased below the
the baseline line baseline
Etiology — Known factors: viruses, Physiologic (growth); Physiologic—aging;

chemicals, radiation, hormones; repair, starvation, injury, decrease
hormones; unknown regeneration, or loss of blood supply
factors stimulation by
carcinogens
Key Features Roundness; Sharp angularity Roundness; uniformity; Extreme variations in

uniformity; of otherwise increase in size cellular features
predictability rounded structures;
unpredictable
irregularity of otherwise
uniform and predictable
structures; extremes
of cellular features
Nucleus
Shape Round Extremes in size and Round Variable

shape
Size Uniform in all Extremes in size and Enlarged but modestly Small pyknotic to large
normal cells, shape pale and swollen
roughly the
size of an entire
neutrophil
Nuclear Membrane Smooth, uniformly Uneven, thick and thin Smooth, uniformly thick Disrupted; irregular
thin areas due to irregular or thin; undulated or beaded appearance
distribution of chromatin; wary due to margination
sharp angularities of chromatin or
wrinkles
Chromatin Finely granular, Fine to coarsely Finely granular, even Pale, disintegrating,
even distribution granular; irregularly clumping, uniform structureless, margination
clumped, forming distribution or dehydrated and
irregular masses with smudgy; gelatinous;
sharp angularities; uneven vacuolated
distribution; intensity
of staining markedly
increased
Parachromatin Delicate, uniform, Excessive clearing; Uniform clearing Clearing ⫹/⫺

Clearing (nuclear pale basophilic variance in the degree of
sap) clearing
Chromatin/ Not observed due Sharp Sharp Blurred

Parachromatin to lack of clearing
Interface
(continued)
Chapter 1: Overview 3
TABLE 1.1 (continued)
Hyperplasia/Hypertrophy
Repair/Regeneration Degeneration/Necrosis
Normal Resting Invasive Cancer (Metaplasia/Dysplasia) Retrogressive Changes
Phase Euplasia Malignant Neoplasia Proplasia Retroplasia
Nucleolus
Number When present, Marked variation in Vary in number Present ⫹/⫺

minimal variation number from cell to cell
Size Small Variable: micro/macro/ May be variable Small and inconspicuous

giant forms to large and pale
Shape Round Round to irregular with Generally round Generally round

jagged edges
Mitoses — When present, normal When present, normal None

and abnormal
Multinucleation — Frequent, nuclei irregular Frequent, nuclei benign, ⫹/⫺

resemble each other
Cytoplasm Normal quality Variable in quantity and Increased in quantity; Variable; changes dependent
and quantity quality; generally scant dense-staining; increased on duration and intensity
cytoplasmic secretions of the causative factor;
altered staining qualities;
biphasic, opaque, foamy,
vacuolated; may condense
to the periphery; clear
around nuclei; loss of cilia
Nuclear/Cytoplasmic Normal Markedly increased Slight increase ⫹/⫺ Variable, never high
Ratio
Cell Borders Well-defined Well to poorly defined Well-defined Poorly defined, frayed
Bare Nuclei None Frequent None Frequent
“The Cell in Health and Disease.” His statement that ● Degeneration (retroplasia)
“morphology bespeaks biologic behavior” and the com- ● Malignant neoplasia
ments below aptly describe the essence of cytopathology.
The functional activity of a cell can be determined by
“Biologic behavior and the level of its activity—stable or
cytoplasmic characteristics and is dependent on the level
in transition—are dependably reflected in the structure of
of differentiation within the cytoplasm. Different cell types
tissues and cells. The high degree of recognition of these
have different functional activities. For example, glandular
morphologic features, the significance of their changes,
cells secrete mucin, as noted by secretory vacuoles; mature
and their predictability form the basis of histology and
squamous cells form keratin, which is seen as dense hyaline
pathology”—and thus, of clinical cytopathology.
orangeophilic cytoplasm; liver cells produce bile; and mel-
Tissue and cellular biologic behavior can be bisected,
anocytes form melanin pigment. Cytoplasmic structures
conceptually, into two areas: general activity and func-
such as cilia and microvilli also aid in cellular functions.
tional differentiation (Frost, 1986).
These features help in the identification of the cell type.
The general activity of the cell is refl ected in the
The functional differentiation found in the cytoplasm
nucleus and is further divided into four categories (Figs.
of normal cells in their euplastic state is typical. Cells in al-
1.1A to F):
tered states such as hyperplasia, degeneration, metaplasia,
● Normal or resting Cell (Euplasia) dysplasia, or neoplasia may exhibit atypical functional dif-
● Hyperplasia/hypertrophy, repair/regeneration/dysplasia ferentiation. Some examples of atypical functional differ-
(proplasia) entiation include dyskeratosis—or abnormal keratinization
A B
C D
E F
Figs. 1.1A to F. A: Euplasia or normal resting phase. Benign respiratory epithelium in resting phase. B: Malignant neoplasia-malignant cells.
Note the malignant nuclei are pleomorphic in size and shape. The nuclear membranes are irregular. There is excessive parachromatin clearing
and irregular deposits of chromatic material on the nuclear membranes. Multiple nucleoli vary in size, shape, and numbers. C: Proplasia rep-
resenting an increase in metabolic activity. Reactive bronchial epithelial cells. D: Proplasia. Reparative changes. The cells are enlarged with in-
creased nuclear size as well as in cytoplasmic amount. Nucleoli are prominent. E: Retroplasia. Degeneration due to radiation injury. The degen-
erating features are noted here in both nucleus and cytoplasm. F: Malignant cell exhibiting the features characteristic of malignant neoplasia.
of squamous cells either at immature levels or in abnormal malignant criteria. Using functional differentiating features
quantity and in an irregular sequence—and abnormal shapes as malignant criteria, no matter how atypical, is not only
due to a process of uneven thinning of the cytoplasm. meaningless but may be misleading and may invite diag-
The cytoplasmic characteristics of cells denoting their nostic disaster (Frost, 1986). The reader is referred to “The
functional differentiation should not be considered to be Cell in Health and Disease” for a detailed discussion.
GENERAL ASPECTS OF SPECIMEN EVALUATION SPECIMEN COLLECTION AND

CYTOPREPARATION
Once the basic concepts are understood, we can turn our
attention to the evaluation of a cytologic specimen. The The specimens for cytopathologic evaluation must be col-
practice of cytopathology involves two specimen types. In lected and submitted according to specific protocols estab-
the first type, referred to as exfoliative cytopathology, the lished by the laboratory that performs cytopreparation
cells are either spontaneously exfoliated from the surface and provides cytopathologic evaluation. Every step in the
or lining epithelium or from the neoplasms and collected process from specimen collection to submission is critical.
at different body sites (e.g., vaginal pool, serous effusions,
urine, cerebrospinal fl uid), or they are abraded (forcibly
CYTOPREPARATION
removed), as in a cervical smear or brushings/washings
(e.g., bronchus, gastrointestinal tract, biliary tract, ure- The methods for cytopreparation vary from one labora-
ters). In the second type, the specimen is obtained by fine tory to another. The conventional methods are still reli-
needle aspiration (FNA) biopsy, referred to as aspiration able and produce best results, providing crisp nuclear
cytopathology. There are major differences between the details. The relatively new technology of liquid-based
two types of specimens. In exfoliative cytology, abnormal preparation has become quite popular. The reader should
cells are dispersed in variable numbers in a milieu of cells refer to the literature for more information on the tech-
that are native to the site. Their identification may be dif- nique. The author’s laboratory prefers the conventional
fi cult if their number is small or if background abnor- methods.
malities obscure the cellular material. Also, metabolically
active cells, which appear flat in tissue sections, round up
CHOICE OF FIXATIVE
upon exfoliation. Spontaneous exfoliation as tissue frag-
ments is not characteristic of certain neoplasms such as The choice of fixative depends on the choice of stain.
squamous carcinomas unless the tumor is poorly differ- Air-drying is required for Romanowsky-type stains.
entiated or the fragments are forcibly removed, unlike However, for wet-fixation, several fixatives are in use;
glandular lesions where tissue fragments usually exfoli- for example, 95% ethyl alcohol is universally used for
ate. Stromal lesions tend not to exfoliate. Papanicolaou stain. The author’s laboratory prefers a
In contrast to exfoliative cytology, the FNA biopsy commercial spray fixative that contains ethyl alcohol but
specimen represents a microbiopsy comprising single cells, which does not result in lysis of the red blood cells and the
cell groups, and tissue fragments. Their interpretation in- nuclear details are better preserved. Intact red cells in the
volves the evaluation of the architectural configuration of background are a helpful indicator for judging nuclear
these tissue fragments (pattern diagnosis), akin to surgical size. Bloody specimens are a nightmare for cytopathol-
pathology, as well as the evaluation of the cytomorphology laboratories and are sure to result in unsatisfactory
ogy of individual cells (exfoliative cytology). A strong preparation and may result in a false negative diagnosis.
foundation in exfoliative cytology and an understanding Bloody specimens can be handled in a number of ways as
of histomorphology are of paramount importance. discussed in related literature (Greenstreet, 2002). A good
However, FNA biopsy differs from surgical pathol- manual technique performed with diligence and care can
ogy in many ways. Unlike histologic sections, smears produce quality preparations. Many cytopathology labo-
prepared from cytologic specimens are not of uniform ratories favor using cytocentrifuge and cytospin prepara-
thickness. Care must be taken in making direct smears or tions for all fluid specimens including bronchial wash-
cell spreads, which requires certain skills. Excessive force ings and lavages. The cytocentrifugation and cytospin
applied while making the smears will distort the pattern preparations are excellent alternatives only if they are
and also destroy the cells. Architectural patterns are dif- properly made. The author’s laboratory uses this tech-
fi cult to evaluate in thick, uneven smears. Folding and nique for poorly cellular samples only (the cellularity is
fragmentation may cause deceptive architectural configu- determined by wet-mount technique). Cost–benefit ratios
rations, which leads to misinterpretation. The relation- and personal preferences influence the methods used for
ship of neoplasms to the surrounding structures and their cytopreparations.
invasive characteristics cannot be evaluated from FNA
biopsy specimens. Certain parameters used to evaluate
CHOOSING THE RIGHT STAIN
malignant characteristics, such as number of mitoses, ne-
crosis whether punctate or diffuse, cannot be applied to The choice of stain should be dictated by the final product
cytologic preparations. Sampling of the lesion remains a that allows proper cytologic evaluation so that an accurate
problem when the morphology is varied. The small size of interpretation is made in the best interest of the patients.
the aspirated biopsy specimen often does not allow ancil- Traditionally, the Papanicolaou stain is used for exfolia-
lary tests or limits the number of stains and studies that tive cytology. It is an ideal staining technique that brings
can be performed, unlike surgical specimens. out crisp nuclear details and is quite suitable for aspiration
biopsy specimens as well. Other stains used for FNA biopsy ● Stromal characteristics in certain lesions;
specimens are Romanowsky stains (Giemsa, Diff-Quik, ● Background—whether bloody, inflammatory, necrotic,
Leishman, Heme3) and hematoxylin and eosin. One can excess stroma, colloid, mucin, and so on.
make arguments for and against each type of stain. Ulti-
mately, the choice depends on how comfortable the exam-
iner is in evaluating a particular stain. The author’s labora- SPECIMEN ADEQUACY
tory prefers Papanicolaou stain for the reasons expressed. The adequacy of the specimen is judged mostly on low
The ideal cytopreparation should allow for power. The criteria for determining the adequacy of
any specimen are site-specific and very often subjective.
● Evaluation of architectural patterns of the tissue
Cytologic criteria for certain types of specimens are stan-
fragments;
dardized (e.g., the Bethesda System for cervical–vaginal
● Proper evaluation of nuclear morphology (All the nuclear
smears and thyroid aspirates, as well as those established
parameters should be clearly visualized. Nuclear details
by the Papanicolaou Society of Cytopathology for Breast
are much more important in cytopathologic evaluation
and Thyroid). Each laboratory should establish standards
than the secondary structures such as colloid, stroma,
based on its own cytologic preparations, stains, fixations,
or matrix);
and the results of cytohistologic correlation when the
● Details of cytoplasmic characteristics;
diagnostic criteria for adequacy are not standardized.
● Visualization and identification of certain diagnostic fea-
The next step is to examine the smear under medium
tures in the background such as stroma and secretions.
power (10⫻). The screening of cervical–vaginal smears,
The cell blocks involve salvaging the grossly vis- sputum, bronchial washings/brushings, serous fluids, and
ible flecks of tissue or sediment; fixing them in formalin, so on is performed by studying overlapped microscopic
alcohol, or in a special medium; and processing them like fi elds going from one end of the slide to the other. For
tissue (paraffin embedding); cutting sections by micro- aspiration biopsy smears, one may focus directly on con-
tome; and staining with H&E. The cell blocks offer the centrated cellular material located under low power.
opportunity to examine the histologic structure and also Examination of the smear under medium and high
allow the use of ancillary testing such as special stains. power (40⫻) allows better visualization of the cells and
assessment of various characteristics than is possible with
low power examinations.
SYSTEMATIC APPROACH TO THE EVALUATION The following section describes the components of a
OF PREPARED AND STAINED cytologic sample and the variations in their presentations.
CYTOLOGIC MATERIAL A systematic review of all of these components is neces-
A cytologic preparation usually consists of isolated cells, sary to appreciate their various characteristics. This ap-
cell groupings or aggregates, and tissue fragments or mul- proach will allow the identification of features specific to
ticellular formations—the proportions of which are vari- any disease entity or neoplasm. One needs to be conver-
able dependant on several factors (discussed in individual sant with the different components as described below.
chapters).
Cytologic evaluation entails the examination of vari- TISSUE FRAGMENTS;
ous characteristics of cells such as size, shape, nuclear fea- ARCHITECTURAL PATTERNS
tures including size, shape, chromatin pattern, membrane
irregularities, mitotic to judge the general activity (particu- A tissue fragment is a multicellular formation. The tis-
larly benign or malignant), and cytoplasmic qualities to de- sue fragments refl ect the architecture of the parent tissue
termine the origin and level of differentiation. Various dis- that they are derived from or the neoplasm from which
ease processes or neoplasms, whether benign or malignant, they originate. Spontaneous exfoliation of tissue frag-
present specific patterns that are often consistent enough to ments is generally seen with glandular epithelium and not
enable one to identify the lesion with confidence. with the squamous type except in poorly differentiated
The smears must be evaluated in a systematic fashion, malignancy. They are present in specimens obtained by
observing several features in sequence and under different brushings, washings, and by aspiration biopsy. Fragments
magnifications. of epithelial cells demonstrate various architectural con-
An initial examination of the smear under low power figurations, often similar to their histologic counterparts.
(4.5⫻) provides valuable information regarding the over- However, the tissue fragments in cytologic samples vary
all makeup of the slides. These are in size and are of uneven thickness. Interpreting these is
like fi tting the pieces of a jigsaw puzzle together. Knowl-
● Quality of fixation and staining; edge of histopathology is essential since the cytologic fea-
● Cellularity (to assess the adequacy); tures need to be translated into a histopathologic pattern
● Concentration of cellular material on the smear; and diagnosis. Various types of tissue fragments are listed
● Architectural patterns of tissue fragments; and illustrated in Figures 1.2A to Y.
A B
C D
a b c F
E
Figs. 1.2A to F. A: Sheet (honeycomb); two-dimensional (all component cells in one plane of focus), in monolayer, well-defined cell bor-
ders, nuclei regularly spaced in relation to one another, nuclear polarity maintained; this appearance is seen when the structure is lined by
a single layer of cells, and seen “en face” (e.g. mesothelium, a gland, or a follicle). Exception is an epithelium that is pseudostratified, which
appears syncytial even though it is single layered as the nuclei are placed at different levels (e.g., respiratory epithelium [see Fig. 1.1], fal-
lopian tube lining [see Fig. 4.15]). B: Syncytium; a tissue fragment that may be either two-dimensional (monolayered) or three-dimensional
with component cells having poorly defined borders, nuclei overlapped, crowded, and with altered polarity. C: Syncytium (monolayered)
with component cells in one plane of focus but has poorly-defined cell borders; overlapped nuclei with altered polarity. Compare with
monolayered sheet in Figure 1.2A. D: Acinar or follicular or glandular. Syncytial tissue fragment with component cells arranged around
a lumen (e.g., an acinus, thyroid follicle, endocervical glands). E: Cluster; a syncytial tissue fragment with extreme crowding and overlap-
ping of cells and nuclei; it is necessary to examine such tissue fragments in multiple planes of focus. F: A three-dimensional syncytial tissue
fragment or a sphere, seen in three different planes of focus (a, b, c). Note the different patterns (e.g., a pseudocyst from adenoid cystic
carcinoma). (continued)
G H
I J
K L
Figs. 1.2G to L. (continued) G: Papillary; implies finger-like slender tissue fragments with or without branching; a central core of fibro-
vascular connective tissue must be present; epithelial cells line the core. H: A papillary frond with a central core of fibrovascular tissue
(arrows) and lining of malignant cells. I: Papillary-like. Similar to papillary but without apparent central connective tissue core. J: “Indian
file”. Cells arranged in tandem (arrow); characteristic of lobular type mammary carcinoma or small cell carcinoma or reactive meso-
thelial cells. K: Cribriform. Tissue fragment perforated with small apertures like a sieve (e.g., adenoid cystic carcinoma; mammary duct
adenocarcinoma). L: Tubular. Elongated tissue fragment with central lumen (e.g., a duct). (continued)
M N
O P
Q R
Figs. 1.2M to R. (continued) M: Trabecular. Cords, two or more cells thick (e.g., liver parenchyma or hepatocellular carcinoma). Cords
may be straight, curvy, or branching and anastomosing. N: Strip. A narrow, thin tissue fragment. O: Onion-skin. Spiral arrangement or
concentric arrangement of cells (e.g., cells of small cell carcinoma, squamous carcinoma, or papillary thyroid carcinoma). This feature is
more noticeable in a fluid environment. P: Cartwheel. A tissue fragment with the cells radiating from the center; nuclei at the perimeter.
Q: Luminal border (arrow). Tissue fragments originating from a lining epithelium of either a gland or follicle or surface epithelium lining
a cavity (e.g., tissue fragments of epithelium lining a gland). R: Palisading. Cells arranged side by side in rows like pales in a picket fence;
typically seen in endocervical glands. Also a characteristic feature in endocervical adenocarcinoma in situ or colonic adenocarcinoma.
(continued)
S T
U V
W X
Figs. 1.2S to X (continued) S: Fascicles with palisading nuclei: a bundle of cells with nuclei side by side. T: Feathery. Like feathers with
barbs springing from a shaft. Note the cells directing away from the luminal border, a feature characteristic of endocervical adenocarci-
noma in situ. U: Syncytial tissue fragment with smooth external border (e.g., adenocarcinoma in serous fluids). Usually three-dimensional
and needs to be examined in multiple planes of focus. V: Tissue fragment with knobby borders (e.g., mesothelial cells benign or malig-
nant). W: Rosette (rose-like). Cells arranged around a space (not a true lumen); various types of rosettes are described in pathology. Some
examples are the Homer-Wright rosette in neuroblastomas; Flexner-Wintersteiner rosettes in retinoblastoma; ependymal rosettes with
cytoplasmic processes converging onto the central space, and granulosa cell tumor (Call-Exner bodies). X: Psammoma body. Calcific con-
cretions that always appear basophilic and concentric in hematoxylin-eosin stained histologic preparations. With a Papanicolaou stain,
psammoma bodies stain either basophilic or multicolored ranging from purple, violet, and orange to amber with a starburst pattern.
Psammoma bodies can be single or multiple; naked or incorporated in a tissue fragment of epithelial cells. (continued)
and nuclear structure; other nuclear characteristics; and

the presence of mitosis. These are discussed in the follow-
ing paragraphs.
Cell Size
The size of an abnormal cell and its nucleus are important
parameters. Cells are often referred to as small, medium,
or large. The size is always compared to a normal cell
or its nucleus (e.g., a red blood cell, an entire neutro-
phil, a lymphocyte, a histiocytic nucleus, an intermediate
squamous cell nucleus, or an endocervical glandular cell
nucleus). Compared to the size of a resting lymphocyte,
Y a small cell is roughly three to three and a half times as
Fig. 1.2Y. (continued) Y: Psammoma body incorporated in a tissue large, while a medium-sized cell is three to six times as
fragment composed of malignant cells. To be of diagnostic impor- large, and a large cell is six to 10 times as large. A giant
tance, a psammoma body must be incorporated in a tissue fragment. cell is generally more than 10 times larger than the lym-
phocyte (Figs. 1.3A to D).
CELLULAR MORPHOLOGY
Cell Composition
Several parameters are examined for the evaluation of
cellular components. These include cell size and shape; The term monomorphic describes cells with identical
nuclear size and shape; location; number; nuclear cytoplas- forms, while pleomorphic refers to cells with a variation
mic ratios; chromatin characteristics; nuclear membranes in shape and size. Polymorphic, on the other hand, refers
A B
C
Figs. 1.3A to D. Small. Three to 3.5 times the size of a resting lymphocyte (arrow) (e.g., small cell carcinoma). B: Medium. Four to six
times the size of a resting lymphocyte. Inset. FNA of a reactive lymph node with several lymphocytes, for comparison. C: Large. Six to ten
times the size of the resting lymphocyte. Inset. FNA of a reactive lymph node with several lymphocytes for comparison. D: Giant. Larger
than 10 times the size of a resting lymphocyte. Inset. FNA of a reactive lymph node with several lymphocytes, for comparison.
A B
C D
E F
Figs. 1.4A to F. A: Monomorphic. All cells are of similar size and shape. B: Pleomorphic. Cells are variable in size and shape. C: Polymor-
phic. Cells are in various stages of development (e.g., germinal center cells of lymphoid tissue). D: Biphasic. Neoplasm demonstrating two
cell lines (e.g., fibroadenoma). Note an epithelial component (E), widely separated by neoplastic stromal component (S) (H&E). E: Bipha-
sic. FNA of a fibroadenoma showing epithelial tissue fragments in the background of abundant stroma. F: Triphasic. Neoplasm with three
cell lines (e.g., Wilms’ tumor). Histologic section showing a glandular and a primitive cell component (H&E). (continued)
to different cell types (e.g., germinal center cells of the type, (e.g., an adenocarcinoma or a squamous carcinoma)
lymphoid follicle or hematopoietic cells from a bone mar- represents one cell line. A fi broadenoma of the breast or
row) (Figs. 1.4A to C). a mixed tumor of the salivary gland have two compo-
The term monophasic, biphasic, or triphasic relate to nents (e.g., epithelial and stromal) and are referred to as
the number of cell lines presenting different morphologic biphasic or bimorphic (Figs. 1.4D and E). Wilms’ tumor
patterns in a given neoplasm. A neoplasm with one cell or nephroblastoma with all three cell lines (epithelial,
G H
Figs. 1.4G to I. (continued) G: Triphasic. FNA of a Wilms’ tumor

showing malignant mesenchymal component. H: Triphasic. Same
case as above showing a glandular component. I: Triphasic. Same
I case showing a primitive cell component.
stromal, and blastemal) is triphasic. Synovial sarcoma is

Cell Shapes
usually biphasic with epithelial and fibroblast-like spindle
cells (Figs. 1.4F to I). Rarely will the tumor show only Various epithelial, mesenchymal, and hematopoietic cells
one pattern, which is referred to as monophasic. The term present different shapes and sizes, which are consistent in
monophasic is added when a neoplasm that is generally their euplastic states. Abnormal shapes are noted in tran-
biphasic or triphasic shows only one component or cell sition states such as metaplasias, dysplasia, and particu-
line (e.g., monophasic synovial sarcoma). Neoplasms can larly in neoplasia. The range is very wide, and some cell
be of mixed epithelial types (e.g., adenosquamous). shapes are illustrated in Figures 1.5A to S.
A B
Figs. 1.5A and B. A: Round or spherical. B: Oval; plasmacytoid or an egg-shaped. (continued)
C D
E F
G H
Figs. 1.5C to H. (continued) C: Cuboidal; four equal sides. D: Columnar; tall, narrow at one end, cylindrical. E: Boxcar; rectangular.
F: Spindle-shaped; slender rod, broader in the middle. Note bipolar cytoplasmic processes. G: Spindle-shaped. Note unipolar cytoplasmic
processes. H: Fiber cell; thin, filamentous. (continued)
I K
J L
Figs. 1.5I to M. (continued) I: Triangular cell; three sided. J: Cau-

date. Cell with a tail. K: Polygonal. Cell with multiple sides. L:
Racket-shaped; cell with an oval-shaped head and a cytoplasmic
process resembling the handle. M: Hobnail; shaped like a nail with
a large head. The nucleus is housed in the head. (continued) M
Nuclear Characteristics Cytoplasmic Qualities

Nuclear morphology is the most important feature The origin of the cell (cell type) and its level of differentia-
reflecting the general activity of the cell while allowing tion indicating its functional state is reflected in the cyto-
for the differentiation between benign and malignant plasm. Characteristics of the cytoplasm such as amount,
lesions. Various parameters such as nuclear size, shape, texture, secretory products, and staining qualities are all
chromatin pattern, nuclear membranes, parachromatin, signifi cant. Many neoplasms are characterized or typed
and nucleoli (Table 1.1; Figs. 1.6A to X) must be prop- by cytoplasmic qualities (e.g., clear cell type, oxyphilic
erly evaluated. cell type, signet-ring cell type) (Figs. 1.7A to O). One must
N O
P Q
R S
Figs. 1.5N to S. (continued) N: Tadpole. Cell with one end being globular or bulbous, extended into an elongated slender cell body
ending in a smaller bulbous end. O: Lacunar; cells within a small cavity (e.g., cartilage). P: Strap; band or a strip, flat (arrows) (e.g., skeletal
muscle). Q: Strap; band or a strip, flat, e.g. skeletal muscle. R: Cross-cytoplasmic striations (e.g., striated muscle fiber). S: Goblet cells.
Large barrel-shaped cytoplasmic vacuole above the nucleus.
A B
C D
E F
G H
Figs. 1.6A to H. A: Round; spherical and monomorphic. B: Anisonucleosis; variations in size and shape of the nucleus. C: Oval; egg-
shaped (arrows) and oblong: greater length than breadth (arrowheads). D: Cigar-shaped; long tubule with blunt ends (e.g., smooth muscle
cell nucleus). E: Spindle. Slender rod, broader in the middle. F: Bipolar; two poles equidistant from the center. G: Comma; curved, broad at
one end, tapered at the other (arrows). H: Kidney-shaped (e.g., a histiocyte). Note the notch in the nuclear membrane (arrows). (continued)
I J
K L
M N
O P
Figs. 1.6I to P. (continued) I: Molded; flattening of portion of nuclear membrane by another nucleus (arrows). J: Bi- or trinucleation. Two
or three nuclei. K: Multinucleation. Multiple nuclei. L: Lobulated (e.g., megakaryocyte); must be differentiated from multinucleation. M: Mir-
ror image. Nuclei resembling each other (e.g., Reed-Sternberg cell in Hodgkin lymphoma). Chromatin Pattern and Distribution (Figs. 1.6N to
W). N: Powdery to finely granular, evenly distributed chromatin. O: Coarsely granular, dark-staining (hyperchromatic). P: “Salt & pepper.”
Uniformly coarse granularity of chromatin, typical of neuroendocrine neoplasia. (continued)
Q
R
S
T
U
V
Figs. 1.6Q to W. (continued) Q: Pyknotic. Clumped, denatured;
darkly stained structureless chromatin. R: Nucleolar characteristics
and parachromatin clearing. Parachromatin or the nuclear sap ap-
pears excessively clear and sharply demarcated from the clumped,
coarsely granular chromatin with a sharp interface. Nucleolus
should stain red with a Papanicolaou stain and blue with Ro-
manowsky. Chromocenters stain the same as chromatin (i.e., hema-
toxylin). Micronucleoli can be extremely small, single, or multiple
(arrowheads). Macronucleoli (arrows) are usually large and cherry-
red. Other Nuclear Characteristics S: Grooved or clefted. Long, nar-
row trench on surface or deep wrinkles on the surface (arrows). A
nonspecific feature that can be seen in both benign and malignant
lesions. T: Intranuclear pseudoinclusions. Cytoplasmic invagina-
tion into the nucleus, which appears as sharp “holes” bordered by
condensed chromatin (arrows). Pseudoinclusions may be single or
multiple. A nonspecific finding encountered in many different types
of malignancies as well as some benign conditions. U: Mitosis, ab-
normal, tripolar (arrow). V: Mitosis, abnormal, aneuploid (arrow). W
W: Karyorrhexis. Fragmentation of the nucleus.
19
A B
C D
E F
G H
Figs. 1.7A to H. A: Pale cytoplasm. 7B: Dense cytoplasm. C: Biphasic. Two-tone cytoplasm. D: Keratinization. The keratin stains dense
cyanophilic, bright yellow-orange, and refractile. E: Endoplasm-ectoplasm in squamous cells (atypical functional differentiation of
squamous cells (arrow). Note the dense, metabolically active endoplasm is surrounded by cleared, mature cytoplasm that is seen in inter-
mediate/superficial squamous cells. F: Ringing: Concentric rings of endoplasm and ectoplasm (arrows); indicates atypical functional differ-
entiation of squamous cells in multiple cycles (see Fig. 1.7E). G: Herxheimer’s spiral (arrow); wrinkled endo-ectoplasmic border forming an
intracytoplasmic fibrillar, to corkscrew-shaped structure; usually stains eosinophilic; of no significance. H: Cross striations in the cytoplasm
(arrows); skeletal muscle fiber. (continued)
I J
K L
M N
Figs. 1.7I to O. (continued) I: Microvilli, cytoplasmic brush bor-

der (arrows) (e.g. mesothelial cell), seen as peripheral fuzzy border.
J: Cytoplasmic secretions; foamy, bubbly, vacuolated. K: Cytoplas-
mic secretions; single, signet-ring type vacuole. Note the indenta-
tion of the nucleus. L: Cytoplasmic secretions. Single large bubble
gum type vacuole (arrow). M: Emperipolesis: Active penetration by
one cell/s into and through a larger cell. Neutrophils are frequently
seen in the cytoplasm of adenocarcinomas. N: Leukoerythrophago-
cytosis: Phagocytosis of neutrophils, lymphocytes, and red blood
cells. O: Hyaline globules within the cytoplasm (arrows). Hyaline
globules within the cytoplasm represent different entities in differ-
O ent cells (e.g., intermediate filaments rhabdoid tumors).
21
remember that no matter how extreme or bizarre cyto- chyma. The supporting tissue presents several character-
plasmic features appear, they cannot differentiate malig- istics, which are, at times, unique to a lesion. It can be a
nant from benign. loose myxoid with abundant ground substance, collagen-
ized, fi brillar, chondroid, osteoid, or could contain amy-
loid (Fig. 1.8). Neoplasms are often characterized by their
Stroma
stromal contents. Some neoplastic cells incite a stromal
The term stroma describes the supporting tissue or matrix response that is sometimes excessive and referred to as
of an organ, in contrast to functioning tissue or the paren- desmoplasia.
A B
C D
E F
Figs. 1.8A to F. A: Loose fibrovascular connective tissue stroma. B: Fibrillar stroma (Papanicolaou). C: Fibrillar stroma (Romanowsky).
D: Collagenous, dense stroma. E: Mucoid (Romanowsky). Metachromatic staining. F: Mucoid stroma (Papanicolaou). (continued)
G H
I J
Figs. 1.8G to J. (continued) G: Myxoid stroma. H: Chondroid stroma (Romanowsky). I: Neuropile. Network of delicate nerve fibers
seen as granular background. J: Amyloid deposits in the stroma. Amyloid appears as a cellular, amorphous deposit, staining eosinophilic
to cyanophilic in routinely stained Papanicolaou-stained preparations.
Background epithelial hyperplasia versus adenocarcinoma; and meso-

thelial hyperplasia versus malignant mesothelioma).
The term background refers to the milieu, surroundings,
● Benign neoplasms versus malignant neoplasms (e.g.,
or environment in which the parenchymatous cells lie.
papilloma versus papillary carcinoma; adenoma versus
Background features are dependent on the tumor (e.g.,
adenocarcinoma).
growth pattern, whether cystic or solid, vascularity, exces-
● Typing neoplasms (e.g., small round cell neoplasms of
sive stroma and type of stroma, infl ammation, types of
childhood; carcinoma versus malignant lymphoma;
infl ammation, and necrosis). Some are characteristic or
spindle cell neoplasms).
unique to certain disease processes, aiding greatly in diag-
● Primary malignant neoplasms versus metastatic tumors
nosis. One must be familiar with the different cytologic
(e.g., primary lung adenocarcinoma versus metastatic
features of infl ammatory necrosis, infarction, and tumor
lung adenocarcinoma; hepatocellular carcinoma ver-
diathesis (Fig. 1.9).
sus metastatic carcinoma).
● Identifi cation of a primary source in cases of dissemi-
AN APPROACH TO DIFFERENTIAL DIAGNOSIS nated tumors or occult primary cancer.
By putting the basic concepts into practice and taking a sys- Differential diagnostic problems in the above settings
tematic approach to evaluating a cytologic smear, a diag- may stem from a multitude of causes:
nostic impression is possible in most instances. Difficulties
● Some neoplasms present diverse morphologic patterns
in arriving at a diagnosis arise in various settings where the
mimicking virtually every type of known malignancy.
cellular features overlap or deviate from the norm.
A prime example of this is malignant melanoma.
Some difficulties include
● Many neoplasms arising from diverse sources present
● Differentiation between nonneoplastic processes versus similar or identical morphologic patterns (e.g., small
neoplasia (e.g., epithelial repair versus carcinomas; duct round cell tumors in childhood).
A B
Figs. 1.9A to C. A, B: Diathesis. Background characterized by old

blood, fragmented red cells, nuclear and cellular debris and protein-
aceous fluid in the background. C: Infarction showing coagulative
necrosis as a result of ischemia. Note the ghostly appearance of the
C papillary structure.
● A metastatic neoplasm may present a different mor- 3. Architectural patterns of the tissue fragments—follicular/
phologic pattern than the primary source. acinar, rosettes, trabecular, papillary, fascicles
● Previous cytohistologic material may not be available 4. Stroma—mucinous/myxoid, chondroid, amyloid, col-
for review. loid, fibrillar, collagenous
● Certain neoplasms are ubiquitous (e.g., malignant lym- 5. Composition of the tumor—monophasic, biphasic, poly-
phoma, neuroendocrine tumors, and malignant mela- morphic, lymphoepithelial, metaplastic, mixed epithelial,
noma). These enter as diagnostic possibilities at almost epithelial stromal
every location. 6. Growth pattern—solid, cystic, papillary
● A patient may develop more than one primary tumor. 7. Background—Clean, bloody, necrotic, infarction,
● Adenocarcinomas and squamous carcinomas can be inflammatory; acute or chronic
diagnosed for what they are. However, the primary site
Once a neoplasm is placed in a specific category, any
can never be unequivocally determined in cases of dis-
feature unique to a tumor, if present in the case in ques-
seminated tumor.
tion, will allow an accurate diagnosis. When confronted
With overlapping cytologic features, the diagnostic with a difficult case, the interpreter must
possibilities may be unlimited.
The categorization of neoplasms based on shared ● Analyze clinical and laboratory data, as well as radio-
morphologic features has facilitated the differential diag- logic findings,
nostic process. These categories are ● Review previous cytohistologic material whenever avail-
able, and
1. Cell characteristics ● Judiciously use ancillary tests.
Cell size—small cell tumors, large cell tumors, giant
cell tumors Some frequently used ancillary tests to aid the final
Cell shape—round cell tumors, spindle cell tumors, diagnosis include the following:
pleomorphic cell tumors
2. Cytoplasm (quality and quantity) and functional dif- ● Histochemical stains
ferentiation—clear cell, granular cell, oxyphilic cell ● Immunochemical stains
tumor, signet-ring, keratinizing, mucinous ● Ultrastructural examinations
TABLE 1.2 COMMONLY USED HISTOCHEMICAL STAINS IN DIFFERENTIAL DIAGNOSES OF NEOPLASMS
Tissue Component Method Tissue Fixation Substance Identification Diagnostic Application

Carbohydrates PAS, diastase Routine Glycogen Rhabdomyosarcoma; Ewing’s;
degradable renal cell
PAS, diastase Routine Neutral Adenocarcinomas; B-cell

resistant mucopolysaccharide lymphoma; liver cell carcinoma
(secretory products of
glands and tumors)
Alcian blue at Routine Acid mucopolysaccharide Adenocarcinoma

pH 2.5 (stromal mucin)
Mucicarmine Routine Acid mucopolysaccharide Adenocarcinoma
Fibrillar Proteins Congo red Routine Amyloid Medullary thyroid carcinoma;

amyloidosis (must be examined
under cross-polarized light)
Thioflavin T Routine Amyloid Medullary thyroid carcinoma;

amyloidosis (must be examined
under fluorescent microscopy)
Lipids Oil red; Sudan Unfixed tissue; Lipid Liposarcoma, adrenal cortical
black frozen section carcinoma, renal cell carcinoma;
or air-dried malignant mesothelioma; ovarian
smear stromal
Neuroendocrine Grimelius Routine Argyrophil granules Neuroendocrine tumors
Granules Masson-Fontana Routine Argentaffin and Neuroendocrine tumors

argyrophil granules
Formaldehyde Fresh frozen Catecholamines Neuroendocrine tumors

induced
fluorescence
Nucleic Acids Methyl Frozen; fresh; RNA/DNA B-cell lymphoma; plasmacytoma

green-pyronine air-dried
● Flow cytometry and image cytometry for ploidy analysis The histochemical stains that are most useful in cyto-
● Molecular studies pathology are listed in Table 1.2.
IMMUNOCHEMICAL STAINS
HISTOCHEMICAL STAINS
With the advent of immunochemical stains and the con-
Most histochemical stains identify a generic substance with tinuous development of new monoclonal and polyclonal
groups of related molecules rather than a specific component, antibodies, pathologists can now offer a more specific diag-
which presents some limitations. For example, a malignant nosis by localizing several of the cytoplasmic and nuclear
neoplasm may be confirmed as an adenocarcinoma; how- structures. In fact, immunochemistry has revolutionized
ever, its site of origin cannot be determined by histochemi- diagnostic cytosurgical pathology. The list of available
cal stains. Special fixatives required for certain stains add antibodies is extensive. Some are specific, many non-
more limitations. Histochemical stains in cytologic material specific, while some have only research applications. The
are best performed on cell blocks; smears, although used, results also depend on fixation, preservation, technique,
are not ideal. Enzyme histochemical stains require fresh and slide background and must be quality-controlled.
tissue and need to be specially processed. These stains are Immunochemistry may be performed on both
rarely applied due to the availability of immunostains. smears and cell blocks. The smears may be wet-fixed and
TABLE 1.3 IMMUNOCYTOHISTOCHEMICAL STAINS’ DIAGNOSTIC MARKERS
Tumor Type Antibodies (Positive Reactivity)
Adenocarcinoma, General Cytokeratin super (cocktail of low and high molecular weight cytokeratin antibodies);
carcinoembryonic agent (CEA); epithelial membrane antigen (EMA); B72.3; Leu M1
Adenocarcinoma, Specific Types
Colon CK20; Villin
Lung-Adenocarcinoma CK7, PE10 (monoclonal antibody against pulmonary surfactant)
Lung-Bronchioloalveolar TTF-1, alveolar surfactant proteina

Non-Mucinous
Prostate Prostatic specific antigen (PSA); prostatic acid phosphatase (PSAP)
Ovary Estrogen receptor (ER); progesterone receptor (PR); CA125, WT-1
Breast Estrogen receptor (ER); progesterone receptor (PR); gross cystic disease fluid protein
(GCDFP); 15/AP-l5, mammaglobin
Central Nervous System (CNS)

Neoplasms
Astrocytic Tumors Glial fibrillar acidic protein (GFAP); cytokeratin limited cocktail (CK3)
Meningioma EMA, vimentin, cytokeratins, progesterone receptor (PR)
Chordoma Keratin; vimentin; S100 protein
Germ Cell Tumors
Yolk Sac Tumor Alpha fetoprotein (AFP); cytokeratin
Choriocarcinoma Human chorionic gonadotrophin (HCG); placental alkaline phosphatase (PLAP)
Seminoma (Germinoma) Placental alkaline phosphatase (PLAP), C-kit, OCT4
Embryonal Carcinoma Cytokeratin; placental alkaline phosphatase (PLAP); Ki-67 (CD30 Ber-H2)
Hepatocellular Carcinoma Hep Par-1, alpha fetoprotein (AFP); carcinoembryonic agent (CEA) (polyclonal)
Langerhans Histiocytosis S100 protein, CD1a
Hematolymphoid Leukocyte common Ag (LCA, CD45RB); TdT (lymphoblasts)
Hodgkin Lymphoma Leu-M1 (CD15); Ki-67 (CD30, BER-H2);
B-Cell Lymphoma L-26 (CD20); CD79a, kappa lambda surface light chain immunoglobulin (Slg)
Macrophage Mac 387 (tissue macrophage subset/myeloid leukemia); KP-1 (CD68), CD163 (macrophage-
associated antigen)
Myeloid Myeloperoxidase (MPO), C-kit
Plasma Cell Kappa/lambda cytoplasmic immunoglobulin (lg) light chains; immunoglobulin (lg) – A, M,
D; CD138
(continued)
Tumor Type Antibodies (Positive Reactivity)

Malignant Melanoma S100 protein; HMB-45, Melan-A, tyrosinase
Malignant Mesothelioma Calretinin
Nerve Sheath Tumors S100 protein; Leu 7 (CD57)
Neuroendocrine Carcinoma Cytokeratin; neuron specific enolase (NSE); synaptophysin; chromogranin; CD56
(N-CAM); specific peptides, TTF-1 (for small cell carcinoma of lung)
Renal Cell Carcinoma Epithelial membrane antigen (EMA); renal cell carcinoma marker (RCC); vimentin, CD10,
CK7
Neuroblastoma Synaptophysin, chromogranin, beta-catenin, CD56
Salivary Gland Neoplasms
Mixed Tumor S100 protein, GFAP
Sarcomas
Ewing’s sarcoma Fli1 protein, CD99 [013 (H3A-71)], vimentin
Rhabdomyosarcoma Desmin; myoglobin; myogenin; myoD1
Leiomyosarcoma Muscle specific actin; smooth muscle actin (HHF35); desmin
Fibrosarcoma Vimentin
Synovial sarcoma EMA, keratin super; CD99, BCL-2, TLE1
Chondrosarcoma S100 protein; vimentin
Vascular Factor VIII; CD34; CD31; ulex europaeus
Squamous Carcinoma CK5/6, p63
Thyroid
Follicular, Hürthle Cell, Papillary Thyroglobulin, TTF-1
Anaplastic Thyroglobulin ⫹/⫺, TTF-1 ⫹/⫺
Medullary Calcitonin, chromogranin, synaptophysin
unstained or Papanicolaou-stained. The latter can be di- biopsy procedure is done when immediate interpretation
rectly processed. The destaining of a previously stained is rendered so that additional material can be aspirated
smear is not recommended. As compared to surgical pa- and appropriate immunostains may be requested. Simi-
thology specimens, cytological specimens are very often of larly, during cytopreparation, a wet-mount (see Appendix,
limited quantity and cellularity and do not always permit Chapter 6) may alert the cytotechnologist/pathologist to
cell block preparations. Smears may be few in number. It the necessity of ancillary tests. Additional smears may be
is imperative that pathologists be selective regarding the prepared ahead of time for immunohistochemical stains,
choice of antibodies, although a smear that is negative for and an aliquot may be saved for ultrastructural studies
one antibody may be processed for another. It is prudent or fl ow cytometry. Table 1.3 provides a list of frequently
to anticipate immunochemical staining at the time that a used antibodies. The list is by no means complete.
TABLE 1.4 ULTRASTRUCTURAL FEATURES OF NEOPLASMS AND THEIR DIAGNOSTIC APPLICATION
Tumor Type Ultrastructural Features Diagnostic Application

Adenocarcinoma Lumen with surface microvilli; intracytoplasmic Adenocarcinoma versus malignant mesothelioma
(General) lumina; secretory granules; cell junctions;
intermediate filaments; basal lamina
Adenocarcinoma versus squamous carcinoma
Adenocarcinoma
(Specific Type)
Bronchioloalveolar Mixtures of Clara cells (non-ciliated columnar cells Primary lung adenocarcinoma versus metastatic
Carcinoma with cytoplasmic granules), mucinous cells and carcinoma
pneumocyte II
Colonic (Intestinal) Mucin granules, rigid microvilli with core Metastatic carcinoma
Adenocarcinoma microfilament and glycocalyx
Squamous Desmosomes; filopodia; tonofilaments Poorly-differentiated squamous carcinoma

Carcinoma (lymphoepithelioma) versus small cell (NEC)
versus malignant lymphoma
Renal Cell Carcinoma Glycogen particles; lipid droplets; few irregular Clear cell versus chordoma
microvilli; cell junctions
Chromophobe Renal Microvesicles; mitochondria with tubulovesicular Metastatic renal cell carcinoma, clear cell type
Cell Carcinoma cristae versus primary clear cell carcinoma salivary glands
Anaplastic Sparse organelles; poorly formed intercellular Anaplastic carcinoma versus soft tissue sarcoma;
Carcinomas (General) junctions anaplastic carcinoma versus malignant lymphoma
Thymoma Tonofilaments; desmosomes Thymoma versus carcinoma of other organs

versus lymphoma
Malignant Long slender, bushy microvilli; desmosomes; Adenocarcinoma versus mesothelioma

Mesothelioma glycogen; basal lamina
Sarcomas
Malignant Fibrous Mixture of cells, irregular, rough endoplasmic reticulum Differentiation from other sarcomas and
Histiocytoma (RER); lysosomes; lack of features of other sarcoma undifferentiated carcinomas
Liposarcoma Lipid vacuoles; nuclear indentations; basal lamina Differentiation from other sarcomas
Rhabdomyosarcoma Z-bands alternating (thick and thin filaments); Differentiation from other small blue cell tumors
myosin/ribosome complex
Fibrosarcoma Extracellular collagen; rough endoplasmic Differentiation from other spindle cell tumors
reticulum; paucity of cytoplasmic filament
Peripheral Nerve Entangled thin cytoplasmic processes with Differentiation from other spindle cell tumors
Sheath Tumors prominent basal lamina; long spacing collagens
(Schwann Cell) (Luse body); pseudo mesaxon
Angiosarcoma Granules with tubular array (Weibel-Palade body); Differentiation from other spindle cell tumors
cell junction; pinocytic vesicle; basal lamina; lumen
or neolumen formation
(continued)
Tumor Type Ultrastructural Features Diagnostic Application

Leiomyosarcoma Actin microfilaments; dense bodies; pinocytotic Differentiation from other spindle cell tumors
vesicles; basal lamina; membrane attachment
plaque
Synovial sarcoma Epithelial: glandular epithelium spindle cells: cell Differentiation from other spindle cell tumors
junction; intermediate filament; RER
Chordoma Cytoplasmic vacuoles; mitochondria–RER Differentiation from other clear cell tumors
complex; cell junction; intermediate filament
Langerhans Birbeck granules Differentiation from other histiocytosis

Histiocytosis
(Histiocytosis X)
Melanoma Premelanosomes and melanosomes Melanoma versus carcinoma versus

neuroendocrine tumor versus malignant
lymphoma versus sarcoma
Oncocytomas Mitochondria, residual body (lipofuscin) Differentiation from other oxyphilic tumors
Neuroendocrine Dense core granules of neurosecretory type Adenocarcinoma or squamous carcinoma versus
Tumors Including NEC; malignant lymphoma versus NEC
Small Cell
Undifferentiated
Carcinomas
Paraganglioma Chief cells with neurosecretory granules; Paraganglioma versus alveolar soft part sarcoma
sustentacular cells; basal lamina
Malignant Lack of cell junctions; nuclear blebs; sparse Lymphoma versus poorly differentiated carcinoma
Lymphomas cytoplasmic organelles versus neuroendocrine versus other small round
cell tumors of childhood
Neuroblastoma Neurites with neurosecretory granules; Differentiation from other small blue cell tumors
microtubules
Ewing’s Sarcoma/ Primitive cells rich in glycogen; small, poorly Differentiation from other small blue cell tumors
PNET formed cell junctions; rare neurosecretory granules
ELECTRON MICROSCOPY content of the neoplastic cells and the biologic behavior.
Their application in clinical cytopathology is limited. The
The application of electron microscopy in cytopathologic
reader may refer to the literature for more information.
specimens is limited primarily to distinguishing morpho-
logically similar neoplasms or those that appear undiffer-
entiated under light microscopy. Table 1.4 describes the THE APPLICATION OF MOLECULAR
salient features of various neoplasms at the ultrastruc- TECHNIQUES TO CYTOLOGIC SPECIMENS
tural level that aid in accurate identification. In this era of molecular diagnostics and personalized
therapy, physicians are looking beyond definitive diag-
nosis (i.e., a molecularly targeted therapy, particularly
FLOW CYTOMETRY AND IMAGE CYTOMETRY
in advanced stage cancer). Molecular tests that detect
Flow cytometry for DNA analysis and image cytometry genetic alterations such as mutations, deletions, trans-
are used in cases of hematologic or lymphoid malignancy locations, and so on that can be used to characterize
and in some solid tumors for correlation between the DNA malignancy may complement morphologic findings and
immunohistochemistry to enhance diagnostic accuracy. EGFR [ERBB1] gene for selecting patients for tyrosine
However, their applications in current clinical cytologic kinase inhibitor therapy). Several techniques are being
samples are limited since the findings , to date, are restricted used to identify genetic abnormalities such as hybridiza-
to investigational studies or are from early clinical trials. tion, polymerase chain reaction (PCR), genomic mapping,
Molecular techniques are being applied in several areas and fl uorescence in situ hybridization (FISH). Although
of clinical cytology to increase the sensitivity and specific- their utility in a service environment is currently restricted
ity of screening tests (e.g., Human papilloma virus [HPV] to some diseases, the future offers many diagnostic assays
DNA testing in cervical exfoliative cytology screening in and predictive markers for targeted therapy in a neoadju-
cases of atypical squamous epithelial cells of unknown vant setting or when cytology material is the only avail-
significance [ASC-US]). These tests also increase diagnos- able option in a clinical setting where there is no luxury
tic accuracy and add prognostic or predictive informa- of a larger tissue sample for evaluation. The reader may
tion (e.g., hotspot mutations in exon 19 and 21 of the refer to the literature for more information.
SUGGESTED READING
Azzopardi JG. Problems in breast pathology. In: Bennington JL, National Cancer Institute. Fine Needle Aspiration of Breast
ed. Major Problems in Pathology. Philadelphia: WB Saunders, Workshop Subcommittee. The uniform approach to breast
1979;11. fine needle aspiration biopsy. Diagn Cytopathol 1997;16:
Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia: 295–311.
Churchill Livingstone, 2006. Soloman D, Nayar R. (eds). The Bethesda System for Reporting
Frost JK. The cell in health and disease. In: Ward GL, ed. Mono- Cervical Cytology: Definitions, Criteria and Explanatory Notes,
graphs in Clinical Cytology. 2nd ed. New York: S Karger, 1986;2. 2nd edition. New York: Springer, 2004.
Greenstreet P, Purslow MJ, Kini SR. Chapter 2, Respiratory Speci- The Papanicolaou Society of Cytopathology Task Force on Stan-
men Types for Cytologic Diagnosis, Specimen Procurement, dards in Practice: Guidelines of the Papanicolaou Society of
Collection Methods, Specimen Submission, Cytopreparation Cytopathology of the examination of fine-needle aspiration
and Staining. In: Kini SR, ed. Color Atlas of Pulmonary specimens from thyroid nodule. Diagn Cytopathol 1996;15:
Cytopathology. New York, Springer-Verlag, 2002. 84–89.
Chapter 2: General Aspects of Gynecologic Cytopathology 31
SECTION I: GYNECOLOGIC CYTOPATHOLOGY
2 GENERAL ASPECTS
OF GYNECOLOGIC
CYTOPATHOLOGY,
REPORTING SYSTEM, AND
BENIGN CELLULAR CHANGES*
transmitted disease and thereby decreasing the incidence

PAST AND PRESENT of cervical epithelial neoplasia. The vaccine therapy is still
in the preliminary stages and long-term follow-up studies
The landmark presentation by Papanicolaou on the detec- are necessary to judge the effects of the vaccine.
tion of cancer cells in vaginal smears in 1928, eventually All the above events contributed immensely to lower-
led to the routine screening of cervical–vaginal smears for ing the incidence of cervical cancer and related deaths in
cervical cancer in all women in the United States. The cer- the Western world. However, the success of the tremen-
vical–vaginal cytology over the last several decades greatly dously useful test was overshadowed by some instances
expanded in depth and dimensions by implementing wide- of missed diagnoses of cervical cancers and the publicity
spread screening programs—from increased detection of it received in media. The reasons given in many cases of
premalignant and malignant lesions to the development of missed diagnoses were inadequate sampling or a lack of
colposcopy, guided biopsies, and various methods of treating diagnostic cells. Yet, the issue of specimen adequacy had
precursor lesions; from refining diagnostic criteria to adopt- never received enough attention. As the knowledge base
ing newer diagnostic techniques and establishing the role of regarding cervical neoplasia was being widened, gyneco-
HPV in cervical carcinogenesis. The cervical screening pro- logic cytology experienced several modifications of classi-
gram has become the most successful cancer screening pro- fications for precursor changes from Papanicolaou’s class
gram, which resulted in a massive decline in the incidence of system to Reagen’s classification of dysplasia (mild, mod-
cervical cancer and deaths in the Western hemisphere. erate, severe) and carcinoma in situ, and Richart’s clas-
The introduction of liquid-based preparations for cy- sifi cation of cervical intraepithelial neoplasia grade I to
tologic examination was extended a warm welcome by III. The lack of consistency in the nomenclature and usage
the cytology community and has replaced conventional of various diagnostic terms did result in some confusion
smears in most laboratories in the USA. Liquid-based cy- over patient management. The above stated problems—
tology provided additional opportunities to perform mo- specifically the misdiagnosed cervical cancers and related
lecular testing for HPV antigens as well as simultaneous deaths—received considerable public and media attention
testing for gonococcal and chlamydia organisms. and came under government scrutiny, resulting in the in-
Liquid-based cytology also paved the road to auto- volvement of Congress and leading to consensus meetings
mated cytology and to the development of automated in 1988, sponsored by the National Cancer Institute. The
screening devices. experts participating in those meetings developed guide-
The development of the HPV vaccine has raised lines for reporting cervical–vaginal cytology, referred to
new hopes for decreasing the incidence of this sexually as The Bethesda System (TBS).
The objectives of the consensus meetings and the
development of a new reporting system were to
*Note: The following images in this chapter are the courtesy
of Ms. Karen Atkinson, MPA, CT (ASCP), CMIAC, Director of 1. Emphasize the importance of an adequate specimen;
Education and Training, BD Diagnostics-Women’s Health and 2. Offer standardized reproducible criteria and terminol-
Cancer, and Mr. Tim Collins, BS, CT (ASCP), Senior Scientist,
Research and Development, BD Diagnostics-Women’s Health and ogies for various precursor lesions so as to
Cancer: Figures 4, 6C, 7C, 9E, 11A and 11B; e-Figures 2B, 4B, 5B, a. reduce inter-observer variability;
5C, 8B, 9B, 15B, 17, 18, 20A, and 20B. b. communicate effectively with clinicians;
31
32 Section I: Gynecologic Cytopathology
c. help to develop a consistent and uniform patient of the endocervix. Entities such as endometrial tissue from
management strategy based on a “Pap” smear diag- the lower uterine segment, tubal metaplasia, microglandu-
nosis; and lar hyperplasia, high-grade squamous intraepithelial lesions
3. Provide recommendations. (HSIL; carcinoma in situ) involving crypts and glands are
being encountered more frequently. These hitherto unfamil-
The Bethesda System (TBS) of reporting a cervical–
iar cytologic patterns have caused diagnostic dilemmas and
vaginal cytologic diagnosis has three parts:
now constitute some of the important diagnostic pitfalls.
1. Specimen adequacy. The advantage of the endocervical brush in sampling
2. General categorization. a normal endocervical canal and receding transitional
3. Recommendations (optional). zones in postmenopausal women has also resulted in a
higher diagnostic yield for high-grade squamous epithe-
Following the initial TBS, there had been two subsequent
lial lesions. However, the recognition of these lesions in
modifications in 1991 and 2001.
an atrophic background has become one of the problem
For the detailed format of the reporting system, see
areas of cervical–vaginal cytology (see Chapter 3).
Appendix.
Adequate samples not only reduce the number of
The statement on adequacy was long awaited. Its impor-
false negative cases but also allow the identification of
tance in the evaluation of the cervical–vaginal smear cannot
several benign disease processes besides cervical cancer
be overemphasized. Adequate sampling of the transitional
and premalignant lesions. These benign cellular changes
zone (squamo-columnar junction) where precursor lesions
are covered in this chapter, while squamous lesions, glan-
are initiated is essential and constitutes an integral part of
dular lesions, and miscellaneous entities are discussed in
obtaining a cervical sample (Fig. 2.1). For conventional cy-
the subsequent three chapters.
tology, a thin cell spread and adequate fixation are prereq-
As the cytology community and clinicians—mainly
uisites, and clinicians should be provided with instructions
the gynecologists—became familiar with TBS 1988, cer-
for proper sampling techniques, specimen fixation, and the
tain flaws or inconsistencies were encountered, particular-
submission of the specimen to the laboratory. Liquid-based
ly with regard to atypical squamous cells. A second NCI
cytology has the added advantage of eliminating human er-
consensus meeting in 1991 resulted in the refinement of
rors responsible for thick, unsatisfactory smears and poor
diagnostic terminologies, specifically in reference to “Atyp-
fixation. The specimen must be accompanied by forms that
ical Squamous Cells” (ASC); this subsequently led to the
are adequately filled out with pertinent clinical data. The
third NCI-sponsored consensus conference in 2001, which
use of an endocervical brush or a brush and spatula pro-
redefined the category of ASC into two broad groups in
duces an adequate specimen in most instances. The use of
an attempt to identify women with high-risk for HSIL and
both sampling devices reduces the chance of an inadequate
to streamline the clinical management process for ASC-US
specimen due to a lack of endocervical/metaplastic cells.
and ASC-H. This was followed by the ASC-US/LSIL Triage
Certain anatomic areas or tissues that were not acces-
Study (ALTS), the results of which focused on the detection
sible to the spatula in the past are now being sampled by the
of oncogenic HPV in the group ASC-US and colposcopy
endocervical brush. These areas include the lower uterine
for ASC-H cases. This formed the basis for recommended
segment and the proximal endocervical canal, which have a
guidelines in 2007 for cervical screening and the algorithm
higher incidence of tubal metaplasia. The sharp bristles of the
for patient management, both of which were modified in
brush reach and sample the depths of the crypts and glands
2009. These new guidelines have raised several issues that
have cast doubts in the minds of the cytopathology com-
munity regarding the future of cervical cytology.
FUTURE OF CERVICAL CYTOLOGY

(CERVICAL-VAGINAL SMEARS)
The recommended guidelines in 2009 by the ASCCP for

cervical cytology have created an uncertainty among cyto-
pathologists and cytotechnologists regarding the routine
screening of cervical cytology and screening programs,
and the future of cytotechnologists’ career. Is the screen-
ing of cervical cytologic preparations being replaced
by HPV altogether? Is increasing the interval (3 years)
Fig. 2.1. Gross photograph of a uterus depicting the endocervix between the screenings too long, particularly in high-risk
with mucosal folds or rugae, ectocervix lined by pearly white opaque individuals? Can the infection contracted in the interim
mucosa, squamocolumnar junction, and lower uterine segment. period be allowed to progress without surveillance? Does
a younger age (less than 21 years) exclude the develop- They are small, undifferentiated (i.e., no appreciable
ment of high-grade lesions? Is colposcopy always reliable? cytoplasm) with a high nuclear/cytoplasmic ratio.
Are the specimens (endocervical curettage and cervical 2. Parabasal Cells: These lie in between primitive cells
biopsies always diagnostic? Are these recommendations and mature squamous cells. They are of intermedi-
cost effective? Is the vaccine going to be effective? Will the ate maturity. Parabasal cells round up on exfoliation.
incidence of HPV infection decline? Their cytoplasm is thick, and the nucleus is central
Answers to all these questions will only be provided with a low nuclear/cytoplasmic ratio.
by future studies on the outcome. 3. Intermediate Type: These are mature cells with thin trans-
parent cytoplasm, polygonal in shape with folded bor-
ders and central round nuclei with granular chromatin.
4. Superficial Squamous Cells: These represent senes-
NORMAL COMPONENTS OF THE FEMALE
cence. The cells are similar to those of the intermediate
GENITAL TRACT AND CHARACTERISTICS
type but with pyknotic nuclei.
OF NORMAL SQUAMOUS AND
GLANDULAR EPITHELIUM Mature squamous cells orient parallel (horizontal polar-
ity) to the basement membrane (or to the lumen of the vis-
cera or the surface (i.e., skin). Primitive or basal cells lie per-
CHARACTERISTICS OF NORMAL STRATIFIED pendicular (vertical polarity) to the basement membrane.
SQUAMOUS EPITHELIUM General features shared by squamous cells (Figs. 2.3
The stratifi ed squamous epithelium consists of various and 2.4) include the following:
layers (Fig. 2.2). ● Those lying on the surface exfoliate singly.
1. Primitive (Basal; Germinal Cell): These cells lie on the ● Nucleus is centrally located.
basement membrane and are not normally exfoliated. ● Nuclear is chromatin granular.
Fig. 2.2. Histologic section of the cervix showing nonkeratinizing

stratified squamous epithelium lining the ectocervix, squamoco-
lumnar junction, and endocervix lined by a single layer of mucin-
producing columnar epithelium (H&E).
Fig. 2.3. A conventional cervical smear containing superficial and Fig. 2.4. A liquid-based preparation showing superficial and inter-
intermediate type squamous cells and a honeycomb sheet of normal mediate type squamous cells and a honeycomb sheet of normal en-
endocervical glandular epithelium. docervical glandular epithelium.
TABLE 2.1 MORPHOLOGIC FEATURES OF SQUAMOUS CELLS
Primitive Cells Superficial

(Basal Cell) Parabasal Metaplastic Intermediate Squamous
Cell Size
Diameter (␮m) 8–10 15–20 15–20 30–60 40–60
Area (␮m²) 125 642 492 1256
Shape Round to oval Round to oval Round to oval Polygonal Polygonal
Amount of Cytoplasm Scant Modest Modest, dense Abundant, pale clear Abundant, pale clear
Cytoplasmic Stain Cyanophilic Cyanophilic Cyanophilic Cyanophilic or Eosinophilic

eosinophilic
Keratohyaline Granules None None None ⫹/⫺ ⫹/⫺
Nuclear to Cytoplasmic Ratio
In diameter (␮m) 7–9 8–13 8–13 10–12 5–7
In area (␮m²) 50 35 50 36 15
Shape Round to oval Round to oval Round to oval Round Round
Chromatin Coarsely granular Granular Granular Granular Pyknotic, dense
Nucleolus Absent Absent ⫹/⫺ Absent Absent
● Nucleolus is absent. ● The shape is symmetrically columnar with a broad

● Low nuclear/cytoplasmic ratio. luminal end and a narrow basal end.
● Cell death by pyknosis. ● The nucleus resides at the narrow end.
● Abundant cytoplasm. ● The nucleus is round to oval, with finely granular
● Cytoplasm dense in parabasal (metabolically active) chromatin.
cells. ● Micronucleoli are frequent.
● Cytoplasm uniformly thin and transparent in mature ● The cytoplasm is pale, foamy, or flocculent.
squamous cells. ● Cytoplasmic secretions may be seen.
● Well-defined cell borders. ● Tissue fragments of columnar epithelium when seen “en
● Keratohyaline granules may be present. face” present a honeycomb pattern with well-defined cell
borders, central nuclei regularly arranged in relationship
A list of morphologic features of squamous cells is
to other cells, and a modest amount of cytoplasm.
presented in Table 2.1.
● Tissue fragments of columnar epithelium seen “on end”
appear as strips with a luminal border, cells lined up in par-
CHARACTERISTICS OF NORMAL
allel, with nuclei presenting a palisading arrangement.
ENDOCERVICAL GLANDULAR EPITHELIUM
● Tissue fragments of pseudostratifi ed columnar epithe-
The endocervical canal is lined by a single layer of mucin- lium (tubal metaplasia) appear syncytial (crowded and
producing columnar epithelium, which extends into the overlapped) due to nuclei placed at different levels.
underlying simple glands; these glands are lined by a simi-
lar epithelium. The columnar cells are oriented perpendic- ENDOMETRIAL CELLS
ular to the basement membrane (i.e., they present vertical
Normal endometrial cells exfoliate during the menstrual
polarity) (Figs. 2.5 and 2.6A to C):
cycle and up to 12 to 14 days following the onset (Figs.
● Columnar cells exfoliate either singly or in tissue 2.7A to C). Endometrial cells are described in more detail
fragments. in Chapter 4.
Fig. 2.5. A conventional cervical smear showing a tissue fragment

of normal endocervical glandular epithelium presenting a honey-
comb arrangement of cells with nuclei centrally spaced, maintaining
polarity, well-defined cell borders, finely granular evenly distributed
chromatin and micronucleoli and pale cytoplasm.
A B
C D
Figs. 2.6A to D. Liquid-based preparations. A: Tissue fragment of normal endocervical glandular epithelium presenting
a honeycomb arrangement of cells with nuclei centrally spaced; maintaining polarity; well-defined cell borders; finely
granular, evenly distributed chromatin and micronucleoli; and pale cytoplasm. B: A strip of endocervical glandular
epithelium showing palisading of nuclei. C: Columnar endocervical cells. D: A tissue fragment of normal endocervical
glandular epithelium presenting a honeycomb arrangement of cells with nuclei centrally spaced; maintaining polarity;
well-defined cell borders; finely granular, evenly distributed chromatin and micronucleoli; and pale cytoplasm.
A B
Figs. 2.7A to C. Conventional smears A, B: normal endometrial

C cells. C: liquid-based preparation. Normal endometrial cells.
SQUAMOUS METAPLASIA TABLE 2.2 METAPLASTIC SQUAMOUS CELLSa

Squamous metaplasia of the endocervical glandular epi- Presentation Generally in large numbers; isolated;
thelium is a physiologic process occurring in all women. It loosely cohesive groups or in sheets; cells
reflects the change in functional differentiation of columnar attached to each other by processes
epithelium to the nonkeratinizing squamous epithelium.
This process of alteration in functional differentiation is Cell Size Variable, small (immature cells)
reflected in the cytoplasm and not the nucleus. Table 2.2 resembling the histiocytes to the size of
lists the characteristics of metaplastic squamous cells. parabasal 15–20 ␮m diameter
The first indication of a metaplastic reaction is the
appearance of a single layer of primitive cells between the Cell Shape Round, oval, triangular, caudate or
tadpole forms
basement membrane and the columnar cells (Fig. 2.8A).
These multiply to form several layers (Fig. 2.8B), and as
Cell Borders Poorly defined in immature forms; well-
they mature, they begin to show squamous differentiation
defined in more mature cells
by acquiring more cytoplasm (Figs. 2.8C and D). The co-
lumnar cell layer may be retained superficially; however, Nucleus Slightly larger than the intermediate
it eventually sloughs off. The metaplastic epithelium— cell nucleus, finely granular, evenly
when it assumes full maturation—cannot be differenti- distributed chromatin; smooth nuclear
ated from the native stratified squamous epithelium. membrane; nucleolus ⫹/⫺
The cells shed from or scraped off of a very imma-
ture metaplastic reaction may contain prominent nucle- Cytoplasm Pale lacy to dense, biphasic staining ⫹/⫺;
oli. Their cytoplasm is pale, lacy, with a slight increase cytoplasmic processes (spider forms);
in the nuclear/cytoplasmic ratio (Figs. 2.9A to E). Their occasionally vacuolated
cell borders are generally well-defined. Metaplastic cells a
The metaplastic squamous cells should be considered as squamous cells
are often attached to each other by processes (Fig. 2.9D). of intermediate maturity (comparable to native parabasal cells).
SQUAMOUS METAPLASIA
A B
C D
Figs. 2.8A to D. Process of squamous metaplasia. A: The first event is the appearance of a subcolumnar layer of primi-
tive cells (arrows) (H&E). B, C: The primitive cells proliferate, enlarge, acquire cytoplasm, and begin to demonstrate
squamous differentiation. D: At this point, the metaplastic squamous cells resemble parabasal cells; in other words,
they represent squamous cells of intermediate maturity. The latter will eventually fully mature and cannot be differenti-
ated from the native mature squamous epithelium.
A B
Figs. 2.9A to B. Conventional smears. Cytologic spectrum of metaplastic squamous cells. A, B, C: Immature metaplas-
tic cells in various stages of development. Note that immature metaplastic cells have scant cytoplasm with high N/C
ratios and can be easily mistaken for high-grade lesions. However, their nuclei are uniform with compact chromatin.
(continued)
C D
Figs. 2.9C to E. (continued) D: Fully developed metaplastic cells

containing well-defined cell borders, abundant dense cytoplasm.
The cytoplasmic processes resulted from forcible removal of the
cells and are referred to as spider cells. E: Liquid-based preparation.
E Metaplastic squamous cells (arrow) in liquid based preparation.
The variable cytoplasm is often dense and cyanophilic duce maturation to intermediate cells. Such an epithelium
and occasionally exhibits biphasic staining characteris not prone to infl ammation. This pattern is referred to
istics. Small vacuoles may be present in the immature as estratrophy. In the absence of both estrogen and pro-
metaplastic cells. These are often misinterpreted as either gesterone, the epithelium becomes thin and atrophic, and
endometrial stromal cells, histiocytes, or even endocervi- maturation stops at the parabasal level. This pattern is
cal glandular cells. referred to as teleatrophy. The atrophic mucosa is dry and
more vulnerable to inflammation (Figs. 2.10 to 2.13).
ENDOCRINE STATUS
CELLULAR CHANGES IN ATROPHY
The stratified squamous epithelium of the vagina—and to
BACKGROUND
some extent, the cervix—is hormonally responsive. Estro-
gen induces the maturation of the stratified squamous In the absence of both estrogen and progesterone, the
epithelium into intermediate and superficial layers before stratified squamous epithelium of the cervix and vagina
exfoliation. undergo atrophic changes with a lack of maturation. The
The squamous epithelium of the vagina is also prolif- atrophic mucosa remains dry and more prone to infection.
erative under the influence of progesterone, but the matu- The cervical–vaginal smear shows a cellular pattern that is
ration progresses only to the intermediate cell level. Thus, characterized by atrophic parabasal cells with cellular and
during the reproductive stage of life, the vaginal smear will inflammatory debris in the background (Table 2.3; Figs.
contain predominantly superficial cells during the follicu- 2.10 to 2.13). The squamous cells may exhibit varying
lar phase and intermediate cells during the luteal phase. degrees of atypia that cause diagnostic difficulties. The dry
In pregnancy and postpartum or during lactation, the atrophic mucosa results in inherent drying artifacts. The
smear generally shows a predominance of intermediate squamous cell nuclei are often enlarged with pale smudgy
cells and parabasal cells respectively. chromatin. Pleomorphic shapes and sizes with nuclear
During childhood or in the postmenopausal period, enlargement mimic intraepithelial and invasive lesions.
the lack of estrogen results in atrophic patterns. The pres- The topical or parental administration of short-term
ence of progesterone in postmenopausal patients will in- estrogen therapy will induce the maturation of the lining
Fig. 2.10. Conventional smear. Atrophic smear consisting of only

parabasal cells.
A B
Figs. 2.11A and B. Liquid-based preparations. A: Atrophic smear showing several tissue fragments of squamous epithe-
lium of intermediate and parabasal type. B: Atrophic smear with a lack of maturation.
TABLE 2.3 CYTOPATHOLOGIC FEATURES OF THE epithelium. The repeat smear will be clean, and the atypia if
ATROPHIC CERVICAL–VAGINAL SMEAR due to atrophy will disappear, while that due to squamous
intraepithelial lesion or carcinoma will be better visualized.
Variable cellularity
Miniature polygonal to round squamous cells with HYPERKERATOSIS AND PARAKERATOSIS

orangeophilic cytoplasm and dot-like pyknotic nuclei (red
atrophy or pseudoparakeratosis The normally nonkeratinizing stratified squamous epi-
thelium of the ectocervix and the vagina undergo hyper-
Parabasal cells with nuclear enlargement and pale, smudgy plasia in response to chronic inflammation or injury. The
chromatin epithelium may thicken with elongation and widening of
Occasional intermediate cells with binucleation or the rete pegs and undergo hyperkeratosis with layers of
multinucleation acellular keratin overlying the prominent granular cell
layer. Parakeratosis retains pyknotic nuclei in the superfi-
Pleomorphic forms with nuclear enlargement; smudgy, pale cial layers of squamous cells, including miniature forms.
to hyperchromatic nuclei In cytologic samples, hyperkeratosis is seen as masses
of acellular keratin and anucleated squames. Parakerato-
Tissue fragments of atrophic parabasal epithelium
sis is represented by hyperkeratinized mature squamous
Bare nuclei with smudgy chromatin cells with pyknotic nuclei.
Hyperkeratosis and parakeratosis are common in a
Blue blobs cervix with uterine prolapse. This type of surface reaction
may also be present in cases of squamous intraepithelial
Estrogen effect—none
lesions or invasive cancers (see Chapter 3). The underlying
Fig. 2.12. Conventional smear. Atrophic smear with only cellular Fig. 2.13. Liquid-based preparation of an atrophic smear contain-
debris, lacking any epithelial cells. There are fair numbers of varying- ing blue blobs.
sized globular dense-staining structureless bodies referred to as
“blue blobs.” They may be mistaken for pyknotic nuclei of malig-
nant squamous cells or psammoma bodies.
disease process may not be evident in the samples obtained PREGNANCY-ASSOCIATED CHANGES
by routine methods.
Cytologic changes identified in cervical–vaginal smears
from patients during pregnancy or postabortal/postpartum
NORMAL MICROBIOLOGIC FLORA AND states are varied. They can be specific as well as nonspecific
COMMON INFECTIONS (Table 2.7; Figs. 2.14 to 2.18).
The nonspecific changes are almost always present, with
The normal vaginal cavity harbors several types of micro-
the exception of hematoidin crystals (hematoidin cockle-
organisms under normal conditions. These are not patho-
burs), which are seen in roughly 3% of pregnant patients.
genic and do not cause symptoms. The most common
Hematoidin crystals (Figs. 2.15A and B) result from the
microorganisms are lactobacilli, which are present in
breakdown of red blood cells, releasing brownish-yellow
women in the reproductive age group. Other organisms
hematoidin pigment that is then surrounded by inflamma-
include Gardnerella vaginalis and bacteroides.
tory cells. These are occasionally seen in malignancies. The
The vagina is also prone to several types of infections.
specific changes of pregnancy include the occasional pres-
The more frequent ones are listed in Table 2.4 and illus-
ence of syncytial and cytotrophoblasts, decidual cells, and
trated in e-Figures 2.1 to 2.10.
endocervical glandular cells with Arias-Stella-like reaction
(Tables 2.7 and 2.8).
BENIGN CELLULAR CHANGES
Decidua
Benign cellular changes in squamous and glandular epi-
thelium can occur due to a multitude of causes (Tables 2.5 Cervical stroma may be decidualized during pregnancy. If the
and 2.6; e-Figs. 2.11 to 2.22). These changes depend on the overlying epithelium is ulcerated, decidua will be scraped off
etiologic factor, the intensity, and the duration of the stimulus and be present in the cervical-vaginal smear. The decidual
or injury. The changes can be reactive, regenerative, hyper- cells are generally few in number and occur singly or in small
plastic, or of a degenerative type resulting in cell damage groups (Fig. 2.16). They are polygonal with well-defined
or death. The same etiologic features that cause prolifera- cell borders, abundant pale cytoplasm, a central round
tive or reactive/regenerative change may cause degeneration. nucleus, and are about—two to three times the size of an
Inflammatory response is common to all types of injuries. entire neutrophil. The nuclear chromatin is generally pale,
Some may be specific, while others are nonspecific. Etiologic bland with one or more nucleoli; occasionally the nuclei
agents may be identified by virtue of their morphologic are deep-staining with smudgy chromatin. These cells may
characteristics or by the cellular changes induced by them. be mistaken for low-grade squamous intraepithelial lesions
The importance of recognizing these benign cellular (see Chapter 3). However, the presence of a nucleolus favors
changes lies in the fact that they may be misinterpreted as decidual origin rather than intraepithelial neoplasia.
either precursor or malignant lesions. The most frequent-
Trophoblasts
ly observed benign cellular changes are listed in Table 2.6.
For detailed information, the reader is referred to com- The occurrence of syncytiotrophoblasts or cytotropho-
prehensive literature on the subject. blasts in a cervical–vaginal smear is a rare event. They
TABLE 2.4 NORMAL VAGINAL FLORA AND COMMON INFECTIONS
Clinical Features Cytopathologic Features See Fig(s).
Döderlein Bacilli Normal flora representing multiple Delicate rods, singly and in pairs; cytolysis of e-Fig. 2.1
strains of lactobacilli, nonmobile intermediate cells; bare nuclei; no inflammatory
anaerobic, non-spore-forming gram response
positive; maintain acidity of the vagina
(pH 3–4.2) by converting cytoplasmic
glycogen into lactic acid
Coccoid Gram positive, coccoid bacteria in Background dirty gray-blue; granular; inflammation
Bacteria alkaline pH; up to 30% are streptococci
Gardnerella Caused by Gardnerella vaginalis; small Superficial squamous cells totally covered by bacilli— e-Figs.
Vaginalis gram variable bacillus; superficial referred to as “clue” cells; cytolysis absent 2.2A and
vaginitis; do not invade living tissue; B
40% asymptomatic
Chlamydial Most common sexually transmitted Affects metaplastic or glandular cells, frequent e-Fig. 2.3
Infection/ disease, causes urethritis, vaginitis, multinucleation; diffuse acidophilic or cyanophilic
Chlamydia cervicitis, including lymphofollicular coccoid granularity; single to multiple cytoplasmic
Trachomatis cervicitis; pelvic inflammatory inclusions 1–2 ␮m; multiple, often molded cyanophilic
disease (PID), is the frequent cause of inclusion bodies, surrounded by a clear zone mixed
infertility, transmitted to newborn with diffuse acidophilic coccoid particles in cytoplasm;
follicular cervicitis; correlation of morphologic patterns
with other confirmatory methods is poor
Candida Most commonly observed fungal Yeast forms with budding 3–6 ␮m or delicate filaments e-Figs.
Albicans infection of the lower genital tract; 3% with pseudoseptate forms, acute branching, organisms 2.4A and
of women asymptomatic; thick vaginal intracellular or extracellular; inflammation ⫹/⫺ B
discharge
Herpes Simplex Sexually transmitted, cervical–vaginal Squamous and glandular cell involvement; cytomegaly, e-Figs.
Virus involvement may be asymptomatic, multinucleation; molded nuclei, ground glass 2.5A to C
vulvar involvement intensely painful appearance; intranuclear inclusions; perinuclear
blisters/shallow ulcers clearing; inflammation; immuno confirmation
Cytomegalovirus Usually in immunocompromised Endocervical glandular cell with large intranuclear e-Fig. 2.6
patients basophilic inclusion separated by cleared areas; nuclear
membrane thickened
Molluscum Usually seen in vulva only, rarely seen Large acidophilic intracytoplasmic inclusions in e-Fig. 2.7
Contagiosum in cervical–vaginal smears squamous cells; nuclei compressed and indistinct
Trichomonas Parasites; flagellate; common cause Small pear-shaped structures 10–25 ␮m in diameter; e-Figs.
Vaginalis of vaginitis; may be asymptomatic; faint gray or pink, red granularity; small eccentric pale- 2.9A and
itching, thin discharge staining nucleus; intense inflammation, neutrophils B
covering the squamous cells, flagella identified on wet-
mount only—associated with Leptothrix
Leptothrix Non-pathogen Filamentous rod-like bacilli, often associated with e-Fig.

trichomonads 2.9A
Actinomyces Non-mobile, non-spore forming Actinomyces—as dense basophilic balls, composed e-Figs.
anaerobic, gram positive, irregularly of delicate filamentous organisms with branching at 2.8A and
staining filamentous bacteria acute angles; may be associated with degraded material B
originating from the IUD
Entamoeba Rare (1% of IUD users) A protozoan often associated with actinomyces sp.; e-Fig.
Gingivalis a histiocyte type unicellular organism with ingested 2.10
fragments of leukocytic nuclei and cellular debris; do
not contain intracytoplasmic red blood cells unlike
entamoeba histolytica
41
TABLE 2.5 ETIOLOGY OF NONNEOPLASTIC EPITHELIAL CHANGES

(BENIGN CELLULAR CHANGES)
I. Drying Artifacts
Poor Fixation
Atrophy in Postmenopausal Women
II. Reactive/Regenerative Changes in Response to Various Types of Stimuli

Infections: Bacterial, Fungal, Viral, Protozoan
Trauma: Pregnancy, Post-Partum, Post-Instrumentation (Biopsy, Laser, Cautery)
Mechanical Irritation: IUD, Diaphragm, Pessary, Tampon, Foreign Body
III. Degenerative or Retrogressive Changes

Infections: Bacterial, Fungal, Viral, Protozoan
Trauma: Pregnancy, Post-Partum, Post-Instrumentation (Biopsy, Laser, Cautery)
Mechanical Irritation: IUD, Diaphragm, Pessary, Tampon, Foreign-Body
Ionizing Radiation
Chemical: Chemotherapy, Gels, Foams, Douches
IV. Alterations Due to Hormones

Oral Contraceptives
Pregnancy, Postpartum, Breastfeeding
Postmenopause
TABLE 2.6 BENIGN CELLULAR CHANGES

Inflammation Very common occurrence, see Admixture of superficial, intermediate, parabasal cells; e-Figs.
Associated Table 2.5 neutrophils covering squamous cells forming ball-like 2.15A to
Changes structures (cannon ball); neutrophilic debris; dirty background; 2.19
squamous cells; with mild nuclear enlargement; smudgy,
pale chromatin; micronucleoli ⫹/⫺; orangeophilic, slight
perinuclear clearing; frayed cytoplasm; endocervical glandular
cells with nuclear enlargement; prominent nucleoli; increased
cytoplasmic secretions; associated with repair/regeneration
Repair/ Very common occurrence, see Cells in two-dimensional sheets; single cells infrequent; e-Figs. 2.12
Regeneration Table 2.5 cell borders well-defined; low N/C ratios; nuclei round, and 2.13
slightly enlarged, smooth nuclear membrane; finely granular
chromatin; multiple micronucleoli/macronucleoli, may be
irregular; mitoses frequent; cytoplasm abundant, pale to
dense; may be permeated by neutrophils
Follicular Presence of lymphoid follicles Polymorphic lymphoid cells with germinal center cells; e-Figs.
(Lymphocytic) with germinal centers in tingible body histiocytes; inflammatory background; 2.11A
Cervicitis cervical stroma; 50% of cases capillaries traversing through the lymphoid aggregates and B
are associated with chlamydial
infections; also present frequently
in atrophic smears
Intrauterine Seen in patients with long-standing Actinomyces—as dense basophilic balls, composed of delicate e-Figs.
Device (IUD) use of IUD; (A) genital tract filamentous organisms with branching at acute angles; 2.14A to C
Associated infections—Actinomyces in 13– inflammation; cellular changes; reactive endometrial and
Changes 22% of IUD users; non-mobile, endocervical cells; large bubble gum vacuoles; granulomatous
non-spore forming anaerobic, inflammation; metaplastic squamous cell with atypia; bizarre
gram positive, irregularly staining cells with marked nuclear atypia; calcification; disintegrated
filamentous bacteria; entamoeba material from IUD
gingivalis rare (1% of IUD users);
(B) cellular changes
(continued)

Radiation Internal (intracavitary) or external Acute—fine to large vacuolization of the cytoplasm; first in e-Figs. 2.20
Induced radiation; acute effects occur basal/parabasal cells then in intermediate and superficial to 2.22
Changes within days; late changes may cells; cytomegaly/karyomegaly with normal N/C ratio;
persist for a longer period of time multinucleations; wrinkling of nuclear membrane;
pleomorphic shapes; cellular and amorphous debris;
nuclear vacuoles; leukophagocytosis; finely vacuolated
cytoplasm; smudged nuclear chromatin.
Late—repair/regenerative changes; persistence of acute
changes; biphasic cytoplasmic staining; multinucleation;
pale, smudgy nuclei; low N/C ratio
may be present in the first or third trimester as well as in tin is fi nely granular or compact, and nucleoli are rare
post abortion and postpartum periods. (Fig. 2.14).
Syncytiotrophoblasts vary in size and shape with a Cytotrophoblasts are only rarely recognized. They are
mean cell area of 500 ␮m2. They have abundant dense round with well-defined cell borders and contain hyperchro-
cytoplasm and may contain from 4 to over 200 uniform, matic irregular nuclei. The trophoblasts show positive immu-
overlapped, but not molded nuclei. The nuclear chroma- noreactivity to human chorionic gonadotropin antibodies.
Pregnancy-Associated Changes (See Figs. 2.14 to 2.18)
Fig. 2.14. Conventional smear from a pregnant woman in her first

trimester, showing a multinucleated syncytiotrophoblast.
A B
Figs. 2.15A and B. A: Conventional smear showing bright orange hematoidin crystals surrounded by histiocytes and
are referred to as “hematoidin cockleburs.” B: Liquid-based preparation showing hematoidin crystals.
Arias-Stella Reaction-Like Changes in Endocervical of the hyperplastic lining of the epithelium of endometrial
Glandular Epithelium in Cervical Smears during glands with intraluminal tufting. The cells are hypertrophic
Pregnancy and Postpartum States with voluminous clear to pale eosinophilic cytoplasm, large
Arias–Stella reaction (ASR) represents an exaggerated hyperchromatic nuclei with altered polarity, smudgy chro-
cytonuclear change involving the gestational endometrium. matin, and irregular nuclear membranes. A hobnail pattern
It is hormonally related and associated with intrauterine with large nuclei protruding into the lumen is frequent. ASR
or extrauterine pregnancy or trophoblastic disease. The may also be seen in the glandular epithelium of the cervix,
hormones involved are probably chorionic gonadotropin, fallopian tube, endometriosis, or vaginal adenosis. These
estrogen, and progesterone. Histologically, ASR consists changes regress following termination of the pregnancy.
Fig. 2.16. Conventional smear. History of pregnancy. These large

round to polygonal cells with central large bland nuclei probably
represent decidual cells.
A B
Figs. 2.17A and B. Conventional smears. Endocervical glandular atypia (inflammation associated changes).
A B
Figs. 2.18A to B. ASR-like changes. A, B, C: Conventional smear from a pregnant woman. Markedly atypical changes involving endocervi-
cal glandular cells mimicking adenocarcinoma. Note high N/C ratios, prominent nucleoli, and pleomorphism. (continued)
C D
Figs. 2.18D. (continued) D: Liquid-based preparation showing markedly pleomorphic, enlarged endocervical glandular cells in a pregnant
woman. (Courtesy of Dr. Mariza de Peralta-Venturina, Cedar-Sinai Hospital, Los Angeles, California.)
TABLE 2.7 PREGNANCY-ASSOCIATED CHANGES TABLE 2.8 CYTOPATHOLOGIC FEATURES

OF ARIAS-STELLA REACTION-LIKE CHANGES
Specific Nonspecific
Presentation Cells isolated, in aggregates, and in tissue
Decidua Low estrogen effect
fragments with crowded and overlapped nuclei
Syncytiotrophoblasts and Inflammation
cytotrophoblasts Cells Variable; small to large
Arias-Stella-like reaction Reactive/reparative changes Nuclei Round to oval with marked variation in
involving glandular epithelium Hematoidin crystals size with giant forms; N/C ratio variable,
generally high; chromatin granular, often
smudgy, ground glass appearance, intranuclear
inclusions and prominent nuclear grooves;
The ASR-like changes involving endocervical glandu- single/multiple macronucleoli/micronucleoli
lar epithelium are sometimes observed in cervical smears
taken during pregnancy or the immediate post abortion/ Cytoplasm Variable, scant to abundant; vacuolated,
postpartum period. However, these changes have never pale to dense; leukophagocytosis
been confi rmed histologically. Repeat smears tend to be
negative. Background Generally inflammatory; other pregnancy
Cytologic changes suggestive of ASR-like changes associated changes such as repair/
regeneration; hematoidin crystals
are quite striking and very alarming (Table 2.8; Figs.
2.17 and 2.18), representing a potential diagnostic pit-
Differential Squamous and endocervical adenocarcinoma
fall. The differential diagnoses include repair, endocervi- Diagnoses The cellular changes regress upon
cal adenocarcinoma, and poorly differentiated squamous termination of the pregnancy
carcinoma.
SUGGESTED READINGS
Benoit JL, Kini SR. “Arias-Stella” reaction-like changes in endocer- Koss LG, Melamed MR, eds. Koss’ Diagnostic Cytology and Its
vical glandular epithelium in cervical smears during pregnancy Histopathologic Bases. 5th ed. Philadelphia: Lippincott Wil-
and postpartum states—A potential diagnostic pitfall. Diagn liams & Wilkins, 2005.
Cytopathol 1996;14:349–355. Papanicolaou GN. New Cancer Diagnosis. In: Proceedings The
Bibbo M, Wilber DC, eds. Comprehensive Cytopathology. 3rd ed. Third Race Betterment Conference; 1928:528–534; Battle
Philadelphia: Saunders, 2008. Creek, MI: Race Betterment Foundation.
Cox JT, Moriarty AT, Castle PL. Statement on HPV DNA test utili- Solomon D, Nayar R, eds. The Bethesda System for Reporting
zation, commentary. Acta Cytol 2009;53:249–252. Cervical Cytology: Definitions, Criteria and Explanatory Notes.
Frost JK. The cell in health and disease. In: Ward GL, ed. Mono- 2nd ed. New York: Springer, 2004.
graphs in Clinical Cytology. 2nd ed. New York: S Karger, 1986.
Gupta PK, McGrath C. Microbiology, inflammation, and viral
infections. In: Bibbo M, Wilber DC, eds. Comprehensive Cyto-
pathology. 3rd ed. Philadelphia: Saunders, 2008.
APPENDIX
THE BETHESDA SYSTEM 2001
SPECIMEN TYPE the general categorization above and/or in the interpreta-

tion/result section of the report, whether or not there are
organisms or other nonneoplastic findings)
Indicate conventional smear (cervical-vaginal smear) ver-
sus liquid-based versus other.
ORGANISMS
● Trichomonas vaginalis
SPECIMEN ADEQUACY ● Fungal organisms morphologically consistent with
Candida spp
● Shift in flora suggestive of bacterial vaginosis
● Satisfactory for evaluation (describe presence or absence
● Bacteria morphologically consistent with Actinomyces
of endocervical/transformation zone component and
spp
any other quality indicators [e.g., partially obscuring
● Cellular changes consistent with herpes simplex virus
blood, inflammation, etc.].)
● Unsatisfactory for evaluation (specify reason) Other nonneoplastic findings (optional to report; list not
• Specimen rejected/not processed (specify reason) inclusive):
• Specimen processed and examined but unsatisfac-
● Reactive cellular changes associated with
tory for evaluation of epithelial abnormality because
• inflammation (includes typical repair)
of . . . (specify reason)
• radiation
• intrauterine contraceptive device (IUD)
● Glandular cells status post hysterectomy
GENERAL CATEGORIZATION (OPTIONAL) ● Atrophy
● Other
● Negative for intraepithelial lesion or malignancy ● Endometrial cells (in a woman ⬎40 years of age)
● Epithelial cell abnormality: See interpretation/result (Specify if “negative for squamous intraepithelial
(specify “squamous” or “glandular” as appropriate) lesions”)
● Other: See interpretation/result (e.g., endometrial cells
in a woman ⱖ40 years of age) EPITHELIAL CELL ABNORMALITIES
Squamous Cell
AUTOMATED REVIEW
● Atypical squamous cells
• of undetermined significance (ASC-US)
If case is examined by an automated device, specify the • cannot exclude HSIL (ASC-H)
device and result. ● Low-grade squamous intraepithelial lesion (LSIL)
encompassing: HPV/mild dysplasia/CIN 1
● High-grade squamous intraepithelial lesion (HSIL)
ANCILLARY TESTING encompassing: Moderate and severe dysplasia, CIS/
CIN 2 and CIN 3
• with features suspicious for invasion (if invasion is
Provide a brief description of the test methods and report suspected)
the result so that it is easily understood by the clinician. ● Squamous carcinoma
Glandular Cell
INTERPRETATION/RESULT ● Atypical
• endocervical cells (NOS or specify in comments)
Negative for intraepithelial lesion or malignancy (when • endometrial cells (NOS or specify in comments)
there is no cellular evidence of neoplasia, state this in • glandular cells (NOS or specify in comments)
● Atypical Other Malignant Neoplasms: (specify)

• endocervical cells, favor neoplastic
• glandular cells, favor neoplastic
● Endocervical adenocarcinoma in situ
EDUCATIONAL NOTES AND
● Adenocarcinoma
SUGGESTIONS (OPTIONAL)
• endocervical
• endometrial Suggestions should be concise and consistent with clinical fol-
• extrauterine low-up guidelines published by professional organizations.
• not otherwise specified (NOS) (References to relevant publications may be included.)
3 SQUAMOUS LESIONS*
● Squamous intraepithelial lesions (SIL)

INTRODUCTION
• Low-grade squamous intraepithelial lesions (LSIL)
• High-grade squamous intraepithelial lesions (HSIL)
The squamous lesions of the uterine cervix and vagina ● Squamous carcinoma
span a wide spectrum of cellular changes, ranging from
Since its introduction in 1988, ASCUS emerged as
benign alterations to preneoplastic (precursor) and neo-
the most confusing and controversial issue in gynecologic
plastic processes. The benign proliferative, reactive, or
cytopathology. It was modifi ed in 1991, and once again,
degenerative changes that have no bearing on cervical
it turned into a major diagnostic dilemma. The 2001 TBS
carcinogenesis have been described in Chapter 2. Cellular
redefi ned the category of ASC into two subcategories,
changes that do not qualify as premalignant or precur-
namely, ASC-US and ASC-H. The concept of atypical
sor lesions but are more than those seen in benign reac-
squamous cells and their differential diagnoses require
tions are grouped into a category designated as “Atypical
the understanding and knowledge of intraepithelial and
Squamous Cells” by The Bethesda System (TBS).
invasive squamous lesions. Hence, the latter categories
The squamous preneoplastic lesions are variably
are discussed fi rst, followed by the cytologic features of
termed as dysplasia, cervical intraepithelial neoplasia
ASC-US and ASC-H.
(CIN), and more recently, as squamous intraepithelial le-
The areas of potential diagnostic problems in the
sions by TBS. The precursor lesions are so named because
cytopathologic evaluation of squamous cell lesions of the
studies have shown that a certain number of squamous
cervix include the following:
intraepithelial lesions, if left untreated, progress into higher
grades and into invasive malignancy. However, there are ● Grading squamous intraepithelial lesions.
no objective means of predicting this type of behavior for ● Differentiating benign nonneoplastic cellular changes
any given case. from all squamous lesions (i.e., atypical, intraepithelial,
Prior to TBS (1988), human papilloma virus (HPV) and invasive).
changes involving the squamous epithelium were reported ● Recognizing high-grade squamous intraepithelial lesions
using multiple diagnostic terms such as condyloma, con- in various settings.
dylomatous atypia, atypical condyloma, or squamous ● Recognizing high-grade intraepithelial lesions or
atypia, to name only a few. Since the etiologic relationship squamous carcinoma when only a few (but diagnostic)
of HPV in cervical carcinogenesis has been established, abnormal cells are present.
these changes are included in the category of low-grade ● Interpreting cellular alterations in the background of
squamous intraepithelial lesions. atrophy and their differentiation from squamous cell
The Bethesda System 2001 classification of squamous lesions.
epithelial lesions includes the following: ● Interpreting keratinizing lesions.
● Defining the diagnostic category of ASC and differenti-
● Atypical squamous cells (ASC)
ating ASC from intraepithelial and invasive squamous
• Atypical squamous cells of unknown significance
lesions.
(ASC-US)
• Atypical squamous cells, cannot exclude high-grade
lesions (ASC-H)
SQUAMOUS INTRAEPITHELIAL LESIONS
*Note: The following images in this chapter are the courtesy of Ms.
Karen Atkinson, MPA, CT (ASCP), CMIAC, Director of Education
and Training, BD Diagnostics-Women’s Health and Cancer, and Mr. As defined by TBS, squamous intraepithelial lesions
Tim Collins, BS, CT (ASCP), Senior Scientist, Research and Devel- encompass a spectrum of noninvasive abnormalities of the
opment, BD Diagnostics-Women’s Health and Cancer: Figures 3A,
5A, 6, 10, 15A to 15C, 19A to 19C, 23, 28, 29, 32, 41B, 42A and stratified squamous epithelium, variably known as condy-
42B, 44A to 44C, 45A and 45B, 48A and 48B, 53, 64D to 64F, 71, loma, dysplasia/carcinoma in situ, and cervical intraepi-
89A and 89B, 98A to 98G. thelial neoplasia (CIN).
48
Chapter 3: Squamous Lesions 49
TABLE 3.1 TERMINOLOGY FOR THE PRECURSOR abnormal shapes represent atypical functional differen-
LESIONS OF CERVICAL SQUAMOUS CARCINOMA tiation. Small dyskeratotic, round cells with excessive
keratinization and high N/C ratios represent prema-
Dysplasia/ Cervical Squamous ture keratinization of moderate to severely dysplastic
Carcinoma Intraepithelial Intraepithelial squamous cells.
In Situ Neoplasia (CIN) Lesion (SIL)
3. The histologic grading is based on the extent of primi-
Mild (slight) CIN I Low-grade tive cell proliferation, while the cytologic grading is
Dysplasia (includes Human dependent on nuclear morphology and the level of dif-
Papilloma Virus ferentiation of the abnormal squamous cells lying on
changes) the surface that are either spontaneously exfoliated or
removed by spatula/brush.
Moderate CIN II High-grade 4. Histologic grading does not correspond with TBS.
Dysplasia Dysplasia and CIN terminologies are still in use.
5. In tissue biopsies, unlike TBS, HPV-associated changes
Severe Dysplasia CIN III High-grade are still reported separately, sometimes as epithelial
atypia or as condyloma.
Carcinoma In Situ CIN III High-grade
LOW-GRADE SQUAMOUS
INTRAEPITHELIAL LESION (LSIL) [MILD
The Bethesda System has attempted to simplify the DYSPLASIA, CERVICAL INTRAEPITHELIAL
categorization by NEOPLASIA (CIN) GRADE I]
1. Subclassifying the squamous intraepithelial lesions into
Histologic Features
two grades—low and high—unlike CIN;
2. Including HPV-associated changes into low-grade These lesions involve the stratified squamous epithelium
lesions; of the portio (e-Fig. 3.1). The mildly dysplastic squamous
3. Including moderate dysplasia into high-grade SIL. epithelium is multilayered with primitive cell proliferation
extending to the inner one-third of the epithelial thickness.
However, the usage of the terms dysplasia and CIN
The nuclei of the primitive cells exhibit vertical polarity;
has been fi rmly established in the practice of cytopathol-
the cell borders are indistinct and may exhibit normal or
ogy and surgical pathology. The Bethesda System is not
abnormal mitoses, and their cytoplasm is indiscernible.
followed in surgical pathology where the category of
The normal maturation sequence is disrupted and orderly
moderate dysplasia or CIN II is still being used. For these
stratification is lost. Although maturation to parabasal
reasons, corresponding terms from different classifica-
and intermediate cells continues to the surface, there is
tions as listed in Table 3.1 are being used in many centers,
a synchronism between cytoplasmic and nuclear matu-
including the author’s laboratory.
ration. The surface is lined by intermediate and superfi-
cial squamous cells with horizontal polarity that contain
large hyperchromatic nuclei with or without binucleation
GRADING SQUAMOUS and multinucleation (e-Figs. 3.2 and 3.3). Keratinization
INTRAEPITHELIAL LESIONS may be present. Features of HPV-associated changes are
often noted.
Intraepithelial lesions are full thickness abnormalities
with squamous cells exhibiting various degrees of differ- Cytopathologic Features
entiation. While grading the lesions from cytologic speci-
The abnormal cells seen in cervical smears represent those
mens, the examiner must bear in mind that
lying on the surface and are intermediate type squamous
1. The level of maturation of squamous cells is deter- cells, mostly present singly, in groups, or in sheets (Table
mined by the functional activity, amount of cyto- 3.2; Figs. 3.1 to 3.3). These cells have well-defined cell
plasm, and the nuclear to cytoplasmic (N/C) ratios. borders, with a centrally located nucleus that is three to
By noting the nuclear size alone, grading may be dif- four times (or more) larger than their normal counterpart.
ficult. The entire cell must be taken into account (see Binucleation and multinucleation may be present, and the
Appendix). cells may be increased in size. The nuclear membrane
2. Metaplastic, dysplastic, and malignant cells represent is smooth to irregular, and the chromatin is granular.
cells in transition and may show atypical functional Nucleoli are absent. The cytoplasm is generally pale and
differentiation. Dyskeratosis (excessive keratinization) transparent but may show keratinization. HPV-associated
of squamous cells, whether mature or immature, and changes are often coexistent.
Fig. 3.1. Conventional smear showing mature intermediate type Fig. 3.2. Conventional smear showing discrete, mature intermedi-
squamous cells containing large nuclei with coarse chromatin, con- ate type squamous cells containing large nuclei with coarse chroma-
sistent with LSIL or mild dysplasia. tin, consistent with LSIL or mild dysplasia.
A B
Figs. 3.3A to C. Liquid-based preparations (SP) showing tissue

fragments of intermediate type squamous cells with enlarged nuclei
C consistent with LSIL.
into two groups—low-risk and high-risk—based on the

HUMAN PAPILLOMA VIRUS (HPV) INFECTION
frequency and association with invasive cancer. The HPV
AND ASSOCIATED CHANGES
types 6, 11, 42, 44, 53, 64, 57, and 66 belong to the low-
HPV infection is a sexually transmitted disease and risk group, while types, 16, 18, 31, 33, 36, 39, 45, 51,
proven to be oncogenic. More than 100 types have been 56, 58, 59, and 68 belong to the high-risk group. HPV
isolated, of which 40 or more types infect the female geni- 16 is the most common type associated with cervical
tal tract. Of these, only a minority cause cervical cancer. squamous cancer, while type 18 is associated with endo-
The virus types that cause genital infection are divided cervical adenocarcinoma. Persistent infection by high-risk
TABLE 3.2 CYTOPATHOLOGIC FEATURES OF LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION,

INCLUDING HPV-ASSOCIATED CHANGES
Low-Grade SIL (Mild Dysplasia CIN I) Low-Grade SIL HPV Associated Changes
Presentation Intermediate type squamous cells; Intermediate type squamous cells; isolated, in
isolated, loose aggregates, and in sheets loose aggregates, and in sheets; clustering more
frequent
Number of Cells Variable Variable
Cytomegaly ⫹/⫺ Frequent
Pleomorphism ⫹/⫺ Frequent
Nucleus
Location Central Central to eccentric
Size Enlarged 3–4 times the normal Enlarged 3–4 times the normal intermediate cell
intermediate cell nucleus or larger nucleus
Chromatin Fine to coarsely granular; hyperchromatin Coarsely granular/smudgy; hyperchromatic
Nuclear Membrane Smooth to irregular Smooth to irregular or wrinkled (raisinoid)
Nucleolus Absent Absent
Nuclear/Cytoplasmic Ratio Slightly increased Slightly increased
Bi-Multinucleation ⫹/⫺ Frequent
Cytoplasm Abundant, pale, transparent; Keratohyaline Sharply cleared area around nucleus;
granules condensation of cytoplasm at the periphery;
distinctive rigid cell border (wire looping)
Keratinization ⫹/⫺ ⫹/⫺
Cellular Borders Well-defined Well-defined
Background Clean Clean
virus may lead to the development of cervical cancer. The the least common presentation. The hallmark of HPV-
presence or absence of HPV infection can be detected by associated change is koilocytosis—marked perinuclear
a variety of molecular diagnostic techniques and now has cytoplasmic clearing with hyperchromatic enlarged
become a routine procedure in the practice of gynecologic nuclei, frequent bi-multinucleation and varying degrees
cytopathology. of keratinization.
Histologic Features Cytopathologic Features

HPV-associated changes are mostly noted in strati- HPV-associated changes are generally seen in inter-
fied squamous epithelium. The lesions are prolifera- mediate type mature squamous cells characterized by
tive, characterized by several morphologic patterns. marked perinuclear clearing of the cytoplasm and are
The majority of the lesions are flat (flat condyloma) referred to as koilocytosis (Table 3.2; Figs. 3.4A and
(e-Fig. 3.3) or show multiple finger-like projections B, 3.5A and B). The cytoplasm of the koilocytes is fre-
with keratinization (spiked) (e-Fig. 3.4A and B). Exo- quently condensed at the periphery. The interface of
phytic papillary growth with or without a peduncle is the cleared cytoplasm and the condensed peripheral
A B
Figs. 3.4A and B. A: Conventional smear showing mature squamous cells with variably enlarged nuclei, surrounded by
cleared cytoplasm with peripheral condensation. The pattern is consistent with HPV-associated changes or LSIL.
B: Low-grade squamous dysplasia, HPV.
A B
Figs. 3.5A and B. A: Liquid-based preparations demonstrating HPV-associated cytologic changes.
cytoplasm imparts a rigid wire loop appearance to the dysplasia and invasive well-differentiated squamous car-
koilocyte. The affected cells may show both cytomegaly cinoma (see Table 3.9).
and karyomegaly with frequent binucleation and multi-
nucleation. The nuclei may be central or eccentric with
granular to clumped chromatin and smooth to irregular
wrinkled nuclear borders, the latter being referred to HIGH-GRADE SQUAMOUS
as a raisinoid nucleus. The abnormal cells are seen sin- INTRAEPITHELIAL LESIONS (HSIL)
gly but are often clustered together. Keratinization and
abnormal pleomorphic forms are frequent (Figs. 3.6A The high-grade squamous intraepithelial lesions include
and B). moderate dysplasia and severe dysplasia/carcinoma in
situ, nonkeratinizing and/or keratinizing types. In the for-
mer category, the higher grade implies less functional dif-
DIFFERENTIAL DIAGNOSES OF
ferentiation (less maturity) and is judged by the amount
LOW-GRADE SQUAMOUS
of recognizable cytoplasm that indicates the squamous
INTRAEPITHELIAL LESIONS (LSIL)
nature of the cell. In moderate dysplasia, the parabasal/
The differential diagnosis of LSIL includes cellular metaplastic cells have appreciable amounts of dense cyto-
changes seen in benign reactive processes as well as plasm and increased N/C ratios. In severe dysplasia, the
changes defi ned by TBS as ASC-US. These are discussed abnormal cells have scant but recognizable cytoplasm,
in the section on ASC (see Tables 3.12 and 3.13). Low- and with in situ cells, the cytoplasm is insignificant or
grade squamous intraepithelial lesions with keratiniza- indiscernible. The spectrum of these changes is seen in
tion should be differentiated from high-grade keratinizing e-Figures 3.5 to 3.10 and Figures 3.7A to C and 3.8.
A B
Figs. 3.6A and B. Conventional smear. A: Keratinizing dysplasia showing squamous cells with varying size, pyknotic nuclei, and kerati-
nized cytoplasm. B: Keratinized squamous cells forming a pearl—a feature often seen in verrucous lesions of HPV.
A B
Figs. 3.7A to C. Conventional smear showing a spectrum of HSIL.

A: Moderate dysplasia. The cells are of intermediate maturity
(parabasal/metaplastic type) with high N/C ratios; dense, moder-
ate amount of cytoplasm and coarsely granular chromatin. B: A
streak of severely dysplastic squamous cells with high N/C ratios
scant but recognizable amount of cytoplasm, and coarsely granular
chromatin. C: Carcinoma in situ cells. These cells are smaller with
very high N/C ratio, scant indiscernible cytoplasm. The nuclei are
pleomorphic in size and deep-staining chromatin. Note that with
increasing grades, the abnormal cells contain decreasing amounts of
C cytoplasm with increasing high N/C ratios.
is generally multilayered. There are more cells per unit area

HIGH-GRADE SQUAMOUS INTRAEPITHELIAL
as compared to the normal counterpart. The primitive cell
LESION (HSIL) [MODERATE DYSPLASIA,
proliferation extends roughly to the middle two-thirds of
CERVICAL INTRAEPITHELIAL NEOPLASIA
the epithelium with ill-defined cell borders, vertical polar-
(CIN) GRADE II]
ity of the nuclei, and frequent normal/abnormal mitoses.
Maturation of the primitive cells proceeds only up to
Histologic Features
the parabasal stage with the cells containing large nuclei
This epithelial alteration is noted in the transitional zone and high N/C ratios (e-Figs. 3.5 and 3.6). Keratinization
and proximally in the endocervical canal. The epithelium may be seen in individual cells at all levels. The surface
Fig. 3.8. Liquid-based preparation showing carcinoma in situ cells. Fig. 3.9. Conventional smear showing HSIL, moderate dysplasia.
These abnormal squamous cells are of parabasal/metaplastic type
with well to poorly defined cell borders, round to oval nuclei with
high N/C ratios and variable but scant cytoplasm.
Fig. 3.10. Liquid-based preparation showing HSIL, moderate dys- Fig. 3.11. Conventional smear showing HSIL, moderate keratinizing
plasia. The abnormal cells are arranged in a sheet with well-defined dysplasia. These squamous cells of intermediate and parabasal type
cell borders and moderate amounts of dense cytoplasm. have keratinized cytoplasm, enlarged nuclei, and high N/C ratios.
epithelial lining contains parabasal/metaplastic cells with moderate dysplasia. The term “metaplastic dysplasia” is
high N/C ratios. used by some and is not warranted.
The keratinizing lesions are generally noted on the
portio, distal to the transitional zone. Cytological distinc-
Cytopathologic Features tion between moderate and severe keratinizing dysplasia
is difficult in most instances (see below).
The abnormal squamous cells are round to oval, either
native parabasal type or metaplastic type (Table 3.3; Figs.
3.9 to 3.11). These cells are present as discrete cells, in
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL
loose aggregates, or in sheets and rarely in syncytial tis-
LESION (HSIL) [SEVERE DYSPLASIA/CARCINOMA
sue fragments. The cell borders are well-defined; their
IN SITU AND CERVICAL INTRAEPITHELIAL
cytoplasm is variable, pale to dense, and cyanophilic. The
NEOPLASIA (CIN), GRADE III]
nucleus is round to oval at two and a half to three and a
half times the normal counterpart (parabasal cell), result- There are basically two broad histologic groups of CIN III.
ing in a high N/C ratio. The nuclear membrane is sharp; One is characterized by full thickness involvement of the
the chromatin is coarsely granular; and nucleoli are absent. epithelium by primitive cell proliferation and is a nonkerati-
Dyskeratosis may be present. Metaplastic squamous cells nizing type (e-Figs. 3.7 and 3.8); the second group is referred
represent intermediate maturity—the same as parabasal to as severe keratinizing or pleomorphic dysplasia or well-
cells—and the dysplastic changes, when present, represent differentiated carcinoma in situ (e-Figs. 3.10A and B).
TABLE 3.3 CYTOPATHOLOGIC FEATURES OF HIGH-GRADE SQUAMOUS LESIONS (HSIL)
HSIL Moderate HSIL Severe Keratinizing

Dysplasia/CIN II HSIL SD/CIS, CIN III Dysplasia
Cellularity Variable Variable, may be marked Variable, may be marked
Presentation Cells mostly isolated, in Cells isolated, often in streaks, in loosely Cells mostly isolated; in
aggregates or in tissue cohesive groups and in tissue fragments loosely cohesive groups, tissue
fragments fragments
Tissue Fragments In sheets, occasionally in In syncytial arrangements; may have In syncytial arrangements,
syncytial arrangements smooth external contour, nuclei crowded, keratin pearls; cells may be in
overlapped, may form swirls; nuclei at the bundles
periphery with horizontal polarity; may
have luminal border; nuclei horizontal;
cytoplasm discernible (focus up and down)
Type of Cell Parabasal or metaplastic Parabasal/metaplastic/reserve or primitive Squamous cells at all levels of
type cell maturation
Cells Round to oval, medium- Round to oval; small (size of reserve or Markedly pleomorphic
sized; well-defined to rigid primitive cell) to medium-sized, less than
cell borders; abnormal or equal to parabasal/metaplastic
forms may be present
Nucleus Enlarged (2.5–3.5 times Large compared to the cell size; high N/C Enlarged, round to oval,
normal intermediate ratio 1:1 measurements elongated to spindle-shaped;
squamous/metaplastic N/C ratio moderate to high
squamous cell); increased
N/C ratio
Chromatin Prominent nuclear Fine to coarsely granular, crisp nuclear Coarsely granular to dense
membrane with coarsely membrane with/without irregularities; pyknotic
granular chromatin nuclear grooves
Nucleoli Absent Generally absent Absent
Cytoplasm Variable; scant to modest; Indiscernible to scant; cell borders Excessively keratinized amount
dense; rarely foamy or well-defined to rigid, individual cell; variable, rigid cell borders;
vacuolated; keratinization keratinization ⫹/⫺; occasionally lacy to generally clean anucleated
⫹/⫺ vacuolated keratinized squames
Background Clean Clean Clean
Severe Dysplasia/Carcinoma In Situ of the cell borders. Their nuclei demonstrate vertical polarity.
Nonkeratinizing Type (HSIL) Their cytoplasm is scant, indistinct, and N/C ratios are
very high. The nuclei are hyperchromatic, exhibiting nor-
Histologic Features. These lesions involve the transitional
mal and abnormal mitoses at all levels up to the surface.
zone and may extend proximally into the endocervical
Individual cell keratinization may also be seen through-
canal or distally onto the portio. They are characterized
out the entire thickness of the epithelium.
by primitive cell proliferation involving the full thickness
of the epithelium (e-Figs. 3.7A and B), which may extend Cytopathologic Features. With adequate sampling of
into the underlying endocervical glands and their crypts the involved area, the abnormal cells are present in large
(e-Figs. 3.8A and B). Some maturation of the cells may be numbers as discrete cells, in loosely cohesive groups, or in
present at the surface. The epithelium is generally several syncytial tissue fragments (Table 3.3; Figs. 3.12 to 3.24).
layers thick but infrequently may consist of only a few In conventional smears, the cells originating from
layers. These primitive cells are crowded with ill-defined nonkeratinizing severe dysplasia/carcinoma in situ are
Fig. 3.12. Conventional smear. HSIL showing the characteristic Fig. 3.13. Conventional smear. HSIL showing diagnostic carcinoma
morphology of carcinoma in situ. The cells are round, discrete, with in situ cells in streaks.
well to poorly defined cell borders, high N/C ratios; scant to in-
discernible cytoplasm. The nuclei are round to crisp nuclear mem-
brane, smooth to irregular nucleoli. The chromatin is granular.
Fig. 3.14. Conventional smear. HSIL showing diagnostic carcinoma

in situ cells mixed with moderately dysplastic cells.
A B
Figs. 3.15A to C. Liquid-based preparations depicting HSIL. A: Abnormal squamous cells ranging from mature
squamous to parabasal/metaplastic type with large hyperchromatic nuclei. B, C: Syncytial tissue fragments of high-
grade dysplastic cells. (continued)
C Figs. 3.15C. (continued)
Fig. 3.16 Conventional smear depicting HSIL, consisting of in situ Fig. 3.17 Conventional smear with HSIL. Typical carcinoma in situ
type cells present as discrete cells, in loosely cohesive groups and in cells in a syncytial tissue fragment. The nuclei are crowded with
syncytial tissue fragment. altered polarity.
Fig. 3.18 Conventional smear with HSIL. These carcinoma in situ cells
are much smaller with high N/C ratios, and indiscernible cytoplasm.
A B
Figs. 3.19A to C. Liquid-based preparation; HSIL; syncytial tissue

C fragments of carcinoma in situ cells.
Fig. 3.20. Conventional smear. Syncytial tissue fragment of in situ Fig. 3.21. Conventional smear. Syncytial tissue fragment of in situ
cells. The smooth outline of the tissue fragment suggests endocervi- cells. The smooth outline of the tissue fragment suggests endocervi-
cal gland involvement. cal gland involvement.
seen isolated, in aggregates, and in syncytial tissue frag- cells or metaplastic squamous cells (Fig. 3.7B), to cells
ments (Figs. 3.12 to 3.14, 3.16 to 3.18). The cells are often that lack cytoplasm and thus squamous differentiation
seen in mucus streaks (Fig. 3.13). The cytomorphology of (Fig. 3.7C). The latter are referred to as “carcinoma in
the abnormal cells depends on the level of differentiation situ” type cells or, simply, as in situ type cells.
as noted by decreasing amounts of cytoplasm and increas- The typical in situ cell is an undifferentiated cell
ing nuclear size. The abnormal cells range from dysplastic (primitive cell) that is round to oval; its size varying from
squamous cells of intermediate maturity, either parabasal that of a small basal type cell (95 μm2) to the parabasal/
Fig. 3.22. Conventional smear. Syncytial tissue fragment of in situ Fig. 3.23. Liquid-based preparation. Syncytial tissue fragment of in
cells. The smooth outline of the tissue fragment suggests endocervi- situ cells. The smooth outline of the tissue fragment suggests endo-
cal gland involvement. Note the luminal border (arrow). cervical gland involvement.
Fig. 3.24. Conventional smear showing syncytial tissue fragment

of in situ cells. The smooth outline of the tissue fragment suggests
endocervical gland involvement. Note the luminal border (arrow).
These cells are often interpreted as atypical endocervical glandular
cells.
metaplastic cell (435 ␮m2). The cell borders are generally These changes are often difficult to differentiate from
well-defined and rather rigid if the cytoplasm is kerati- endocervical glandular atypia or adenocarcinoma in
nized (premature keratinization). The nucleus occupies situ (see Chapter 4).
almost the entire cell resulting in a very high N/C ratio. The cytomorphology of HSIL in liquid-based prepa-
The nucleus is round to oval, its membrane sharp, crisp, rations differs to some extent. The flat appearance of the
smooth to irregular, and undulated. The nuclear chroma- abnormal cells in mucus streaks is lacking. The cells are
tin is coarsely granular and evenly or irregularly distrib- smaller in size, more clustered together, densely stained,
uted. The presence of a nucleolus is infrequent. Nuclear and their chromatin structure is less crisp that that seen
grooving is seen very frequently. The cytoplasm is very in conventional smears. Also, the tissue fragments ball up,
scant—sometimes lacy or vacuolated—and may show appear three-dimensional, and nuclear details are difficult
keratinization (Figs. 3.12 to 3.14). to appreciate (Figs. 3.15A to 3.15C, 3.19 to 3.23).
In syncytial tissue fragments, the nuclei are crowd-
ed, overlapped with altered polarity, and the cells have
High-Grade Squamous Intraepithelial Lesion/Severe
ill-defined cell borders (Figs. 3.16 to 3.18). By chang-
Keratinizing Dysplasia (HSIL)
ing the plane of focus, some amount of cytoplasm can
always be appreciated. These syncytial tissue fragments Severe keratinizing dysplasia—also known as well-
of in situ cells sometimes have smooth external con- differentiated carcinoma in situ, pleomorphic dyspla-
tours, luminal border, and even gland openings (Figs. sia, and CIN Grade III—is considered to be a precursor
3.20 to 3.24). Such tissue fragments represent endocer- lesion of keratinizing squamous carcinoma and occurs
vical gland or crypt involvement (e-Figs. 3.8A and B) on the portio. Because of the keratinization, the surface
that are removed forcibly by the endocervical brush. may grossly appear white (leukoplakia).
Fig. 3.25. Conventional smear showing severe keratinizing squamous Fig. 3.26. Conventional smear showing pleomorphic, discrete, and
dysplasia (HSIL). The abnormal squamous cells are discrete and loosely cohesive dysplastic cells with high N/C ratios, many with
loosely cohesive, small to medium-sized with well-defined cell bor- keratinized cytoplasm and pyknotic nuclei. The cytologic pattern is
ders, round, and contain keratinized cytoplasm. Their nuclei are large that of a severe keratinizing dysplasia.
with high N/C ratios with many being pyknotic.
Fig. 3.27. Conventional smear showing severe keratinizing squamous Fig. 3.28. Liquid-based preparation. Severe dysplasia (HSIL) show-
dysplasia (HSIL) as seen by markedly pleomorphic squamous cells ing pleomorphic squamous cells with high N/C ratio. This type of
with round to spindle forms, large hyperchromatic nuclei, and ker- liquid-based preparation generally does not demonstrate deep cyto-
atinization. Except for the presence of nucleoli, the cells resemble plasmic orangeophilia, so characteristic of keratinization.
those originating from a well-differentiated squamous carcinoma.
Histologic Features. The involved epithelium generally numbers, mostly discrete, but groups and syncytial tis-
shows considerable thickening with marked keratini- sue fragments with keratin pearl formations are also seen
zation on the surface. Although the epithelium appears (Figs. 3.25 to 3.28; see Figs. 3.82A and B). The abnormal
well-differentiated, with stratifi cation, there are marked cells range from small to large, round, polygonal, spindle-
nuclear abnormalities as seen by enlargement, pleomor- shaped, fiber, to tadpole forms. Their cytoplasm is variable
phism, altered polarity, and frequent normal and abnor- in amount, scant to abundant, excessively keratinized,
mal mitoses at all levels. The nuclear chromatin is densely staining bright orange to yellow to cyanophilic with a
staining and often pyknotic. The luminal surface may hyaline appearance. The cell borders are well-defined and
show layers of keratin, which contain exfoliated pleomor- rigid. The nuclei are large with coarsely granular chro-
phic and dysplastic squamous cells in the absence of cilia. matin. Large pyknotic nuclei are a common occurrence.
The morphology resembles the pattern seen in Bowen’s Hyperkeratinized anucleated squames with pleomorphic
disease of the skin. shapes and sizes may be seen in the background. The typi-
cal bright orangeophilic, hyalinized texture of excessively
Cytopathologic Features. Markedly pleomorphic keratinized squamous cells is dependant on using the
squamous cells with extreme dyskeratosis characterize orange G stain. This appearance is usually not appreci-
severe keratinizing dysplasia. The cells exfoliate in large ated in liquid-based preparations.
TABLE 3.4 HIGH-GRADE SQUAMOUS

DIAGNOSTIC PROBLEMS AND INTRAEPITHELIAL LESION DIAGNOSTIC
DIFFERENTIAL DIAGNOSES OF HSIL PROBLEMS & DIFFERENTIAL DIAGNOSES
Discrete Severely Dysplastic/In Situ Cell

As stated earlier, the abnormal squamous cells originat-
ing from HSIL occur isolated, in aggregates, or in tissue
Immature Squamous Metaplastic Cells
fragments. The differential diagnostic entities are depen-
dant not only on whether the lesion is the nonkeratiniz- Endometrial Stromal Cells (Superficial & Deep)
ing or keratinizing type but also on its presentation. The
differential diagnoses for single or discrete cells are differ- IUD-Associated Changes
ent than that for tissue fragments. Diagnostic difficulties
are also encountered when the number of cells is small or Tissue Fragments of Severely Dysplastic/In Situ Cells
when diagnosis is obscured by blood, inflammation, or
the background of atrophy (Table 3.4). Tissue Fragments of Squamous Metaplasia
Tissue Fragments of Atrophic Parabasal Cells

DIFFERENTIAL DIAGNOSES OF DISCRETE
MODERATE TO SEVERELY DYSPLASTIC/ Tubal Metaplasia
IN SITU TYPE CELLS
Microglandular Hyperplasia
Moderate to Severely Dysplastic/In Situ Type Cells
versus Immature Squamous Metaplasia Endocervical Adenocarcinoma In Situ
The moderate to severely dysplastic cells or in situ type Endometrial Adenocarcinoma

cells are round, small in size with high N/C ratios, and
possess scant to indiscernible cytoplasm. They have a Small Number of Abnormal Squamous Cells
round nucleus with coarsely granular chromatin, lacking
nucleoli, with smooth to irregular nuclear membranes, Poor Cellular Preservation
and occasionally, some have keratinization. The cytologic
presentation of discrete cells with crisp nuclear details Inflammation, Bloody Smear Obscuring the Cellular Details
occurring in mucus streaks in a conventional smear is a
readily recognizable feature, which is not appreciated in Background of Atrophy
liquid-based preparations. These abnormal cells in liquid-
based preparations are dispersed, tend to stain darker, and
cells as well as severely dysplastic or in situ cells. Fea-
also show decrease in their size. The first diagnostic prob-
tures that favor HSIL include high N/C ratios, coarsely
lem is recognizing these single cells as that of high-grade
granular chromatin, and a lack of nucleoli. Also a lon-
lesions. Secondly, immature metaplastic cells with slight
gitudinal nuclear groove is quite characteristic of cells
nuclear enlargement (Figs. 3.29 to 3.33) are extremely
of HSIL. Superfi cial stromal cells have pale nuclei with
difficult, if not impossible, to differentiate from moderate
lower N/C ratios and may exhibit degenerating nuclei
to severely dysplastic squamous cells or in situ cells (Figs.
with clumped chromatin. Liquid-based preparations do
3.34 and 3.35). Helpful features include a lack of coarsely
not present endometrial stromal cells in streaks as they
granular chromatin, round nuclei without irregularity,
get dispersed in the liquid medium and further dispersed
and appreciable cytoplasm. The normal metaplastic cell
during processing.
nuclei appear uniform and lack the variation present in
Deep endometrial stromal cells, on the other hand,
dysplastic cells. When differentiation between metaplas-
are usually obtained by brushing the lower uterine seg-
tic and dysplastic cells present diffi culties, these cells are
ment (Figs. 3.39 and 3.40). These are short spindle-shaped
interpreted as atypical squamous cells, where HSIL or
cells with coarsely granular cytoplasm and very high N/C
ASC-H cannot be excluded.
ratios. The uniformity of cells and lack of any appreciable
cytoplasm favors stromal origin.
versus Endometrial Stromal Cells
The superfi cial stromal cells of the endometrium (Figs.
versus IUD Associated Cells
3.36 and 3.37) are often present in streaks similar to cells
of HSIL (Fig. 3.38). The presence of lacy, bubbly cyto- Small isolated cells morphologically resembling in situ type
plasm—a feature displayed by the endometrial stromal cells have been described in cervical smears from patients
cells—is also seen in immature metaplastic squamous using an intrauterine device (Figs. 3.41 and 3.42). Such
Difficulties in Cytologic Diagnoses of High-Grade Intraepithelial Squamous Lesions (See Figs. 3.29 to 3.35)
Fig. 3.29. Conventional smear showing immature metaplastic Fig. 3.30. Conventional smear. These immature metaplastic
squamous cells. These small cells with high N/C ratios and scant squamous cells have uniform, round nuclei, denser moderate
cytoplasm can be misinterpreted as carcinoma in situ cells. amount of cytoplasm. Such cells are often difficult to differentiate
from moderate (high-grade) dysplasia.
Fig. 3.31. Conventional smear. A large group of loosely cohesive, Fig. 3.32. Liquid-based preparation. Squamous metaplastic cells
pleomorphic, metaplastic cells, interpreted as high-grade squamous le- with mildly enlarged nuclei and hyperchromatic nuclei. These are
sion. Cervical biopsy demonstrated extensive squamous metaplasia. often interpreted as HSIL.
Fig. 3.33. Liquid-based preparation (TP). Squamous metaplastic Fig. 3.34. Conventional smear. Carcinoma in situ cells for compari-
cells in tissue fragments with dark-staining nuclei, a feature com- son with metaplastic cells.
monly seen in liquid-based preparations is likely to result in inter-
preting these cells as HSIL.
A B
Figs. 3.35A and B. Liquid-based preparation. A: Carcinoma in situ cells, TP. B: Carcinoma in situ cells. Compare the cytomorphology with
in situ cells presented in conventional smear, where the nuclear characteristics are better visualized.
High-Grade Squamous Intraepithelial Lesion versus Endometrial Stromal Cells (See Figs. 3.36 to 3.40)
Fig. 3.36. Conventional smear. A streak of discrete small, round, Fig. 3.37. Conventional smear. Another example of superficial en-
superfi cial endometrial stromal cells that mimic high-grade in situ dometrial stromal cells that mimic high-grade squamous cells.
type squamous cells.
Fig. 3.38. Conventional smear. A large population of discrete in situ Fig. 3.39. Conventional smear. Deep endometrial stromal cells may
type cells, surgically proven to be HSIL. Note the similarity with be interpreted as that of HSIL. These cells are obtained from brush-
endometrial stromal cells. ing the lower uterine segments. Deep stromal cells do not exfoliate
spontaneously. They are short and spindle-shaped with poorly de-
fined cell borders, scant cytoplasm, and dark nuclei with high N/C
ratios. The cells are uniform.
Fig. 3.40. Conventional smear. Spindle-shaped endometrial stromal

cells. The cervical biopsy showed endometriosis. This tissue frag-
ment mimics HSIL.
High-Grade Squamous Intraepithelial Lesion versus IUD-Associated Cells (See Figs. 3.41 and 3.42)
A B
Figs. 3.41A and B. Conventional smear demonstrating IUD-associated changes. These small, round mononuclear cells
with high N/C ratios mimic carcinoma in situ cells and may interpret as such. The nuclear chromatin is usually smudgy.
History of IUD usage is very important. These, however, cannot be differentiated from HSIL cytologically.
Figs. 3.42A and B. Liquid-based preparation. IUD-associated chang-

es mimicking HSIL.
cells are generally few in number and are not accompa- fragments are often monolayered with well-defined cell
nied by cells representing lower grades of SIL in the smear. borders and appreciable cytoplasm. The nuclear enlarge-
Their nuclei are also of the more degenerative type, being ment is minimal. The nuclei within the tissue fragments
hyperchromatic with smudgy chromatin. The presence of of immature metaplastic cells are uniform with evenly
these IUD-associated cells does not exclude a coexistent dispersed chromatin and exhibit low N/C ratios as com-
high-grade lesion. The diagnostic category of ASC-H is pared to syncytial tissue fragments of HSIL (Figs. 3.15C
appropriate for such cells. and 3.17).
DIFFERENTIAL DIAGNOSES OF TISSUE Syncytial Tissue Fragments of Moderate to Severely

FRAGMENTS OF MODERATE/SEVERELY Dysplastic/In Situ Type Cells versus Atrophic
DYSPLASTIC/IN SITU CELLS Squamous Epithelium
A common cytologic presentation of high-grade squamous Large tissue fragments of atrophic parabasal cells in cervi-
lesion is the presence of syncytial tissue fragments with cal scrapes may appear to be syncytial, particularly when
component cell nuclei presenting a characteristic cytomor- fragments show folding at the edges (Fig. 3.43). By chang-
phology of HSIL. The latter can be mimicked by tissue ing the plane of focus, the nuclear details can be evalu-
fragments originating from several different sources, as ated. The entire cell population in these tissue fragments
listed in Table 3.4. is uniform and very similar to squamous cells present in
the background. The presence of such tissue fragments
Syncytial Tissue Fragments of Moderate to Severely in large numbers is one of the diagnostic problems in
Dysplastic/In Situ Type Cells versus Squamous liquid-based preparations and is discussed in the section
Metaplasia on ASC-H (Figs. 3.44 and 3.45). The tissue fragments
Tissue fragments of immature metaplastic cells may be show more crowding of smaller nuclei that are densely
misinterpreted as HSIL (Figs. 3.32 and 3.33). The tissue stained and have scant cytoplasm with high N/C ratios.
High-Grade Squamous Intraepithelial Lesion versus Atypical Changes in Atrophic Background (See Figs. 3.43 to 3.52)
A B
Figs. 3.43A to C. Conventional smear. A: The atrophic squamous

epithelium is easily brushed and dislodged off the cervical stroma
and present as large tissue fragments folding upon themselves and
appear syncytial (low power). B: Higher magnification shows nuclei
appearing to be crowded and overlapped due to enfolding. However,
note the nuclei are uniform, containing finely granular chromatin.
C C: Syncytial tissue fragment of HSIL for comparison.
A B
Figs. 3.44A to C. Liquid-based preparations. Atrophic smears show-

ing several tissue fragments consisting of crowded and overlapped
parabasal type squamous cells containing dark-staining nuclei. Such
tissue fragments strongly resemble those from HSIL and are a com-
C mon diagnostic problem.
A B
Figs. 3.45A and B. Liquid-based preparation showing high-grade squamous lesion in atrophic background. Note the
morphologic overlap between benign cells in the background of atrophy and HSIL. It is diagnostically helpful to find
single in situ cells in the background.
Misinterpretation of these tissue fragments as HSIL is

Syncytial Tissue Fragments of Moderate to Severely
a common occurrence. The helpful diagnostic features
Dysplastic/In Situ Type Cells versus Endocervical
include similarity between the cytomorphology of the
Glandular Epithelium with Tubal Metaplasia
component cells of the tissue fragments and the back-
ground cells. The atrophic parabasal cells lack the nuclear The tissue fragments of endocervical glandular epithelium
characteristics of in situ cells (Figs. 3.43A and B). The tis- with tubal metaplasia contain hyperchromatic, oval nuclei
sue fragments of atrophic epithelium are not true syncy- exhibiting vertical polarity and pseudostratification. The
tial as in HSIL (Fig. 3.43C). latter imparts a syncytial look to the tissue fragment and,
in the absence of cilia, is frequently misinterpreted as lems. Such tissue fragments have smooth external contours
HSIL (Fig. 3.46) (see Tubal Metaplasia, Chapter 4). and appear almost as a glandular cast (Figs. 3.20 to 3.24).
By viewing these in multiple planes of focus, the cytoplasm
Syncytial Tissue Fragments of Moderate to of the cells can be appreciated as being of squamous type.
Severely Dysplastic/In Situ Type Cells versus Very frequently, they are interpreted as atypical endocer-
Microglandular Hyperplasia vical glandular cells or endocervical adenocarcinoma—
Tissue fragments of endocervical epithelium exhibiting both in situ and invasive (Figs. 3.48 to 3.50).
microglandular hyperplasia may also be misinterpreted Conversely, tissue fragments of endocervical adeno-
as HSIL (Fig. 3.47), particularly when the characteristic carcinoma may be interpreted as HSIL. This is discussed
acinar pattern and cytoplasmic vacuoles is lacking (see in detail in Chapter 4, in the section on endocervical
Microglandular Hyperplasia, Chapter 4). adenocarcinoma.
Syncytial Tissue Fragments of Moderate to Severely Syncytial Tissue Fragments of Moderate to Severely
Dysplastic/In Situ Type Cells with Endocervical Dysplastic/In Situ Type Cells versus Endometrial
Gland Involvement versus Endocervical Adenocarcinoma
Glandular Lesions
Cells originating from small cell in situ carcinoma may
The tissue fragments of carcinoma in situ representing resemble endometrial glandular cells (Figs. 3.19B and C).
gland or crypt involvement are frequent diagnostic prob- Although well-defined cell borders and dense cytoplasm
Fig. 3.46. Conventional smear showing a syncytial tissue fragment Fig. 3.47. Conventional smear. Endocervical glandular cells origi-
of crowded, overlapped, hyperchromatic and pleomorphic nuclei nating from microglandular hyperplasia may present as syncytial
without nucleoli suggesting the diagnosis of high-grade squamous tissue fragment with enlarged, crowded nuclei and mimic HSIL.
intraepithelial lesion. The cervical biopsy showed tubal metaplasia.
In the absence of cilia and a luminal border, tubal metaplasia is
often interpreted as HSIL.
A B
Figs. 3.48A and B. Liquid-based preparation (SP). Syncytial tissue fragments of endocervical glandular epithelium
with high N/C ratios may suggest HSIL with endocervical gland involvement.
Fig. 3.49. Conventional smear. Endocervical adenocarcinoma in situ Fig. 3.50. Conventional smear showing a syncytial tissue fragment
(AIS) often shares morphological similarity with squamous carci- of HSIL. Note the morphologic similarity with endocervical carci-
noma in situ (see Fig. 3.50). noma in situ (Fig. 3.49)
in some cells may aid in the correct identification of HSIL, zation of the lining stratifi ed squamous epithelium (see
differentiation may be very difficult. Table 3.8). These are hyperkeratosis/parakeratosis, cellu-
lar changes in the background of atrophy, HPV-associated
changes, and keratinizing well-differentiated squamous
DIFFERENTIATING LOW-GRADE
carcinomas; they are discussed in the section on differen-
FROM HIGH-GRADE SQUAMOUS
tial diagnoses of squamous carcinoma.
INTRAEPITHELIAL LESIONS
The squamous intraepithelial lesions form a continuum;
thus, it is not unusual to encounter abnormal squamous
cells representing different grades of SIL in the same cyto- SQUAMOUS CARCINOMA OF
logic sample. The final interpretation is based on the cells THE UTERINE CERVIX
that present the highest degree of abnormality. However,
grading becomes an issue when few cells representing high-
grade lesions are present in the background of fair num- The incidence of invasive squamous carcinoma of the
bers of cells with low-grade abnormality. There may be cervix is declining in North America with a drop from
several reasons for the small number of abnormal cells that 34 per 100,000 women in 1947 to 15.3 per 100,000 in
are of a high-grade type: 1) The high-grade lesion is small 1970. This spectacular decrease is the result of success-
focal and not readily visualized or accessible to sampling; ful screening programs along with the effective treatment
2) Even if these are interpreted as high-grade, their pres- of precursor lesions. There seems to be a considerable
ence may not be confirmed on a colposcopy and/or biopsy; difference in the incidence of squamous cancer in the
on the other hand it is not unusual to find histologically screened population (4.5 per 100,000 women) as com-
confirmed high-grade lesions in cases where the cytologic pared to the unscreened population (29 per 100,000).
diagnosis of LSIL was based on predominant abnormal- Cervical cancer is still the fourth most common cause
ity represented by a large number of low-grade and a few of cancer deaths among women. Currently, the annual
high-grade cells. Some laboratories recommend and use incidence of cervical cancer in the USA is estimated to be
diagnostic terminology such as “low-grade SII, high-grade 12,000/year. However, its incidence in women in under-
cannot be excluded” or “SIL grade cannot be determined.” developed countries is very high due to a lack of surveil-
These patterns are encountered just too often to be lance programs.
ignored. The author’s laboratory has followed the diag- Squamous carcinomas comprise 75% of all cervical
nostic terminology of “ungraded dysplasia, probably low- cancers. The role of HPV types 16 and 18 as the etiologic
grade or probably high-grade.” The high-grade lesions factor is now well-established. The average age of the pa-
were confirmed in 6 to 11% of the ungraded dysplasias. tient at the time of detection for cervical cancer is stated
to be 51.4 years; about 15 to 23 years older than patients
with HSIL, although it can occur in much younger women.
Of late, there seems to be an increase in cervical cancers in
KERATINIZING HSIL
women under the age of 35.
The differential diagnoses of keratinizing HSILs include Patients with invasive cancer may complain of ab-
other diagnostic entities that exhibit a marked keratini- normal vaginal bleeding, discharge, pain radiating to the
sacral area, weakness, weight loss, edema of the lower lium (e-Figs. 3.11 and 3.12). The latter invariably shows
extremities, rectal pain, and hematuria. They may also be intraepithelial neoplasia of a severe degree with extensive
asymptomatic. Many older women with squamous carci- involvement of the glands. The cells at the site of the inva-
noma did not have cervical smears examined within the sion are more differentiated with a significant amount of
past five years. cytoplasm and pale vesicular nuclei and nucleoli in con-
The prognosis and biologic behavior depends on trast to the primitive type cells in neighboring areas (e-Fig.
the stage. The incidence of metastatic spread locally and 3.12). The cells invading the stroma can be in the form
to the distant organs is higher in advanced stages with of cords or tongues, with irregular jagged borders and an
increasing morbidity and mortality. inflammatory cell response in the stroma. The presence
of lymphatic or vascular invasion rules out the diagnosis
of microinvasive carcinoma, regardless of the depth of
invasion.
MICROINVASIVE SQUAMOUS CARCINOMA
CYTOPATHOLOGIC FEATURES OF
MICROINVASIVE CARCINOMA
Microinvasive squamous carcinoma represents earlier
stages of squamous carcinoma with minimal stromal The cytomorphology of microinvasive squamous carci-
invasion. It is defined as a malignant squamous lesion noma varies with the depth of invasion. The cells most
with stromal invasion to a depth of 3 to 5 mm, with- characteristic of microinvasive carcinoma are identified
out vascular and lymphatic invasion. Microinvasive when the depth of invasion is 2 to 3 mm. In lesser degrees
carcinoma represents stage Ia of the FIGO staging sys- of invasion, the exfoliated abnormal cells resemble those
tem. These have a low-risk for lymph node metasta- of carcinoma in situ, and in greater degrees of invasion,
ses. Microinvasive carcinomas run a favorable clinical the abnormal cells are more characteristic of invasive
course. squamous carcinoma.
Histologically, microinvasive squamous carcinomas The abnormal cells are generally in situ type—present
present in large numbers, mostly in syncytial tissue fragments.
The presence of nucleoli and parachromatin clearing are
1. Extensive CIN III.
significant features favoring microinvasion. Tumor diath-
2. Widespread, expansile, and deep extension into endo-
esis is frequently noted. Frank invasion is not suggested
cervical crypta.
because of the predominant cell patterns representing
3. Luminal necrosis and intraepithelial maturation.
HSIL (Figs. 3.51 and 3.52). It is certainly not possible to
The diagnosis of microinvasion is based on the pres- identify microinvasive squamous carcinoma from a cyto-
ence of one or more tongues of malignant cells penetrat- logic sample with certainty. The diagnosis is best phrased
ing through the basement membrane of the lining epithe- as “HSIL, invasion cannot be ruled out.”
Fig. 3.51. Conventional smear. These abnormal cells are small, Fig. 3.52. Conventional smear showing a syncytial tissue fragment
round to oval with poorly defined cell borders and scant to insig- of cells diagnostic of HSIL, except for the presence of nucleoli, which
nificant cytoplasm. The nuclei show altered polarity and are mildly favored the possibility of invasion. The cervical biopsy confirmed a
pleomorphic in size. The chromatin is granular. The pattern is that microinvasive squamous carcinoma.
of HSIL. However, the presence of nucleoli should suggest the pos-
sibility of invasive carcinoma. The follow-up biopsy revealed a mi-
croinvasive squamous carcinoma.
WELL-DIFFERENTIATED SQUAMOUS
INVASIVE SQUAMOUS CARCINOMA CARCINOMA
OF THE UTERINE CERVIX
Histologic Features
Squamous carcinomas of the cervix include the conven-
Well-differentiated carcinoma is characterized by infiltrat-
tional type and several morphologic variants such as
ing and anastomosing islands of large polygonal squamous
basaloid, verrucous, warty (condylomatous), papillary,
cells with abundant keratinized cytoplasm, often forming
squamotransitional, and lymphoepithelial type. These
keratin pearls in the center of the cell masses (e-Fig. 3.13A).
variants occur infrequently. Only the conventional one
Areas of necrosis within these islands are also frequent.
will be discussed in detail.
The malignant squamous cells may exhibit intercellular
Grossly, the squamous carcinomas of the cervix pres-
bridges, and the nuclei may not show significant enlarge-
ent a wide variation. It may show only a focal induration or
ment, but prominent macronucleoli are quite character-
a shallow ulceration. The lesion could be a slightly elevated
istic. The keratin may evoke a foreign-body-type reaction.
granular area, friable, and may bleed to the touch. The tu-
mor may present as a discrete ulcer with rolled hard edges
Cytopathologic Features
or a polypoid exophytic growth. The malignant lesions may
be fixed with the involvement of the adjacent tissue. The smears contain variable numbers of malignant cells,
Histologically, squamous carcinomas have been typed from very few to overwhelming cellularity (Table 3.5;
according to the predominant cell type or the degree of Figs. 3.53 to 3.60). The neoplastic cells in well-differ-
differentiation. For example, they can be classified as entiated carcinomas tend to occur singly or in loosely
nonkeratinizing, keratinizing, and small cell types or as cohesive groups and infrequently in tissue fragments.
well-differentiated, moderately differentiated, and poorly Pleomorphism is noted by extreme variations in size and
differentiated types (FIGO System). shapes. They can be small, medium-sized, and large, to
TABLE 3.5 CYTOPATHOLOGIC FEATURES OF SQUAMOUS CARCINOMA
Well-Differentiated (Keratinizing) Moderately to Poorly Differentiated

Squamous Carcinoma (Non-Keratinizing) Squamous Carcinoma
Presentation Cells mostly isolated, in loosely cohesive groups, or in Malignant cells isolated, in loosely cohesive groups
syncytial tissue fragments; keratin pearls ⫹/⫺ and in syncytial tissue fragments
Number of Variable Variable

Malignant Cells
Configuration of Marked pleomorphism with extreme variation in size Mostly round, sometimes polygonal; size variable
Malignant Cells and shape; small, round, oval, polygonal, fiber, spindle, to small to medium-sized
tadpole forms; spindle cells often run in parallel bundles
Nucleus Central location; round, oval, oblong to elongated, Central location; large with high N/C ratio; round
increased in size; nuclear membrane smooth to oval, nuclear membrane smooth to irregular;
to irregular; chromatin coarsely granular with fine to coarsely granular chromatin; irregular
parachromatin clearing or deep-staining structureless chromocenters, parachromatin clearing; single/
pyknotic, single/multiple; micronucleoli/macronucleoli multiple; micronucleoli/macronucleoli prominently
may not be readily apparent seen
Cell Borders Well-defined, rigid Well-defined
Cytoplasm Variable, scant to abundant; excessively keratinized Variable, generally scant; individual cells may
with refractile quality; (Halloween orange) endoplasm/ show keratinization; endoplasm/ectoplasm and
ectoplasm and ringing; anucleated pleomorphic forms ringing ⫹/⫺
with and without keratinization frequent
Background Generally clean, necrosis ⫹/⫺ Clean to inflammatory; necrosis ⫹/⫺
Differential HPV-associated changes, radiation-induced changes, Repair/regenerative pemphigus vulgaris, poorly

Diagnoses severe keratinizing dysplasia differentiated endometrial or endocervical carcinoma
Cytologic Features of Squamous Carcinoma (See Figs. 3.53 to 3.71)
Fig. 3.53 Liquid-based preparation showing squamous carcinoma Fig. 3.54 Conventional smear. Squamous carcinoma. The malig-
cells. nant squamous cells are in syncytial tissue fragments. Discrete cells
are in the background, along with inflammatory cells.
Fig. 3.55. Conventional smear presenting well-differentiated squamous Fig. 3.56. Conventional smear showing well-differentiated squamous
carcinoma cells. The malignant cells are discrete, loosely cohesive, carcinoma. The malignant cells are mostly discrete, markedly pleo-
very pleomorphic in size and shapes, with enlarged nuclei, many be- morphic in size with frequent giant forms. The cells are clearly ma-
ing pyknotic. Most malignant cells exhibit excessive keratinization lignant and display cytoplasmic keratinization.
of their cytoplasm.
Fig. 3.57. Conventional smear showing well-differentiated squamous Fig. 3.58. Conventional smear showing a well-differentiated squamous
carcinoma. These malignant squamous cells are smaller in size, carcinoma. The malignant squamous cells are spindle-shaped and are
round, and present a dispersed pattern. Some are keratinized. The present in fascicles. Their cytoplasm is keratinized.
nuclear chromatin is finely granular with micronucleoli.
Fig. 3.59. Conventional smear depicting a well-differentiated squamous

carcinoma. The malignant squamous cells present elongated spindle
and fiber forms and are mixed with pleomorphic, small to large, round
to oblong malignant squamous cells.
A B
C D
Figs. 3.60 A to D. Liquid-based preparations showing squamous carcinoma. A: Low power showing a large number
of malignant cells, dispersed and in tissue fragments. B: Higher magnification of a different field showing malignant
cells with high N/C ratios and scant cytoplasm. The discrete malignant cells are pleomorphic. The nuclear details in
liquid-based preparations are less crisp as they tend to stain darker and overlap. C: A different example of squamous
carcinoma. The low-power magnification presents a strikingly large population of mostly discrete malignant squamous
cells. D: Higher magnification showing the pleomorphic malignant squamous cells. (continued)
E F
Figs. 3.60 E to F. (continued) E, F: Liquid-based preparation (Thin-Prep) showing squamous carcinoma. The
malignant squamous cells are pleomorphic, discrete, and in syncytial tissue fragments. They contain scant
cytoplasm. The nuclei show compact chromatin. The nuclear details are not sharp.
giant forms with round, polygonal, spindle, to fiber and Cytopathologic Features
caudate forms. Their cell borders are generally well-
The smears from moderate to poorly differentiated carci-
defi ned. The malignant cell nuclei vary in size presenting
nomas tend to show a large population of malignant cells
high N/C ratios in small round cells, and only a modest
that exhibit remarkable variation in size and shape, rang-
increase in large differentiated cancer cells. The nuclei are
ing from small round to large polygonal to spindle forms
centrally located; variable in size; and round, oblong, or
(Figs. 3.61 to 3.69). They may be isolated, in aggregates,
spindle-shaped with smooth to irregular nuclear mem-
or in syncytial tissue fragments. Their nuclei are gener-
branes. Binucleation or multinucleation may be present.
ally large with irregular membranes, coarsely granular
Their chromatin is coarsely granular with parachromatin
chromatin, excessive parachromatin clearing, and single
clearing. Large pyknotic nuclei are characteristic. Both
to multiple micronucleoli/macronucleoli. The cytoplasm
micronucleoli and macronucleoli are conspicuously seen.
is variable, scant to abundant, may show endoplasm/
The fiber cells and tadpole cells may be present with long
ectoplasm with or without ringing. Individual malignant
cytoplasmic extensions. The former are often seen in
cells may show keratinization. The cell borders are gen-
loose bundles. The cytoplasm of the malignant cells may
erally well-defi ned to rigid. In poorly differentiated car-
be scant to abundant and variably keratinized. It stains
cinomas, scant cytoplasm may not allow proper typing.
eosinophilic, cyanophilic to orangeophilic with brilliant
With spindle cell differentiation, the malignant cells often
hues suggesting excessive keratinization. Anucleated
present themselves in parallel bundles (Figs. 3.60 to 3.63).
squamous cells with and without keratinization, with
The background is more often bloody, inflammatory, with
or without pleomorphic forms are present in the back-
necrotic debris, obscuring the cellular details. Such smears
ground. Keratin pearls are often seen in well-differenti-
may be rendered unsatisfactory for cytologic evaluation,
ated carcinomas. The background can be clean or may
leading to a false negative diagnosis.
show cellular and infl ammatory debris and diathesis.
In fact, excessive necrosis and infl ammation is the most
frequent cause for a false negative diagnosis. NEUROENDOCRINE CARCINOMA
(SMALL CELL CARCINOMA)
MODERATE TO POORLY DIFFERENTIATED Neuroendocrine carcinomas of the cervix are rare, aggres-
SQUAMOUS CARCINOMA sive neoplasms associated with a poor prognosis. They
represent a group of tumors with a spectrum of morpho-
Histologic Features logic features including classic carcinoid tumors to small
cell carcinomas with or without focal squamous or glan-
The moderate to poorly differentiated squamous carci- dular differentiation.
nomas demonstrate limited squamous differentiation
(e-Fig. 3.13B). They are present as large islands of malig-
Histologic Features
nant squamous cells, diffusely infi ltrating the stroma.
Depending on the degree of differentiation, the cells may Neuroendocrine carcinomas are extremely cellular com-
be medium-sized to large, round to polygonal, or small posed of small round to oval cells with hyperchromatic
resembling primitive cells with scant cytoplasm. nuclei and scant cytoplasm with a very high N/C ratio,
Fig. 3.61. Conventional smear showing moderately differentiated Fig. 3.62. Conventional smear showing a moderately differentiated
squamous carcinoma. The malignant squamous cells are large, squamous carcinoma. The malignant cells are medium-sized with vari-
round, pleomorphic with variable dense cytoplasm. Their nuclei are able dense cytoplasm. Their nuclei are large and clearly malignant.
clearly malignant.
Fig. 3.63. Conventional smear showing a moderately differenti- Fig. 3.64. Conventional smear showing a moderately differenti-
ated squamous carcinoma. The malignant cells are medium-sized to ated squamous carcinoma. The malignant cells are medium-sized
large, some with oblong shapes. They contain scant cytoplasm. to large, round with scant cytoplasm, resembling in situ type cells
except for the presence of nucleoli.
Fig. 3.65. Conventional smear showing a poorly differentiated Fig. 3.66. Conventional smear depicting squamous carcinoma. The
squamous carcinoma. The malignant cells are small, round with malignant squamous cells are loosely cohesive except for the two
poorly defi ned cell borders, scant cytoplasm with high N/C ratios. large cells with abundant cytoplasm. The rest of the cells are poorly
The nuclear chromatin is finely granular with micronucleoli. The differentiated.
squamous nature of these cells is not readily apparent, and these
cells can be misinterpreted as that of endometrial carcinoma. Note
the inflammatory background, which obscures the diagnostic cells.
74
Fig. 3.67. Conventional smear depicting cells of a poorly differenti- Fig. 3.68. Conventional smear showing a poorly differentiated
ated squamous carcinoma. Majority of the malignant cells are small squamous carcinoma. The syncytial tissue fragment comprises small
with scant to indiscernible cytoplasm, except for an occasional one cells with indiscernible cytoplasm and small densely stained nuclei.
with denser cytoplasm suggesting squamous differentiation.
Fig. 3.69. Conventional smear. These malignant cells are very small,
loosely cohesive, and in syncytial tissue fragments, presented mor-
phology mimicking endometrial carcinoma cells and was interpret-
ed as such. The surgical follow-up confirmed a poorly differentiated
squamous carcinoma.
infiltrating in the form of cords and nests and trabeculae DIAGNOSTIC ACCURACY AND
(e-Fig. 3.14). Broad zones of necrosis and high mitotic DIFFERENTIAL DIAGNOSES OF
activity are characteristic. The immunoprofile includes SQUAMOUS CARCINOMA
positive reactivity to neuroendocrine markers, cytokera-
tin, TTF-1, and CD56. False Negative Diagnosis
The false negative diagnosis of squamous carcinoma can
be grouped into two broad categories (Figs. 3.72 to 3.77).
The cytopathologic features of small cell carcinoma of 1. Virtual absence of malignant cells in the smears. The
the cervix are similar to those described for neuroendo- possible reasons include
crine tumors (see Chapter 10). The smears show a large a. The lesion is too small or not accessible to the sam-
population of small round to oval cells (three to three and pling device;
a half times the resting lymphocyte), isolated, in aggre- b. Improper sampling technique;
gates, and in syncytial type tissue fragments without any c. Difficulty in dislodging the diagnostic cells (e.g.,
architectural pattern (Figs. 3.70 and 3.71). The cells have hyperkeratotic lesion);
scant to insignificant cytoplasm, large nuclei with coarsely d. Ulcerated or fungating lesion that bleeds easily, result-
granular “salt & pepper” chromatin, and inconspicuous ing in a less than optimal or unsatisfactory smear.
nucleoli. Nuclear molding is also seen. The N/C ratio is 2. Screening or interpretive errors. Possible sources are
extremely high. The background shows cellular debris a. The number of malignant cells are too small;
as a result of necrosis. Some neoplastic cells may exhibit b. The malignant cells are obscured by blood, inflam-
squamous or glandular differentiation. matory tissue, or necrotic debris;
A B
Figs. 3.70A and B. Neuroendocrine carcinoma, conventional smears. A: Syncytial tissue fragments of small cells with
poorly defined cell borders, with indiscernible cytoplasm. B: Another example of a small cell carcinoma (neuroendo-
crine carcinoma, grade III). The malignant cells are very small, present as dispersed cells, and in syncytial tissue frag-
ments. Note poorly defined cell borders, indiscernible cytoplasm, coarsely granular deep-staining chromatin, present-
ing a typical “salt & pepper” pattern of neuroendocrine neoplasia. No nucleoli are present.
Fig. 3.71. Liquid-based preparation from a case of neuroendocrine

carcinoma of the cervix. The malignant cells are very small, dis-
persed singly, and in small aggregates. The salt & pepper chromatin
pattern of typical neuroendocrine tumor cells is not readily seen.
Diagnostic Problems with Squamous Carcinoma False-Negative Diagnosis (See Figs. 3.72 to 3.77)
Fig. 3.72. Squamous carcinoma, conventional smear. Excessive in- Fig. 3.73. Conventional smear showing discrete, small malignant
fl ammation in the background has totally obscured the malignant squamous cells with poorly defined cell borders were overlooked,
cells (arrows) resulting in a false negative diagnosis. resulting in a false negative diagnosis. Note, however, that these
cells are small with high N/C ratios and hyperchromatic nuclei and
demonstrate premature keratinization.
Fig. 3.74. Conventional smear. This rare small malignant cell such as Fig. 3.75. Conventional smear. Another example of missed diagno-
seen here (circle) is one of the prime reasons for a missed diagnosis. sis of squamous carcinoma, presenting rare tissue fragment of small
cells with pale open chromatin and micronucleoli.
Fig. 3.76. Conventional smear. Woman in her seventies. The diath-

esis was overlooked in this case. The malignant squamous cells ap-
pearing as bare nuclei were not recognized as malignant. Note that
these elongated, hyperchromatic nuclei do not represent atrophic
squamous cells. This presentation is highly abnormal and deserves
special attention. A routine smear subsequently showed a typical
pattern of squamous carcinoma.
A B
Figs. 3.77A to B. Conventional smear. Extensive inflammation obscuring the sparse malignant cells resulting in a missed
diagnosis. A: A discrete malignant squamous cell (arrow). B: Acute inflammatory cells obscuring the solitary malignant
squamous cell (arrows). (continued)
Fig. 3.77 C. (continued) C: This syncytial tissue fragment of malig-

nant squamous cells was overlooked. Such cells often get blended
C with inflammatory infiltrate.
c. Abnormal cells missed by the screening personnel; taining prominent nucleoli causing some diagnostic dif-
d. Interpretive errors on the part of the pathologist. ficulties. However, epithelial reparative cells are always
present in tissue fragments. Their N/C ratios are low in
Some examples of false positive diagnoses are il-
spite of nuclear enlargement. Single cells with obvious
lustrated in Figures 3.78 to 3.81. The incidence of false
malignant criteria are lacking (Figs. 3.78 to 3.80).
negative diagnoses of squamous carcinoma is variably re-
ported to be in the range of 20 to 66%. Atrophic Smear with Squamous Cell Atypia. Squamous
Koss has listed two situations whereby false positive cells in atrophy often exhibit considerable nuclear atypia
diagnoses of squamous carcinoma are rendered: 1) the that may be misinterpreted as malignant (e-Figs. 3.16 to
samples showing a clear evidence of malignancy are not 3.18; see Table 3.12). Atrophic miniature, round to polygo-
confi rmed by biopsies; and 2) misinterpretation of a be- nal squamous cells with orangeophilia and pyknotic nuclei,
nign process by the cytopathologists. The second category can be mistaken for cells of invasive carcinoma. Intermedi-
is discussed below in differential diagnoses. ate and parabasal cells both may show significant nuclear
enlargement as well as pleomorphic shapes (e-Figs. 3.16 and
Differential Diagnoses of Squamous Carcinoma 3.18). The basophilic round structures, referred to as “blue
The differential diagnoses of squamous carcinoma include blobs” and seen in atrophic smears, may also be mistaken
1) benign cellular changes of repair/regeneration, cellular for malignant cell nuclei. An estrogen proliferation test
and nuclear atypia in the background of atrophy, kera- generally helps to either confirm or exclude malignancy.
tinizing lesions, rare appearance of pemphigus vulgaris,
and ASR-like changes (Table 3.6); 2) HSILs; and 3) glan- Excessively Keratinized Pleomorphic Squamous Cells. The
dular malignancies, both primary and secondary. cells scraped off the superfi cial layers of a condyloma
or severe keratinizing dysplasia (HSIL) or keratinizing
Repair/Regeneration. A repair or regenerative process squamous carcinoma appear as pleomorphic squamous
may yield cells with enlarged pleomorphic nuclei con- cells in variable numbers. They can be small, round,
spindle, or fiber forms with well-defined cell borders, and
containing dense orangeophilic excessively keratinized
TABLE 3.6 DIFFERENTIAL DIAGNOSES OF cytoplasm. Their nuclei are either pyknotic or hyperchro-
INVASIVE SQUAMOUS CARCINOMA matic with coarse granularity and high N/C ratios. When
they are present as discrete cells and in small numbers,
● Repair/Regeneration they may be overlooked. Also, recognition of these cells is
● Atrophic Smear with Atypia poor. They are often referred to as atypical parakeratosis
● Pemphigus Vulgaris and reported as ASC-US.
● ASR-Like Changes
● Keratinizing Lesions Pemphigus Vulgaris of the Cervix. Pemphigus vulgaris
• Hyper/Parakeratosis is a bullous skin lesion that frequently affects the mucus
• LSIL–HPV-Associated Changes membranes. Genital involvement has been reported, with
• HSIL–Severe Keratinizing Dysplasia typical blistering lesions present on the uterine cervix.
• HSIL (Carcinoma In Situ) Characteristic cellular changes (Table 3.7; e-Fig. 3.15, Fig.
● Poorly Differentiated Adenocarcinoma of Endocervix or
3.81) may even be seen in the absence of bullous lesions.
Endometrium
● Metastatic Adenocarcinoma
The affected cells are round to polygonal (some with
irregular borders) and represent acantholytic squamous
False-Positive Diagnosis of Squamous Carcinoma (See Figs. 3.78 to 3.82)
Fig. 3.78. Conventional smear. Radiation induced changes with en- Fig. 3.79. Conventional smear showing reparative/regenerative
larged nuclei containing prominent nucleoli may mimic squamous cells with macronucleoli is another cause for an over diagnosis of
carcinoma cells. Note the vacuolated cytoplasm suggesting degen- squamous carcinoma.
eration.
Fig. 3.80. Conventional smear showing pleomorphic squamous Fig. 3.81. A conventional smear from a case of pemphigus vulgaris
cells enlarge nuclei containing granular chromatin, parachromatin involving the cervix. The parabasal squamous cells are present in
clearing, and prominent nucleoli. These can be easily interpreted large numbers; contain enlarged nuclei; prominent, elongated nucle-
as malignant. Elsewhere in the smear, there were cells that showed oli; and can easily be mistaken for squamous carcinoma cells.
typical morphology of the herpes virus infection.
TABLE 3.7 CYTOPATHOLOGIC FEATURES OF cells. They often present as sheets, or in loosely cohesive
PEMPHIGUS VULGARIS groups appearing to be in the process of separating from
one another. Their nuclei are uniformly enlarged with
● Large exfoliation of abnormal round to polygonal high N/C ratios. The nuclear membrane is sharp and the
squamous cells, isolated and often in sheets with cells in chromatin finely granular. The nuclei of these acantholytic
the process of separating from one another cells contain multiple nucleoli, often large and oblong
● Uniform nuclear enlargement with moderately increased (bullet-shaped), which are considered to be a characteris-
N/C ratios tic feature of cervical pemphigus. The cytoplasm of these
● Sharp nuclear membrane
squamous cells is frequently wispy, with multiple processes
● Nuclear chromatin finely granular
● Multiple large and oblong (bullet-shaped) nucleoli
probably representing the detached junctional complexes.
● Cytoplasm wispy with multiple cellular processes The differential diagnosis includes squamous carcinoma.
Uniform nuclear morphology favors a benign diagnosis.
ASR-Like Changes. ASR typically involves gestational lodge very few cells. The abnormal cells within the thick
endometrium and consists of hypersecretory, hyperplas- keratinized layer may be well-differentiated with exces-
tic epithelium with clear cytoplasm and atypical nuclei, sive cytoplasmic keratinization and pyknotic nuclei.
which may be mistaken for clear cell carcinoma. Such a Cytologic evaluation of keratinizing lesions becomes dif-
reaction rarely occurs in the cervix and probably involves ficult since grading is usually based on adequate numbers
the endometriotic foci. Since these reactions regress and of abnormal cells present in the smear and their level of
disappear following the termination of pregnancy, cyto- differentiation (the less mature the cells are, the higher
logic changes can never be confirmed. Nevertheless, the the grade of SIL becomes).
smears with ASR contain very pleomorphic large to giant With hyperkeratosis due to benign processes, the
forms with enlarged nuclei containing granular chroma- cervical–vaginal smear shows only acellular keratin and
tin and multiple nucleoli (see Chapter 2, Fig. 2.18B). may be reported as keratosis.
HPV infection is often characterized by warty or a
Keratinizing Squamous Carcinoma versus Keratinizing verrucous growth with keratinization, resulting in exfo-
Lesions. The stratified squamous epithelial lining in the liation of pleomorphic dyskeratotic cells. Their nuclei,
female genital tract is the nonkeratinizing type. Kerati- however, do not exhibit malignant changes (Fig. 3.6B).
nization may occur as a response to chronic irritation The N/C ratios are usually only slightly increased.
such as uterine prolapse or chronic inflammation (Fig. Pleomorphic cell shapes with excessive keratinization,
3.90), or it may represent an abnormal reaction occur- in the absence of malignant criteria, should deter the
ring in SIL, including HPV-associated changes as well examiner from making a malignant diagnosis. Exces-
as squamous carcinoma. The excessive keratin layers sively keratinized cells with higher N/C ratios are more
appear as a white opaque plaque popularly referred to indicative of high-grade lesions or even carcinoma. It
as leukoplakia. On visual examination, it is not possible is important to acknowledge the fact that immature
to differentiate leukoplakia due to a benign reactive pro- squamous cells (small round cells or in situ type cells)
cess from those representing intraepithelial or malignant are capable of demonstrating keratinization—a feature
lesions. The layers of keratin covering a high-grade lesion unfortunately being referred to as atypical parakera-
or carcinoma may be very thick and may not dislodge tosis. The cytologic features of various keratinizing le-
abnormal cells during the sampling process or may dis- sions are listed in Table 3.8. Keratinized lesions need
TABLE 3.8 DIFFERENTIAL DIAGNOSES SIGNIFICANCE OF SQUAMOUS KERATINIZING LESIONS
Diagnostic Entity Significance Cytopathologic Features See Fig(s).

Hyperkeratosis/Parakeratosis A benign reactive process Lamellated keratin hyperkeratotic
frequently seen with uterine cells with pyknotic nuclei; same size as
prolapse or chronic inflammation normal superficial squamous cell nucleus
(Parakeratosis); anucleated cells; miniature
forms present in atrophy have low N/C ratio;
keratin pearls
Low-Grade Squamous Precursor to squamous Lamellated keratin ⫹/⫺: large numbers of 6B

Intraepithelial Lesion (Mild carcinoma mature squamous cells with dyskeratosis;
Dysplasia/CIN I) Human enlarged hyperchromatic or pyknotic nuclei;
Papilloma Virus Infection N/C ratio mildly increased, abnormal forms
Changes frequent; keratin pearls
High-Grade Squamous Precursor to well-differentiated Lamellated keratin ⫹/⫺; generally marked 25

Intraepithelial Lesion (Severe or keratinizing squamous exfoliation of abnormal cells; extremely 82
Keratinizing Dysplasia/ carcinoma pleomorphic in size and shape; small
Pleomorphic Dysplasia) to large, round, polygonal, caudate,
spindle-shaped to fiber forms; excessive
keratinization large hyperchromatic,
frequently pyknotic nuclei, very high N/C
ratio
Well-Differentiated Keratinizing Same as above except for presence of 55

Squamous Carcinoma nucleoli
to be sampled aggressively to dislodge the underlying malignant diagnosis. In general, the differentiation between
abnormal cells. the two entities is difficult (Figs. 3.82A and B).
Keratinizing Squamous Carcinoma versus Keratinizing Squamous Carcinoma versus Poorly Differentiated Endo-
HSIL. The cytologic patterns seen in squamous carcinoma cervical and Endometrial Carcinoma. The malignant cells
in situ or severe keratinizing dysplasia may be interpreted originating from poorly differentiated adenocarcinomas
as invasive squamous carcinoma. The cells of nonkerati- share morphologic features with poorly differentiated
nizing squamous carcinoma in situ may contain micronu- squamous carcinomas. Both show scant undifferentiated
cleoli, thus suggesting the possibility of an invasive pro- cytoplasm. Cells suggesting atypical squamous differen-
cess. Similarly, the cells of pleomorphic dysplasia present a tiation (e.g., endoplasm/ectoplasm with well-defined or
cytologic pattern that may be identical to that of keratiniz- rigid cell borders) may help in identifying squamous car-
ing squamous carcinoma. The presence of nucleoli favors a cinomas (Figs. 3.83 to 3.86).
A B
Figs. 3.82A and B. A: Severe keratinizing dysplasia, as seen here, may present fascicles of spindle-shaped, excessively
keratinized squamous cells containing enlarged, elongated, spindle-shaped, hyperchromatic nuclei. A diagnosis of
well-differentiated squamous carcinoma is strongly suspected. However, the presence of nucleoli is required for an un-
equivocal diagnosis of squamous carcinoma. B: A different field showing discrete pleomorphic keratinized squamous
cells, mimicking invasive squamous carcinoma. No nucleoli are present. The biopsy confirmed a severe keratinizing
dysplasia. No squamous carcinoma was confirmed on a follow-up cone biopsy.
Moderately to Poorly Differentiated Squamous Carcinoma versus Adenocarcinomas (See Figs. 3.83 to 3.86)
Fig. 3.83. Conventional smear showing small malignant cells Fig. 3.84. Conventional smear showing poorly differentiated squamous
with scant cytoplasm and enlarged round nuclei containing gran- carcinoma. The malignant cells are small with ill-defined cell borders
ular, uniformly distributed chromatin were interpreted as endo- and scant cytoplasm may be interpreted as a glandular carcinoma.
metrial adenocarcinoma. Cervical biopsy confirmed a squamous
carcinoma.
Fig. 3.85. Conventional smear. A poorly differentiated endometrial Fig. 3.86. Conventional smear. Invasive endocervical poorly differen-
carcinoma interpreted as squamous carcinoma because of large cell tiated adenocarcinoma mimicking a poorly differentiated squamous
size. carcinoma.
Morphologic Changes Involving the Mature

ATYPICAL SQUAMOUS CELLS (ASC) Squamous Cells
Superficial Type. These mature squamous cells with
In 1988, TBS included a diagnostic category ASC-US, or
pyknotic dead nuclei represent senescence. The only cyto-
atypical squamous cells of unknown significance, to desig-
logical changes observed are hyperkeratosis and paraker-
nate a group of lesions that were variously interpreted as
atosis. Excessively keratinized normal-sized mature cells
squamous atypia, reactive atypia, benign atypia, inflamma-
(superfi cial squamous cells) or miniature forms contain-
tory atypia, condylomatous atypia, atypical condyloma,
ing normal-sized pyknotic nuclei are referred to as par-
or Papanicolaou Class II. In 1991, TBS modified this cate-
akeratosis. The presence of lamellated keratin (keratosis)
gory by including three subgroups: ASC-US favor reactive,
and parakeratotic cells are seen, as with chronic inflam-
ASC-US favor intraepithelial neoplasia, and ASC-US, not
mation and irritations seen in uterine prolapse. These are
otherwise specified. The cytologic criteria were defined as
benign changes and are not atypical. The term ASC-US is
“cellular abnormalities that are more marked than those
not appropriate.
attributable to reactive changes but that quantitatively and
Hyperkeratosis is also seen in squamous intraepithe-
qualitatively fell short of a definitive diagnosis of SIL.”
lial lesions, both low and high-grade, as well as in kera-
It was recommended that this category should com-
tinizing squamous carcinoma. Smears from such lesions
prise no more than 5% of all cases. The ASC-US cases
may show abnormal squamous cells with dyskeratosis
varied considerably from institution to institution, as did
and dyskaryosis. However, a poor sampling technique
the confirmed high-grade lesions. The management of cas-
may yield only keratin.
es diagnosed as ASC-US posed a difficult problem for the
gynecologists. It was realized that 10 to 20% of women
with an ASC-US diagnosis were found to have HSIL.
Morphologic Changes Involving Intermediate
It was apparent that cases involving the mature
Type Squamous
squamous cells in the ASC-US group fell short of criteria
designated for LSIL and, in fact, were suspicious for LSIL, The criteria defi ned by TBS for ASC-US involving the
while a signifi cant proportion of cases involving the immature intermediate type squamous cell include the
mature squamous cells indeed were proven to be HSIL on following:
follow-up. Hence, in 2001, TBS redefined the category of
● Nuclear enlargement—of two and a half to three
ASC into two groups:
times that of a normal intermediate squamous cell
1. Atypical squamous cells of unknown significance nucleus.
(ASC-US); and ● Slight variation in nuclear size and shape, binucleation,
2. Atypical squamous cells, cannot exclude HSIL (ASC-H). or multinucleation.
● Slight hyperchromasia, evenly distributed chromatin
without granularity.
ATYPICAL SQUAMOUS CELLS OF
● Smooth and regular nuclear outline, very limited
UNDETERMINED SIGNIFICANCE (ASC-US)
irregularity.
This category involves the mature type squamous cells, ● Presence of some, but not all, of the features diagnostic
superficial, and intermediate type. of HPV cytopathologic effect.
These are TABLE 3.9 MIMICS OF ASC-US (MATURE

SQUAMOUS CELLS)
● Well-defined, optically clear perinuclear cavity;
● Peripheral rim of thickened cytoplasm; ● Inflammation-Associated Changes
● Nuclear alterations—either enlargement or wrinkled ● Orangeophilia Due to Stain Retention
nuclear outline with smudged chromatin. ● Atrophy-Associated Changes
● Radiation-Associated Changes
According to TBS, the cells suggestive of SIL ● Decidua
but sparse in numbers or with confounding artifacts ● LSIL (Mild Dysplasia/CIN I and HPV-Associated
such as air-drying or degeneration, preclude a defini- Changes)
tive diagnosis of SIL. An ASC-US diagnosis is thus
recommended.
The differential diagnoses of ASC-US of intermediate
type squamous cells include benign cellular changes and ever, the clearing is not sharply bordered by peripherally
LSIL (Table 3.9; see Figs. 3.87 to 3.95). condensed cytoplasm, as seen in HPV-induced changes.
ASC-US VERSUS LSIL ASC-US VERSUS RADIATION-ASSOCIATED

CHANGES
It is not always possible to differentiate ASC-US from
cells of LSIL. With borderline changes, the diagnostic Cervical–vaginal smears from patients who have received
interpretation remains subjective and is often based on ionizing radiation contain abnormal squamous cells with
the pathologists’ thresholds. The abnormal cells may be pleomorphic shapes, biphasic cytoplasmic staining, and
interpreted either as ASC-US or low-grade SIL (see Table enlarged nuclei with multinucleation. The nuclear chro-
3.13 for cytologic differences). matin is often smudgy. Radiation-induced changes are
morphologically similar to those of low-grade dysplasia.
An ASC-US diagnosis is justified in such cases (Fig. 3.91).
ASC-US VERSUS
INFLAMMATION-ASSOCIATED CHANGES
ASC-US VERSUS DECIDUA
Benign cellular changes induced by inflammation include
nuclear enlargement and some perinuclear clearing (Fig. Decidual cells are only infrequently encountered in
3.90). The nuclei are round with smooth nuclear mem- cervical- vaginal smears (Figs. 3.94 and 3.95). These are
branes. The reactive nucleus will show finely granular large polygonal to oval cells with abundant pale cytoplasm
chromatin sometimes with nucleoli, while the degenerated and centrally placed, slightly enlarged nuclei containing
ones may show darkly stained smudgy chromatin. The fine to coarsely granular chromatin and a prominent nucle-
perinuclear clearing may mimic koilocytic change; how- olus. Degenerating decidual cells may have densely stained
Atypical Squamous Cells of Unknown Significance (ASC-US) (See Figs. 3.87 to 3.95)
Fig. 3.87. Mature squamous cells with mildly enlarged nuclei con- Fig. 3.88. A tissue fragment of mature squamous cells with mini-
taining coarsely granular chromatin. The background is clean. These mally enlarged nuclei. Some cells exhibit the clearing of cytoplasm
qualify for the diagnosis of ASC-US. suggesting HPV-associated changes and are interpreted as ASC-US.
A B
C D
Figs. 3.89 A to E. Examples of ASC-US. A: Mature intermediate

type squamous cells with mildly enlarged nuclei. B: The squamous
cell shows considerable enlargement (cytomegaly) with mildly en-
larged nucleus. C: A tissue fragment of mature squamous cells with
crowded, uniform, but mildly enlarged central nuclei. D, E: Interme-
diate type mature squamous cells with slight nuclear enlargement
and perinuclear clearing, suggestive but not diagnostic of HPV-
E associated changes. Liquid-based preparations (SP).
Fig. 3.90. A conventional smear showing mature squamous cells with

slight nuclear enlargement. There is considerable inflammation in the
background. Although, these are suggestive of inflammation-associat-
ed changes, an LSIL cannot be excluded. An ASC-US is justified.
84
Fig. 3.91. Conventional cervical-vaginal smear showing radiation- Fig. 3.92. Conventional smear showing changes of LSIL for com-
induced changes. Note marked cytomegaly and karyomegaly with parison.
multinucleation. The cytoplasm is foamy and vacuoled. The changes
are observed in mature as well as parabasal cells. The nuclear en-
largement is variable, and the chromatin is dark and smudgy. The
cytologic changes are interpreted as ASC-US.
Fig. 3.93. Conventional smear showing changes of LSIL for com-

parison.
A B
Fig. 3.94. A: Conventional smear of a pregnant woman showing an enlarged polygonal cell with abundant pale cyto-
plasm and multiple nuclei with pale granular chromatin. This cell may either represent a decidual cell or an abnormal
squamous cell, hence interpreted as ASC-US. B: A conventional smear from a woman with a history of miscarriage.
This large intermediate type squamous polygonal cell with vacuolated, degenerating cytoplasm and enlarged nucleus
may either represent LSIL or a decidual cell.
compact chromatin, in which case, they are difficult to siderably in size, with occasional giant forms. Bare nu-
differentiate from cells of LSIL. Decidual cells strongly clei are often seen. The nuclear chromasia is deep, and
resemble ASC-US or LSIL except for the presence of a the chromatin smudgy. These are difficult to differentiate
nucleolus. A history of pregnancy is helpful (Table 3.10). from the cells of SIL or carcinoma and are reported as
ASC-US (e-Figs. 3.16 to 3.18). Local estrogen therapy
and a repeat smear are recommended in such cases. With
ASC-US VERSUS ORANGEOPHILIA
induced maturation and a cleaner background, cells with
Orangeophilia resulting from stain retention due to inad- atrophy-associated changes disappear, and cells repre-
equate rinsing or a thick smear mimics dyskeratosis. sentative of squamous intraepithelial lesions are better
Nuclear abnormalities in such cases are lacking. visualized. Table 3.11 lists differential diagnostic clues in
the atrophic smear.
ASC-US VERSUS ATROPHY-ASSOCIATED
CHANGES MORPHOLOGIC CHANGES INVOLVING
PARABASAL AND METAPLASTIC
Postmenopausal smears frequently show atrophic min-
SQUAMOUS CELLS
iature polygonal to round squamous cells with pyknotic
nuclei and orangeophilic cytoplasm mimicking the dysk- This group poses more diagnostic problems since their
eratotic cells of SIL. However, the orangeophilia lacks the differential diagnosis includes HSIL; hence, the abnor-
intense hyaline quality of excessive keratinization. mal cells are referred to as “atypical squamous cells, can-
The intermediate as well as parabasal cells in an not exclude high-grade intraepithelial squamous lesion,
atrophic background may show marked pleomorphism ASC-H” (Figs. 3.96 to 3.98F). The criteria for ASC-H
with spindle and tadpole forms. Their nuclei vary con- according to TBS include the following:
Fig. 3.95. Liquid-based preparation showing an enlarged round cell

containing enlarged poorly preserved nucleus with smudgy chroma-
tin; probably represents a decidual cell, but SIL cannot be excluded.
Atypical Squamous Cells Cannot Exclude High-Grade Lesion (ASC-H) (See Figs. 3.96 to 3.98)
Fig. 3.96. A conventional smear showing rare in situ type cells in an Fig. 3.97. A conventional smear. These were the only abnormal cells
extensive infl ammatory background precluding a definite cytologic in the entire smear. Although, morphologically, they fit the criteria
diagnosis of HSIL. for HSIL, the number of cells is too small for a definite diagnosis.
A B
C D
E F
Figs. 3.98A to F. Spectrum of cytologic changes of ASC-H in liquid-based preparations (SP). A, B, C: Rare, in situ type
cells. D: Few scattered in situ type cells in an inflammatory background. E, F: Rare syncytial tissue fragment of small
abnormal squamous cells suggesting HIS in an atrophic background.
TABLE 3.10 CYTOPATHOLOGIC FEATURES OF ASC-US, INTERMEDIATE TYPE MATURE SQUAMOUS

CELLS & LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION INCLUDING HPV-ASSOCIATED CHANGES
ASC-US Mature Squamous Low-Grade SIL Mild Low-Grade SIL HPV

Cell Intermediate Cell Type Dysplasia (CIN I) Associated Changes
Presentation Cells isolated, and in sheets, in Cells isolated, and in sheets, in Cells isolated, in loose
loose aggregates loose aggregates aggregates, and in sheets
Number of Cells Variable, generally small Variable Variable
Cytomegaly ⫹/⫺ ⫹/⫺ Pleomorphism in size and

shape frequent
Nucleus
Location Central Central Central to eccentric
Size 2–3 times the size of a normal Enlarged more than 3–4 times Enlarged more than 3 times
intermediate cell nucleus the normal intermediate cell the normal intermediate cell
nucleus or larger (normal nucleus
⫺35 ␮m² or size of an entire
neutrophil)
Chromatin Finely granular, evenly Fine to coarsely granular Coarsely granular/smudgy,

distributed; slight hyperchromatic hyperchromatic
hyperchromasia
Nuclear Membrane Smooth Smooth to irregular Smooth to irregular or

wrinkled (raisinoid)
Nucleolus Absent Absent Absent
Nuclear/Cytoplasmic Ratio Slightly increased Slightly increased Slightly increased
Bi-multinucleation ⫹/⫺ ⫹/⫺ Frequent
Cytoplasm Abundant, clear with or Abundant, pale, transparent Sharply cleared area around
without perinuclear clearing keratohyaline granules nucleus (perinuclear halo);
condensation of cytoplasm at
the periphery; distinctive rigid
cell border (wire looping)
Keratinization ⫹/⫺ ⫹/⫺ ⫹/⫺
Cytoplasmic Borders Well-defined Well-defined Well-defined
Background Clean Clean Clean
Cells usually occur singly or in small fragments of less The diagnostic diffi culties involving isolated or dis-
than 10 cells; occasionally, in conventional smears, cells crete small round cells with high N/C ratios are discussed
may “stream.” in the section on differential diagnoses of HSIL (Tables
3.4 and 3.12).
● The cells are the size of metaplastic cells with nuclei
that are about one and a half to two and a half times
“CROWDED SHEET PATTERN” (TBS)
larger than normal.
● The ratio of nuclear to cytoplasmic area may approxi- ● A microbiopsy of crowded cells containing nuclei that
mate that of HSIL. may show loss of polarity or are difficult to visualize.
TABLE 3.11 CLUES IN THE DIFFERENTIAL DIAGNOSES OF CELLULAR CHANGES IN ATROPHIC SMEAR
Cellular Features Mistaken For Diagnostic Clues See Fig(s).

Miniature Squamous Cells with Orangeophilic Keratinizing Lack of refractile dyskeratotic cytoplasm with e-Figs. 16A
Cytoplasm and Pyknotic Nuclei dysplasia rigid cell borders; low N/C ratio and B
Parabasal Cells with Nuclear Enlargement High-grade Smudgy nuclei, lack of nuclear details; nuclear e-Fig. 16C
dysplasia borders indistinct and disintegrating
Intermediate Type Squamous Cells with Bi- & LSIL Low N/C ratio; smudgy nuclei e-Fig. 16D
Multinucleation
Pleomorphic Shapes SIL/SCC Multiple cytoplasmic processes; e-Figs. 18A

lack of refractile dyskeratotic cytoplasm with and B
rigid cell borders
Tissue Fragments of Atrophic Parabasal Cells HSIL Uniform nuclei, cytoplasm around cells easily 43A and B,
appreciated; not a true syncytium (focus up 44A and B
& down)
Bare Nuclei and Blue Blobs SIL/SCC Structureless nuclei, lack other features of SIL/ See Chapter
SCC in the background 2, Fig. 2.8
TABLE 3.12 DIFFERENTIATING FEATURES AMONG METAPLASTIC SQUAMOUS CELLS, ATYPICAL

METAPLASTIC CELLS, (ASC-H) AND HSIL
ASC-H (Atypical Metaplastic

Squamous Cells or Atypical
Immature Metaplastic Squamous High Grade Squamous
Metaplastic Squamous Cells Cells) Intraepithelial Lesion (HSIL)
Presentation Number variable; discrete or in Number variable; discrete, in Number variable; discrete;
loosely cohesive groups or sheets; loosely cohesive groups or sheets; in loosely cohesive groups or
cells attached to each other by some cells attached to each other syncytial tissue fragments;
cytoplasmic processes by cytoplasmic processes cytoplasmic processes not present
Cells Size variable, immature cells Size variable, range from small, Size variable, small (size of the
are small, round, the size of resembling the endometrial basal cell) to the size of parabasal
endometrial stromal cell or stromal cells or histiocytes, up to
histiocyte; the more mature ones the size of parabasal cells; spider
are about the size of a parabasal forms with cytoplasmic processes
squamous 12–15 ␮m in diameter
as round, oval, or caudate forms
Cell Borders Well-defined in more mature Ill-defined in immature cells, Well-defined in single cells
cells; ill-defined in immature cells well-defined in more mature cells
Nucleus Round, slight enlargement, finely Round to oval, up to twice the Enlarged, occupying most of the
granular, evenly distributed size of the normal parabasal cellular area; chromatin coarsely
chromatin; smooth nuclear cell nucleus; smooth nuclear granular; sharp nuclear membrane
membrane; nucleolus may be membrane; chromatin finely with or without irregularity and
present in immature forms; low granular, evenly dispersed; N/C undulation; nuclear grooving
N/C ratio (compared to HSIL) ratio not as high as HSIL
Cytoplasm Pale lacy to bubbly in immature Lacy, pale to dense, may be Pale to dense, scant;
forms; dense to biphasic staining biphasic keratinization ⫹/⫺
in mature forms; cytoplasmic
processes frequent
TABLE 3.13 MIMICS OF ASC-US AND ASC-H
Type of Cells Cytopathologic Differential See ch. 3

Involved Cytopathologic Features Diagnosis Diagnoses Significance Fig(s).
Superficial Hyperkeratosis and parakeratosis, normal- Benign Keratinizing Not significant, 89C
Cells sized to miniature squamous cells; pyknotic Lesions unless 89E
small nuclei; orangeophilic cytoplasm accompanied
by nuclear
enlargement
Intermediate Non-inflammatory background; slight ASC-US LSIL May antedate 89D

Cells nuclear enlargement (2.5–3 times the normal SIL, some studies and 89F
size); binucleation and multinucleation; have shown
nucleus round, smooth membrane, higher incidence
normochromic to slight hyperchromasia of SIL in patients
with ASC-US on
colposcopy and
biopsy
Intermediate Non-inflammatory background, mild ASC-US HPV May represent 88

Cells pleomorphic in size; dyskeratosis; slight HPV
nuclear enlargement; perinuclear clearing
⫹/⫺; keratin pearls
Intermediate Inflammatory background; slight nuclear Benign; ASC-US — 90

Cells enlargement up to twice the normal size; Inflammation HPV
pale, finely granular or smudgy chromatin; Associated
indistinct perinuclear clearing, cytoplasmic Changes
eosinophilia
Intermediate Thick folded sheets of epithelium; No Abnormality ASC-US —

Cells orangeophilia due to stain retention; no HPV
nuclear enlargement (focus up and down to
appreciate cell borders and low N/C ratio)
Intermediate Clean background; nuclei 2.5–3 times the ASC-US; LSIL — 91

Parabasal size of a normal parabasal cell nucleus or Radiation
Cells larger; smudgy to finely granular chromatin, Associated
multinucleation; cytomegaly; history of Changes
radiation
Parabasal/ Inflammatory background ⫹/⫺: sheets ASC-H HSIL Progression to 98B

Metaplastic of cells with abundant cytoplasm; nuclei HSIL in some
Cells enlarged but N/C ratio near normal; series
granular chromatin prominent nucleoli,
some piling of nuclei with altered polarity
Immature Small round cells; high N/C ratio; scant, ASC-H (Atypical SIL/SCC May represent 29, 31
Metaplastic pale to lacy cytoplasm, at times dense; cell Immature SIL/SCC, 32, 33
Cells borders well to poorly defined; large nucleus; squamous estrogen
smooth nuclear membrane, hyperchromasia, Metaplastic proliferation test
uniformly distributed chromatin Cells) “Favor is helpful
HSIL”
Parabasal Atrophic background, air-drying ⫹/⫺; ASC-H HSIL — 43A and

Cells enlargement of nuclei sometimes marked; B
chromatin smudgy or finely granular;
cellular pleomorphism (tadpole or spindle
cells)
(continued)
Type of Cells Cytopathologic Differential See ch. 3

Involved Cytopathologic Features Diagnosis Diagnoses Significance Fig(s).
Parabasal/ Discrete, few small round cells, well-defined ASC-H versus 96, 97,
Metaplastic cell border; scant cytoplasm; large round HSIL 98
Cells nucleus with high N/C ratio; smudgy
nuclear chromatin; ⫹/⫺ inflammatory
background; history IUD usage;
nucleolus ⫹/⫺
Excessively Cells pleomorphic, small round to ASC-H versus Frequently e-Fig. 18

Keratinized fiber forms; spindle-shaped; excessive HSIL/Squamous overlooked and
Cells keratinization; rigid cell borders; large Carcinoma misinterpreted
pyknotic nuclei with moderate to high N/C as ASC-US or
ratio called atypical
parakeratosis
Decidua Large round to polygonal cells; well-defined ? ASC-US — 94

cell borders; abundant pale cytoplasm; ? Decidua 95
centrally placed slightly enlarged nucleus
with smooth nuclear membrane, evenly
dispersed finely granular chromatin; normal
to slight hyperchromasia; prominent
nucleolus; history of pregnancy helpful
Squamous Small concentric arrangements of squamous Benign Keratin pearls —

Pearls cells, small pyknotic nuclei, orangeophilia in HPV, SIL,
but no keratinization or carcinoma
(the cells are
keratinized and
the nuclei larger)
Degenerating Small round cells, discrete, often present Benign Cellular May be mistaken
Endocervical in streaks, poorly defined cell borders, Changes for SIL
Cells Pseudo- foamy to bubbly eosinophilic cytoplasm;
Parakeratosis deep-staining nucleus, referred to as
pseudoparakeratosis (pill effect)
● Dense cytoplasm, polygonal cell shape, and fragments ated with a higher risk of oncogenic HPV DNA detec-
with sharp linear edges generally favor squamous over tion and greater risk of underlying CIN 2 or worse
glandular (endocervical) differentiation. (30–40%) compared to ASC-US (10–15%) of under-
lying CIN 2 or worse. The risks associations were
This group of ASC-H refers to the tissue fragments of similar for both conventional smears and liquid-based
cells that mimic HSIL and is discussed in the section on preparations.
differential diagnoses of HSIL (Table 3.13). The consensus guidelines based on the ALTS study,
recommended two different follow-up strategies for
women with ASC-US diagnoses and those with ASC-H.
THE SIGNIFICANCE OF ASC-US AND ASC-H
Oncogenic (high-risk) HPV testing is the preferred
DIAGNOSES AND THE MANAGEMENT OF
management for ASC-US in contrast to colposcopy
WOMEN WITH ASC DIAGNOSIS—CURRENT
for ASC-H. Specific algorithms were recommended by
GUIDELINES
ACOG and ASCCP. These guidelines were revised in
Results from the ASC-US/LSIL Triage Study (ALTS) 2009. The reader should refer to related literature for
found that the interpretations of ASC-H were associ- information.
SUGGESTED READINGS
Atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion” is a distinct cytologic category.
squamous intraepithelial lesions triage study (ALTS) group: Histologic outcomes and HPV prevalence. Am J Clin Pathol
Human papilloma virus testing for triage of women with cyto- 2007;128:398–403.
logic evidence of low-grade intraepithelial squamous lesions: Selvaggi SM. Cytologic features of high-grade squamous intraepi-
Baseline data from a randomized trial. J Natl Cancer Inst thelial lesions involving endocervical glands on thin-layer
2000;92:397–402. cytology. Acta Cytol 2005;49:689–690.
Cibas ES. Cervical and vaginal cytology. In: Cibas ES, Ducatman BS, Sherman ME, Castle PE, Solomon D. Cervical cytology of atypical
eds. Cytology Diagnostic Principles and Clinical Correlates. squamous cells-cannot exclude high-grade squamous intraepi-
3rd ed. Philadelphia: Saunders, 2009. thelial lesion (ASC-H): Characteristics and histologic outcomes.
Cox JT, Moriarty AT, Castle PL. Statement on HPV DNA test Cancer 2006:298–305.
utilization, Commentary. Acta Cytol 2009;53:249–252. Sherman ME, Solomon D, Schiffman M. Qualifications of ASCUS:
Frable WJ. Litigation cells: Definition and observations on a cell A comparison of equivocal LSIL, and equivocal HSIL, cervical
type in cervical/vaginal smears not addresses by the Bethesda cytology in the ASCUS/LSIL Triage Study. Am J Clin Pathol
System. Diagn Cytopathol 1994;11:213–215. 2001;116:386–394.
Koss LG, Melamed M. Diagnostic Cytology and its Histopatho- Solomon D, Nayar R, eds. The Bethesda System for Reporting
logic Bases. 5th ed. Philadelphia: Lippincott Williams & Cervical Cytology: Definitions, Criteria, and Explanatory notes.
Wilkins, 2005. 2nd ed. New York: Springer, 2001.
Kurman RJ, Solomon D. The Bethesda System for Reporting Solomon D, Papillo JL, Davey DD. Statement of HPV DNA test
Cervical/Vaginal Cytologic Diagnoses. New York: Springer- utilization. Acta Cytol 2009;53:247–248.
Verlag, 1994. Stolar MH, Schiffman M. Interobserver variability of cervical cyto-
McGrath CM, Kurtis JD, Yu GH. Evaluation of mild-to-moderate logic and histologic interpretations: Realistic estimate from the
dysplasias on cervical-endocervical (Pap) smear: A subgroup ASCUS-LSIL triage study. JAMA 2001;285:1500–1505.
of patients who bridge LSIL and HSIL. Diagn Cytopathol Tavassoli FA, Devilee P, eds. Pathology and Genetics. Tumors of
2000;23:245–248. the Breast and Female Genital Organs. WHO Classification of
Nasser SM, Cibas ES, Crum CP, et al. The significance of the Tumors. Lyon, France: IARC Press, 2003.
Papanicolaou smear diagnosis of low-grade squamous intraepi- Wright TC Jr, Massad LS, Dunton CJ, et al. 2006 consensus
thelial lesion cannot exclude high-grade squamous intraepithe- guidelines for the management of women with abnor-
lial lesion. Cancer 2003;99:272–276. mal cervical cancer screening tests. Am J Obstet Gynecol
Owens CL, Moats DR, Burroughs FH, et al. “Low-grade 2007;197:346–355.
squamous intraepithelial lesion cannot exclude high-grade
APPENDIX
COMPARATIVE NUCLEAR AREAS IN CERVICAL

SQUAMOUS INTRAEPITHELIAL LESIONS
Nuclear Nuclear
Diameter Area
(µm) (µm2) Cell Type
6.8 35 intermediate squamous cell
8.0 50 squamous metaplastic cell

squamous parabasal cell
9.8 75 small cell carcinoma in-situ

small cell carcinoma
11.3 100 squamous cell atypia (ASCUS)
13.8 150 moderate dysplasia
14.9 150-175 intermediate carcinoma in-situ
14.9 175 slight or mild dysplasia

LSTL
14.9 175 large cell carcinoma in-situ
1
Modified from Patten SF. Diagnostic cytopathology of squamous neoplasia of the uterine cervix. American
Society of Clinical Pathology, 1993.
4 ENDOMETRIUM AND
ENDOCERVIX*
The glandular lesions in The Bethesda System 2001 are cervical–vaginal screening. However, the same is not
classified as follows: true for endometrial adenocarcinoma, which has now
Epithelial Cell Abnormalities become the most common malignant neoplasm of the
Glandular Cell female genital tract, accounting for 10 to 20 per 100,000
Atypical populations per year in Western countries. The detec-
Endocervical Cells (NOS or specify in comments) tion of endometrial adenocarcinoma in cervical–vaginal
Endometrial Cells (NOS or specify in comments) smears is dismally low, particularly for low-grade carci-
Glandular Cells (NOS or specify in comments) nomas and in asymptomatic patients. The widely used
Atypical one-slide technique for cervical cancer screening using
Endocervical Cells, Favor Neoplasia a spatula and endocervical brush is not an ideal choice
Glandular Cells, Favor Neoplasia for the detection of endometrial cancer, which is perhaps
Endocervical Adenocarcinoma In Situ better detected in vaginal pool specimens. Some institu-
Adenocarcinoma tions advocate sampling the vaginal pool for patients
Endocervical over 40 years of age. Although direct sampling of the
Endometrial endometrium by such means as endometrial washings or
Extrauterine aspirations appears to be an ideal solution, its success
Not Otherwise Specified rate has been variable.
The diagnostic problems encountered in evaluating
Note: Benign appearing endometrial cells in women over cervical–vaginal smears for endometrial lesions include
40 years during the second half of menstrual cycle and in the following:
all postmenopausal women are to be reported separately
with the clarification that there is no squamous abnormal- ● Differentiating abnormal endometrial cells from normal
ity. This will be further discussed in the section on “Signif- appearing endometrial cells in women over 40 years
icance of Endometrial Cells in Cervical-Vaginal Smears.” during the second half of her menstrual cycle and at
This chapter will first describe the endometrial lesions, any time in the postmenopausal state.
followed by endocervical lesions. ● Differentiating abnormal endometrial cells originating
from several benign conditions (including hyperplasia)
ENDOMETRIUM from cells of low-grade endometrial adenocarcinoma
cells.
● Recognizing endometrial carcinomas in asymptomatic
INTRODUCTION and high-risk patients, particularly in the presence of
The decline in the incidence of cervical cancer and few carcinoma cells.
cancer-related deaths is certainly a triumph for routine ● Difficulty in recognizing certain nonspecific cytopatho-
logic features that coexist with low-grade endometrial
*Note: The following images in this chapter are the courtesy of carcinomas but may serve as a clue to the presence of
Karen Atkinson, MPA, CT (ASCP), CMIAC, Director of Education malignancy when present by themselves (in conven-
and Training, BD Diagnostics-Women’s Health and Cancer, and tional smears).
Tim Collins, BS, CT (ASCP), Senior Scientist, Research and Devel- ● Differentiating poorly differentiated endometrial car-
opment, BD Diagnostics-Women’s Health and Cancer: Figures 3A
and 3B, 4A and 4B, 6B, 8, 9, 14, 21, 23C, 40C, 40D, 45A to 45C,
cinomas from other malignancies such as endocervical
46A and 46B, 49A and 49B, 50, 51A to 51D, 65, 67, 70A and 70B; adenocarcinoma, squamous carcinoma, and metastatic
e-Figures 2A, 2B, 4A and 4B, 6. carcinoma.
94
Chapter 4: Endometrium and Endocervix 95
CELLS ORIGINATING FROM MENSTRUAL

THE CYTOMORPHOLOGY OF NORMAL ENDOMETRIUM
ENDOMETRIAL CELLS
Endometrial cells are readily seen in cervical–vaginal
smears from the beginning of the menstrual flow until
The cytomorphology of normal endometrial cells depends
the twelfth day of the cycle, although some variation of
on the sampling techniques. Spontaneously exfoliated
a few days may be encountered (Table 4.1; e-Figs. 4.1 to
cells present different cytologic features compared to
4.4). The menstrual endometrium consists of glandular
those obtained by direct endometrial aspiration. The
cells and superfi cial stromal cells (e-Figs. 4.5 and 4.6).
same holds true for endometrial sampling of the lower
The deep stromal cells from the inactive endometrium are
uterine segment using an endocervical brush. The cyto-
sometimes seen in cervical-vaginal smears via endocervi-
logic features of normal endometrial cells also depend
cal brushings. Deep stromal cells do not exfoliate sponta-
on the type of cytologic preparations. For example,
neously. They are short spindle-shaped cells with poorly
endometrial cells in conventional smears present con-
defi ned cell borders and scant cytoplasm with uniform
siderably different morphology than those in liquid-
nuclei containing bland chromatin (e-Fig. 4.7).
based preparations, where they often appear “above the
plane” of squamous cells. The endometrial cells are pres-
LOWER UTERINE SEGMENT CELLS
ent themselves in tight three-dimensional clusters, loose
aggregates, and as single cells. The latter can be appre- The lower uterine segment (LUS), also referred to as the
ciated only in smears with a clean background. The isthmus of the cervix (see Chapter 2, Fig. 2.1), constitutes
endometrial cells are better preserved in liquid-based the upper third of the cervix but, histologically, resembles
preparations, presenting crisper nuclear details. How- the uterine body and is lined by endometrium. This area
ever, intense crowding and “balling up” of the cells may may be inadvertently sampled by an endocervical brush
not allow visualization of the cytomorphologic details. and thus encountered in cervical smears. The incidence
Intracytoplasmic vacuoles are easily seen, as is single cell of LUS cells is reported as roughly 7% in cervical smears.
necrosis or apoptosis. Their cytologic presentation is characteristic (Table 4.2,
TABLE 4.1 CYTOPATHOLOGIC FEATURES OF SPONTANEOUSLY EXFOLIATED ENDOMETRIAL

CELLS ORIGINATING FROM MENSTRUAL ENDOMETRIUM
Conventional Smear Liquid-Based Preparation

Glandular Cells Isolated, in aggregates or in tissue fragments; Cells appear in tight three-dimensional structures,
cells are small, round to oval (about the size above the plane of squamous cells, and in loose
of an entire neutrophil); cytoplasm is scant, aggregates; cells may be isolated but difficult to
indistinct, variably staining, sometimes appreciate. Cell preservation often better; nuclei
vacuolated; cell borders are indistinct; may be bean-shaped with granular chromatin and
nucleus is small, 6 to 7 ␮m in diameter nucleoli; cytoplasm is scant with or without vacuoles
(30–35 ␮m²); nucleoli indistinct; coarsely
granular to compact chromatin
Superficial Stromal Cells Isolated and in loose aggregates; present Often appear as aggregates of histiocytes, permeated
in streaks, mixed with degenerating single by neutrophils; isolated superficial stromal cells are
glandular cells; round to oval, larger than not appreciated
glandular cells; moderate bubbly to pale
cytoplasm; nucleus round to reniform with
finely granular chromatin; micronucleoli
⫹/⫺
Deep Stromal Cells In aggregates; oblong to short spindle- Same

shaped with scant indistinct cytoplasm, oval
or elongated nuclei with coarsely granular,
evenly dispersed chromatin
Mixed Cell Clusters Double-contoured cell masses with compact Same

(Endometrial Wreaths) central stromal cells and peripheral
glandular or stromal cells, often permeated
by neutrophils
TABLE 4.2. CYTOMORPHOLOGIC FEATURES OF ENDOMETRIAL METAPLASIAS

ENDOMETRIAL CELLS OF THE LOWER UTERINE
SEGMENT (LUS) The endometrium, which is derived from the Müllerian
system, may undergo metaplastic change to several differ-
Presentation Large tissue fragments of endometrial stroma ent types of epithelia that are not normally found in the
with and without tubular endometrial glands endometrium. These include squamous, clear cell, hobnail,
ciliated or tubal, eosinophilic, mucinous, and papillary
Stromal Very uniform, round to spindle-shaped; nuclei syncytial. Conditions associated with various metaplasias
Cells are oval with finely granular chromatin; mitoses include endometritis, polyps, atrophy, hyperplasias, and
may be seen; cells at the periphery are loose, adenocarcinoma. Histologically, these various types of
stringing out; cytoplasm is scant; capillaries metaplasias involving the endometrium are insignificant
traversing through the tissue fragments
and easily recognized but not in cytologic specimens. Only
the papillary syncytial type metaplasia can be identified,
Glands Tubular with or without branching; often
which is diagnostically significant. Its complex papillary
surrounded by stroma; gland openings ⫹/⫺;
monolayered or syncytial tissue fragments growth pattern along the surface of the endometrium may
⫹/⫺; nuclei extremely crowded with simulate features of endometrial adenocarcinoma. Cells
peripheral palisading; mitoses ⫹/⫺; nucleoli originating from this lesion exfoliate as papillary-like tis-
⫹/⫺; cytoplasm is very scant, insignificant; sue fragments, constituting an important diagnostic pit-
the glandular structures have smooth external fall, particularly in postmenopausal women (see Table 4.6,
contours e-Figs. 4.10A to D, 4.11, 4.12, 4.13A to D; see Fig. 4.34).
Differential ● Cervical and Vaginal Endometriosis

Diagnoses ● Squamous Carcinoma In Situ
ENDOMETRIAL HYPERPLASIA
● (Gland & Crypts Involvement) Endometrial hyperplasia typically occurs during the peri-
● Endocervical Glandular Atypia menopausal or early postmenopausal period. The prob-
● Endocervical Adenocarcinoma ability of this condition increases with obesity and the use
● (In Situ and Invasive)
of exogenous hormones, particularly unopposed estrogen.
● Abnormal Presence of Endometrial
● Cells
Endometrial hyperplasia may be defined as a benign, non-
● Endometrial Adenocarcinoma invasive condition of proliferating endometrium in which
the glands are in architectural disarray, showing increased
density, and assuming abnormal configurations. The glan-
dular cells may or may not exhibit nuclear atypia. The
e-Figs. 4.8 and 4.9). The differential diagnoses of LUS presence of nuclear atypia is emphasized as a predictor of
cells include several diagnostic entities (Table 4.2). premalignant behavior.
Hyperplastic endometrial glands generally appear
ENDOMETRIAL CELLS IN PATIENTS ON without obvious orientation toward the endometrial
HORMONAL REPLACEMENT THERAPY surface and assume a shape that is somewhat rounded,
small or large (simple), or with outpouchings or infold-
Patients on hormonal replacement therapy (HRT) with ings (complex). The degree to which the endometrial stro-
a cyclic regime have regular bleeding cycles. In these ma also proliferates determines in part how closely the
patients, endometrial cells may be seen in cervical samples glands will be spaced. Hyperplastic endometrial glands
preceding, during, or immediately after the cycle. These without atypia are formed by cells having the usual pro-
endometrial cells present the same cytomorphology as liferative type nucleus, which is elongated with dense
the cells seen in cyclic women during the menstrual cycle chromatin. Those glands with atypia exhibit nuclei that
(Table 4.1, e-Fig. 4.3). Women on continuous HRT may are ovoid, rounded, or occasionally angular. These nuclei
have breakthrough bleeding with the presence of benign have chromatin that is fi nely divided and pale. Nucleoli
endometrial cells in the cervical smear. may be prominent. Polygonal-shaped stromal foam cells
(lipophages) may be present in the stroma between the
DIRECT ENDOMETRIAL SAMPLING endometrial glands.
Several methods and devices have been used to obtain

direct sampling of the endometrium. Although such meth-
ENDOMETRIAL HYPERPLASIA
ods appear to be ideal for the diagnosis of endometrial
cancers, in reality, the success rates have been variable. The cytologic presentation of endometrial hyperplasias
These procedures are painful to the patient and are dif- is variable. The exfoliation of endometrial cells is not
ficult to perform due to narrow endocervical canals. consistent. They may be few in number, transient, and—
The reader may refer to related literature for more rarely—numerous. The smear background is often clean,
information. characterized by a high estrogen effect.
Depending on the type of hyperplasia (e.g., simple, com- endometrial adenocarcinomas. The presence of nucleoli in-
plex, or atypical), the endometrial cells may vary from ap- dicates atypical hyperplasia or low-grade adenocarcinoma.
pearing normal to severely abnormal (Figs. 4.1 to 4.3). Fre-
quently, the only clue to a hyperplastic or neoplastic condition
ADENOCARCINOMA OF THE ENDOMETRIUM
is the presence of isolated normal to atypical endometrial
cells in an otherwise unremarkable smear. Different grades Endometrial adenocarcinoma has become the most com-
of hyperplasia cannot be effectively recognized from cyto- mon invasive cancer of the female genital tract, and its inci-
logic samples since they form a spectrum in the evolution of dence is on the rise. A strong association has been noted
Fig. 4.1. Conventional smear. Endometrial hyperplasia. These en- Fig. 4.2. Conventional smear. Extensive exfoliation of endome-
dometrial cells in a postmenopausal woman are minimally enlarged, trial cells in a postmenopausal woman, interpreted as diagnostic
some with cytoplasmic vacuoles. They were interpreted as suspicious of adenocarcinoma. Endometrial curettings revealed complex
for adenocarcinoma. Endometrial curettings confirmed hyperplasia. hyperplasia.
A B
Figs. 4.3A to C. A, B: Liquid-based preparations. Abnormal endo-

metrial cells in a postmenopausal woman. The cells are mildly en-
larged and have cytoplasmic vacuoles. C: Liquid-based preparation
(ThinPrep). Endometrial cells in a postmenopausal woman. Follow-
up confirmed hyperplasia. (Courtesy of Dr. Mariza de Peralta-
C Venturina, Cedar-Sinai Hospital, Los Angeles, California.)
between unopposed estrogen replacement therapy (without sue. The villoglandular variant usually behaves as a well-
progestational drugs) and the development of endometrial differentiated carcinoma and must be distinguished from
carcinoma. Studies on the epidemiology of endometrial car- papillary serous adenocarcinoma, which progresses as a
cinomas have brought to attention two pathogenetic forms: high-grade neoplasm with early lymphatic involvement.
one estrogen related and the other non-estrogen related. The
former is low-grade, occurs in a younger age group (pre-
menopausal and early postmenopausal), and is often associ-
ENDOMETRIAL ADENOCARCINOMA
ated with endometrial hyperplasia. The latter type is more
aggressive, associated with atrophic endometrium, occurs The cytopathologic features of endometrial adenocar-
in older women, and is rarely associated with hyperplasia. cinoma depend on the histologic type and grade of the
tumor (Table 4.3). The neoplastic cells arising from grade
I carcinoma are usually few in number, small in size, with
HISTOLOGIC CLASSIFICATION OF
a strong resemblance to their normal counterparts or to
ENDOMETRIAL CARCINOMA
the cells of hyperplasia from which they are difficult to
Of the several morphologic types of endometrial carci- differentiate (Figs. 4.4 to 4.10).
nomas, the endometrioid type is most frequently encoun- Grade I adenocarcinomas are generally preceded by
tered (see Appendix). hyperplasias. Smears from such patients frequently show
a high estrogen effect and a clean background, although
this is not the case all the time. Very often, cells from well-
Endometrial (Endometrioid) Carcinomas
differentiated adenocarcinoma exfoliate singly and in small
This is the most common form, accounting for over 75% numbers. They are about the same size or slightly larger
of all endometrial carcinomas. The histologic diagnosis than the entire neutrophil. The nucleus either occupies the
of endometrial adenocarcinoma of the endometrioid type entire cell with a scant rim of cytoplasm or can be eccentric
requires the recognition of the architectural features of with pale to dense cytoplasm. Small to large cytoplasmic
stromal invasion together with the cytologic features of vacuoles may be seen, sometimes containing neutrophils.
nuclear atypia. Evaluation for this purpose utilizes several Unlike histiocytes, which they strongly resemble and are
“malignant criteria” with no single feature being diagnos- often mistaken for, endometrial carcinoma cells contain
tic. Malignant endometrial glands usually appear in com- nuclei with coarsely granular chromatin and prominent
plex patterns, showing back-to-back arrangements, or may macronucleoli. These cells, referred to as histiocyte-like
form extensive papillations. The glands are often contained endometrial carcinoma cells by Frost (personal communi-
within fibrotic stroma, and there may be evidence of necro- cation, 1976), are easily overlooked. At times, these cells
sis, such as cellular debris and neutrophils, contained within are present in streaks surrounded by old fragmented red
the glandular lumina. The glands are formed by columnar blood cells, fibrin, and proteinaceous fluid referred to as
cells that are commonly stratified to create papillary infold- diathesis. Large histiocytes with abundant clear to foamy
ings or cribriform bridges across the lumina. The malignant cytoplasm in the stroma are a frequent finding in histologic
nuclei may appear similar to the nuclei of atypical hyper- sections of endometrial hyperplasias and well-differentiated
plasia or may have accentuated irregularity (more altera- adenocarcinoma and are referred to as lipophages. Their
tion of size, nuclear membrane configuration, or chromatin presence alone may warrant appropriate investigation to
pattern). Abnormal mitotic figures may be present. rule out endometrial pathology. These features are seen only
The FIGO grading system for endometrial adenocar- in conventional smears.
cinoma is based upon the architecture of the malignant Cytopathologic features of endometrial adenocar-
glands with consideration given to nuclear appearance. cinomas in liquid-based preparations present as three-
A grade I adenocarcinoma (well-differentiated) is almost dimensional groups or in syncytial tissue fragments with
entirely gland-forming with less than 5% of the tumor or without papillary or papillary-like configurations and
appearing solid or devoid of lumina. A grade II tumor acinar pattern. The syncytial tissue fragments have smooth
(moderately differentiated) may be up to 50% solid, external contours. Their nuclei tend to be larger with more
while a grade III tumor (poorly differentiated) is beyond open chromatin and micronucleoli (Figs. 4.4, 4.5, 4.6B,
this threshold. A high degree of nuclear cytologic atypia 4.8 and 4.9). Although diathesis described in convention-
raises grade I and II tumors by one degree. al smears is not appreciated in liquid-based preparations,
Variations from the classic endometrioid pattern of certain features, which are referred to as a “clinging diath-
adenocarcinoma described above are well recognized. esis,” are described by suggesting similar phenomena and
Areas of squamous differentiation may be encountered are noted by the presence of cellular debris clinging to the
admixed within an endometrioid tumor. The villoglandu- periphery of the endometrial cell clusters.
lar pattern of adenocarcinoma consists of delicate fronds Moderately to poorly differentiated endometrioid
lined by malignant but generally well-ordered tall colum- adenocarcinomas, on the other hand, generally exfoli-
nar cells arranged around thin cores of fibrovascular tis- ate significant numbers of neoplastic cells (Table 4.3,
TABLE 4.3 CYTOPATHOLOGIC FEATURES OF ENDOMETRIAL ADENOCARCINOMA
Well-Differentiated Endometrial Adenocarcinoma Moderate to Poorly Differentiated Endometrial

Endometrioid Type Adenocarcinoma Endometrioid Type
Number of Variable, generally low Moderate to marked
Malignant Cells
Presentation Malignant cells isolated; in loosely cohesive groups Malignant cells, isolated; in loosely cohesive groups
or in syncytial tissue fragments with tightly packed or in syncytial tissue fragments with or without an
nuclei acinar pattern
Cells Small, round to cuboidal, same size as the normal Medium-sized, round to cuboidal
endometrial or slightly larger; signet-ring forms ⫹/⫺
Nucleus Slightly enlarged compared to normal counterpart, Moderately enlarged, round to oval, high N/C
round to oval, high N/C ratio, may be eccentric; ratio, may be eccentric; nuclear membrane
nuclear membrane smooth to irregular; chromatin smooth to irregular; chromatin fine to coarsely
fine to coarsely granular; parachromatin clearing granular; parachromatin clearing; multiple micro/
⫹/⫺; micronucleoli or prominent large nucleolus macronucleoli
Cytoplasm Scant, insignificant, pale to vacuolated, at times Variable, scant to moderate; squamous
dense and eosinophilic; large secretory vacuoles differentiation ⫹/⫺
filled with neutrophils (chemotaxis)
Background Large foamy stromal histiocytes or lipophages; Lipophages absent; estrogen effect low (atrophic);
estrogen effect high; clean or bloody and bloody and inflammatory with cellular and necrotic
inflammatory; diathesis ⫹/⫺ debris diathesis ⫹/⫺
Immunoprofile Coexpression of vimentin and cytokeratin; ER/PR Same

strongly positive; negative reactivity with MIB1,
p53, p16, beta-catenin
Fig. 4.4. Liquid-based preparation. Abnormal endometrial cells in Fig. 4.5. Liquid-based preparation (ThinPrep). Abnormal endo-
a postmenopausal woman. Follow-up confirmed endometrial ad- metrial cells. Small endometrial cells in a tight cluster confirmed
enocarcinoma. as adenocarcinoma on biopsy. (Courtesy of Dr. Mariza de Peralta-
Venturina, Cedar-Sinai Hospital, Los Angeles, California.)
Figs. 4.11 to 4.17), which appear clearly malignant and as other poorly differentiated malignant neoplasms (see
are easily recognized. Since poorly differentiated carci- Table 4.11).
nomas generally occur in older women without a history
Immunoprofile
of hyperplasia, the smears often show an atrophic back-
ground with inflammation and diathesis. The poorly The endometrioid adenocarcinomas are strongly reactive
differentiated endometrioid adenocarcinomas must be to ER/PR, vimentin, and cytokeratin. They are nonreac-
differentiated from serous papillary carcinomas as well tive to MIB1, beta-catenin, and p53.
A B
Figs. 4.6A and B. A: Conventional smear. These endometrial cells are small, slightly pleomorphic with coarsely granu-
lar chromatin and micronucleoli. Follow-up confirmed an adenocarcinoma. B: Liquid-based preparation. Slightly
enlarged, endometrial cells in an atrophic background, interpreted as suspicious, confirmed an adenocarcinoma on
follow-up.
Fig. 4.7. Conventional smear. The endometrial cells in a postmeno- Fig. 4.8. Liquid-based preparation. Atypical endometrial cells.
pausal woman were interpreted as suspicious for adenocarcinoma. These endometrial cells were interpreted as suspicious for adenocar-
No malignancy was confirmed on curettings. cinoma. Note the slight pleomorphism and cytoplasmic vacuoles.
Follow-up was negative.
Fig. 4.9. Liquid-based preparation. These endometrial cells in a Fig. 4.10. Conventional smear. Rare, isolated endometrial cells in
postmenopausal woman were interpreted as suspicious for adeno- a postmenopausal woman. Their nuclei are minimally enlarged,
carcinoma, confirmed on follow-up. and the chromatin is granular. Interpreted as positive, confirmed on
biopsy.
Fig. 4.11. Conventional smear. A streak of abnormal cells in a post- Fig. 4.12. Conventional smear. The endometrial cells in a post-
menopausal woman. The cells are mildly enlarged. The nuclei have menopausal woman. Note the moderate enlargement and granular
well-preserved coarsely granular chromatin with micronucleoli in- chromatin with nucleoli. Their cytoplasm is pale and lacy. Adeno-
terpreted as endometrial adenocarcinoma, confirmed on follow-up carcinoma was confirmed on curettings.
biopsy.
Fig. 4.13. Conventional smear. Malignant endometrial cells in Fig. 4.14. Liquid-based preparation. Abnormal endometrial cells in
a hemorrhagic background. The nuclei are slightly enlarged with a postmenopausal woman, interpreted as positive and confirmed as
granular chromatin and contain micronucleoli. moderately differentiated endometrial adenocarcinoma.
Fig. 4.15. Conventional smear. Postmenopausal woman. The en-

dometrial cells are in a syncytial tissue fragment, with enlarged
and crowded overlapped nuclei, containing granular chromatin
and nucleoli, confirmed as moderately differentiated endometrial
adenocarcinoma.
Fig. 4.16. Conventional smear. Moderate to poorly differentiated Fig. 4.17. Conventional smear. These malignant cells are discrete
endometrial adenocarcinoma cells. and loosely cohesive with pleomorphic enlarged nuclei containing
coarsely granular chromatin and nucleoli. Typing these as endome-
trial adenocarcinoma is difficult since they can represent adenocar-
cinoma as endocervical or metastatic or as poorly differentiated
squamous carcinoma.
Fig. 4.18. Conventional smear. Serous papillary adenocarcinoma of Fig. 4.19. Conventional smear. Serous papillary carcinoma of the
the endometrium. The malignant cells can be readily identified. endometrium showing papillary tissue fragments with psammoma
bodies (arrow).
lium with marked cellular and nuclear pleomorphism.

OTHER MORPHOLOGIC TYPES OF The stratified epithelium often displays papillary tuft-
ENDOMETRIAL ADENOCARCINOMAS ing, with a frequent hobnail pattern. The cells of UPSC
are characterized by a marked variation in size and con-
tain pleomorphic bizarre nuclei, macronucleoli, multi-
UTERINE PAPILLARY SEROUS
nucleation, and frequent mitoses. Psammoma bodies are
CARCINOMA (UPSC)
present in approximately 30% of cases. UPSC can be
Uterine papillary serous carcinoma (UPSC) is an uncom- present in a pure form or as a component of endometri-
mon subset of endometrial carcinomas with an aggressive oid carcinoma, and it often coexists with a clear cell
behavior. Strong morphologic resemblance to ovarian component.
serous carcinoma, frequent myometrial and lymphovas- The cells of UPSC are likely to exfoliate in large
cular invasion, peritoneal involvement, and an aggressive numbers and be detected in cervical–vaginal smears
clinical course characterize UPSC. Patients with UPSC are (Figs. 4.18 to 4.21). The diagnostic cells of UPSC are
generally postmenopausal, with a mean age of 66 years. seen isolated, in loose aggregates, or in syncytial tis-
Microscopically, UPSC shows a complex papillary sue fragments with papillary configuration (Figs. 4.18
architecture. The branching papillary glands are usually to 4.21). The malignant cells are generally larger than
densely fibrotic, covered by stratified malignant epithe- those seen in well-differentiated endometrioid carcinoma
A B
Figs. 4.20A and B. Conventional smears. Serous papillary carcinoma of the endometrium. The malignant cells are
poorly differentiated, precluding typing. Final diagnosis depends on histologic examination.
Fig. 4.21. Liquid-based preparation demonstrating endometrial ad- Fig. 4.22. Conventional smear. Adenosquamous carcinoma of the
enocarcinoma of serous papillary type. endometrium. Note the syncytial tissue fragment of the malignant
cells with both glandular and squamous differentiation (arrows).
and exhibit considerable variation in size. Giant forms and UPSC (Table 4.4). Peritoneal and pelvic washings in
are frequently seen. The malignant cell nuclei are round patients with UPSC frequently contain malignant cells,
with irregular membranes, finely granular chromatin, whereas those with typical endometrioid carcinomas usu-
and excessive parachromatin clearing. Micronucleoli are ally do not.
frequent, and the presence of a large cherry–red macro-
nucleolus is characteristic of UPSC cells. The cytoplasm
Immunoprofile
of the malignant cells is variable, clear, and pale to dense,
but it lacks the neutrophil-filled vacuoles that are so fre- UPSCs are non-reactive to ER/PR and are strongly reac-
quently present in endometrioid carcinoma cells. Psam- tive to P53, MIB1, and beta-catenin.
moma bodies—naked or incorporated in a malignant The less common variants of endometrial carcinomas
tissue fragment—may be seen in a fair number of cases such as adenosquamous carcinoma may show large po-
(Fig. 4.19). The background may be atrophic or bloody lygonal cells with squamous differentiation with or with-
with necrotic debris and often contains proteinaceous out keratinization and pleomorphic nuclei, which aids in
fluid (Table 4.4). accurate identification (Fig. 4.22). Clear cell adenocarci-
The presence of large malignant cells with papillary nomas present aggressive behavior. The malignant cells
tissue fragments, pleomorphic nuclei containing macro- are extremely pleomorphic with frequent giant forms
nucleoli, and psammoma bodies suggests the diagnosis containing bizarre nuclei. Their cytoplasm is variable,
of UPSC. However, there is considerable overlap between may be abundant, and is very pale (see Table 4.13; Figs.
the cells of a poorly differentiated endometrioid carcinoma 4.23A to C).
TABLE 4.4 CYTOPATHOLOGIC FEATURES OF UTERINE PAPILLARY SEROUS AND

POORLY DIFFERENTIATED ENDOMETRIAL/ENDOMETRIOID ADENOCARCINOMA
IN CERVICAL–VAGINAL SMEARS
Poorly Differentiated Endometrial/

Feature Uterine Papillary Serous Carcinoma Endometrioid Adenocarcinoma
Presentation Malignant cells isolated, in loose aggregates, and Malignant cells isolated, in loose
in syncytial arrangement aggregates, and in syncytial arrangement
Exfoliation of Cells In large numbers In large numbers
Architecture of Tissue Syncytial with and without acinar or papillary Syncytial with and without acinar pattern
Fragments pattern
Cells Very pleomorphic, medium, large, or giant forms Medium-sized to large
Nuclei Round to oval with irregular nuclear membranes; Round to oval; granular chromatin,
granular chromatin, excessive parachromatin parachromatin clearing
clearing; bizarre forms frequent
Nucleoli Single to multiple micro/macronucleoli, very Single/multiple micro/macronucleoli

prominent
Cytoplasm Scant to abundant, pale to dense Scant to vacuolated
Leukophagocytosis — ⫹/⫺
Psammoma Bodies Frequent —
Background Atrophy Atrophy ⫹/⫺

Bloody Bloody
Necrotic Necrotic
Immunoprofile
ER/PR Nonreactive Strongly reactive
MIB1 Strongly reactive Not reactive
Beta-catenin Strong nuclear staining Not reactive
p53 Reactive Weakly reactive
REPORTING THE PRESENCE OF 2%—they are included in the reporting system as a group
ENDOMETRIAL CELLS IN CERVICAL/VAGINAL by itself and to be accompanied by the statement “nega-
CYTOLOGIC SPECIMENS tive for squamous intraepithelial lesions.” Benign-appear-
ing endometrial cells are usually not derived from hyper-
Normal-Appearing Endometrial Cells plasias or adenocarcinomas. In most cases, their presence
is physiologic, such as when the women have prolonged
The presence of normal-appearing endometrial cells dur-
menstrual cycles, or they are on hormones. Also, these
ing the second half of the menstrual cycle in cyclic women
endometrial cells may originate from several types of
over 40 years of age, or at any time in postmenopausal
benign disorders (see Tables 4.5 to 4.7).
women, is no longer considered an epithelial abnormal-
ity; however, TBS 2001 recommends reporting such a
Abnormal/Atypical Endometrial Cells
fi nding as a separate diagnostic category. Since the risk
for signifi cant endometrial pathology (hyperplasia and Endometrial cells (and their mimics) with abnormal cyto-
adenocarcinoma) in this category is very low—less than morphology are reported as atypical endometrial cells
A B
Figs. 4.23A to C. Conventional smears. Clear cell adenocarcinoma

of the endometrium. A, B, C: The malignant cells are pleomorphic
C with abundant clear to pale cytoplasm.
with no further qualifi cation. They may originate from B). Although rare, neuroendocrine carcinoma with a small
a host of benign conditions (Figs. 4.24 to 4.30) or from cell size enters the differential diagnosis (Fig. 4.30C).
endometrial hyperplasia as well as well-differentiated The cytologic features of abnormal endometrial cells
endometrioid carcinomas. Lesions that lead to the exfolia- are as follows (TBS):
tion of abnormal endometrial cells include the following:
● Cells occur in small groups, usually 8 to 10 cells/group.
● Chronic endometritis, IUD usage, dysfunctional uter- ● Nuclei are slightly enlarged compared to normal endo-
ine bleeding, pregnancy, threatened abortion, imme- metrial cells and may have membrane irregularities;
diate postpartum period, endometriosis of the cervix/ nucleoli may be prominent.
vagina, and following uterine instrumentation; ● Mild hyperchromasia may be seen.
● Sampling of lower uterine segment by endocervical ● Variable scant to abundant vacuolated cytoplasm with
brush; or without neutrophils.
● Withdrawal bleeding in women on HRT (the cellular ● Cell borders are ill-defined.
morphology is similar to that seen in menstrual endo-
The presence of atypical endometrial cells carries a
metrium in cyclic women);
signifi cant risk of endometrial cancer. Endometrial sam-
● Endometrial polyps (hyperplastic and atrophic type);
ples for histologic examination are recommended.
● Endometrial surface papillary syncytial metaplasia
(Table 4.6);
● Endometrial hyperplasia; DIAGNOSTIC ACCURACY AND DIFFERENTIAL
● Well-differentiated endometrioid type endometrial DIAGNOSES OF ENDOMETRIAL
carcinoma. ADENOCARCINOMAS
Because of their small cell size, well-differentiated en- Routine screening of cervical–vaginal samples is primar-
dometrial adenocarcinomas show morphologic overlap ily aimed at the detection of cervical cancer or precursor
with squamous carcinomas for both in situ and invasive lesions. It is unreliable for the detection of endometrial
types with a small cell pattern (Figs. 4.29 and 4.30A and adenocarcinoma or its precursors and has been less than
rewarding. There are several reasons for the low detection False positive diagnoses are rendered: 1) when cells
rate: of non-endometrial origin are interpreted as endometrial
cells; and 2) when benign endometrial cells are interpret-
1. The number of malignant cells from a well-differenti-
ed as abnormal or diagnostic of carcinoma.
ated carcinoma in cytologic specimens is scarce.
The endometrial cell morphology can be mimicked by
2. The neoplastic cells shed intermittently and a repeat
the presence of squamous basal cells particularly seen in
smear may not show similar cells.
3. The cells of a well-differentiated carcinoma or its pre- postmenopausal women (Figs. 4.24A and B). They are seen
cursors are small and often benign-appearing, or they as aggregates of very uniform oval to slightly oblong cells
present minimal abnormalities and are mimicked by lacking cytoplasm. Their nuclei are very uniform, contain-
several benign disease entities. ing finely granular chromatin without nucleoli. The num-
ber of such cells varies and can be remarkably high. The
basal cells are reported to be present in 20% of cervical-
TABLE 4.5 DIFFERENTIAL DIAGNOSES OF vaginal smears in women over 50 years of age. These cells
WELL-DIFFERENTIATED ENDOMETRIOID are also referred to as small blue cells, and were described
ENDOMETRIAL CARCINOMA in women who were taking the drug tamoxifen.
Lymphofollicular cervicitis is another inflammatory
● Benign Endometrial Cells
• Chronic Endometritis
reactive process that may present aggregates of lympho-
• Dysfunctional Uterine Bleeding cytes misinterpreted as endometrial cells. Although not a
• Endometrial Polyps diagnostic problem in conventional smears, the cluster-
• Uterine Leiomyomas ing of cells and their shrinkage with dark-staining may
• Endometrial Surface Epithelial Metaplasia, Papillary be responsible for the morphologic overlap (e-Fig. 4.11B).
Syncytial Type Atrophic endocervical cells are small in size with scant cy-
• Endometrial Hyperplasia toplasm and may also be interpreted as endometrial cells.
• Lower Uterine Segment Cells False positive diagnoses also occur when endome-
• Cervical/Vaginal Endometriosis trial cells originating from benign conditions such as
• Lymphofollicular Cervicitis endometritis, polyps, surface reactions (Müllerian meta-
• Basal Cells Originating from Squamous Epithelium
plasias), or breakthrough bleeding are interpreted as ma-
(Small Cells)
• Atrophic Endocervical Cells
lignant, particularly in postmenopausal women. These
● Squamous Carcinoma In Situ
normal-appearing endometrial cells are very difficult to
● Poorly Differentiated Squamous Carcinoma with Small
distinguish from well-differentiated adenocarcinoma
Cell Pattern (Table 4.7; Figs. 4.25 to 4.27).
● Neuroendocrine Carcinoma Accurate typing of well-differentiated adenocarcinoma
is occasionally challenging. Squamous carcinomas in situ
TABLE 4.6 CYTOPATHOLOGIC FEATURES OF ENDOMETRIAL PAPILLARY SYNCYTIAL

METAPLASIA & ENDOMETRIAL ADENOCARCINOMA
Papillary Syncytial Metaplasia Endometrial Adenocarcinoma

Presentation Mostly in syncytial tissue fragments with papillary Cells isolated, in loose aggregates, or syncytial tissue
configuration; smooth or knobby contour; single cells fragments; papillary fragments when present have a
not readily identified; tissue fragments often large; smooth contour
smooth contours ⫹/⫺
Cells Normal to moderately enlarged Variable, small to moderate enlargement
Nucleus Minimally enlarged with a slight increase in N/C Enlarged; high N/C ratios; round, often with
ratios; round with delicate, crisp, smooth nuclear an irregular nuclear border; chromatin coarsely
membranes; chromatin powdery to finely granular, granular; parachromatin clearing
evenly dispersed with an empty look
Nucleoli Multiple micronucleoli Single/multiple; micro/macronucleoli
Cytoplasm Variable, pale, small to large secretory vacuoles with Scant, secretory vacuoles with neutrophils ⫹/⫺
neutrophils ⫹/⫺
Background Inflammatory to bloody; lipophages absent Inflammatory to bloody; lipophages ⫹/⫺

TABLE 4.7 DIFFERENTIAL DIAGNOSES OF WELL-DIFFERENTIATED ENDOMETRIAL
ADENOCARCINOMA CYTOPATHOLOGIC FEATURES
Diagnostic Entity Clinical Pathologic Features Cytopathologic Features See Fig(s).

Chronic May be associated with pelvic Cells may be seen isolated or in tissue fragments 4.26
Endometritis inflammatory disease; IUD usage; with knobby to irregular contour; nuclei vary in
generally younger age group size, chromatin finely granular with micronucleoli;
cytoplasmic vacuoles with or without neutrophils
Endometrial Polyps Can occur at any age; polyps may be Endometrial cells may be small, atrophic with
hyperplastic or atrophic type compact nuclear chromatin, or present features of
hyperplasia
Lower Uterine Lower uterine segment frequently Tubular glands with marked crowding and e-Figs. 4.8
Segment Sampling sampled by endocervical brush; diagnostic overlapping of uniform small nuclei; single and 4.9
or Endometriosis problems only when stromal component glandular cells not conspicuous
is scant or absent; endometriosis of
cervix/vagina is very rare
Endometrial Frequent in perimenopausal patients; Normal-appearing to abnormal cytomorphology 4.1

Hyperplasia atypical forms are precursors to 4.2
endometrial carcinoma
Papillary Syncytial Often associated with endometrial Ref. Table 4.6 4.27
Metaplasia hyperplasia or well-differentiated e-Figs. 4.10
carcinoma; may be seen in atrophic to 4.13
endometrium, a potential diagnostic pitfall
Lymphofollicular Non-specific inflammatory condition, Lymphocytes are well-preserved and easily e-Fig.
Cervicitis often associated with infection by recognizable in conventional smears; in LBP, the 4.11B
chlamydia lymphocytes cluster together, are smaller in size
and densely stained and may be mistaken for
endometrial cells
Stripped Basal Frequently seen (20%) in women over Oval to slightly oblong, small, very uniform 4.24A and
Cell Nuclei of the 50 years of age; also described in women nuclei often piled on each other; nuclear borders B
Atrophic Squamous taking nonsteroidal hormone tamoxifen well-defined; granular, evenly distributed to
Epithelium Small therapy compact chromatin; no cytoplasm
Blue Cells
Squamous Generally located higher up in the Cells isolated, in aggregates or in syncytial 3.18
Carcinoma In Situ, endocervical canal tissue fragments with no architectural pattern; 3.19C
Small Cell Type marked crowding and overlapping of nuclei
with coarsely granular chromatin; inconspicuous
nucleoli; cytoplasm very scant; diagnostic clues
cytoplasmic keratinization in single cells
Poorly Generally located higher up in the Large numbers of exfoliated cells, isolated in 3.69
Differentiated endocervical canal aggregates and in syncytial tissue fragments without
Squamous any architectural patterns; cells are round, small in
Carcinoma Non- size with well to poorly defined cell borders, scant
Keratinizing Type to indiscernible cytoplasm; high N/C ratios; smooth,
with Small Cell irregular nuclear membranes, coarsely granular
Pattern chromatin, parachromatin clearing; nucleoli that
have few cells with keratinization and a central
nuclei are clues to correct diagnosis
Neuroendocrine Very uncommon; highly aggressive Large numbers of exfoliated malignant cells; small 4.70
Carcinoma neoplasm; diffusely infiltrating; necrosis, (roughly three times the size of lymphocytes); 4.71
high mitotic activity high N/C ratios, scant indiscernible cytoplasm,
deep-staining; coarsely granular chromatin;
nucleoli are inconspicuous; nuclear molding ⫹
107
Differential Diagnoses of Well-Differential Endometrial Adenocarcinoma (See Figs. 4.24 to 4.30)
A B
Figs. 4.24A and B. Conventional smear. A: Cells originating from the basal layer of the atrophic squamous epithelium appear small with
poorly defined cell borders, high N/C ratios, compact chromatin, and resemble endometrial cells being misinterpreted as endometrial ad-
enocarcinoma. B: Cervical biopsy to show the basal layer (arrow) (H&E).
Fig. 4.25. Conventional smear. Well-preserved endometrial cells in Fig. 4.26. Conventional smear. Abnormal glandular cells, probably
the postovulatory phase can resemble adenocarcinoma cells. Age of endometrial origin, in a patient wearing an IUD.
and menstrual history are prerequisites for the interpretation of
endometrial cells.
Fig. 4.27. Conventional smear showing papillary endometrial syn- Fig. 4.28. Conventional smears. Endometrial hyperplasia. These
cytial metaplasia. These abnormal endometrial cells in a postmeno- endometrial cells in a postmenopausal woman were interpreted as ad-
pausal woman were interpreted as adenocarcinoma. Curettings enocarcinoma. The curettings confirmed endometrial hyperplasia. Dif-
confirmed papillary syncytial metaplasia. ferentiation of well-differentiated endometrial adenocarcinoma cells
from endometrial hyperplasia is very difficult from cytology alone.
Fig. 4.29. Liquid-based preparation showing squamous carcinoma

in situ. These small in situ type squamous cells in a tight syncytial
arrangement strongly resemble endometrial adenocarcinoma cells.
A B
Figs. 4.30A to C. Conventional smears. A, B: Squamous carcinoma

composed of small cells strongly resembling endometrial adenocar-
cinoma. C: Neuroendocrine carcinoma cells. The small cell size can
C be mistaken for endometrial adenocarcinoma.
as well as invasive squamous carcinomas with a small cell cinomas may be very challenging. Immunostains are fre-
size or neuroendocrine carcinomas present typing diffi- quently essential to type the histologic tissue (Table 4.8).
culties (Figs. 4.29 and 4.30A to C).
The diagnostic accuracy is high with poorly differ-
UTERINE SARCOMAS
entiated endometrial adenocarcinomas. The carcinoma
cells usually exfoliate in large numbers and are clearly
malignant. The differentiation of poorly differentiated Uterine sarcomas are unusual malignant neoplasms and
endometrial or endocervical adenocarcinomas, metastatic include leiomyosarcomas, endometrial stromal sarcomas,
adenocarcinomas, or poorly differentiated squamous car- and malignant mixed mesodermal tumors (MMMT).
TABLE 4.8 DIFFERENTIAL DIAGNOSES OF POORLY DIFFERENTIATED ENDOMETRIAL ADENOCARCINOMA
Endometrial Non-Keratinizing
(Endometrioid) Poorly
Adenocarcinoma Uterine Serous Differentiated
Poorly Papillary Endocervical Extrauterine Squamous
Differentiated Carcinoma Adenocarcinoma Adenocarcinoma Carcinoma
Number of Malignant
Cells in Cervical- Variable, generally Variable, generally Generally large Variable, often in small Generally large
Vaginal Smears large large numbers numbers numbers
Arrangements of Isolated, in loosely Isolated, in loosely Isolated, in loosely Isolated, in loosely Isolated, in loosely
Cells cohesive groups cohesive groups or cohesive groups or cohesive groups cohesive groups or
or in syncytial in syncytial tissue in syncytial tissue or in syncytial in syncytial tissue
tissue fragments fragments with fragments with tissue fragments; fragments with
with or without or without acinar or without acinar characteristics of no architectural
acinar pattern; pattern; papillary pattern; rosettes primary tumor may pattern
smooth contours configuration ⫹/⫺; papillary be present (e.g.,
⫹/⫺; smooth configuration— Indian file in breast,
contours infrequent picket fence pattern in
colonic, papillary with
psammoma bodies in
ovarian)
Cell Size Medium-sized to Medium-sized to Medium-sized, Variable size, uniform, Small to medium-
large, round; cell large, round; cell round to oblong; small to medium sized, round,
borders are poorly borders are poorly cell borders are pleomorphic; cell occasionally
defined; high N/C defined; high N/C poorly defined; borders are poorly polygonal to
ratios ratios high N/C ratios defined; high N/C spindle-shaped
ratios cell; well to poorly
defined cell borders;
high N/C ratios
Nucleus Central to Central to eccentric, Central to Central to eccentric, Central nuclei;

eccentric, round, round, smooth to eccentric, round, round, oval to round to oval;
smooth to irregular nuclear oval to oblong oblong, depending smooth to irregular
irregular nuclear membranes; fine to or elongated, on the tumor type, nuclear membranes;
membranes; coarsely granular smooth nuclear smooth to irregular fine to coarsely
fine to coarsely chromatin with membranes; fine to nuclear membranes; granular chromatin
granular parachromatin coarsely granular fine to coarsely with parachromatin
chromatin with clearing; micro/ chromatin, granular chromatin, clearing;
parachromatin macronucleoli, parachromatin parachromatin pyknotic nucleoli
clearing; micro/ cherry-red clearing; micro/ clearing; micro/ ⫹/⫺; micro/
macronucleoli macronucleoli macronucleoli macronucleoli macronucleoli
Cytoplasm Variable, scant Variable, scant Scant, pale Scant, pale Variable, scant
to abundant, to abundant, to modest,
pale, dense to pale, dense to pale to dense;
vacuolated, often vacuolated keratinization may
contain neutrophils be observed
Background Psammoma bodies Psammoma bodies No psammoma Psammoma bodies No psammoma

⫹/⫺; diathesis; ⫹/⫺; diathesis; bodies; diathesis; ⫹/⫺; generally clean; bodies; diathesis
bloody bloody bloody bloody ⫹/⫺ ⫹/⫺; bloody ⫹/⫺
Immunoprofile ER/PR ⫹ ER/PR ⫺ ER/PR ⫺ Breast ER/PR ⫺

P53 ⫺ P53 ⫹ P16 ⫹ ER/PR ⫹ Cytokeratins
MIB1 ⫺ MIB1 ⫹ Ki-67 ⫹ diffuse GRFP ⫹ AEI/AE3 ⫹
P16 ⫺ Vimentin ⫺ CEA ⫹ Ovaries CAM5.2 ⫹
CEA ⫺ Cytokeratin ⫺ CA125 ⫹ HPV assessment if
Vimentin ⫹ Beta-catenin ⫹ WT1 ⫹ indicated
Cytokeratin ⫹ (nuclear) Colon/Rectum
Beta-catenin ⫺ CK7
CK20 ⫹
CDX2 ⫹
110
Exfoliative cytology is of limited or no value in the glandular type or with squamous differentiation. Papillary
detection of uterine leiomyosarcoma or stromal sarcomas. tissue fragments with psammoma bodies may also be
Fine needle aspiration biopsy has been used effectively in present. The malignant cells of mesenchymal origin can
the diagnosis of recurrent tumors. be very pleomorphic, small to large, spindle-shaped, fiber-
like, tadpole-shaped, or large polygonal with bizarre nu-
clei and multinucleation (Figs. 4.31 to 4.36). Diagnosis is
MALIGNANT MIXED MESODERMAL TUMORS
OF THE ENDOMETRIUM (MMMT)
TABLE 4.9 CYTOPATHOLOGIC FEATURES OF
MMMT of the endometrium are rare but highly aggres- MALIGNANT MIXED MESODERMAL TUMOR
sive neoplasms consisting of malignant epithelial and
stromal elements. Rarely, do they originate in the cervix, Presentation Cells are isolated, in aggregates, or in
uterine tubes, ovaries, and peritoneum. syncytial tissue fragments; malignant cells
MMMT occurs exclusively in older postmenopaus- that are mostly epithelial type with rare
al women who present with abnormal uterine bleeding, mesenchymal types
abdominal pain, weight loss, vaginal discharge, and ab-
dominal enlargement. A history of past radiation to the Architecture Syncytial with or without acinar or papillary
pelvis is present in the majority of patients. The uterus is pattern
generally enlarged, often with a fungating mass protrud-
ing from the os. The tumor is soft and bulky with areas of Cells Extreme pleomorphism is frequent; small
to large to giant forms; round, cuboidal,
cystic necrosis and hemorrhage.
polygonal to spindle forms
Histologically, these neoplasms are composed of malig-
nant epithelial and stromal components. The epithelial com- Nuclei Small to large or giant forms,
ponent is generally an endometrial adenocarcinoma, but multinucleation, central to eccentric location;
other types such as squamous, papillary, clear cell, or undif- chromasia variable; nuclear membrane
ferentiated carcinoma may be seen. The malignant stromal smooth to irregular
component, consisting of normal elements native to the
corpus such as endometrial stroma or smooth muscle, are Nucleoli Single/multiple; micro/macronucleoli
referred to as homologous, while those with rhabdomyosar-
coma, chondro, and osteosarcoma are called heterologous. Cytoplasm Variable, scant to abundant; pale to dense or
The cytologic identification of MMMT (Table 4.9) vacuolated; squamous differentiation ⫹/⫺
from cervical–vaginal smears is difficult for several reasons.
Most smears are bloody with cellular and necrotic debris, Psammoma ⫹/⫺
rendering the cytologic material unsatisfactory for evalua- Bodies
tion. When present, the malignant cells are poorly preserved
Background Bloody to clean; atrophic to high estrogen
and obscured and are generally of the epithelial type.
effect, inflammatory to necrotic; loose
Malignant stromal cells do not exfoliate as easily as
myxoid stroma around malignant cells ⫹/⫺
epithelial cells do. The epithelial component could be a
Mesodermal Tumors of the Uterine Corpus (See Figs. 4.31 to 4.37)
Fig. 4.31. Conventional smear. Malignant mixed Müllerian tumor. Fig. 4.32. Conventional smear. Malignant mixed Müllerian tumor.
The malignant cells are a poorly differentiated glandular type with The malignant cells are markedly pleomorphic with giant-sized nuclei.
squamous differentiation.
Fig. 4.33. Conventional smear. Malignant mixed Müllerian tumor. Fig. 4.34. Conventional smear. Malignant mixed Müllerian tumor.
Malignant spindle cells embedded in a myxoid stroma. Pleomorphic malignant cells with spindle forms.
A B
Figs. 4.35A to C. Liquid-based preparation. Malignant mixed Mül-

lerian tumor. A, B: Adenocarcinoma cells. C: Stromal component
C showing pleomorphic spindle cells.
made when both stromal and epithelial components are

ENDOMETRIAL STROMAL SARCOMAS
present, which is more likely with direct sampling. Os-
teoid and chondroid type cells from MMMT have been These are the least common of the uterine sarcomas
identifi ed when samples were obtained directly from the occurring in older women. The patients may present
endometrial cavity. with vaginal bleeding or with abdominal pain. The
Differential diagnosis includes stromal repair and uterus is usually enlarged. Cytohistologically, stromal
foreign-body-type multinucleated cells secondary to sarcomas are composed of neoplastic cells ranging from
inflammation. those that strongly resemble the normal endometrial
Fig. 4.36. Liquid-based preparation. Malignant mixed Müllerian

tumor. Adenocarcinoma component is more often spontaneously
exfoliated than the malignant stromal component.
A B
Figs. 4.37A and B. Conventional smear. Endometrial stromal sarcoma. When the cells in a syncytial tissue fragment
have no clues to their origin without a history, endometrial stromal sarcoma cannot be diagnosed accurately.
stromal cells to very pleomorphic malignant cells with endocervix, the brush can reach proximal portions of the
a high mitotic rate. The neoplastic cells characteristi- endocervical canal where some of the diagnostic entities
cally occur isolated with only a rare tissue fragment in such as tubal metaplasia, microglandular hyperplasia,
aspiration biopsy specimens (Figs. 4.37A and B). and LUS are more common. The long, thin, and sharp
bristles of the brush are able to sample the deeper (sub-
epithelial) areas of the endocervix as well, which helps
to detect endocervical gland involvement by HSIL as
ENDOCERVIX
well as endocervical neoplasia that is often deep-seated.
In addition, the brush can sample the narrow endocer-
INTRODUCTION vical canals in postmenopausal women. Although some
of these lesions may be clinically insignificant, they pres-
Prior to the routine use of the endocervical brush, endo-
ent diagnostic problems due to their cytologic features,
cervical glandular cytology was limited to inflammatory,
which overlap with preneoplastic and neoplastic cervical
reactive/reparative changes, and adenocarcinoma. The
lesions. This group of lesions often presents abnormal
latter constituted only 10% or less of cervical cancers.
glandular cells that are diagnostically challenging and
Pathologic processes, such as microglandular hyperpla-
represent the cytologic category of “atypical glandular
sia, tubal metaplasia, hormonally induced changes, pre-
cells” (AGC). Roughly 20% or higher cases of AGC are
cursor lesions of endocervical adenocarcinoma (endocer-
associated with SIL.
vical dysplasia) or squamous carcinoma in situ involv-
Areas of concern in endocervical glandular cytology
ing endocervical glands and crypts and LUS cells, are
can be summarized as follows:
now being frequently encountered in cytologic samples
obtained with an endocervical brush. In addition to ● Recognition and diagnosis of endocervical adenocarci-
sampling the squamocolumnar junction and the distal noma (in situ and invasive).
● Differentiation of benign endocervical glandular BENIGN ENDOCERVICAL

changes from malignant endocervical lesions. GLANDULAR CHANGES
● Defi ning the diagnostic category: “atypical glandular
The cervix is prone to injury (e.g., physical, infectious, or
cells.”
chemical) (see Chapter 2, Table 2.4). The fragile, sensi-
● Differentiating endocervical adenocarcinoma from
tive glandular epithelium reacts readily exhibiting retro-
endometrial and metastatic carcinomas and poorly dif-
gressive, reactive/reparative, or hyperplastic changes that
ferentiated squamous carcinoma.
depend on the type and severity of the injury. The cellular
● Differentiating squamous carcinoma in situ from endo-
changes may be non-specific or specific.
cervical adenocarcinoma, both in situ and invasive.
Non-specific changes include nuclear enlargement
with finely granular chromatin and prominent nucleoli.
HISTOLOGY AND CYTOLOGY OF THE Multinucleation is frequent. Reactive endocervical cells
NORMAL ENDOCERVIX maintain the normal architectural configuration (i.e., hon-
eycomb arrangement or palisading pattern in epithelial
The surfaces and clefts (see Chapter 2, Figs. 2.1 and
strips). Their cytoplasm may remain pale, be dense, or con-
2.2) of the endocervical canal are lined predominantly
tain large cytoplasmic vacuoles that are sometimes filled
by a monolayer of secretory columnar cells. These cells
with neutrophils. Mitoses may be conspicuously present.
have cytoplasm that varies from lacy and pale to gran-
Specific changes are characteristically noted in a her-
ular and amphophilic. The basally located nuclei are
pes virus infection (see Chapter 2, Table 2.5) or in a cyto-
ovoid with powdery chromatin and occasionally con-
megalovirus infection.
tain an inconspicuous micronucleolus. Mitotic figures
are rare.
Secretory columnar cells are abundant in samples ob- MICROGLANDULAR HYPERPLASIA
tained by endocervical brushings or scrapings. In cellular OF THE CERVIX
specimens, the endocervical columnar cells occur singly, Microglandular hyperplasia (MGH) is a benign change
in strips, and in two-dimensional tissue fragments. The of the endocervical mucosa that is frequently associated
appearance and size of the cells are dependent on the site with pregnancy or exogenous progesterone use (birth
of cellular sampling and the method being used. These control pills or HRT). Depending on the degree of epi-
cells have a surface area of 188⫾40 ␮m2. When viewed thelial proliferation, involved areas of the mucosa appear
en face, the individual cells appear round, while in sheets either sessile or polypoid. The usual histologic pattern is
they appear cuboidal. Viewed laterally, the cells appear that of closely spaced large and small glands formed by
columnar with a tapered end, which contains the nucleus. monolayered cuboidal cells (e-Figs. 4.14A and B). The
The cytoplasm is variable, scant to abundant, pale, bub- cells often show variability in size and shape. They may
bly, and has big vacuoles. Cilia may be noted infrequently appear columnar with subnuclear vacuoles, or they may
along the luminal border. The cell borders are delicate. appear attenuated or spindled, giving the lesion a reticular
The mean nuclear area ranges from 54.8 to 82 ␮m2. The pattern. Less commonly, epithelial cells appear polygonal
nuclei are round to oval with a delicate nuclear mem- and form solid or trabecular arrangements. The usual
brane and powdery chromatin that is evenly distributed. glands of microglandular hyperplasia are mucin-filled
Micronucleoli are frequent. Protrusion of the nuclear and may contain neutrophils. The nuclei of the epithelial
contents (referred to as the nuclear nippling) may occur cells are small and rounded with bland chromatin. Occa-
at one pole. sionally, they have a small nucleolus. Mitotic figures are
In liquid-based preparations, large endocervical glan- rare. Histologically, MGH (particularly the florid growth
dular epithelial tissue fragments are diffi cult to visualize. pattern) is known to mimic adenocarcinoma.
They are above the plane of squamous cells, appear poly- Cytologic features of MGH are not well-documented.
poid, are very thick, and the morphology of the compo- Furthermore, there are no cytologic changes specific for
nent cells is difficult to appreciate. Focusing up and down MGH. Retrospective review of biopsy-proven cases of MGH
and examination in various planes is required. Normal- has shown cytologic features (Table 4.10) that overlap with
appearing cells are usually apparent at the periphery. The those of endocervical adenocarcinoma or squamous carci-
cytomorphology of endocervical glandular cells in small- noma in situ as well as tubal metaplasia (see Table 4.14;
er tissue fragments is similar to that seen in conventional Figs. 4.38A and B). Since microglandular hyperplasia fre-
smears. quently presents as polypoid lesions, inflammation and re-
The endocervical cells obtained by a brush are well- active/reparative changes are often present as well.
preserved and may show different morphologic charac-
teristics (e.g., large size of the tissue fragments with slight
TUBAL METAPLASIA
nuclear enlargement and crowding, leading to confusion
and diagnostic difficulties; refer to the differential diagno- Tubal metaplasia of the endocervix involves a change from
ses of large tissue fragments) (see Fig. 4.54A). normal endocervical glandular epithelium into ciliated
TABLE 4.10 CYTOPATHOLOGIC FEATURES OF TABLE 4.11 CYTOPATHOLOGIC FEATURES OF

MICROGLANDULAR HYPERPLASIA TUBAL METAPLASIA
Presentation Endocervical glandular cells Presentation In tissue fragments

isolated (in streaks) or in tissue
fragments Architecture Strips with terminal bar; cilia ⫹/⫺;
lack of honeycomb arrangement,
Architecture Honeycomb sheets ⫹/⫺; syncytial crowding and overlapping of
with or without acinar pattern nuclei, palisading arrangement
(gland openings) or with a luminal frequent in strips
border
Cells Variable in size
Cells Variable in size; small to medium
Nuclei Round, oval to oblong, varying
Nuclei Normal to modest increase in degrees of anisonucleosis;
size; round, smooth, nuclear chromatin fine to coarsely granular,
borders; hyperchromasia ⫹/⫺; smooth nuclear membrane
finely granular chromatin; micro/
macronucleoli; pyknosis ⫹/⫺ Nucleoli Variably present
(pseudoparakeratosis); mitoses are
rare to absent Cytoplasm Variable, scant to abundant; pale
to eosinophilic; vacuoles and
Cytoplasm Variable, pale to dense; vacuolated leukophagocytosis are absent
with or without leukophagocytosis;
orangeophilic (pseudoparakeratosis) Differential Diagnoses Endocervical Adenocarcinoma In
Situ (AIS)
Differential Diagnoses Endocervical Adenocarcinoma Squamous Carcinoma In Situ
HSIL (HSIL)
Atypical Endocervical Glandular Atypical Endocervical Glandular
Cells (AGC) Cells (AGC)
tubal type epithelium. It is reported to be present in 20% or simply as atypical glandular cells (AGC) (see Tables
of cone biopsy specimens and 62% of hysterectomy spec- 4.17 to 4.19).
imens. Tubal metaplasia is noted in women of all ages, is
more frequent in the upper endocervix, and can involve
ADENOCARCINOMAS OF THE
surface epithelium as well as the lining of superficial and
UTERINE CERVIX
deep endocervical glands.
Histologically, tubal metaplasia is identifi ed by the Adenocarcinomas of the uterine cervix are less common
presence of pseudostratified ciliated columnar epithelium than squamous carcinomas, accounting for less than 10%
(e-Figs. 4.15A to D). The glands are somewhat irregular, of all cervical malignancies. However, in recent years,
nuclei are elongated and hyperchromatic in contrast to their incidence is on the rise. The role of HPV as a caus-
pale, mucin-producing endocervical glandular epithelium ative agent, particularly type 18, has been established in
with basally located uniform nuclei. the carcinogenesis of endocervical adenocarcinoma.
In cervical smears (Table 4.11), the cells of tubal meta- Histologically, endocervical carcinomas are classified
plasia are generally present in syncytial tissue fragments into several morphologic types (see Appendix) based on
of various sizes without an acinar pattern or in strips with cell type and growth pattern. The conventional adenocar-
stratifi ed nuclei exhibiting vertical polarity and luminal cinomas are of the endocervical columnar cell type that
borders (Figs. 4.39 and 4.40). Their nuclei are variable in produces intracellular mucin.
size, round, oval to oblong, hyperchromatic, and have
coarsely granular chromatin. Nucleoli are inconsistent.
ENDOCERVICAL ADENOCARCINOMA
The cytoplasm is variable, scant to abundant, and pale
IN SITU (AIS)
to eosinophilic. Secretory vacuoles with or without neu-
trophils are not seen. Strips showing the presence of cilia Adenocarcinoma in situ (AIS) of the endocervix is
on the luminal borders clinch the diagnosis (Figs. 4.40C regarded as a precursor lesion of invasive adenocarci-
and D). However, in the absence of cilia, cells originating noma. Changes preceding AIS are not well-documented
from tubal metaplasia may be misinterpreted as endocer- and not easily recognized, although some use the term
vical adenocarcinoma in situ, HSIL (Figs. 4.40A and B), endocervical dysplasia. In situ lesions occur at an earlier
Endocervix (See Figs. 4.38 to 4.40)
A B
Figs. 4.38A and B. Conventional smear microglandular hyperplasia. The tissue fragments of endocervical glandular cells show an acinar
pattern. The nuclei have compact chromatin. Their cytoplasm is pale and vacuolated, has low N/C ratios, has a lack of nucleoli, and single
malignant cells in the background support the benign nature.
A B
Figs. 4.39A and B. Conventional smears. Tubal metaplasia. Large tissue fragment of glandular epithelium with closely packed, overlapping
nuclei containing coarsely granular chromatin appearing very atypical. Presence of cilia on the luminal borders will support the diagnosis
of tubal metaplasia.
A B
Figs. 4.40A to B. Liquid-based preparation. Tubal metaplasia. A, B: The tissue fragments of atypical glandular epithelium with syncytial
arrangement may be misinterpreted as squamous intraepithelial lesion, particularly in the absence of cilia, constituting a common diagnos-
tic pitfall. (continued)
C D
Figs. 4.40C to D. (continued) C, D: Liquid-based preparation. Tubal metaplasia. Note the presence of cilia (arrows).
age preceding the invasive counterpart by approximately of round to elongated nuclei and with luminal borders.
5 to 20 years. The nuclei tend to separate from the main body of the
Adenocarcinoma in situ of the endocervical mucosa tissue fragment, causing a feathery effect (Figs. 4.42 to
may involve both the endocervical surface epithelium and 4.46). Some tissue fragments exhibit gland openings
the glands, with the lesion most frequently involving the with a rosette formation (Figs. 4.42 and 4.43). Intense
gland necks. These lesions can be focal and superficial or crowding and overlapping of hyperchromatic nuclei is
extensive and multifocal. The transition between benign a hallmark of AIS. The malignant cell nuclei are round
and malignant epithelium is often sharp, and frequently, to elongated and variable in size with coarsely granular
AIS is associated with a dysplastic change in adjacent chromatin. The nuclear membrane is smooth, and nucle-
squamous epithelium. The cells of AIS are commonly of oli are inconspicuous or absent. Mitoses are frequent.
the endocervical type with intracytoplasmic mucin, but AIS cells have insignificant cytoplasm. The background
an intestinal variant with goblet cells and an endometri- is clean.
oid pattern lacking intracellular mucin have also been In liquid-based preparations, the cytopathologic
described. The usual pattern of AIS consists of a lining of presentation of AIS is equally striking. The cellularity
columnar cells showing nuclei that are enlarged and pleo- is variable but can be overwhelming with single, intact
morphic but that tend to be elongated. Nuclear chromatin cells. The syncytial tissue fragments vary in size and
is coarse, and mitotic fi gures are frequent (e-Figs. 4.16A numbers, being more three-dimensional with extreme
to D). The malignant epithelial cells may be monolayered nuclear crowding. A pseudostratified strip of cells, of-
or sufficiently stratifi ed to produce cribriform bridging ten presenting as a short bird tail–like arrangement, may
across the glandular lumina. The tumor is not invasive of be the most important feature. The peripheral feather-
the surrounding stroma, which does not exhibit reactive ing of cells, strips, and rosettes are not as prominent in
or desmoplastic changes. In situ lesions are not visible by liquid-based preparations as in conventional smears. The
simple visual inspection or colposcopic examination of nuclear chromatin is coarsely granular, and nucleoli may
the cervix; a deep cone biopsy is often required to estab- be present.
lish a diagnosis. A signifi cant proportion of AIS cases (25–85%) are
found associated with squamous intraepithelial neoplasia
and squamous carcinoma. Cellular features of both may
Cytopathologic Features of Endocervical AIS
be present in the smears (see Figs. 4.47A to D).
The cytologic presentation of AIS in conventional smears
is very characteristic (Table 4.12; Figs. 4.41 and 4.42).
INVASIVE ENDOCERVICAL
Under a low-power objective (4.5⫻), the presence of
ADENOCARCINOMA
large numbers of intensely hyperchromatic, syncytial tis-
sue fragments of endocervical epithelium is very striking The histologic features that help distinguish in situ from
and almost diagnostic (Figs. 4.41A to C). These tissue invasive adenocarcinoma of the usual endocervical type
fragments vary in size from small to large with animated include the pattern of the glandular–stromal interface
forms, exhibiting marked crowding and overlapping of (irregular budding), the appearance of the surrounding
the nuclei. The tissue fragments of malignant endocer- stroma (reactive with the proliferation of fibroblasts
vical epithelium exhibit several architectural patterns. and chronic inflammation), the appearance of the malig-
Some are present as strips with a palisading arrangement nant epithelial cells (transformation of the nuclei to an
TABLE 4.12 CYTOPATHOLOGIC FEATURES OF ENDOCERVICAL ADENOCARCINOMA

IN SITU (AIS) AND INVASIVE
AIS Invasive
Presentation Cells are mostly in tissue fragments, less frequently Cells are isolated, exfoliation is in large numbers in
isolated loosely cohesive groups and in syncytial tissue fragments
Architecture Strips of epithelium with altered nuclear polarity, Syncytial, with and without acinar pattern; papillary
of the Tissue luminal border; stratification may or may not be with branching ⫹/⫺; cells enlarged, round, cuboidal to
Fragments present; large tissue fragments with branching columnar or spindle-shaped
pattern and gland openings; nuclei is crowded with
a lack of cytoplasmic borders and a honeycomb
arrangement; cells string out at the periphery with
a feathery pattern; rosettes or acinar pattern; bird
tail pattern seen in liquid-based preparations
Nuclei Variably, enlarged (8–15 ␮m); round, oval to Round, oval, oblong, central to eccentric; size variable
elongated; intensely hyperchromatic nuclei with 8 to 25 ␮m or more; chromatin fine to coarsely
granular chromatin; nucleoli inconsistent; mitoses granular with parachromatin clearing; multiple micro/
frequent macronucleoli
Cytoplasm Scant Variable, pale, bubbly to dense, scant to abundant
Background Clean Bloody, cellular debris
Endocervical Adenocarcinoma In Situ (AIS) (See Figs. 4.41 to 4.46)
A B
Figs. 4.41A to C. Conventional smear. A: Enormously enlarged

branching tissue fragments of glandular epithelial cells with mark-
edly hyperchromatic nuclei present a striking diagnostic feature
of AIS (low power). B: The cells have elongated nuclei containing
very coarse granular chromatin, and they lack nucleoli. The gland
lumens or openings (arrows) within the tissue fragments are also
very characteristic features of AIS. C: A different example of AIS,
consisting of irregular tissue fragments with multiple lumens. Such
a pattern under low magnification is almost diagnostic of AIS in
C conventional cervical-vaginal smears (low power).
A B
C D
Figs. 4.42A to E. Conventional smear AIS. A: A strip of glandular

cells with a luminal border, elongated hyperchromatic nuclei fan-
ning out away from the luminal border (feathering). B: Syncytial
tissue fragments of AIS cells with round, oval to elongated nuclei
and high N/C ratios. Note the intensely stained granular chromatin
without nucleoli is highly suggestive of AIS. C, D: Cells of AIS in
syncytial arrangement. Note the glandular openings. E: These malig-
nant cells from AIS contain micronucleoli. Open chromatin pattern
E and nucleoli should suggest the possibility of invasive carcinoma.
Fig. 4.43. Liquid-based preparation AIS. Syncytial tissue fragments

of endocervical cells with crowded, elongated nuclei exhibiting a
loss of polarity and feathering of the nuclei. Note the gland opening
(arrow). The cytomorphology of AIS in liquid-based preparations
is not as striking as that seen in conventional smears. The smaller
cell size, clumped chromatin, smudgy appearance, and balling up of
cells does present some interpretative problems.
119
Fig. 4.44. Liquid-based preparation AIS. Tissue fragment of AIS

cells with a gland opening. The nuclei are elongated with palisading
and feathering.
A B
Figs. 4.45A and B. Liquid-based preparation AIS. A, B: These strips of endocervical cells demonstrate the feathering
artifact. The nuclei are extremely hyperchromatic.
A B
Figs. 4.46A and B. Liquid-based preparation. Showing tissue fragments of endocervical cells with hyperchromatic,
elongated nuclei with feathering, consistent with endocervical adenocarcinoma in situ (AIS).
open chromatin pattern with identifiable nucleoli), and may be associated with squamous differentiation (ad-
increased cytoplasm imparting a squamoid appearance. enosquamous carcinoma).
Other features that characterize tumor invasion are deep
gland extension and lymphatic involvement (e-Figs.
Cytologic Features of Invasive Adenocarcinoma
4.17A to E).
Adenocarcinoma of the endocervix is commonly Single malignant cells, loosely cohesive groups, and syn-
of endocervical or endometrioid types, either of which cytial tissue fragments against a bloody and necrotic
AIS Coexistent with Squamous Carcinoma In Situ (CIS) (See Fig. 4.47)
A B
C D
Figs. 4.47A to D. Conventional smear. A: Typical cytomorphologic pattern of AIS. B: Same smear with tissue fragments
of CIS cells. The cone biopsy confirmed both AIS and CIS. C: Liquid-based preparation showing both CIS (arrow) and
AIS cells (A). D: Liquid-based preparation AIS (A) and CIS (arrow ).
background characterize most of the typical invasive pattern while those of the intestinal type may exhibit a
endocervical adenocarcinomas (Table 4.12; Figs. 4.48 to typical palisading alignment of the oblong nuclei. Muci-
4.52). The malignant cells are generally present in large nous tumors generally show variable amounts of mucin
numbers. The isolated cells are round, sometimes oval to in the background as well as intracellular mucin. Ade-
oblong, medium-sized, with scant cytoplasm and large nosquamous carcinomas show malignant cells exhibiting
nuclei. The latter are round with granular chromatin, both squamous and glandular features (Fig. 4.53D).
parachromatin clearing, and prominent nucleoli. The tis- Adenoma malignum, also known as minimal devia-
sue fragments are syncytial with or without an acinar pat- tion adenocarcinoma, is a rare subtype presenting diag-
tern. The differential diagnoses are listed in Table 4.14. nostic diffi culties both histologically and cytologically
(Figs. 4.53A and B). As the name implies, its morphol-
Immunoprofile ogy deviates very minimally from the normal, both archi-
The endocervical adenocarcinoma cells are immunoreac- tecturally and cytologically. The malignant cells are tall,
tive to p16. They react negatively to ER/PR. columnar with abundant mucin, basally located, have
somewhat crowded nuclei, are often bland in appearance,
OTHER MORPHOLOGIC VARIANTS OF and have occasional mitoses.
ENDOCERVICAL ADENOCARCINOMA Reported cytologic findings from a retrospective review
of cases with adenoma malignum include
The cytomorphology of uncommon but specific morpho-
logic variants present certain characteristic features that 1. Tissue fragments of endocervical epithelium in mono-
allow correct typing (Figs. 4.53A to E). The villoglandular layered sheets, multilayered strips, or three-dimen-
type present tissue fragments with a papillary branching sional clusters, with or without an acinar pattern.
Cytopathologic Features of Invasive Endocervical Adenocarcinoma (See Figs. 4.48 to 4.53)
Fig. 4.48. Conventional smear showing cells of invasive endocervi- Fig. 4.49. Conventional smear depicting invasive endocervical ad-
cal adenocarcinoma. The pleomorphic malignant cells are discrete, enocarcinoma. The malignant cells are round, large with high N/C
loosely cohesive, and in syncytial tissue fragments. The nuclei are ratios, and contain nucleoli.
large and clearly malignant.
A B
Figs. 4.50A and B. Invasive endocervical adenocarcinoma.
Fig. 4.51. Liquid-based preparation showing invasive endocervical

adenocarcinoma.
A B
Figs. 4.52A to C. Liquid-based preparation demonstrating invasive

C endocervical adenocarcinoma cells.
A B
Figs. 4.53A to C. Conventional smears. Invasive endocervical ad-

enocarcinoma. Morphologic variants. A: Adenoma malignum. This
well-differentiated morphologic variant of endocervical adenocarci-
noma is very difficult to identify from cervical-vaginal smears. The
malignant cells are small and contain abundant mucin. B: Adenoma
C malignum. C: Villoglandular type. (continued)
123
D E
Figs. 4.53D to E. (continued) D: Adenosquamous carcinoma. Note both glandular (G) and squamous (S) components.
E: Clear cell carcinoma showing a tissue fragment of very pleomorphic malignant cells containing variable, abundant,
pale cytoplasm.
TABLE 4.13 CYTOPATHOLOGIC FEATURES OF TABLE 4.14 DIFFERENTIAL DIAGNOSES OF

CLEAR CELL CARCINOMA ENDOCERVICAL ADENOCARCINOMA IN SITU
(AIS) AND INVASIVE
Arrangement Cells are isolated, in loosely cohesive groups
and in syncytial tissue fragments; hobnail AIS Invasive Adenocarcinoma
pattern may be present
Generous Sampling of Repair/Regenerative Changes
Cells Medium to large with poorly defined cell Endocervical Component Progesterone Effect
borders; moderate to high N/C ratios; round, Lower Uterine Segment (Endogenous or
polygonal to hobnail type Cells and Cervical Exogenous)
Endometriosis Pregnancy-Associated
Nuclei Large, round, often eccentric, very Reactive/Reparative Process Changes
pleomorphic; coarsely granular to smudgy Inflammation-Associated (Arias-Stella-Like Reaction)
chromatin; nucleoli are inconsistent; Changes
multinucleation ⫹/⫺ Cellular Changes with
Tubal Metaplasia Hormonal Therapy
Cytoplasm Variable, scant to abundant, clear to pale, Microglandular Hyperplasia Endometrial Adenocarcinoma
weakly staining either eosinophilic or Endocervical Glandular Non-Keratinizing Squamous
cyanophilic Atypia Cells Carcinoma
Squamous Carcinoma In Extrauterine Adenocarcinoma
Background Clean, bloody or inflammatory; naked nuclei Situ
2. Individual cells ranged from cuboidal to columnar. fall is the presence of large epithelial tissue fragments
3. Cytoplasm, which is lacy to vacuolated and abundant. from various sources. A common example is the benign
4. Nuclei, which are round to oval, granular, have pale endocervical epithelium obtained by vigorous brush-
chromatin, and have some crisp nuclear membrane ings. Under low power, these samples mimic the pattern
without prominent nucleoli. of AIS (Fig. 4.54A). A higher magnification reveals the
5. Eccentric nuclei due to large cytoplasmic vacuoles. characteristic honeycomb and regular nuclei. Another
source is endometrium where the endometrial cells
Clear cell carcinomas present marked cellular and
appear well-preserved, occur in large tissue fragments,
nuclear pleomorphism; they often have bizarre nuclei and
and make their appearance prior to the onset of men-
abundant, pale cytoplasm (Table 4.13; Fig. 4.53E).
strual flow (Fig. 4.54B). Lower uterine segment samples
are generally very characteristic with both abundant
stroma and tubular glands. A lack of or minimal stromal
component may mimic AIS (Fig. 4.54C). The same diag-
ENDOCERVICAL AIS
nostic problem may be encountered while sampling cer-
The differential diagnoses of AIS include several diag- vical endometriosis (Figs. 4.54D and E). Tubal metapla-
nostic entities (Table 4.14). A common potential pit- sia may yield large epithelial tissue fragments; without
Differential Diagnoses of Endocervical Adenocarcinoma, In Situ and Invasive (See Fig. 4.54)
A B
C D
E F
Figs. 4.54A to F. Differential diagnoses of large epithelial tissue fragments. Conventional smears. A: Generous sam-
pling of endocervical mucosa. B: Menstrual endometrium. C: Lower uterine segment cells. D: Cervical smears showing
several glandular structures (medium power). E: Higher magnification showed stromal component, supporting the
diagnosis of endometriosis. F: Several large tissue fragments of endocervical epithelium with a loss of the honeycomb
architecture. The nuclei are crowded and overlapped. Some of the fragments under higher magnification showed cilia,
consistent with tubal metaplasia.
cilia or terminal bars, this can easily be interpreted as DIFFERENTIAL DIAGNOSES

AIS (Fig. 4.54F). OF INVASIVE ENDOCERVICAL
Syncytial tissue fragments of endocervical glandular ADENOCARCINOMA
cells with an acinar pattern, in the case of microglandu-
Invasive endocervical adenocarcinomas generally do not
lar hyperplasia, may be mistaken for both in situ (AIS)
present any difficulties in recognizing it as a malignant neo-
and invasive endocervical adenocarcinoma. The cells of
plasm and as an adenocarcinoma. The problems relate to the
tubal metaplasia, likewise, mimic endocervical AIS (see
typing of the malignancy. Malignant neoplasms that present
Chapter 3, Fig. 3.46).
morphologic overlap include poorly differentiated endo-
Considerable diagnostic difficulties exist in separat-
metrial adenocarcinoma, metastatic adenocarcinomas, and
ing the tissue fragments of AIS and high-grade squamous
poorly differentiated squamous carcinomas (Table 4.8).
intraepithelial neoplasia or CIS. The cells of squamous
Benign lesions that may be mistaken for invasive en-
carcinoma in situ when involved with the endocervical
docervical adenocarcinomas include exuberant repair/
glands, present as syncytial tissue fragments with smooth
regeneration, inflammation-associated changes, pregnan-
external contours, which resemble glandular casts. The
cy-related changes (Table 4.16), and microglandular hy-
nuclei often appear round with powdery chromatin with
perplasia. These lesions present considerable nuclear atypia
or without micronucleoli (see Chapter 3, Figs. 3.20 to
with prominent macronucleoli. These are discussed below
3.24). Very often this distinction is not possible on a cy-
in the section on atypical endocervical glandular cells.
tologic basis. The difficulty is compounded when both
AIS and CIS coexist, as they often do. The similarities
ATYPICAL ENDOCERVICAL
between the two entities and their differentiating features
GLANDULAR CELLS
are listed in Table 4.15 and illustrated in Figures 4.55
to 4.57. The category “Atypical Glandular Cells,” designated by
Endocervical glandular cells (not uncommonly) present TBS, refers to the cellular changes that fall between those
cytologic atypia severe enough to require the diagnostic of a definite benign reactive process(es) and those of an
consideration of possible AIS or an invasive adenocar- unequivocal AIS or adenocarcinoma and represent 0.2 to
cinoma. This problem is discussed under the heading of 0.3% of all cervical-vaginal smears. This diagnostic term
atypical endocervical glandular cells (see below). should be strictly reserved for cellular changes that raise
TABLE 4.15 DIFFERENTIATING FEATURES BETWEEN ADENOCARCINOMA IN SITU AND SQUAMOUS

CARCINOMA IN SITU (HSIL) WITH GLAND INVOLVEMENT
Adenocarcinoma In Situ (AIS) Squamous Carcinoma In Situ (CIS, HSIL)

Presentation Mostly in tissue fragments, single cells are infrequent Tissue fragments, cell aggregates and single cells
Architecture Irregular with or without gland openings; nuclei Irregular with or without gland openings; nuclei around
around the openings with vertical polarity; the openings with horizontal polarity and without
nuclei at the periphery stringing out with a feathery pattern; cells at the periphery with squamous
feathery pattern; bird tail pattern in liquid-based features
preparations
Cells Small, uniform, elongated to columnar Generally round; occasionally oblong
Nuclei Oval, elongated; round, oval to elongated, Pleomorphic in size, small to medium-sized; round, oval to
smooth contour; chromasia marked; coarsely elongated with frequent irregular contour; fine to coarsely
granular chromatin; nucleoli are rare; mitoses are granular chromatin; nucleoli are rare; mitoses ⫹/⫺
frequent
Cytoplasm Hardly visible Variable, pale to dense; keratinization ⫹/⫺
Cell Borders Poorly defined Well-defined when visible
Background Generally clean Dysplastic squamous cells
May coexist with HSIL May coexist with AIS

Squamous Carcinoma In Situ (CIS) versus Adenocarcinoma In Situ (AIS) (See Figs. 4.55 to 4.57)
The cytomorphology of squamous carcinoma in situ and AIS often overlap. Their cytologic differentiation becomes difficult and
challenging.
A B
Figs. 4.55A and B. Conventional smears. A: CIS. B: AIS. Note the cytologic similarities.
A B
C D
Figs. 4.56A to D. Conventional smears. A: CIS. B: AIS. At first glance, the cytomorphology of both tissue fragments
appear identical. Note that the nuclei in (A) are rounded and are surrounded by scant cytoplasm. The tissue fragment
shows a luminal border, and at the opposite end, some nuclei demonstrate horizontal polarity. The cells in (B) dem-
onstrate elongated nuclei and some feathering. C: Showing syncytial tissue fragment of squamous in situ cells (HSIL).
The tissue fragment has a smooth external contour favoring endocervical gland involvement. Note the HSIL cells in the
background. D: The tissue fragments are syncytial. The component nuclei are extremely hyperchromatic with high N/C
ratios and indiscernible cytoplasm. The morphology is more in line with HSIL. However, the biopsy confirmed AIS.
TABLE 4.16 CYTOPATHOLOGIC FEATURES OF THE ARIAS-STELLA REACTION-LIKE CHANGES VERSUS

POORLY DIFFERENTIATED ENDOCERVICAL ADENOCARCINOMA
Arias-Stella Reaction Poorly Differentiated Endocervical Adenocarcinoma

Presentation Moderate exfoliation; cells are isolated, Moderate to marked exfoliation of malignant cells; cells
in aggregates and in tissue fragments with are isolated, in loosely cohesive groups, or in syncytial type
crowded and overlapped nuclei tissue fragments with or without acinar or papillary pattern
Cell Size Variable; small to large; marked Cells are small to medium-sized with high N/C ratio;
pleomorphism mild pleomorphism
Nuclei Enlarged, round to oval, N/C ratio is variable, Round to oval, with or without irregular borders;
generally high; chromatin is granular, often chromatin fine to coarsely granular with parachromatin
smudgy, ground glass appearance, intranuclear clearing; bizarre in clear cell variant with giant forms
inclusions and prominent nuclear grooves
Nucleoli Variable, single/multiple micro/macronucleoli Variable, single/multiple micro/macronucleoli
Cytoplasm Variable, scant to abundant; vacuolated, pale Variable, scant to abundant; usually abundant in clear
to dense leukophagocytosis cell variant
Background Generally inflammatory; other pregnancy- Inflammatory, tumor diathesis ⫹/⫺

associated changes
Diagnostic Clues History of pregnancy, cytologic features History of pregnancy not related to the findings and do
associated with pregnancy; absence of cells not disappear at the termination of pregnancy; cytologic
with features of AIS; cytologic changes changes associated with pregnancy are not present; AIS
disappear at the termination of pregnancy may be present in the background
suspicion for AIS or invasive adenocarcinoma (Table TABLE 4.17 DIFFERENTIAL DIAGNOSES OF ATYPI-
4.17). Cellular changes that are clearly indicative of CAL ENDOCERVICAL GLANDULAR CELLS
benign diagnostic entities should not be interpreted and
reported as AGC. When the deviation from usual and Nonneoplastic
known cytologic features of various glandular lesions Exuberant Sampling of Endocervical Mucosa
precludes a defi nite diagnosis or when overlapping cyto-
Endometrial Cells
pathologic features make accurate identification difficult,
the diagnosis of AGC is rendered (Figs. 4.58 to 4.75; e-Fig. Lower Uterine Segment Cells
4.18). The diagnostic term AGC may be further qualified Cervical Endometriosis
as either “favor neoplastic” or “not otherwise specified”
Repair/Regeneration
(NOS). The examples of various diagnostic entities with
variations in their cytologic pattern that warrant the diag- Inflammation-Associated Changes
nosis of AGC are listed in Tables 4.18 and 4.19. Roughly IUD-Associated Changes
30% of cases with AGC have a significant lesion with the
majority representing cervical intraepithelial lesions. AIS Hormone (Progesterone) Related Changes (pregnancy,
and invasive adenocarcinomas represent 3% and 5%, birth control pills)
respectively, in this group. Radiation-Associated Changes
A colposcopy and guided biopsy is recommended
Tubal Metaplasia
for women with a diagnosis of AGC because of a higher
incidence of abnormalities. Vaginal bleeding, if present, Microglandular Hyperplasia
will require endometrial sampling as well. HPV test- Neoplastic
ing is also recommended. In cases where the cytologic
Endocervical Adenocarcinoma In Situ (AIS)
diagnosis of “probably neoplastic” is not confirmed, a
repeat cervical-vaginal smear and/or a diagnostic exci- Endocervical Adenocarcinoma, Invasive
sional procedure is recommended. The reader should Adenocarcinomas, Extrauterine Origin
refer to the most current guidelines recommended by
High-Grade Squamous Intraepithelial Lesion (HSIL)
ASCCP and ACOG.
A B
Figs. 4.57A and B. Conventional smears. A: Syncytial tissue fragment of HSIL. B: Syncytial tissue fragment of cells
proven to be AIS. Note how the cytologic distinction between the two is almost impossible.
Atypical Endocervical Glandular Cells (AGC) (See Figs. 4.58 to 4.75)
Fig. 4.58. Conventional smear. This is a normal endocervical epi- Fig. 4.59. Conventional smear. A syncytial tissue fragment of en-
thelium showing a honeycomb sheet with well-defined cell borders, docervical cells with poorly defined cell borders and altered nuclear
uniform round nuclei that maintain the polarity, and finely granular polarity. The nuclei are variable in size and some demonstrate nu-
chromatin and micronucleoli. These are the baseline features. cleoli. Cervical biopsy was non-diagnostic.
Fig. 4.60. Conventional smear. Atypical endocervical glandular cells. Fig. 4.61. Conventional smear. This is another example of atypical
A syncytial tissue fragment of glandular cells with their nuclei contain- endocervical glandular cells with considerable nuclear enlargement
ing fine to coarsely granular chromatin and nucleoli. The cytoplasm and pleomorphism. Follow-up was benign.
is variable. These may represent tubal metaplasia, microglandular
hyperplasia or high-grade intraepithelial squamous lesions, or simply
reactive changes. Follow-up in this case was benign.
129
Fig. 4.62. Conventional smear. Atypical endocervical glandular Fig. 4.63. Conventional smear. Markedly atypical endocervical
cells. Prominent nucleoli may suggest invasive adenocarcinoma. glandular cells with prominent nucleoli are suspicious for adeno-
Note that there are no single cells, and N/C ratios are low. Follow- carcinoma. Follow-up was benign. Note that there are no single
up was benign. abnormal cells in the background.
Fig. 4.64. Conventional smear. Markedly atypical endocervical Fig. 4.65. Liquid-based preparation. Syncytial tissue fragment of
glandular cells in herpes virus infection. The infected cells prior to atypical endocervical glandular cells with mitoses (arrows), suspi-
the development of inclusions may exhibit remarkable atypia mim- cious for AIS.
icking malignancy.
Fig. 4.66. Conventional smear. Abnormal-appearing endometrial Fig. 4.67. Liquid-based preparation. Atypical endocervical glandu-
cells sometimes mimic atypical endocervical glandular cells. lar cells with elongated nuclei—a feature seen in AIS. Follow-up
was benign.
Fig. 4.68. Conventional smear. Atypical endocervical glandular

cells with syncytial architecture proven to be microglandular hy-
perplasia on biopsy.
A B
Figs. 4.69A and B. Conventional smear. Atypical endocervical glandular cells proven to be tubal metaplasia. Note
the syncytial architecture of the tissue fragment and the absence of cilia. These cells are also difficult to differentiate
from HSIL.
A B
Figs. 4.70A and B. Liquid-based preparation. A typical endocervical glandular cells. Tissue fragments of endocervical
epithelium with elongated nuclei, luminal border, and feathering; suspicious for AIS. Follow-up was benign.
Fig. 4.71. Conventional smear. Arias-Stella reaction of the endocer- Fig. 4.72. Conventional smears. Atypical endocervical glandular
vix. Markedly atypical endocervical glandular cells with prominent cells. The honeycomb architecture is slightly disrupted due to the
nucleoli, suspicious for carcinoma. The patient was pregnant. The altered polarity of some nuclei. Their cytoplasm is scant. The nucle-
changes disappeared following termination of the pregnancy. ar chromatin is coarse and dark-staining. No nucleoli are present.
Note the luminal borders (arrow) and a gland opening. These are
suspicious for AIS.
Fig. 4.73. Conventional smear. Atypical endocervical glandular cells Fig. 4.74. Conventional smear showing syncytial tissue fragments
in strips and syncytial tissue fragment. Their nuclei are extremely of glandular cells with extreme crowding and marked hyperchro-
hyperchromatic, round to elongated, crowded, and overlapped. masia. Follow-up confirmed AIS. Compare these with Figures 4.72
Nucleoli are not present. The cytologic pattern is suspicious for AIS and 4.73.
and was confirmed on biopsy.
Fig. 4.75. Liquid-based preparation. Atypical endocervical glandu-

lar cells. A strip with crowded, elongated, hyperchromatic nuclei
demonstrating the feathering artifact. The cytologic pattern is sug-
gestive of AIS. The follow-up was benign.
TABLE 4.18 DIFFERENTIAL DIAGNOSES OF ATYPICAL ENDOCERVICAL GLANDULAR CELLS (AGC) CYTOPATHOLOGIC FEATURES
Generous
Sampling of Atypical Endocervical
Endocervical Micro- Endocervical Adenocarci- Squamous
Tissue Lower Uterine Glandular Arias-Stella Tubal Repair/ Glandular noma In Situ Carcinoma
Criteria Fragments Segment Cells Hyperplasia Reaction Metaplasia Regeneration Cells (AGC) (AIS) In Situ (CIS)
Presentation Large tissue Large tissue Small to Cells isolated, Small to Small to Small to Small to large Cells isolated, often
fragments fragments moderate- in groups large tissue large tissue large tissue tissue fragments in streaks, in loose
sized tissue and in tissue fragments fragments fragments of aggregates and in
fragments fragments endocervical syncytial tissue
cells fragments
Architecture Sheets with a Tubular Honeycomb Honeycomb Syncytial Monolayered Lack of Syncytial with Syncytial with
of Tissue honeycomb endometrial glands ⫹/⫺; syncytial ⫹/⫺; syncytial or strips; sheets, honeycomb or without or without
Fragments arrangement with or without pattern ⫹/⫺; ⫹/⫺; luminal crowding and occasionally arrangement; branching; smooth contour;
or strips with branching; luminal borders ⫹/⫺; overlapping of isolated cells, strips ⫹/−; strips, luminal borders
the palisading enveloped by borders ⫹/⫺; gland openings nuclei; luminal minimal variable feathering; ⫹/⫺ or gland
of the nuclei stromal cells; gland openings are not present border; vertical overlapping; crowding rosettes; luminal openings (in gland
and with capillaries ⫹ ⫹/⫺ polarity of no luminal and overlap borders, intense involvement) cells
a luminal traversing; no nuclei; cilia borders; no of nuclei; crowding and at the periphery
border; gland luminal border, ⫹/⫺; no gland gland openings feathering overlapping of and around
openings are crowded nuclei; openings ⫹/⫺; luminal nuclei, vertical gland opening
not seen gland openings ⫹ borders; orientation with horizontal
gland of cells at the orientation;
openings periphery and sometimes arranged
around gland in a concentric or
openings whorled fashion
Cells Normal-sized Endometrial Mild Markedly Mild Enlarged Variably Small to Small to medium-
endocervical glandular cells enlargement pleomorphic; enlargement enlarged normal-sized to sized
cells smaller than ⫹/⫺ small, large, or enlarged
endocervical giant forms
N/C Ratios Normal Very high Mild increase Variable may Increased Low Variably Markedly Markedly increased
be markedly increased increased
increased
(continued)
Generous
Sampling of Atypical Endocervical
Endocervical Micro- Endocervical Adenocarci- Squamous
Tissue Lower Uterine Glandular Arias-Stella Tubal Repair/ Glandular noma In Situ Carcinoma
Criteria Fragments Segment Cells Hyperplasia Reaction Metaplasia Regeneration Cells (AGC) (AIS) In Situ (CIS)
Nucleus Normal-sized; Endometrial Round, mild Marked Nuclei are oval Nuclei are Nuclear Oval to Round, oval,
round, smooth glandular cells, variation in variation in to elongated; variably enlargement elongated sometimes irregular
nuclear nuclei are smaller size, finely size; chromatin coarsely enlarged, ⫹/⫺; round nuclei; intensely nuclear membranes,
membranes, with coarse granular is granular granular smooth nuclear to oval, hyperchromatic; crisp–even to
finely granular chromatin; mitoses chromatin; to smudgy; chromatin; membranes, coarsely mitoses are irregular; fine to
evenly ⫹/⫺; stromal cell micronucleoli; micro/ nucleoli granular granular frequent; coarsely granular
dispersed nuclei are oval mitoses are macronucleoli; inconspicuous; chromatin; chromatin; micronucleoli chromatin; nuclear
chromatin; to oblong with rare to absent intranuclear mitoses nucleoli mitoses ⫹/⫺; are absent or grooves ⫹/⫺ altered
micronucleoli; finely granular inclusions; are absent, are very nucleoli ⫹/⫺ inconspicuous polarity; mitoses
mitoses are chromatin; mitoses ⫹/⫺ pleomorphic in prominent; are infrequent;
absent nucleoli are size ⫹/⫺ mitoses ⫹/⫺ micronucleoli ⫹/⫺
inconspicuous;
mitoses ⫹/⫺
Cytoplasm Pale, moderate Scant Variable, pale Variable, scant Scant Moderate to Scant to Scant, Scant but
to dense; to abundant, abundant moderate indiscernible discernible cells,
secretory pale to dense borders well-defined
vacuoles with
and without
neutrophils
Diagnostic Honeycomb Stromal Lack of Pregnancy Cilia along the Lack of — Intensely Keratinized cells,
Clues pattern; component individual postpartum luminal border single cells; hyperchromasia; ⫹/⫺ squamous
uniform nuclei with capillaries cells; large state; changes monolayered elongated nuclei differentiation
and glandular cytoplasmic disappear on tissue with a feathery
component vacuoles; termination of fragments; low pattern
acinar pattern pregnancy N/C ratio
TABLE 4.19 CYTOPATHOLOGIC CLUES IN THE DIFFERENTIAL DIAGNOSES OF ATYPICAL

ENDOCERVICAL GLANDULAR CELLS (AGC)
Cytologic Pattern Diagnostic Considerations Diagnostic Clues

A) Generous sampling of normal endocervical Normal Endocervical Normal architecture, pale nuclei
mucosa with very large branching tissue Epithelium with finely granular chromatin and
fragments; uniform nuclei in a honeycomb versus micronucleoli; pale cytoplasm—
arrangement (Fig. 4.54A) Endocervical Adenocarcinoma In Situ favor benign epithelium
B) Large tissue fragments of glandular epithelium; Endometrial Sampling from Granular chromatin and lack of
intense crowding and overlapping; tubular Lower Uterine Segment or intense hyperchromasia; favor
pattern with or without gland openings; finely Endometriosis endometrial glandular cells;
granular chromatin; micronucleoli ⫹/⫺ (Figs. versus presence of endometrial stromal
4.54B, C, and D) Endocervical Adenocarcinoma In Situ cells favor lower uterine segment
cells or endometriosis
C) Monolayered tissue fragments of endocervical Atypical Repair Lack of single cells; low N/C ratio;
epithelium; minimal crowding and versus two-dimensional configuration,
overlapping; slight enlargement of the nuclei; Endocervical Adenocarcinoma favor repair
prominent micro/macronucleoli; brisk mitoses;
lack of mucin secretions (Figs. 4.62, 4.63)
D) Monolayered tissue fragments of endocervical Non-Specific Reactive Changes History of birth control pills or
cells, loss of honeycomb pattern; altered versus HRT; changes are non-specific; no
polarity; nuclei pleomorphic in size and Endocervical Adenocarcinoma single cells; smudgy chromatin; low
occasional giant forms; fine to coarsely N/C ratio
granular or smudgy dense chromatin; micro/
macronucleoli; variable cytoplasm; low N/C
ratio (Figs. 4.64, 4.65)
E) Markedly pleomorphic glandular cells are Arias-Stella-Like Reaction History of pregnancy; changes
discrete, in aggregates and in syncytial tissue versus disappear following termination of
fragments without any architectural patterns; Endocervical Adenocarcinoma pregnancy
cells are small, large, or giant forms with
high N/C ratios; nuclei with macronucleoli,
smudgy chromatin; intranuclear inclusions;
inflammatory background (Figs. 2.18, 4.71)
SUGGESTED READINGS
Bean SM, Connolly K, Roberson J, et al. Incidence and clinical de Peralta-Venturina MN, Purslow MJ, Kini SR. Endometrial cells
significance of morphologically benign-appearing endometrial of the lower uterine segment (LUS) in cervical smears obtained
cells in patients age 40 years or older: The impact of the 2001 by endocervical brushing: A source of potential diagnostic pit-
Bethesda System. Cancer 2006;108(1):39–44. fall. Diagn Cytopathol 1995;12:263–270.
Benoit JL, Kini SR. “Arias-Stella” reaction-like changes in endocer- Gomez-Fernandez CR, Gangei-Azar P, Capote-Dishaw J, et al.
vical glandular epithelium in cervical smears during pregnancy Reporting endometrial cells in Pap smears. An outcome
and postpartum states–A potential diagnostic pitfall. Diagn appraisal. Gynecol Oncol 1999;74:381–384.
Cytopathol 1996;14:349–355. Johnson TL, Kini SR. Endometrial metaplasia as a source of atypi-
Biscotti CV, Gero MA, Toddy SM, et al. Endocervical adenocarci- cal glandular cells in cervicovaginal smears. Diagn Cytopathol
noma in situ; an analysis of cellular features. Diagn Cytopathol 1994;14(1):25–31.
1997;17:326–332. Koss LG. Diagnostic Cytology and Its Histopathologic Basis. 4th
Browne TJ, Genest DR, Cibas ES. The clinical significance ed. Philadelphia: JB Lippincott Co., 1992.
of benign-appearing endometrial cells on a Papanico- Kurman RJ, Solomon D. The Bethesda System for Reporting Cer-
laou test in women 40 years or older. Am J Clin Pathol vical/Vaginal Cytologic Diagnoses: Definitions, Criteria and
2005;124(6):834–837. Explanatory Notes for Terminology and Specimen Adequacy.
Cibas ES. Cervical and vaginal cytology. In: Cibas ES, Ducatman New York: Springer-Verlag, 1994.
BS, eds. Cytology Diagnostic Principles and Clinical Correlates. Novotny DB, Maygarden SJ, Johnson DE, Frable W. Tubal meta-
3rd ed. Philadelphia: Saunders, 2009. plasia: A frequent potential pitfall in the cytologic diagnosis of
endocervical glandular dysplasia on cervical smears. Acta Cytol Solomon D, Nayar R, eds. The Bethesda System for Reporting Cer-
1992;36:1–10. vical Cytology: Definitions, Criteria, and Explanatory Notes.
Nucci MR, Oliva E. Gynecologic Pathology In: Goldblum JR, ed. 2nd ed. New York: Springer, 2004.
Foundations in Diagnostic Pathology. Philadelphia: Churchill Tavassoli FA, Devilee P, eds. Pathology and Genetics. Tumors of
Livingstone, 2009. the Breast and Female Genital Organs. WHO Classification of
Opjorden SL, Caudill JL, Humphrey SK, Salomao DR. Small cells Tumors. Lyon, France: IARC Press, 2003.
in cervical-vaginal smears of patients treated with tamoxifen. Thrall M, Kjeldahl K, Gulbahce HE, Pambuccian SE. Liquid-based
Cancer 2001;93(1):23–28. Papanicolaou test (SurePath) interpretations before histologic
Pacey NF. Glandular neoplasms of the uterine cervix. In: Bibbo M, diagnosis of endometrial hyperplasias and carcinomas: Study
ed. Comprehensive Cytopathology. 2nd ed. Philadelphia: WB of 272 cases classified by the 2001 Bethesda system. Cancer
Saunders, 1997:231–250. 2007;111(4):217–223.
Papanicolaou GN. New cancer diagnosis. In: Proceedings Third Wilbur DC. Glandular lesions of the uterine cervix. In: Bibbo M,
Race Betterment Conference; 1928;582; Battle Creek, Race Wilbur DC, eds. Comprehensive Cytopathology. 3rd ed. Phila-
Betterment Foundation. delphia: Saunders, 2008.
Schnatz PF, Guile M, O’Sullivan DM, Sorosky JI. Clinical signifi- Wright CA, Leiman G, Burgess SM. The cytomorphology of papil-
cance of atypical glandular cells on cervical cytology. Obstet lary serous carcinoma of the endometrium in cervical smears.
Gynecol 2006;107(3):701–708. Cancer 1999;87:12–18.
APPENDIX
HISTOLOGIC CLASSIFICATION OF ENDOME-

TRIAL AND ENDOCERVICAL CARCINOMAa
(WORLD HEALTH ORGANIZATION, 2003)
Endometrium Endocervix
1. Endometrioid Carcinoma Adenocarcinoma
2. Endometrioid Carcinoma Variants: Mucinous Adenocarcinoma
(a) With Squamous Differentiation Endocervical
(b) Villoglandular Intestinal
Signet-Ring Cell
(c) Secretory
Minimal Deviation
(d) Ciliated Villoglandular
(e) Other Endometrioid Adenocarcinoma
3. Mucinous Adenocarcinoma Clear Cell Adenocarcinoma
4. Serous Adenocarcinoma Mesonephric Adenocarcinoma
5. Clear Cell Carcinoma Early Invasive Adenocarcinoma
6. Mixed Adenocarcinoma Adenocarcinoma In Situ
7. Squamous Carcinoma Glandular Dysplasia
8. Transitional Cell Carcinoma Other Epithelial Tumors
9. Small Cell Carcinoma Adenosquamous Carcinoma
10. Undifferentiated Carcinoma Adenoid Cystic Carcinoma
a
Tavassoli FA, Devilee P. eds. Pathology and Genetics. Tumors of the Breast and Female Genital Organs. WHO Classification of Tumors.
Lyon: IARC Press, 2003.
5 MISCELLANEOUS
VULVAR SCRAPINGS
LESIONS OF THE VAGINA AND VULVA AND VAGINAL SMEARS
Cytologic evaluation of the vulvar and vaginal smears
VAGINAL CYSTS has been useful in identifying vulvar and vaginal intraepi-
The most common type of vaginal cysts includes Mül- thelial neoplasia (VAIN), carcinomas, and other types of
lerian type, epidermal inclusion cyst, and Gartner’s malignancies. It was used extensively to identify adenosis
cyst. These are all benign and surgically excised. Fine and clear cell carcinoma in patients exposed to diethyl-
needle aspiration is not a routine diagnostic technique. stilbestrol (DES) in utero. Lateral vaginal wall scrapings
e-Figures 5.1A and B demonstrates an aspiration were also used to judge the hormonal status.
biopsy of a Gartner’s cyst showing benign, uniform Vulvar cancers are usually squamous type (Figs. 5.1
cuboidal cells. to 5.3). The majority of vaginal intraepithelial lesions are
identified in patients previously treated for cervical intra-
epithelial neoplasia or invasive cancers. The vaginal lesions
VIRAL INFECTIONS are often multifocal. The cellular changes are similar to
those of cervical intraepithelial lesions. Primary squamous
Viral infections that commonly involve the vulva and the cancers of the vagina are extremely rare (Fig. 5.4).
vagina include those caused by the herpes simplex virus,
molluscum contagiosum, cytomegalovirus, and human
papilloma virus.
Genital herpes simplex virus infections involve both CLEAR CELL CARCINOMA
the vulva and the vagina, manifested by papules, vesicles, Primary clear cell adenocarcinoma of the vagina accounts
and erosions/ulcers that appear over a period of hours to for 1% of all invasive carcinomas of the female genital
days. Vulvar lesions are extremely painful, whereas vagi- tract. The risk of developing clear cell carcinoma in DES-
nal lesions tend to be asymptomatic. Scrapings or vaginal exposed women from birth to age 34 years is estimated
smears show typical cytopathic effects of herpes virus in- at 0.1%. The risk of development increases from age 15,
fection (e-Fig. 5.2). reaching a plateau from 17 to 22 years of age, and declin-
ing thereafter.
The neoplasm frequently originates from the anterior
VAGINAL ADENOSIS wall. Histologically, three patterns are noted: tubulocystic,
Vaginal adenosis is defined as the presence of benign solid, and papillary. The cells have abundant clear cyto-
endocervical glandular or tubal and endometrial glands, plasm containing glycogen and nuclei bulging toward the
either replacing the squamous epithelium or forming glandular lumen, designated as a hobnail pattern. Their
glandular structures in the lamina propria. Adenosis is cytologic features (Fig. 5.5) are discussed in Chapter 4;
almost always located in the upper one third of the vagi- see Table 4.13.
nal wall.
PAGET’S DISEASE OF
VAGINAL ENDOMETRIOSIS THE VULVA AND VAGINA
Vaginal endometriosis is uncommon. It can occur on the Paget’s disease of the vulva (extramammary Paget’s dis-
surface or deep in the vaginal wall. It may present clini- ease) is a malignant neoplasm involving the skin of the
cally as vaginal bleeding or a mass. Smears of the vagina embryonic milk line. The lesions frequently appear well
show endometrial tissue consisting of glands and stroma demarcated, red, and thickened, with ulcerated areas that
(e-Figs. 5.3A to C). are moist and encrusted. Unlike Paget’s disease of the
138
Chapter 5: Miscellaneous 139
Fig. 5.1. Vulvar scrape. Well-differentiated squamous carcinoma. Fig. 5.2. Vulvar scrape. Moderately differentiated squamous carci-
noma with a pleomorphic cell pattern.
Fig. 5.3. Vulvar scrape. Poorly differentiated squamous carcinoma. Fig. 5.4. Vaginal smear. Moderately differentiated squamous car-
cinoma.
Fig. 5.5. Vaginal smear. Adenocarcinoma cells, proven histologi-

cally as primary clear cell carcinoma. The patient was exposed to
diethylstilbestrol in utero.
breast, which is always associated with an underlying duct and tend to be ovoid with finely granular chromatin and
adenocarcinoma, only 30% cases of vulvar Paget’s disease the presence of a small nucleolus. The lesions are com-
are associated with invasive carcinoma. Histologically, the monly intraepithelial with single Paget’s cells appearing
lesions are characterized by infiltration of the epidermis in the upper epidermis, and with groups of Paget’s cells
by Paget’s cells (e-Fig. 5.4), which are large and rounded involving the lower epidermis, rete ridges, or skin adn-
with pale-staining cytoplasm. The nuclei are pleomorphic exal structures. Cell groupings may form small lumina.
Infrequently, vulvar Paget’s disease may be an extension MALIGNANT MELANOMA

of an underlying adenocarcinoma, such as from Bartho-
Malignant melanoma is the second most common
lin’s gland, or may be a metastasis from sites such as the
malignant neoplasm of the vagina, accounting for 3%
cervix, rectum, or bladder. Paget’s disease may extend
of all primary vaginal malignancies and comprising
into the vagina involving vaginal mucosa, although this is
0.3% of all malignant melanomas. In vulva, 2 to 9%
rare. Vaginal smears show malignant cells (Figs. 5.6A to
of all primary malignancies represent malignant mela-
C) morphologically similar to those seen in vulvar or in
nomas. The cytologic diagnosis can be made either from
nipple scrapes with Paget’s disease (see Chapter 16, Table
smears or from a fine needle biopsy of the vaginal mass
16.19, Fig. 16.46). Differential diagnoses include poorly
(Fig. 5.7).
differentiated carcinomas and malignant melanoma.
A B
Figs. 5.6A to C. A: Vaginal smear. Malignant cells are large and

pleomorphic and represent extension of Paget’s disease of the vulva.
B, C: Paget’s disease. The malignant cells are diagnostic of adeno-
carcinoma. The cytoplasm is vacuolated compressing the nuclei to
C crescent shapes.
Fig. 5.7. Fine needle aspiration. Vaginal mass showing malignant

melanoma cells, containing melanin pigment.
Morphologically, the cells of fallopian tube adenocarci-

CELLS FROM EXTRAUTERINE nomas do not present any specific cytologic features and do
MALIGNANCY not differ from other genital adenocarcinomas. The malig-
nant cells are generally fewer in number, are either isolated
PRIMARY FALLOPIAN TUBE or in syncytial tissue fragments with or without acinar pat-
ADENOCARCINOMA tern, and have a papillary configuration (Figs. 5.8 and 5.9).
The cells are larger than those seen in well-differentiated
Primary cancer of the fallopian tube is extremely rare, endometrioid endometrial carcinoma. The malignant cells
with the reported incidence ranging from 0.15 to 1.1% of often show cytoplasmic vacuoles. Degenerative changes are
malignancies involving the female genital tract. frequent. The background is often watery but may be clean.
Primary tubal carcinomas occur most frequently in The origin of these tubal adenocarcinoma cells cannot be
women in their fifth to seventh decades. Association with determined from their cytologic appearance.
nulliparity and chronic salpingitis has been suggested. The
common presenting symptoms are vaginal bleeding, pres-
OTHER EXTRAUTERINE CANCERS
ent in about 50% or more of the patients, and abdomi-
nal or pelvic pain. Up to 15% of the patients harboring Malignant neoplasms of extrauterine origin can metas-
tubal carcinoma present with a syndrome referred to as tasize to the endometrium, cervix, vagina, or vulva (Figs.
“hydrops tubae profl uens.” It is characterized by colicky 5.10 to 5.17). The malignant cells may also spread from
lower abdominal pain relieved by a profuse, watery, clear the peritoneal cavity into the fallopian tube, then into the
serosanguineous to yellow, intermittent vaginal discharge. uterine cavity to be detected in the vaginal pool. The cyto-
It is thought to be caused by filling and emptying of a par- morphology of the malignant cells and their organization
tially blocked fallopian tube and is the classic diagnostic often reflect the tissue of origin. The smears may or may
sign of tubal carcinoma. Fallopian tube carcinomas gen- not show an inflammatory background and diathesis (Fig.
erally present an aggressive clinical course. 5.13). A clean background is considered an important
Most fallopian tube carcinomas remain undiagnosed feature favoring a metastatic process, although poorly
and are detected at the time of surgery. Preoperative ultra- preserved malignant cells in the background of inflam-
sonography may reveal a sausage-shaped cystic adnexal mation and diathesis have been observed accompanying
mass suggesting tubal pathology. Serum CA125 levels are metastases. Metastatic tumors often show morphologic
generally increased. Diagnostic yield on routine cervical/ similarities to endocervical or endometrial adenocarcino-
vaginal smears is considered to be very low. Abnormal cy- mas. A pertinent clinical history as well as review of the
tology and negative endometrial curettage has led to the previous surgical specimen is essential.
diagnosis of fallopian tube carcinoma in isolated cases. The cells of serous papillary adenocarcinomas of the
Grossly, the fallopian tube is usually swollen because ovary (Fig. 5.12) are large, either isolated or in syncytial
of intraluminal growth. The lumen is fi lled with and arrangement with closely packed nuclei. Papillary con-
dilated by papillary or solid tumor. Bilaterality may be figuration is frequent. The nuclei are round, containing
seen in up to 7% of early stage cases and in up to 3% of powdery to granular chromatin, with single or multiple
advanced cases. Microscopically, the histologic patterns micronuclei, or prominent cherry-red macronuclei. The
include serous papillary and all types of ovarian carcino- cytoplasm may be abundant and vacuolated with bubble
mas. Mucin production may be present. Other malignant gum vacuoles. Single or multiple psammoma bodies are
neoplasms of the fallopian tube include mixed mesoder- characteristic (Fig. 5.12). The background may be clean
mal tumor and leiomyosarcoma. or show diathesis.
A B
Figs. 5.8A and B. Cervical smear showing tissue fragments of adenocarcinoma cells originating from the fallopian tube.
Malignancies from the gastrointestinal tract may in- shaped and contain fi ne to coarsely granular, deep-stain-
volve the cervix/vagina in advanced stages (Fig. 5.13). ing chromatin. The individual cells appear slender and
Cells of colonic adenocarcinoma may present a charac- columnar.
teristic cellular pattern with tissue fragments displaying Mammary carcinoma cells are generally small to me-
papillary or acinar patterns, strips with luminal border, dium-sized presenting themselves either in “Indian files”
and palisading of nuclei (Fig. 5.16). The latter are cigar- or in syncytial fragments (Figs. 5.14 and 5.15).
A B
Figs. 5.9A to C. A, B: Adenocarcinoma cells in conventional

cervical smear, proven to be originating from the fallopian tube.
C: Another example of adenocarcinoma of the fallopian tube detected
in cervical smear, liquid-based preparation (SurePath). (Courtesy of
Ms. Karen Atkinson, MPA, CT(ASCP), CMIAC, and Mr. Tim Collins,
BS, CT(ASCP), BD Diagnostics-Women’s Health and Cancer, North
C Carolina.)
Metastatic Malignancy in Cervical-Vaginal Smears (See Figs. 5.10 to 5.17)
Fig. 5.10. Exuberate exfoliation of adenocarcinoma cells in cervical Fig. 5.11. Metastatic serous papillary adenocarcinoma of the ovary
smear originating from serous papillary cystadenoma carcinoma of in conventional cervical-vaginal smear.
the ovary.
Fig. 5.12. Metastatic serous papillary adenocarcinoma of the ova- Fig. 5.13. Metastatic poorly differentiated adenocarcinoma in cer-
ry in conventional cervical-vaginal smear. Note the psammoma vical/vaginal smear. The patient had a history of disseminated pan-
body (arrow). creatic adenocarcinoma with widespread metastasis.
Fig. 5.14. Metastatic lobular breast carcinoma. Note the “Indian Fig. 5.15. Metastatic duct adenocarcinoma of the breast. The pa-
file” pattern (arrow). tient had a disseminated disease with widespread metastasis.
Fig. 5.16. Metastatic adenocarcinoma of the colon persecuting the Fig. 5.17. Metastatic high-grade urothelial carcinoma of the uri-
characteristic cytomorphology with elongated nuclei and picket nary bladder, liquid-based.
fence arrangement.
High-grade urothelial carcinomas of the urinary blad- Psammoma bodies associated with benign conditions
der may directly involve the vagina (Fig. 5.17). occur in younger patients, are fewer in number, and are
generally incorporated in tissue fragments composed of
benign glandular cells (Figs. 5.20 to 5.23), although naked
PSAMMOMA BODIES IN
psammoma bodies can also occur. Psammoma bodies are
CERVICAL/VAGINAL SMEAR
often associated with endosalpingiosis (Müllerian inclu-
The presence of psammoma bodies in cervical/vaginal smears sions) of the peritoneum and occasionally find their way
is an indication of a possible malignant lesion in the female into the vagina via the fallopian tube and the uterine cav-
genital tract, since they may be associated with ovarian or ity. Figures 5.22 and 5.23 illustrate an example of psam-
endometrial malignancy (Figs. 5.18 and 5.19). However, moma bodies identified in the cervical-vaginal smear in a
psammoma bodies have also been described in association young woman. Their origin was traced to endosalpingio-
with benign processes (Table 5.1). Their occurrence is rare, sis with psammoma bodies on laparoscopy. Please refer to
with a reported incidence of 1 per 33,000 cases. Chapter 6 for more information on endosalpingiosis.
TABLE 5.1 PSAMMOMA BODIES IN CERVICAL/VAGINAL SMEARS
Psammoma Bodies Associated with Benign Diseases Psammoma Bodies Associated with Malignant Diseases
Conditions Associated with Conditions Associated with

Endosalpingiosis of peritoneum Ovarian serous borderline tumors
Intrauterine device (IUD) usage Ovarian serous adenocarcinoma
Ovarian inclusion cysts Endometrial adenocarcinoma
Ovarian cystadenoma Endocervical adenocarcinoma
Endometrial tuberculosis Tubal adenocarcinoma
Serous papillary carcinoma of peritoneum
Younger age group Older age group
Psammoma bodies fewer in number Psammoma bodies in greater numbers
Naked forms frequent; few incorporated in tissue fragments Naked forms variably present but mostly incorporated in
composed of benign glandular epithelium tissue fragments composed of malignant cells
No discrete or groups of malignant cells in the background Malignant cells present in the background
Background clean Clean to bloody; inflammation ⫹/⫺; diathesis ⫹/⫺
Differential Diagnoses of Psammoma Bodies in Cervical-Vaginal Smears (See Figs. 5.18 to 5.24)
Fig. 5.18. Serous papillary carcinoma of the endometrium. The tis- Fig. 5.19. Metastatic serous papillary adenocarcinoma of the ovary.
sue fragment incorporating the psammoma bodies is syncytial type The tissue fragment incorporating the psammoma bodies is syncy-
and composed of malignant cells. tial type and composed of malignant cells.
Fig. 5.20. Psammoma bodies incorporated in a tissue fragment Fig. 5.21. Naked psammoma body in a cervical/vaginal smear from
composed of smaller epithelial cells with uniform nuclei. The back- a younger woman.
ground is clean. The patient is younger in age.
Fig. 5.22. A conglomerate of multiple psammoma bodies incorporat-

ed in a tissue fragment of epithelial cells with indistinct morphologic
details. The woman was in her 30s. An ultrasound of the abdomen re-
vealed a cystic ovary. An abdominal laparoscopy was performed that
revealed a benign ovarian cyst and endosalpingiosis of the pelvic peri-
toneum. Pelvic washings were submitted for cytologic evaluation.
A B C D
Figs. 5.23A to D. A, B, C: The washings revealed few aggregates of small benign epithelial cells with poorly defined cell
borders, scant cytoplasm, high N/C ratios, and compact chromatin. D: Also present in the washings were tissue frag-
ment of benign epithelial cells, incorporating a psammoma body consistent with endosalpingiosis.
Fig. 5.24. Atrophic vaginal smear containing acellular globules re-

ferred to as blue blobs and may be misinterpreted as naked psam-
moma bodies.
TABLE 5.2 DIFFERENTIAL DIAGNOSES OF MULTINUCLEATED GIANT CELLS IN

CERVICAL/VAGINAL SMEARS
Type of Giant Cells Cytopathologic Features Diagnostic Clues See Fig(s).

Reactive multinucleated endocervical Eccentric nuclei closely packed, Endocervical glandular features e-5.7
cell generally few in numbers (5 to 10),
identical and normal size; finely
granular chromatin; prominent
micronucleoli; inflammation ⫹/⫺
Multinucleated foreign-body type Size variable; large to giant Often present in atrophic patients e-5.5
(histiocytic type) forms; nuclei range from few to with or without inflammation in the
large numbers; round to oval, background
finely granular chromatin with
micronucleoli
Granulomatous inflammation, Size variable, can be enormous; In intrauterine device users; See e-2.22
foreign-body type variable number of benign histiocytic postsurgical procedure (suture
nuclei; cytoplasm dense, may contain granuloma); reaction to keratin
foreign body; epithelioid cells and
fibroblasts present; inflammation in
the background
Granulomatous inflammation, Langerhans-type giant cells; Tuberculosis—rare

specific infection epithelioid cells and fibroblasts
Herpes simplex virus infection Squamous and/or glandular Structureless pale nuclei; e.5.6
cells; size variable, small with multinucleation
few nuclei to enormous size with
many nuclei, stacked up on each
other; homogenous ground glass
appearance; intranuclear eosinophilic
inclusions ⫹/⫺; intense inflammatory
reaction
Radiation reaction Seen in acute reaction to radiation; Pleomorphism; nuclear degeneration; e-5.10
marked cytomegaly with large history of radiation exposure see
pleomorphic nuclei with varying e-Fig.2.21
degrees of degeneration; cytoplasm
abundant with degenerating changes
including vacuolization
(continued)
Type of Giant Cells Cytopathologic Features Diagnostic Clues See Fig(s).

Syncytiotrophoblasts Large cells—size variable with a History of pregnancy, abortion or e-5.8
mean area of 500 ␮m²; abundant, postpartum state e.5.9
dense cytoplasm and contain up
to 400 uniform, overlapped, but
not molded nuclei; finely granular
chromatin; nucleoli not conspicuous
Malignant tumor giant cells Size variable; several pleomorphic, In poorly differentiated carcinomas; e-5.11
irregular nuclei with obvious malignant mixed mesodermal
malignant features tumors
Among the malignant lesions associated with psam- investigation to rule out malignancy in the female genital
moma bodies, serous papillary adenocarcinoma of the tract. A potential diagnostic pitfall regarding the psammo-
ovary tops the list, followed by serous papillary carcinoma bodies is the presence of “blue blobs” (Fig. 5.24) seen in
ma of the endometrium. atrophic smears that mimic the psammoma bodies.
The psammoma bodies originating from malignant
tumors are generally present in large numbers (Figs. 5.10
and 5.12). They may be naked or incorporated in a tissue MULTINUCLEATED GIANT CELLS IN
fragment composed of malignant cells, often with papillary CERVICAL/VAGINAL SMEARS
configurations. The malignant cells generally have large nu- Multinucleated giant cells may originate from various
clei, high nuclear/cytoplasmic (N/C) ratios, and prominent pathologic processes. Table 5.2 describes those encoun-
nucleoli. Cytoplasmic vacuoles are frequent. The back- tered in cervical/vaginal smears. Some are characteristic
ground is often bloody and necrotic. Identification of psam- of certain diseases, whereas others are nonspecific (e-Figs.
moma bodies in cervical/vaginal smears warrants complete 5.5 to 5.11).
SUGGESTED READINGS
Bibbo M, Wilber D, eds. Comprehensive Cytopathology. 3rd ed. Koss LG, Melamed MR, eds. Koss’ Diagnostic Cytology and Its
Philadelphia: Saunders, 2008. Histopathologic Bases. 5th ed. Philadelphia: Lippincott
Fadare O, Chacho MS, Praksh V. Psammoma bodies in cervicova- Williams & Wilkins, 2005.
ginal smears. Significance and practical implications for diag- Muntz HG, Goff BA, McGonigle K, et al. The significance of
nostic cytology. Adv Anat Pathol 2004;11:250–261. psammoma bodies in screening cervical cytologic smears. Am J
Goldblum JR, Series ed. Foundations in Diagnostic Pathology. Vol Obstet Gynecol 2003;188:1609–1614.
3. Philadelphia: Churchill Livingstone Elsevier, 2006:1–32. Nucci MR, Oliva E. Gynecologic Pathology. Philadelphia: Churchill
Hallman KB, Nahhas WA, Connelly PJ. Endosalpingiosis as a Livingstone, 2009.
source of psammoma bodies in a Papanicolaou smear. A case Soloman D, Nayar R. The Bethesda System for Reporting Cervical
report. J Reprod Med 1991;36:675–678. Cytology. Definitions, Criteria, and Explanatory Notes. 2nd ed.
Kern SB. Prevalence of psammoma bodies in Papanicolaou-stained New York: Springer, 2001.
cervical-vaginal smears. Acta Cytol 1991;35:81–88.
SECTION II: NONGYNECOLOGIC CYTOPATHOLOGY
6 SEROUS EFFUSIONS
OVERVIEW OF DIAGNOSTIC PROBLEMS NORMAL HISTOLOGY AND CYTOLOGY
The effusion or accumulation of fl uid in serous cavities The serous cavities derived from the embryonic celomic
(body cavities) is abnormal and results from a multitude cavity include pleural, pericardial, and peritoneal cavities,
of causes. Cytologic evaluation of serous effusions is per- as well as tunica vaginalis testis in males. Under normal
formed mainly to establish the presence or absence of conditions, these serous cavities represent only a potential
malignancy. A malignant diagnosis in the effusions, with space between two layers of serous membranes and con-
or without a known primary, usually signifies advanced tain a few milliliters of fluid. The layer directly in contact
disease. In addition to effusions, pelvic/peritoneal wash- with the viscera is the visceral layer and the outer layer of
ings and cul-de-sac fluids are also evaluated for the pres- the cavity is the parietal layer.
ence of malignancy. The serous membranes are lined by a single layer of
Diagnostic problems in effusion cytology include flattened mesothelium with submesothelial loose connec-
tive tissue containing a fine network of blood vessels and
● Differentiation of reactive/hyperplastic mesothelial
lymphatics (e-Fig. 6.1). Although the normally flattened
cells from malignant mesothelioma;
mesothelial cell is barely discernible in histologic sections,
● Differentiation of reactive/hyperplastic mesothelial
it becomes rounded upon exfoliation (e-Fig. 6.2). When
cells from metastatic adenocarcinoma;
forcibly removed, as in pelvic/peritoneal washings or as-
● Differentiation of malignant mesothelioma from meta-
piration biopsy, mesothelium presents itself in tissue frag-
static adenocarcinomas;
ments with a honeycomb arrangement (e-Fig. 6.3). The
● Differentiation of malignant mesothelioma from malig-
submesothelial collagenous tissue may be dislodged and
nancies other than adenocarcinoma;
seen as collagenous cores, surrounded by benign mesothe-
● Differential diagnosis of an effusion with a large popu-
lial cells (e-Fig. 6.4). The features of normal or quiescent
lation of lymphoid cells; and
mesothelial cells (Table 6.1, e-Fig. 6.5) are better appreci-
● Determination of a primary site in cases of malignant
ated in reactive states (Table 6.2).
effusion with an unknown primary.
A proper cytopreparatory technique for effusion flu-
ids is of paramount importance, more so than for any MECHANISM OF EFFUSION
other type of cytologic specimen. A poorly prepared
Under normal physiological conditions, equilibrium is
smear causes diagnostic uncertainty and may result in
maintained between the hydrostatic pressure in the capillar-
both false positive and false negative diagnoses. Liquid-
ies and the plasma colloid osmotic pressure facilitating the
based preparation has gained considerable popularity in
absorption of fluid by the visceral layer. An effusion devel-
recent years. Some laboratories use it as a complemen-
ops from an imbalance or disruption of the homeostatic
tary test in addition to conventional methods, while oth-
forces that control the movement of fluid across the serous
ers use it exclusively. Some laboratories prefer to use cy-
membrane. The various pathophysiologic factors include
tospin preparations universally for all specimens. Care
must be taken not to make thick and bloody cytospin A) Systemic causes that result in
preparations. Papanicolaou is the staining method of 1. Increased hydrostatic pressure—congestive heart
choice, although Romanowsky stains are used when he- failure
matologic malignancy or lymphoproliferative disorders 2. Decreased oncotic pressure—nephrotic syndrome
are suspected. B) Local causes
The handling of body cavity fl uids and the con- 1. Increased capillary permeability—infection, inflam-
ventional cytopreparatory techniques are described in mation
Appendix. 2. Decreased lymphatic drainage—neoplasia
149
TABLE 6.1 CYTOMORPHOLOGY OF BENIGN (QUIESCENT)
MESOTHELIAL CELLS
Cell
Size Variable, 12–20 ␮m in diameter
Shape Round when single and exfoliated; polygonal in tissue fragments
Borders Well-defined or fuzzy
Nucleus
Location Central or eccentric
Shape Round or reniform
Nuclear Membrane Crisp, well-defined, and smooth
Chromatin Finely granular, evenly distributed
Nucleolus Single/multiple micronucleoli
Cytoplasm
Amount Abundant
Staining Characteristics Pale to dense, fading away at the periphery
Immunoprofile Positive reactivity to cytokeratin 5/6, vimentin, calretinin, WT-1,

mesothelin; negative reactivity to CEA, EMB, Leu MI, BerEP 4;
B72.3
Ultrastructure Numerous; long, slender, exuberant, and wavy microvilli; occur

on any surface of the cells, often between the cells
TABLE 6.2 CYTOMORPHOLOGY OF REACTIVE/HYPERPLASTIC/HYPERTROPHIC MESOTHELIAL CELLS
Presentation Exfoliation of cells in large numbers; singly; in groups or in tissue fragments; one type of cell
Tissue Fragments Cells articulating along flattened surfaces; windows in between the cells; cytoplasmic embrace of
one cell about another (pincer arrangement); also arranged in doublets, triplets, and quadruplets;
small to large flat monolayered sheets with a mosaic pattern; irregular clusters or papillary tissue
fragments with knobby contours
Cells Variable in size; small to large with giant forms
Nucleus Round; central or eccentric; bi- and multinucleation frequent; variably enlarged; mitoses
(regular) ⫹/⫺
Chromatin Finely granular, evenly dispersed; nuclear membrane, sharp but delicate; large vacuoles in long-
standing effusions
Nucleoli Single/multiple, micro/macro
Cytoplasm Abundant, pale to dense; biphasic staining frequent (endo/ectoplasm): peripheral vacuolization and
fuzzy borders; occasionally cytoplasmic spouting; large vacuoles that do not indent the nucleus
Psammoma Bodies Very rare
150
Chapter 6: Serous Effusions 151
C) Increased negative pressure in the pleural cavity— Large hypertrophied mesothelial cells are often joined
bronchial obstruction, atelectasis together with smaller ones. One of the most characteris-
D) Trauma tic features of mesothelial cells is their articulation with
each other. The cells are joined by their apposing surfaces
Effusions that develop due to systemic causes re-
in groups (e-Fig. 6.8) of two (doublets), three (triplets),
semble plasma in all respects and are termed transudates.
and four (quadruplets); in mosaics (e-Fig. 6.9); or in
Transudates have a low cellularity, represented by a few
short chains (e-Figs. 6.11 and 6.12). Windows or clefts
mesothelial cells along with scattered lymphocytes and
are seen between the apposing surfaces. Another type of
macrophages. Fluids that accumulate due to local causes
articulation is one mesothelial cell clasping the other. The
that increase the permeability of capillaries are termed
above-described features are referred to as features of me-
exudates. Exudates have a higher protein content and in-
sothelial lineage. Occasionally, hyperplastic mesothelium
creased cellularity compared to transudates.
presents a papillary-like pattern (without central cores of
fi brovascular tissue). On rare occasions, they may con-
NON-NEOPLASTIC EFFUSIONS tain psammoma bodies. The cytologic features of reactive
hyperplastic/hypertrophic mesothelial cells (Table 6.2)
The majority of non-neoplastic effusions are caused by are illustrated in e-Figures 6.8 to 6.18 (see also Figures
congestive heart failure; a variety of underlying lung 6.13A to C, 6.14A, 6.15A, 6.16A, 6.17A, 6.18A, 6.19A,
diseases such as pleural/pulmonary infections, pulmo- and 6.19C).
nary embolism; acute pancreatitis; and cirrhosis of the Extreme variations in mesothelial cells in response
liver. Some less frequent causes include collagen (auto- to irritants or injuries frequently cause interpretive dif-
immune) disorders, uremia, and chronic infectious fi culties. These variations include overwhelmingly large
processes. numbers of mesothelial cells from bland-appearing to
bizarre forms, from individually dispersed cells to tis-
sue fragments with or without pseudoacinar or papillary
configuration, and from those containing scant cytoplasm
HISTOCYTOLOGIC FEATURE with high N/C ratios to the ones with abundant dense to
OF REACTIVE, HYPERPLASTIC/ vacuolated cytoplasm and signet-ring forms (e-Figs 6.13
HYPERTROPHIC MESOTHELIAL CELLS to 6.18). Differentiation of hyperplastic/hypertrophic
mesothelial cells from malignant mesothelioma (see Figs.
Mesothelium reacts readily to a wide variety of stimuli 6.13 to 6.17) or other malignancies, specifically adeno-
by hypertrophy and hyperplasia of the lining cells. Its carcinomas (see Figs. 6.18 to 6.22), is certainly a diag-
response to injury depends on the cause and intensity nostic challenge. Hyperplasia of mesothelium in chronic
as well as duration. In pleural biopsies as well as in cell renal failure with uremia or due to some viral infections
block preparations, the hyperplastic/hypertrophic meso- can be so florid that, without clinical data, a false positive
thelial lining may be seen as several layers thick with or diagnosis may be rendered.
without papillary-like excrescences (e-Figs. 6.6 and 6.7). The reactive features described above are nonspecific
At times nests of hypertrophic mesothelial cells become and do not determine the cause. However, some pathologic
diagnostic problems because of diffi culty in differenti- processes, such as rheumatoid pleuritis, exhibit character-
ating them from malignant mesothelioma or metastatic istic cytologic features and deserve attention.
adenocarcinomas.
Mesothelial cells exfoliate in variable numbers: few in
RHEUMATOID PLEURITIS
transudates to overwhelmingly large numbers in exudates
(e-Figs. 6.8 to 6.18). Their size varies from 12 ␮m to giant Rheumatoid pleuritis is a necrotizing granulomatous
forms of 60 ␮m. The mesothelial nuclei are round with inflammation involving the pleura and occasionally the
sharp, thin, and crisp nuclear membranes. Their chroma- pericardium. Parenchymal lung and pleural involve-
tin are finely granular and evenly dispersed. Micronu- ment in patients with rheumatoid disease is uncommon.
cleoli are evident in reactive states and nuclear grooves It can manifest as nodules within the lung parenchyma
may be present. Bi- to multinucleation (e-Figs. 6.10A to or in endobronchial location and as pleural nodules
C) is frequent with the formation of giant forms. Regular with pleural effusion. Pulmonary involvement occurs
mitoses are not infrequent in reactive effusions. The cy- predominantly in males with an advanced seropositive
toplasm of the mesothelial cells in reactive states varies rheumatoid arthritis and who have subcutaneous nod-
in amount and in their staining characteristics, ranging ules. However, in some cases, the pulmonary involve-
from pale to dense and biphasic. It is often vacuolated ment can precede the onset of rheumatoid arthritis. The
with single or multiple vacuoles. The cytoplasm at the pe- parenchymal lung nodules clinically and radiologically
rimeter stains pale and appears fuzzy due to microvilli. mimic neoplasia. The rheumatoid lesions may cavitate
Cytoplasmic snouting can also be noted. and be mistaken for tuberculosis or cavitary squamous
152 Section II: Nongynecologic Cytopathology
carcinoma. Endobronchial lesions may also mimic neo- presence of large foamy histiocytes and confirmed by spe-
plasia. The rheumatoid lesion (e-Figs. 6.19A and B) is cial stains (e-Figs. 6.22A to C).
characterized by central fibrinoid necrosis bordered by
elongated spindle-shaped macrophages, multinucleated VIRAL INFECTIONS
giant cells, and fibroblasts. These inflammatory cells may
exfoliate into the effusion fluid (e-Figs. 6.20A to E). Specific viral infections caused by the herpes simplex virus
or cytomegalovirus (e-Figs. 6.23A to C) are rarely seen in
effusion fluids and can be readily identified due to charac-
Cytopathologic Features teristic morphologic alterations.
Cytologic features of rheumatoid infl ammation can be
appreciated in effusion fl uid (e-Figs. 6.20A to E), bron- PARASITIC INFESTATION
chial brushings in cases of endobronchial lesions, and
in fi ne needle aspiration biopsy specimens of localized Special mention is made of a possible rupture of an echi-
parenchymal lesions. The smears of the effusion fluid con- nococcal cyst in the peritoneum, which may be encoun-
sist of a polymorphic cell population of spindle-shaped tered in developing countries where this infestation is still
histiocytes in variable numbers; round, multinucleated prevalent (e-Figs. 6.24A and B).
giant cells; and mixed infl ammatory cells consisting of Granulomas are very rarely encountered in serous ef-
neutrophils, lymphocytes, and small mononuclear mac- fusions; they are not documented in cytologic literature.
rophages. The most striking and characteristic feature of Granulomas (e-Fig. 6.25) may develop as a reaction to
rheumatoid granulomas is the presence of granular, acel- infections or a foreign body.
lular precipitate that can take different hues in Papani-
colaou-stained smears. The spindle-shaped cells measure
up to 160 ␮m long, are fairly uniform in width except PRIMARY NEOPLASMS OF THE SEROUS
at their pointed ends, and contain one or more round to MEMBRANES
elongated nuclei with bland chromatin (e-Fig. 6.20D).
Their cytoplasms are dense, and the cell borders are well-
defi ned. Multinucleation of the spindle cells is occasion- The benign neoplasms of the mesothelium—namely,
ally observed. The large round multinucleated cells are adenomatoid tumors, well-differentiated papillary meso-
distinct from the elongated cells and contain as much as thelioma, or multicystic peritoneal mesothelioma—and
20 or more uniform, round to oval nuclei (e-Fig. 6.20E) localized fi brous tumor of the pleura are infrequent and
and resemble megakaryocytes (e-Fig. 6.21). Cholesterol are generally not encountered or diagnosed from effusion
crystals are often seen (e-Fig. 6.20B). The cytologic fea- specimens.
tures described above are pathognomonic for rheuma-
toid granulomas. However, all these features may not MALIGNANT MESOTHELIOMA
be present in a specimen from every case of rheumatoid
nodule or pleural effusion. It is not uncommon to have Malignant mesothelioma is a primary neoplasm of the
only the granular precipitate or to lack spindle-shaped serous membranes, known for its strong association with
cells. Squamous metaplasia of the bronchi and bronchi- asbestos exposure. It is three times more frequent in men,
oles has been described in the vicinity of the granulomas. commonly occurring between 40 to 60 years of age. The
In fi ne needle aspirates, extensive necrosis and the elon- pleura is more commonly involved than the peritoneum,
gated cells have been reported as suspicious for squamous the pericardium, or the tunica vaginalis testis. More than
carcinoma. one serous membrane may be affected in some cases. A
sudden onset of chest pain, shortness of breath, weak-
ness, and weight loss are often the presenting symptoms
associated with pleural mesotheliomas. Mesotheliomas
INFECTIONS are almost always associated with hemorrhagic effu-
sion. Radiologically, plaque-like thickening of the serous
membrane with irregular nodularity is characteristic. The
TUBERCULOSIS prognosis is invariably poor with death occurring within
a few years. Malignant mesotheliomas may metastasize to
Mycobacterial infections by Mycobacterium tuberculosis
the mediastinal and cervical lymph nodes.
and atypical mycobacteria may result in pleural effusion.
The latter is particularly encountered in patients with
Gross and Microscopic Features
AIDS. Most often, the fl uid exhibits a large lymphocytic
population and occasionally a granulomatous response. Grossly, the serous membranes involved by malignant
Atypical mycobacterial infections can be suspected in the mesothelioma is studded with soft to fi rm white nodules
of varying sizes, or they form a fleshy hemorrhagic tumor types; needless to say, these are rarely identified from ef-
encasing organs such as the lungs. fusion fluids. Sarcomatoid mesotheliomas are less likely to
Histologically, three patterns are recognized: namely, exfoliate in effusions and, thus, are not diagnosed cytologi-
epithelial, sarcomatoid, and mixed epithelial and sarco- cally from the effusion fluid in contrast to epithelial types
matoid (e-Figs. 6.26A to E). Epithelial mesotheliomas are where the exfoliation of cells is remarkably high.
most commonly encountered, consisting of cuboidal to
polygonal cells with abundant eosinophilic cytoplasm and
Cytopathologic Features of Epithelial Type
centrally placed nuclei. Tubulopapillary patterns (e-Figs.
Malignant Mesothelioma
6.26A, 6.26B, and 6.26D) are frequent but may show a
predominantly solid pattern (e-Fig. 6.26C). Psammoma The cytomorphologic pattern of malignant mesothelioma
bodies may be present. Necrosis is not usual. The tumors varies widely (Table 6.3; Figs. 6.1 to 6.12) from cells with
may be extremely cellular with scant stroma or may contain a bland nuclear pattern resembling normal or reactive
markedly desmoplastic stroma. The sarcomatoid pattern is mesothelial cells (Fig. 6.4) to the cells that mimic various
characterized by spindle-shaped cells, resembling a soft tis- types of malignancies—the most common being adeno-
sue sarcoma (e-Fig. 6.26E). Mixed mesotheliomas present carcinomas. The usual presentation includes high cellu-
both epithelial and sarcomatoid patterns in varying propor- larity with neoplastic cells present as isolated, in groups
tions. The morphologic variants of sarcomatous variants or aggregates, and in tissue fragments. The latter pres-
include transitional, lymphohistiocytic, and desmoplastic ents many architectural patterns. Enormous branching
TABLE 6.3 CYTOPATHOLOGIC FEATURES OF MALIGNANT MESOTHELIOMA
Presentation Usually hemorrhagic, overwhelming cellularity, one cell type population; cells isolated, in groups, or
in tissue fragments
Tissue Fragments Small linear with cell to cell apposition and windows in between; cell in cell engulfment or
clasping; monolayered sheets with a mosaic pattern, well-defined borders with windows; syncytial
without any architectural pattern; knobby contours frequent; papillary configuration; large, three-
dimensional cell balls with ⬎50 cells; collagenous cores covered by neoplastic cells; true acinar
pattern absent; papillary architecture; features of mesothelial lineage present; demonstrate features
of mesothelial lineage
Cells Variable in size; medium-sized to large with frequent giant forms; round to polygonal; cell borders
well-defined; rigid or with a microvillus edge; peripheral cytoplasmic snouting; variable N/C ratios
Nucleus Mostly central, rarely eccentric; bi- and multinucleation; pleomorphic in size, round; nuclear
membrane delicate, sharp, and smooth; finely granular, evenly dispersed chromatin; nucleoli
conspicuous single/multiple micro/macro; mitoses ⫹/⫺
Cytoplasm Variable, generally abundant, dense biphasic staining, small peripheral vacuoles; true secretory
vacuoles indenting nuclei not present; endo/ectoplasmic demarcation ⫹/⫺
Background Psammoma bodies rare; inflammatory cells ⫹/⫺
Histochemical Stains PAS ⫹, digestible; Alcian blue—with hyaluronidase predigestion; oil red O for lipid ⫹
Immunoprofile Positive reactivity to Calretinin, both nuclear and cytoplasmic, WT-1 ⫹, cytokeratin 5/6, vimentin,
mesothelin; negative reactivity to CEA, LeuM1, and B72.3
Ultrastructure Numerous; long, slender, exuberant, and wavy microvilli; occur on any surface of the cells, often
between the cells
Differential Diagnoses Mesothelial hyperplasia/hypertrophy

Metastatic adenocarcinoma
Serous papillary tumor of the peritoneum
Squamous carcinoma
Malignant melanoma
A B
Figs. 6.1A and B. Diffuse epithelial malignant mesothelioma. A: Low-power view showing overwhelming cellularity
with varying-sized cell balls in the background of discrete and groups of cells. B: Higher magnification. The tissue
fragments forming three-dimensional clusters have smooth to knobby borders.
A B
Figs. 6.2A and B. Another example of diffuse epithelial malignant mesothelioma. A: Low-power showing marked
cellularity. Note the three-dimensional clusters and tissue fragments with a trabecular pattern. B: Higher magnifica-
tion of the trabeculae shows a knobby contour. The component cells have appreciable dense cytoplasm. The discrete
cells in the background are pleomorphic in size.
A B
Figs. 6.3A and B. A: This malignant mesothelioma consists of multiple giant-sized tissue fragments with complex
branching. B: Higher magnification of a syncytial tissue fragment shows round medium-sized cells with modest cyto-
plasm. The nuclei are round and uniform with granular chromatin. Note the peripheral cytoplasmic snouting (arrows).
Fig. 6.4. These malignant mesothelioma cells present the typical Fig. 6.5. The malignant mesothelioma cells are enormous in size,
features of mesothelial lineage. The neoplastic cells display marked containing dense, abundant cytoplasm with fuzzy borders (arrows).
pleomorphism in size. They are forming doublets (D), triplets (T), The nuclei, likewise, are markedly increased in size and contain ma-
and quadruplets (Q) with some showing windows (W) in between. cronucleoli. The tissue fragment formed by these cells demonstrates
The N/C ratios are low with abundant biphasic cytoplasm. The nu- windows in between the cells.
clei are round, containing granular chromatin and nucleoli.
Fig. 6.6. This case of surgically proven malignant mesothelioma Fig. 6.7. The malignant mesothelioma seen here presents tissue
shows the cells containing pale to foamy cytoplasm due to intracel- fragments forming a pseudoacinar pattern, lacking central lumen
lular fat—a feature often seen in mesotheliomas. (arrows) as noted by the mesothelioma cells surrounding the colla-
gen. The tissue fragments have knobby borders. The neoplastic cells
present typical mesothelial lineage.
Figs. 6.8A. A: The malignant mesothelioma cells demonstrate ex-

treme variation in size from normal to giant forms. Note the dense
biphasic cytoplasm, doublets, fuzzy border, and markedly enlarged
A nuclei with macronucleoli. (continued)
a b
c d
B
Figs. 6.8B. (continued) B: Composite images (a, b, c, d) depicting giant malignant mesothelioma cells.
such as monolayered, trabecular, three-dimensional balls

with scalloped borders, pseudoacinar, and papillary with
central fibrovascular cores. The features of mesothelial lin-
eage are maintained by the neoplastic cells (Figs. 6.4, 6.5,
6.7, and 6.8), supporting the mesothelial differentiation.
The malignant mesothelioma cells present a wide
range in size from small to gigantic forms. They are round
with well-defined cell borders, often displaying peripheral
fuzzy borders (Figs. 6.5, 6.8A and B), as well as cytoplas-
mic snouting. A feature frequently observed is cleared cyto-
plasm along the cells that are peripherally located in three-
dimensional cell balls (Fig. 6.1B, 6.14B). The cytoplasm is
variable, scant to abundant, pale, vacuolated to very dense,
and is often biphasic (Figs. 6.4 to 6.8). The nuclei of the
Fig. 6.9. These malignant mesothelioma cells demonstrate a marked malignant mesothelial cells vary in size from small to giant
variation in size but present the usual features of mesothelial cells. forms and are round with sharp nuclear membranes. The
chromatin is finely to coarsely granular with micro to gi-
ant macronucleoli. The nuclei are usually centrally located.
tissue fragments fi lling an entire low-power fi eld is very Bi- and multinucleation is frequent. Mitotic figures, both
characteristic (Figs. 6.1A, 6.2A, and 6.3A). A diagnosti- regular and atypical, may be seen. Psammoma bodies are
cally useful feature is that the entire cell population repre- rare findings in malignant mesotheliomas (see Chapter 7,
sents one cell type and that is mesothelial. The neoplastic Fig. 7.166A). The background is usually clean, devoid of
mesothelial cells form syncytial tissue fragments of vary- necrosis. Transition forms from benign-appearing meso-
ing sizes from small to large, presenting various patterns thelial cells to malignant ones are also seen.
A B
Figs. 6.10A and B. Malignant mesothelioma A: Low power. B: High power. Liquid-based preparation. The cells pres-
ent the typical morphology of malignant mesothelioma. (Courtesy of Dr. Prabodh Gupta, Director, Cytopathology,
University of Pennsylvania, Philadelphia, Pennsylvania.)
A B
Figs. 6.11A to C. A: Cell block preparation of malignant meso-

thelioma showing a pseudoacinar pattern, lacking central lumen.
Collagen is present in the center (H&E). B: Positive staining with
vimentin. C: Ultrastructural features demonstrating tall, slender,
C bushy villi.
Immunoprofile
The cells of sarcomatoid malignant mesotheliomas do
not exfoliate easily; hence, they usually yield nondiagnos- A broad panel of antibodies is available for the confirmation
tic effusion fluid. However, the cytologic diagnosis can be of the diagnosis of malignant mesothelioma and its differen-
provided on aspiration biopsy specimens of pleura-based tiation from other malignancies. Malignant mesothelioma
nodules. The cytologic features are described and illus- cells are reactive to calretinin, mesothelin, WT-1, and vimen-
trated in Chapter 7. tin. Table 6.4 offers a list of currently used antibodies.
A B
Figs. 6.12A and B. Malignant mesothelioma showing giant multinucleated neoplastic mesothelial cells—a pattern
that can be confused with adenocarcinoma. Note that the entire cell population is formed by mesothelial cells with
varying degrees of atypia.
TABLE 6.4 IMMUNOHISTOCHEMICAL STAINS ARE USEFUL FOR THE DIAGNOSIS OF MESOTHELIOMA
Stain Epithelioid Mesothelioma Expected Resulta Adenocarcinoma Sarcomatoid Mesothelioma

Pancytokeratin Positive Positive Positive
Cytokeratin 5/6 Positive Negative Negative
Calretinin Positiveb Negative Negative
Thrombomodulin Positiveb Negative Negative
WT1 Positiveb Negative Negative
Mesothelin Positive Negative Negative
HBME-1 Positivec Negative Negative
CEA Negative Positive Negative
BerEP4 Negative Positive Negative
CD15 (LeuM1) Negative Positive Negative
B72.3 Negative Positive Negative
Bg8 Negative Positive Negative
MOC31 Negative Positive Negative
TTF-1 Negative Positiveb,d Negative
b
WT1 ⫽ Wilms’ tumor antigen 1; CEA ⫽ carcinoembryonic antigen; TTF-1 ⫽ thyroid transcription factor 1.
a
Result observed in most but not necessarily all cases. See text for details.
b
Nuclear staining.
c
Surface membrane staining.
d
Lung and thyroid only.
Modified from: Churg A, Cagle PT, Roggli VL. Tumors of the Serosal Membranes. AFIP Atlas of Tumor Pathology, series 4. Washington DC: American
Registry of Pathology, 2006;62.
Ultrastructure 3. Differentiation of malignant mesothelioma from met-

astatic malignancies, mainly adenocarcinomas, from
The ultrastructural fi ndings of long bushy microvilli are
various different sources as well as other malignancies
characteristic and diagnostic of malignant mesothelioma
such as metastatic squamous carcinomas or malignant
(Fig. 6.11C).
melanomas.
Diagnostic Difficulties and Differential Diagnoses Reactive/Hyperplastic/Hypertrophic Mesothelial Cells
of Malignant Mesothelioma versus Malignant Mesothelioma. Some benign effusions
Malignant mesotheliomas are uncommon neoplasms. can present highly atypical, reactive, hyperplastic/hyper-
Their cytologic recognition is poor. The cytologic inter- trophic mesothelial cells that mimic malignancies, both
pretation greatly depends on a properly processed fluid primary and metastatic. Cirrhosis, autoimmune diseases,
sample with a good staining technique. Adequate clini- uremia with serous effusions, certain viral infections, and
cal and radiologic data is absolutely essential. The cyto- peritoneal dialysis can all induce marked hypertrophy
logic diagnosis of malignant mesothelioma is usually and hyperplasia (Table 6.6, Figs. 4.13 to 4.17). Nuclear
not a straightforward one. The mesothelioma cells can atypia (e-Fig. 6.17) may even enhance diagnostic difficul-
appear very bland, and the diagnosis can be overlooked, ties. Immunostains are not useful in differentiating benign
resulting in a false negative diagnosis. On the other hand, hypertrophic or hyperplastic mesothelial cells from those
malignant mesothelioma cells may look clearly malignant of malignant mesothelioma. The reason is simple: Both
favoring the diagnosis of other malignancies, specifically benign and malignant mesothelial cells react positively to
adenocarcinomas (Tables 6.5 and 6.6). the same markers. A diagnosis of malignant mesothelioma
The diagnostic diffi culties can be grouped into three must be supported by clinical and radiologic findings.
main categories: Reactive/Hyperplastic/Hypertrophic Mesothelial Cells
1. Differentiation of reactive/hyperplastic/hypertrophic versus Metastatic Adenocarcinomas. The second prob-
mesothelial cells from malignant mesothelioma; lem entails the differentiation of reactive/hyperplastic/
2. Differentiation of reactive/hyperplastic/hypertrophic hypertrophic mesothelial cells from metastatic adeno-
mesothelial cells from metastatic adenocarcinomas; carcinomas (Table 6.6; Figs. 6.18 and 6.19). The marked
TABLE 6.5 DIFFERENTIAL DIAGNOSES OF MALIGNANT MESOTHELIOMA
Cytopathologic Features of Malignant Mesothelioma Diagnostic Entity(ies) Mistaken for See Fig(s).
Hypercellularity, round to polygonal cells presenting mesothelial Reactive hyperplasia/hypertrophy 6.4, 6.13, 6.19;
characteristics (e.g., apposing cell borders, clasping, knobby e-Fig. 6.18
contour, arranged in doublets, triplets, quadruplets, in mosaic)
Hypercellularity, small round to cuboidal cells, pseudoacinar Adenocarcinoma 6.1, 6.7, 6.23A
pattern and B
Three-dimensional cell balls or morulae Adenocarcinoma 6.1, 6.7, 6.23A

and B
Hypercellularity, papillary tissue fragments branching pattern; Reactive hyperplasia e-Fig. 6.14 to
with or without psammoma bodies Papillary adenocarcinoma 6.16
Lung 6.3, 6.22A and B,
Ovary 6.20, 6.21,
Thyroid 6.24, 6.62
Kidney to 6.66
Serous papillary tumor of the
peritoneum
Pleomorphic small to large cells with frequent multinucleation; Reactive hyperplasia 6.12, 6.13 to
dense cytoplasm; background of inflammatory cells or reactive Adenocarcinoma 6.18, 6.57,
mesothelial cells Squamous carcinoma 6.61, 6.71, 6.81
Malignant melanoma
Sarcomas
Extramedullary hematopoiesis
TABLE 6.6 CYTOPATHOLOGIC FEATURES DIFFERENTIATING HYPERPLASTIC/HYPERTROPHIC

MESOTHELIAL CELLS, MALIGNANT MESOTHELIOMA, AND METASTATIC ADENOCARCINOMAS
Reactive/Hyperplastic Malignant Mesothelioma

Mesothelial Cells Epithelial Type Adenocarcinoma
Presentation Fluid—clear, turbid or Always hemorrhagic; exfoliation Hemorrhagic ⫹/⫺; exfoliation
hemorrhagic; exfoliation of cells variable, generally of cells variable, scant mixed
of cells variable, may be overwhelming; cells isolated, with benign mesothelial cells
exuberant; cells isolated, in in groups, or in syncytial tissue to overwhelming population of
groups, or in tissue fragments fragments malignant cells; cells isolated,
in groups, or in syncytial tissue
fragments
Tissue Fragments Small to large in doublets, Small to large with complex Small to large acinar pattern
triplets; in Indian file; flat branching; syncytial architecture ⫹/⫺; papillary configuration
sheets with windows in with architectural pattern or with complex branching ⫹/⫺;
between opposing cell monolayered; three-dimensional three-dimensional spheres ⫹/⫺;
borders; cell clasping another morulae, knotty borders, papillary cell borders poorly defined with
cell; papillary configuration architecture ⫹/⫺; pseudoacinar smooth contour; rarely knobby;
with knobby contour pattern in doublets or triplets doublets and triplets ⫹/⫺;
or in Indian file; opposing cell windows in between ⫹/⫺; Indian
borders with windows in between, file
cell clasping another cell; (Pincer
arrangement)
Cells Monomorphic to Monomorphic to pleomorphic; Cells monomorphic to

pleomorphic; small to large, small uniform to large with pleomorphic; small, uniform to
occasionally giant forms; frequent giant forms; round large with or without giant forms;
round to polygonal with to polygonal; well-defined cell round, oval, well to poorly defined
well-defined cell borders; N/C borders; N/C ratios generally cell borders; N/C ratios have a
ratios normal or slight to moderate to markedly increased; moderate to marked increase
moderately increased occasionally low with marked
cellular enlargement
Nuclei Single, bi- to multinucleation, Single bi- to multinucleation, Single, rarely bi- to
central to eccentric; central to eccentric; round with multinucleation, generally
round with smooth, crisp smooth, crisp nuclear borders; eccentric; round to oval, smooth to
nuclear border; chromatin chromatin finely to coarsely irregular nuclear border; chromatin
finely granular, evenly granular but evenly distributed; fine to coarsely granular, even
dispersed; nucleoli multiple, multiple micronucleoli to single distribution to irregular clumping
micronucleoli; mitoses ⫹/⫺; large macronucleolus; mitoses with parachromatin clearing;
intranuclear inclusion rare ⫹/⫺; intranuclear inclusion ⫹/⫺ multiple micronucleoli to single
large macronucleolus; mitoses
⫹/⫺; intranuclear inclusion ⫹/⫺
Cytoplasm Variable, moderate to Variable, scant to abundant; pale Variable, scant to abundant; clear,
abundant; pale to dense with to dense with peripheral fading; pale to dense; peripheral fading
peripheral fading; biphasic biphasic staining ⫹/⫺; cytoplasmic not present; biphasic staining
staining ⫹/⫺; cytoplasmic snouts present; endo/ectoplasmic infrequent; cytoplasmic snouting
snouting ⫹/⫺; endo/ demarcation ⫹/⫺; cytoplasmic not present; endo/ectoplasmic
ectoplasmic demarcation vacuoles; signet-ring pattern rare demarcation absent; cytoplasmic
⫹/⫺; cytoplasmic vacuoles – vacuoles indenting the nucleus;
multiple to large coalesced; small to large distending the
signet-ring pattern ⫹/⫺ cell with nucleus flush with the
cytoplasm
Psammoma Bodies Rarely present Rarely present Frequent in papillary carcinomas
(continued)
Reactive/Hyperplastic Malignant Mesothelioma

Mesothelial Cells Epithelial Type Adenocarcinoma
Collagenous cores May be present Present Not present
(tissue fragments
with pseudoacinar
pattern with central
collagen core and not
a true lumen)
Background Inflammatory cells ⫹/⫺; Inflammatory cells ⫹/⫺; Inflammatory cells ⫹/⫺;
macrophages ⫹/⫺ macrophages ⫹/⫺ macrophages ⫹/⫺; mesothelial
cells ⫹
Ancillary Tests:
Histochemistry:
PAS PAS ⫹ digestible PAS ⫹ digestible PAS ⫹ nondigestible
Alcian Blue Hyaluronidase digestible ⫹ Hyaluronidase digestible ⫹ Hyaluronidase nondigestible ⫹
Immunoprofile:
CEA Negative Negative Positive
Cytokeratin Positive Positive Positive
Vimentin Positive Positive Negative
Calretinin ⫹ ⫹ ⫺
WT-1 Protein ⫹ ⫹ ⫺
Ultrastructure Slender, bushy microvilli; Slender, bushy microvilli; no Short, stubby microvilli; secretory
no secretory granules; secretory granules; tonofilaments granules; irregularly distributed
tonofilaments surround the surround the nucleus intermediate filaments
nucleus
exfoliation of atypical mesothelial cells often causes a lary tissue fragments with smooth external contours un-
diagnostic dilemma. The interpretative difficulties are like the usual knobby borders, smaller cell size, high N/C
compounded by fl orid papillary change and occasional ratios, and absence of identifiable mesothelial cells in the
psammoma bodies. Clinical history and radiologic find- background. This pattern is cytologically indistinguishable
ings are helpful. However, immunostains will differentiate from metastatic papillary adenocarcinomas (Table 6.7; see
mesothelial cells from epithelial malignancies. Figs. 6.62 to 6.66) and primary peritoneal serous papillary
tumors (Fig. 6.24). The presence of psammoma bodies and
Malignant Mesothelioma versus Metastatic Malignan- intranuclear pseudoinclusions in mesothelioma cells and
cies. The third and most important group of diagnostic in metastatic malignancies compound the diagnostic dif-
diffi culties revolve around separating metastatic malig- ficulties. On rare occasions, papillary mesothelial hyper-
nancy, particularly adenocarcinomas (Table 6.6), from plasia may pose similar diagnostic difficulties.
malignant mesotheliomas. There could be several reasons Metastatic adenocarcinoma from several sources
for this difficulty. present morphologic features that overlap with malignant
Malignant mesothelioma cells may not show the fea- mesothelioma. Metastatic poorly differentiated squamous
tures of their lineage. Instead, the smears may show marked carcinoma and malignant melanomas can cause similar
cellularity with myriads of branching trabeculae or papil- diagnostic difficulties.
Mesothelial Hyperplasia versus Malignant Mesothelioma (See Figs. 6.13 to 6.17)
A B
Figs. 6.13A to C. Pericardial effusion in a patient with uremia. A: Low

power showing overwhelming cellularity with numerous tissue frag-
ments. B: Higher magnification. The tissue fragments are composed of
very pleomorphic mesothelial cells and have knobby contours (higher
magnification). Note the multinucleation. C: These tissue fragments
of large mesothelial cells have two-tone, abundant cytoplasm. One of
the cells contains a large cytoplasmic vacuole, probably the result of
long-standing effusion. These hypertrophic/hyperplastic mesothelial
cells cannot be differentiated from malignant mesothelioma from a
C cytologic specimen (compare with Fig. 6.4).
A B
Figs. 6.14A and B. Comparison of mesothelial hyperplasia A: and malignant mesothelioma. B: Mesothelial hyperpla-
sia can be florid with the exfoliation of syncytial, three-dimensional tissue fragments with marked crowding and over-
lapping. The nuclei are small, and the nuclear details are not clearly visualized. Knobby contours are present in both.
The differentiation between hyperplasia and malignancy must be attempted with clinical and radiologic data.
A B
Figs. 6.15A and B. Comparison of mesothelial hyperplasia and malignant mesothelioma. A: Pericardial effusion in
a woman in her 50s with a history of systemic lupus erythematosus. The fluid was very cellular, consisting of several
varying-sized tissue fragments of cells with similar cells diffusely present in the background. This slender tissue frag-
ment with papillary-like architecture is composed of small uniform cells and has a knobby contour. A clinical history
was not provided and malignancy was suspected but later ruled out. B: Diffuse malignant mesothelioma in the pleural
fluid showing morphologic overlap.
A B
Figs. 6.16A and B. Comparison of mesothelial hyperplasia (A) and malignant mesothelioma (B). Mesothelial hy-
perplasia can exfoliate a large number of cells forming tissue fragments that can be in sheets or in three-dimensional
balls with knobby contours. Both will have a single cell population in the background that presents features of meso-
thelial lineage. Nuclei in both present similar morphology.
A B
Figs. 6.17A and B. Comparison of mesothelial hyperplasia (A) and malignant mesothelioma (B). The cytomorphol-
ogy of cells in hyperplasia and malignant mesothelioma is similar .
Mesothelial Hyperplasia versus Adenocarcinoma (See Figs. 6.18 and 6.19)
A B
Figs. 6.18A and B. Comparison of mesothelial hyperplasia (A) and adenocarcinoma (B). Note the morphologic similarities.
A B
C D
Figs. 6.19A to D. Comparison of mesothelial hyperplasia (A, C) and adenocarcinoma (B, D). A: Three-dimensional
syncytial tissue fragment of tightly packed hyperplastic mesothelial cells from pericardial effusion. B: Malignant me-
sothelioma presenting a large three-dimensional tissue fragment. C: The pleural effusion from a patient with uremia
showing marked cellularity caused by mesothelial hyperplasia. The mesothelial cells are hypertrophic with enlarged
and pleomorphic nuclei that can be easily mistaken for malignancy. D: Malignant effusion caused by lung adenocarci-
noma with exfoliation of large single cells.
Malignant Mesothelioma, Diffuse Epithelial Type versus Metastatic Adenocarcinoma (See Figs. 6.20 to 6.25)
A B
Figs. 6.20A and B. Pleural effusion from a patient with a history of papillary renal cell carcinoma. A: Low power
depicting marked cellularity formed by an enormous number of tissue fragments with tissue fragments forming a tra-
becular pattern. B: Higher magnification showing syncytial arrangement and smooth borders. The component nuclei
have a bland chromatin pattern.
A B
Figs. 6.21A and B. Pleural effusion from an epithelial type diffuse malignant mesothelioma demonstrating morphol-
ogy very similar to that seen in Figure 6.20. Without ancillary testing, the cytologic differentiation between a meso-
thelioma and an adenocarcinoma is not possible in many instances.
A B
Figs. 6.22A and B. Comparison of adenocarcinoma (A) and malignant mesothelioma (B). Note the architectural simi-
larities between the tissue fragments from adenocarcinoma (A) and mesothelioma (B). Mesothelial cells often show
the peripheral rim of cytoplasm with snouting and single cells in the background with the same cytomorphology.
A B
Figs. 6.23A and B. Comparison of adenocarcinoma (A) and malignant mesothelioma (B). Both cases show syncytial
tissue fragments with an acinar pattern. Although knobby contours are typical for mesothelial cells, they can be
seen in adenocarcinomas as well (A). Note that a true lumen is seen in adenocarcinoma (A) (arrow) but not in ma-
lignant mesothelioma (B).
Fig. 6.24. Primary papillary serous carcinoma of the peritoneum.

Peritoneal fluid from a female with the cytologic diagnosis of malig-
nant mesothelioma but proven histologically as primary serous car-
cinoma of the peritoneum. This tissue fragment of malignant cells
exhibits morphology very similar to malignant mesothelioma.
A cellular sample with three-dimensional malignant Serous papillary tumors of the peritoneum are par-
cell clusters (Figs. 6.26 and 6.27) or one with an acinar ticularly diagnostic problems since clinically, grossly, and
pattern (Fig. 6.23A) favors the diagnosis of adenocarci- cytohistologically they resemble malignant mesothelioma
noma. However, similar patterns with three-dimensional and are also CEA negative. The diagnosis can be confirmed
clusters (Figs. 6.1, 6.25A, and 6.27) or acinar structures by immunochemistry and ultrastructural examination.
(Figs. 6.23B) may be seen in malignant mesotheliomas. In the absence of known primary malignancy and rel-
Although dense cytoplasm and biphasic staining are evant clinical/radiologic findings, diagnostic possibilities
typical of mesothelial cells (Figs. 6.8A and B), these features other than malignant mesothelioma must first be ruled out
are also noted in adenocarcinoma cells (see Fig. 6.35) and because of the morphologic overlap between reactive hy-
cells of squamous carcinoma (Fig. 6.71B). Endoplasmic/ perplasia/hypertrophy, malignant mesothelioma, and other
ectoplasmic demarcation is a characteristic feature seen malignancies, particularly adenocarcinomas. It is prudent
in squamous cell cancer but is also exhibited by mesothe- not to render an unequivocal diagnosis of malignant me-
lioma cells. sothelioma unless supported by clinical data, radiologic
Malignant mesothelioma also presents as individu- findings, immunohistochemical stains, and sometimes, ul-
ally scattered pleomorphic cells with multinucleation in trastructural studies.
the background of infl ammatory and benign mesothe- The differentiating features between benign mesothe-
lial cells (Figs. 6.12A and B)—a pattern more in keeping lial cells, malignant mesothelioma, and adenocarcinomas
with metastatic malignancy. Appropriate immunochemi- in general are listed in Table 6.6. Table 6.4 lists the panel
cal stains and, sometimes, ultrastructural studies are nec- of common antibodies utilized in differentiating mesothe-
essary to establish the diagnosis. liomas and adenocarcinomas.
TABLE 6.7 CYTOPATHOLOGIC FEATURES DIFFERENTIATING PAPILLARY LESIONS IN SEROUS FLUIDS
Diagnostic Entity Clinico-Cytologic Features Ancillary Tests

Malignant mesothelioma One cell population; background cells may retain features of Calretinin ⫹
mesothelial lineage WT-1 ⫹
CK5/6 ⫹
Thrombomodulin ⫹
Papillary adenocarcinoma No specific cytopathologic features other than papillary architecture BerEP 4 ⫹
of the lung with or without psammoma bodies; may contain intranuclear TTF-1 ⫹
inclusions Calretinin ⫺
Papillary thyroid carcinoma Papillary architecture, cells with minimal cytologic criteria for TTF-1 ⫹
papillary thyroid carcinoma; frequent psammoma bodies; tissue Thyroglobulin ⫹
fragments of malignant cells in the sample may shoe a follicular
pattern and colloid in lumens
Papillary serous carcinoma No specific features other than papillary architecture; frequent WT-1 ⫹
of the ovary psammoma bodies CA125 ⫹
BerEP 4 ⫹
AE1/AE3 ⫹
Primary serous papillary No specific features other than papillary architecture; frequent MOC-31⫹
carcinoma of the psammoma bodies B72.3 ⫹
peritoneum BerEP⫹4
CA19–9 ⫹
WT-1 ⫹
Serous papillary carcinoma No specific features other than papillary architecture; frequent CK7 ⫹
of the endometrium psammoma bodies WT-1 ⫹
Papillary renal cell Papillary pattern; neoplastic cells may contain hemosiderin; CK ⫹
carcinoma psammoma bodies AE1/AE3 ⫹
Vimentin ⫹
AMACRa ⫹
a
AMACR: Alpha-methylacyl-CoA racemase.
METASTATIC ADENOCARCINOMAS
METASTATIC MALIGNANCY TO
SEROUS MEMBRANES Well-differentiated adenocarcinomas from several differ-
ent primary sites present cytologic features sufficiently
distinctive for accurate identifi cation. The diagnosis is
Metastatic involvement of the serous membranes by
usually easy, particularly when the primary source is
cancers is a common cause of effusion. The incidence
known. Malignant effusion with an unknown primary
of metastatic malignancy is reported to be roughly 45%
is a diagnostic challenge. Ancillary tests such as immuno-
in pleural fluids, 27% in pericardial fluids, and up to
histochemical stains may be required in poorly differen-
35% in ascitic fluids. Epithelial malignancies affect the
tiated adenocarcinomas. The following section describes
serous membranes more frequently. The majority repre-
the characteristics of specific tumor types.
sents adenocarcinomas, while squamous and neuroendo-
crine carcinomas account for less than 5% of malignant Breast
effusions. Among the nonepithelial malignancies, lym-
phomas/leukemias are the most frequent, followed by Breast adenocarcinoma is the most common malignant
malignant melanomas and germ cell tumors. Soft tissue neoplasm to involve the pleura in women. Metastatic breast
and bone tumors rarely involve the serous membranes adenocarcinoma is almost never seen as the initial presenta-
and, when they do, they rarely exfoliate. The cell block tion. Breast carcinomas frequently affect the pericardium
preparations may contain cells or tissue fragments of and peritoneum. The spectrum of cytologic features of
sarcomas. metastatic breast adenocarcinoma is wide. Some features
are very characteristic (Table 6.8; Figs. 6.26 to 6.32) but
A B
Figs. 6.25A to C. Diffuse epithelial type malignant mesothelioma

of the peritoneum for comparison. The ascetic fluid from a female
patient revealed a large number of syncytial tissue fragments of ma-
lignant cells (A) with a trabecular and papillary-like architecture (B,
C). The initial diagnostic consideration was metastatic adenocar-
cinoma, probably of ovarian origin. The immunostains supported
C mesothelial origin, confirmed by ultrastructural examination.
TABLE 6.8 CYTOPATHOLOGIC FEATURES OF BREAST ADENOCARCINOMA IN EFFUSIONS

& THEIR DIFFERENTIAL DIAGNOSES
Cytopathologic Features of Metastatic

Breast Carcinoma Differential Diagnoses See Fig(s).
Small malignant cells, individually Reactive mesothelial cells 6.30–6.32, 6.48, 6.49, 6.60, 6.72A,
dispersed; rare syncytial tissue fragments; Malignant lymphoma 6.72C, 6.75, 6.76 to 6.79
cell borders well to poorly defined; Multiple myeloma
cytoplasmic vacuoles with or without Malignant melanoma
eosinophilic inclusions Germ cell tumor
Adenocarcinoma from other sources
Small malignant cells with scant cytoplasm; Reactive mesothelial cells 6.30, 6.72, 6.75
high N/C ratios; Indian file arrangement Small cell undifferentiated carcinoma e-Fig. 6.11
Small to medium-sized malignant cells Mesothelial hyperplasia 6.26, 6.27 to 6.29, 6.19A
in syncytial tissue fragments, with or adenocarcinoma from any site
without branching; acinar pattern or three- Malignant mesothelioma
dimensional arrangement with closely
packed nuclei, smooth external contour
Pleomorphic malignant cells with giant Adenocarcinoma from any site 6.28, 6.42, 6.53, 6.57, 6.68, 6.71B
forms Malignant mesothelioma
Metastatic Adenocarcinomas of the Breast in Effusion Fluids. Spectrum of Cytopathologic Features (See Figs. 6.26 to 6.32)
A B
Figs. 6.26A and B. A: A very common presentation of metastatic breast adenocarcinoma in serous effusions. The malignant cells are
forming three-dimensional balls or morulae, referred to by some as cannon balls, which may attain a huge size. B: Higher magnification
showing smooth contours in contrast to the knobby contours seen with malignant mesotheliomas. Also note the different cell population
in the background representing mesothelial cells.
Fig. 6.27. Adenocarcinoma cells in the pleural fluid from a patient Fig. 6.28. The malignant cells in this effusion caused by a meta-
with a history of breast duct carcinoma. The cytomorphology rep- static breast adenocarcinoma contain very pleomorphic, clearly ma-
resents a conventional adenocarcinoma. lignant cells in the background of benign mesothelial cells.
Fig. 6.29. The malignant cells in this effusion caused by a metastatic Fig. 6.30. Lobular type breast adenocarcinomas frequently exfoliate
breast adenocarcinoma shows vacuolated abundant cytoplasm. small round cells, dispersed singly in small tissue fragments and ar-
ranged in tandem, referred to as Indian file—a pattern also produced
by metastatic small cell carcinomas and reactive mesothelial cells. The
Indian files can be small and single or can show branching at an angle.
are not specific and may also be seen with other malignan- Lungs
cies. Varying-sized three-dimensional cell balls with smooth
Primary lung cancers account for 40% or more of malig-
external contours, referred to as cannon balls, are one of
nant pleural effusions. Most are due to adenocarcinomas,
the frequently seen features in malignant breast adenocar-
the cytologic patterns of which show a spectrum from well-
cinoma with effusion. Lobular type carcinoma exfoliates
differentiated to poorly differentiated carcinomas (Figs.
as small cells (Figs. 6.30 to 6.32), discrete or in small tissue
6.33 to 6.37). Very often patients with lung adenocarcinoma
fragments with an Indian file pattern (Fig. 6.30) branching
present initially with malignant effusion. In such instances,
at right angles. These cells often present a singly cytoplasmic
determining a primary site becomes a challenge, particularly
vacuole and occasionally contain an eosinophilic hyaline
when the differential diagnoses of the lung include malig-
globule (Fig. 6.31). The antibodies to support the diagnosis
nant mesothelioma (Table 6.9), and papillary or giant cell
of mammary adenocarcinoma are listed in Table 6.4.
carcinomas, or carcinomas from other sources. Morphologic
Fig. 6.31. A single cell exfoliation of small malignant cells is charac- Fig. 6.32. Another example of metastatic lobular carcinoma in a
teristic of lobular breast carcinoma. The helpful diagnostic features patient with a remote history of lobular breast cancer. The fluid
include cytoplasmic vacuoles and hyaline globules (arrows). consisted of predominantly single small cells, with poorly defined
cell borders and scant cytoplasm. The presence of a macronucleolus
is another characteristic feature of lobular carcinoma. Single cell
exfoliation of small malignant cells must be differentiated from ma-
lignant lymphoma. This pattern is also encountered in metastatic
lung and gastric adenocarcinomas.
Metastatic Adenocarcinomas of the Lungs Spectrum of Cytopathologic Features (See Figs. 6.33 to 6.37)
Fig. 6.33. This pleural effusion from a case of lung adenocarcinoma Fig. 6.34. This pleural effusion from a case of lung adenocarcinoma
shows a malignant cell population with features of a conventional shows a malignant cell population with features very similar to that
adenocarcinoma. seen in a mammary duct carcinoma with the formation of three-
dimensional morulae.
Fig. 6.35. A single cell exfoliation is frequently seen with metastatic Fig. 6.36. Metastatic pulmonary adenocarcinoma with a psam-
pulmonary adenocarcinoma. These malignant cells are pleomorphic in moma body—a pattern also exhibited by papillary carcinomas of
size with giant forms. Their cell borders are well-defined. The nuclei are the ovary, the thyroid, the kidney, and occasionally, by malignant
central to eccentric with bi- and multinucleation. They contain abun- mesothelioma.
dant two-tone cytoplasm. Without a history of pulmonary neoplasm,
this pattern must be differentiated from malignant mesothelioma.
Fig. 6.37. Large cell undifferentiated carcinoma of the lung meta-

static to pleura. These are clearly malignant-appearing cells with
eccentric nuclei and suggestion of cytoplasmic secretions as noted
by nuclear flattening or notches (arrows).
TABLE 6.9 CYTOPATHOLOGIC FEATURES OF LUNG ADENOCARCINOMA IN EFFUSIONS

& THEIR DIFFERENTIAL DIAGNOSES
Cytopathologic Features of Lung

Adenocarcinoma in Effusion Differential Diagnoses See Fig(s).
Medium to large, round, malignant cells isolated, Adenocarcinoma from any site 6.19D,
in groups, or in syncytial tissue fragments with or Malignant mesothelioma 6.22A, 6.33
without acinar pattern; cytoplasmic vacuoles ⫹/⫺ to 6.37
Medium to large, round to oval cells with well- Reactive mesothelial cells 6.33, 6.35,
defined cell borders; dense cytoplasm; biphasic Malignant mesothelioma 6.55, 6.56
staining characteristics ⫹/⫺; large nuclei with Squamous carcinoma
high N/C ratios; predominantly single cell pattern Breast and ovary in females
Small to medium-sized cells in syncytial tissue Reactive mesothelial hyperplasia 6.36, 6.65,
fragments with papillary configurations; Malignant mesothelioma 6.55 to 6.57
intranuclear cytoplasmic inclusions; psammoma Papillary thyroid carcinoma
bodies ⫹/⫺ Papillary serous adenocarcinoma of ovary or
endometrium peritoneum
Papillary carcinoma of the kidney
Pleomorphic malignant cells with giant forms; Poorly differentiated adenocarcinoma from any site 6.33, 6.87
bizarre nuclei with multinucleation Anaplastic thyroid carcinoma, carcinosarcoma
171
overlap may preclude accurate identification. Ancillary tests Rupture of the mucinous cystadenoma or cystadeno-
are often required to confirm the diagnosis (Table 6.4). carcinoma may cause pseudomyxoma peritonei—a con-
dition that is characterized by excessive mucin production
Female Genital Tract as a result of the implantation of the peritoneum with
neoplastic cells (Fig. 6.44). Another common source of
The ovary is the most common source of malignant peri-
pseudomyxoma peritonei is mucocele or adenocarcinoma
toneal effusion (Figs. 6.38 to 6.44). Patients frequently
of the appendix.
present with ascites. The pleura and pericardium may also
be involved. In addition to the usual pattern of adenocar-
Gastrointestinal Tract
cinoma, the malignant cells derived from ovarian cancer
often show papillary configuration with psammoma bod- The stomach is a fairly common source of malignant effu-
ies. Mucin production is characterized by large distended sion, both peritoneal and pleural, and rarely pericardial
cytoplasmic vacuoles. The malignant cells may range (Figs. 6.48 and 6.49). The malignant cells range from single
from small to large, occurring as individually dispersed signet-ring type cells to small cells with high N/C ratios or
cells, exhibiting a markedly pleomorphic pattern. Papil- medium to large malignant cells isolated and in syncytial
lary serous adenocarcinomas that present with ascites are tissue fragments with or without acinar pattern. The latter
usually identified with ease but, on occasion, may be dif- is seen with intestinal type gastric cancer. Colon carcino-
ficult to differentiate from papillary serous tumors of the mas are uncommon malignant neoplasms to involve the
peritoneum and malignant mesothelioma (Fig. 6.24). peritoneum or pleura (Fig. 6.50). These mucin-producing
Metastatic Adenocarcinomas of the Ovaries Spectrum of Cytopathologic Features (See Figs. 6.38 to 6.44)
Fig. 6.38. Metastatic ovarian serous papillary adenocarcinomas ex-

foliate large branching papillary tissue fragments of malignant cells,
commonly in the peritoneal cavity.
A B
Figs. 6.39A and B. A malignant pleural effusion specimen processed by liquid-based technology. A: Low power.
B: High power (Papanicolaou). (Courtesy of Dr. Prabodh Gupta, Director, Cytopathology, University of Pennsylvania,
Philadelphia, Pennsylvania.)
A B
Figs. 6.40A and B. Metastatic ovarian adenocarcinoma in ascitic fluid. Note the large secretory vacuoles and psammoma bodies.
Fig. 6.41. Ascitic fluid containing malignant cells from a poorly dif- Fig. 6.42. Ascitic fluid with metastatic adenocarcinoma of the ovary.
ferentiated adenocarcinoma of the ovary. The morphology of the ad- The malignant cells are very pleomorphic with many giant and
enocarcinoma cells overlaps with that of malignant mesothelioma. multinucleated forms. Benign mesothelial cells are present in the
background.
Fig. 6.43. Ascitic fluid with metastatic adenocarcinoma of the ovary Fig. 6.44. Peritoneal fluid with pseudomyxoma peritonei secondary
showing a single cell exfoliation of large round malignant cells with to a metastatic mucinous cystadenocarcinoma of the ovary. There is
well-defined cell borders and appreciable dense cytoplasm. A dif- abundant mucin in the background.
ferential diagnosis of malignant mesothelioma was considered. This
morphology can be seen with any poorly differentiated adenocar-
cinoma as well.
Metastatic Adenocarcinoma of the Endometrium (See Figs. 6.45 to 6.47)
Fig. 6.45. Metastatic adenocarcinoma in peritoneal fluid. The cy- Fig. 6.46. Another example of metastatic adenocarcinoma of the
tomorphology is consistent with the history of endometrial carci- endometrium in peritoneal fluid.
noma, FIGO II. There are no specific cytologic features for endome-
trial adenocarcinomas.
Fig. 6.47. Metastatic clear cell endometrial carcinoma in peritoneal

fluid. The cells are obviously malignant with prominent macronu-
cleoli and high N/C ratios. The tissue fragment of malignant cells
demonstrates an acinar pattern with nuclei placed at the outer edges
or at the perimeter. This hobnail pattern is commonly seen with
clear cell carcinomas.
Metastatic Malignancy from Gastrointestinal Tract (See Figs. 6.48 to 6.51)
Fig. 6.48. Peritoneal fluid containing discrete and tissue fragments Fig. 6.49. Metastatic gastric adenocarcinoma in the peritoneal fluid
of small malignant cells with a signet-ring pattern. The gastric exhibiting a typical pattern of discrete signet-ring type small malig-
brushings had revealed similar cells (see Fig. 6.15). nant cells.
carcinomas do not present any specific cytologic pattern with pale to dense cytoplasm, or show a papillary pattern
that differentiates them from other adenocarcinomas. (Figs. 6.20 and 6.52).
Pancreatic malignancy (Fig. 6.51), accounting for 5 Urothelial malignancies very rarely involve the serous
to 10% of malignant effusion, likewise shows a spectrum membranes or cause effusion. When they do, urothelial
from well-differentiated to poorly differentiated with gi- carcinomas are poorly differentiated with a very pleomor-
ant cell forms. Mucin production and papillary architec- phic pattern and glandular differentiation. The cytologic
ture is not uncommon. pattern of metastatic urothelial carcinoma does not allow
the identification of the primary source.
When prostate adenocarcinomas involve the serous
Genitourinary Tract
membranes, they present various patterns (Figs. 6.53 and
Renal cell carcinomas account for less than 2% of malig- 6.54) from small discrete cells to pleomorphic giant forms
nant effusions. The malignant cells may be discrete, large and tissue fragments with an acinar configuration.
Fig. 6.50. Metastatic adenocarcinoma of the colon in the peritoneal Fig. 6.51. Metastatic pancreatic adenocarcinoma in peritoneal fluid.
fluid. The tissue fragments of malignant cells show focal palisading The cytomorphology is that of any conventional adenocarcinoma.
of elongated nuclei. The cytoplasm is foamy to vacuolated suggest-
ing mucin production.
Metastatic Malignancy from Genitourinary Tract (See Figs. 6.52 to 6.54)
Fig. 6.52. Renal cell carcinomas frequently metastasize to the body Fig. 6.53. Metastatic poorly differentiated carcinoma of the prostate
cavities, presenting a spectrum of morphologic features. This im- presenting anaplastic cells with giant and multinucleated forms—an
age demonstrates a monolayered syncytial tissue fragment of large, uncommon presentation.
round to polygonal cells with abundant pale to granular cytoplasm
and small bland nuclei. The morphology is consistent with a history
of clear cell renal cell carcinoma. This bland cellular morphology
may be misinterpreted as benign mesothelial cells or even histio-
cytes (however, note that histiocytes do not form tissue fragments).
TABLE 6.10 DIFFERENTIAL DIAGNOSES OF MALIGNANT EFFUSION WITH SINGLE CELL

EXFOLIATION OF SMALL TO MEDIUM-SIZED ROUND CELLS
Diagnostic Clues/
Cytopathologic Features Ancillary Tests See Fig(s).
Adenocarcinoma Predominantly single, a few tissue fragments; cell borders h/o breast carcinoma 6.19D, 6.30 to
of the Breast, the well to poorly defined; high N/C ratios; nucleus round to (lobular type) 6.32, 6.35, 6.37,
Lung, the Stomach, oval, central to eccentric; irregular nuclear membrane; fine CEA ⫹ 6.48, 6.49, 6.55,
and the Ovary to coarsely granular chromatin; nucleoli variable; cytoplasm Keratin ⫹ 6.56, 6.59
pale, bubbly, small to large vacuoles indenting the nucleus; LCA ⫺
eosinophilic inclusions in the cytoplasm in breast
Malignant Individually dispersed cells; no tissue fragments; cell CEA ⫺ 6.76, 6.78B
Lymphoma borders poorly defined; large nucleus with high N/C Keratin ⫺
ratios; nucleus round, central, smooth to irregular nuclear LCA ⫹/⫺
membrane; fine to coarsely granular chromatin; central
macronucleoli to multiple micronucleoli; mitoses frequent;
karyorrhexis ⫹/⫺; scant cytoplasm
Multiple Myeloma Individually dispersed cells, no tissue fragments; well- Radiologic findings 6.78A and B
defined cell borders; high N/C ratio; nucleus eccentric; cytoplasmic
nuclear membrane smooth to irregular; chromatin finely Immunoglobulins
granular in immature forms to coarsely granular and Bence–Jones protein
chunky in mature types; nucleoli in immature forms not Bone marrow
apparent in mature; moderate amount of dense cytoplasm; involvement
cytoplasmic globules
Malignant Individually dispersed cells; no tissue fragments; well- h/o malignant 6.61, 6.75
Melanoma defined cell borders; high N/C ratios melanoma
(Amelanotic) HMB ⫹
S100 protein ⫹
Melan-1 ⫹
Germ Cell Tumor/ Individually dispersed, small to medium-sized cells; well- PLAP ⫹
Seminoma defined cell borders; scant cytoplasm; high N/C ratios; CEA ⫺
round nucleus with a single prominent macronucleoli
Reactive Cells mostly isolated; tissue fragment ⫹/⫺; variable size; CEA ⫺ 6.19C
Mesothelial Cells typical mesothelial presentation (apposing cell borders Keratin ⫹
and windows); large nuclei with bi- or multinucleation Calretinin ⫹
⫹/⫺; nuclear chromatin granular, uniformly dispersed, WT-1 ⫹
no parachromatin clearing; nucleoli ⫹; cytoplasm dense; Mesothelin ⫹
biphasic staining ⫹/⫺
Squamous Cells mostly isolated, round, minimally pleomorphic in p-63 6.70, 6.71, 6.72A
Carcinoma size; well-defined cell borders; high N/C ratios; nucleus Keratin
round to irregular; nuclear membrane smooth to irregular
or scalloped; granular chromatin with parachromatin
clearing; micro or macronucleoli ⫹; pyknotic nuclei
⫹/⫺; dense cytoplasm; endo/ectoplasmic borders ⫹/⫺;
keratinization ⫹/⫺; anucleated squames ⫹/⫺
Small Cell Small cells, loosely cohesive or in small tissue fragments; Keratin ⫹ 6.72A, 6.72C
(Neuroendocrine) high N/C ratios; scant cytoplasm; coarsely granular Neuroendocrine
Carcinoma chromatin; inconspicuous nucleoli; nuclear molding markers ⫹
TTF-1 ⫹
The majority of the adenocarcinomas originating centrally located and, in most instances, do not involve
from common sources, such as the lung, the breast, and the the pleura or exfoliate in the pleural cavity. The metastatic
ovary, present features of conventional adenocarcinoma squamous carcinomas that involve the serous membranes
with syncytial tissue fragments showing an acinar pattern. and present in the fluid are readily recognized when they
Presentation as small to medium-sized single, round malig- are well-differentiated. The malignant cells are isolated,
nant cells can be seen with any of these adenocarcinomas very pleomorphic in size and shape with excessive kerati-
(Table 6.10; Figs. 6.55 to 6.61). Some of these malignan- nization and with pyknotic nuclei (Fig. 6.67). Anucleated
cies also present a papillary pattern (e.g., thyroid papillary, keratinized squames and malignant pearls are diagnostic.
renal papillary, ovarian serous papillary, and lung papil- The moderate to poorly differentiated squamous carcino-
lary) (Table 6.7; Figs. 6.62 to 6.66). Giant cell pattern is mas (Figs. 6.68 to 6.70), on the other hand, are often diag-
very unusual and represents poorly differentiated adeno- nostic challenges, particularly in the absence of a known
carcinomas, anaplastic thyroid carcinomas, or sarcomas. primary. Mesothelioma cells (Fig. 6.71A) may exhibit
features such as centrally located nuclei, abundant dense
cytoplasm, well-defined cell borders, and endoplasmic/
OTHER EPITHELIAL MALIGNANCIES
ectoplasmic demarcation that are diagnostic of squamous
carcinomas (Figs. 6.71B and 6.71C). Small discrete malig-
Squamous Carcinoma
nant squamous cells must be differentiated from sev-
Squamous carcinomas involve the serous membranes very eral other neoplasms (Table 6.10, Fig. 6.60). Malignant
infrequently (Figs. 6.67 to 6.71). Most are metastatic from squamous cells, not uncommonly, appear vacuolated (Fig.
the head and neck area or genital organs (e.g., uterine cer- 6.70), resembling adenocarcinoma cells. A helpful feature
vix). Primary squamous carcinomas of the lung are usually in recognizing squamous origin is the tendency to form
Fig. 6.54. Metastatic adenocarcinoma of the prostate in pleural ef-

fusion fluid. The tissue fragment is syncytial, consisting of small,
tightly packed, round nuclei containing prominent nucleoli and
scant cytoplasm. This pattern is more characteristic of prostate ad-
enocarcinoma.
Differential Diagnoses of Single Small to Medium Cells in Serous Effusions (see Table 6.10) (See Figs. 6.55 to 6.61)
Fig. 6.55. Poorly differentiated adenocarcinoma of the lung. Fig. 6.56. Another example of a poorly differentiated pulmonary
adenocarcinoma.
Fig. 6.57. These malignant cells from a pulmonary large cell undif- Fig. 6.58. Single cell exfoliation of malignant cells from an ovarian
ferentiated carcinoma have dense cytoplasm, well-defined cell bor- adenocarcinoma.
ders, and prominent macronucleoli. A differential diagnosis of ma-
lignant mesothelioma must be considered if a diagnosis of primary
lung cancer is not established.
Fig. 6.59. Another example of single cell exfoliation of malignant Fig. 6.60. Metastatic poorly differentiated squamous carcinoma
cells from ovarian adenocarcinoma. may exfoliate as single cells.
Fig. 6.61. Malignant melanoma cells exfoliate singly. They are pleo-
morphic in size, have well to poorly defined cell borders, and con-
tain variable pale to dense cytoplasm. With no history of melanoma,
these cells may be mistaken for malignant mesothelioma or poorly
differentiated adenocarcinoma.
Papillary Adenocarcinomas in the Effusion Fluid (See Figs. 6.62 to 6.66)
Papillary carcinomas can originate in several organs, presenting identical cytomorphologic patterns (Table 6.7) and require a panel
of antibodies to determine the source.
Fig. 6.62. Metastatic serous papillary adenocarcinoma of the ovary. Fig. 6.63. Metastatic papillary renal cell carcinoma.
Fig. 6.64. Metastatic papillary thyroid carcinoma. Fig. 6.65. Metastatic papillary adenocarcinoma of the lung.
A B
Figs. 6.66A and B. Malignant mesothelioma. A: Low power view of a cellular smear with several large papillary tissue
fragments. B: Higher magnification of a tissue fragment with a pseudoacinar pattern.
Metastatic Squamous Carcinoma in Effusion Fluids (See Figs. 6.67 to 6.71)
Fig. 6.67. Well-differentiating keratinizing squamous carcinoma of Fig. 6.68. A tissue fragment of large pleomorphic malignant squamous
the head and neck exfoliating as discrete pleomorphic keratinized cells with well-defined cell borders, and abundant, dense cytoplasm.
cells with pyknotic nuclei. The differential diagnosis includes malignant mesothelioma.
Fig. 6.69. Metastatic squamous carcinoma cells may exfoliate as Fig. 6.70. Poorly differentiated squamous carcinoma in pleural ef-
tissue fragments with a concentric arrangement, referred to as the fusion, simulating the cytomorphology of adenocarcinoma.
onion–skin pattern.
A B C
Figs. 6.71A to C. A: Compare the morphology of malignant mesothelioma cells depicted in this image to squamous carci-
noma cells in B and C. Note, however, that mesothelioma cells exhibit windows in between the cells (arrows).
B, C: Metastatic squamous carcinoma cells in pleural effusion, mimicking the cytomorphology of malignant mesothelioma.
a whorled or an onion–skin pattern, even if the cells are be differentiated from an adenocarcinoma without spe-
moderately differentiated (Fig. 6.69). cial stains.
NEUROENDOCRINE CARCINOMAS GERM CELL TUMORS

Malignant cells derived from small cell neuroendocrine Seminoma, embryonal carcinomas, and yolk sac tumors
carcinomas present several patterns (Figs. 6.72 to 6.74). involve the serous membranes only rarely. Cells derived
The neoplastic cells may appear in small tissue fragments from seminoma are small to medium-sized with high N/C
in an Indian fi le arrangement with short branches curv- ratios and round nuclei with prominent central macronu-
ing off at various angles (Fig. 6.72C) or tight groupings cleoli. Embryonal carcinomas present as poorly differen-
imparting an onion skin appearance (Fig. 6.72B). The tiated carcinomas while yolk sac tumors may present a
characteristic nuclear molding and karyorrhexis are also pattern of adenocarcinoma.
features in favor of metastatic small cell carcinoma (Fig.
6.72A). The differential diagnoses include malignant lym-
MALIGNANT MELANOMA
phoma, lobular breast carcinoma, and poorly differenti-
ated carcinomas. The low-grade endocrine carcinomas or Malignant melanomas, when they involve the serous
the carcinoid tumors may involve the serous membranes cavities, are easily recognized because of clinical history
(Figs. 6.73A and B). Although the typical salt & pepper and the presence of melanin pigment. However, histio-
chromatin pattern of the nuclei allows a correct diagno- cytes that phagocytize melanin pigment must be differ-
sis, adenocarcinoma remains the differential diagnosis. entiated from melanoma cells. The latter possess promi-
An unusual pattern of carcinoid tumor is the goblet cell nent macronucleoli unlike melanophages, which contain
variant, as seen in Figure 6.74. This presentation cannot micronucleoli. The cells of amelanotic melanoma may not
Metastatic Neuroendocrine Carcinomas (See Figs. 6.72 to 6.75)
A B
Figs. 6.72A to C. Small cell neuroendocrine carcinoma metastatic

to the pleura. A: The malignant cells are small with poorly defined
cell borders, scant or indiscernible cytoplasm, high N/C ratios, and
nuclear molding (arrows). B: Small cell carcinoma cells arranged
concentrically forming an onion–skin pattern. C: Small cell carci-
C noma cells in single file or Indian file.
A B
Figs. 6.73A and B. Carcinoid tumor cells in peritoneal washings in a patient with large cystic ovarian teratoma,
containing a carcinoid tumor that extended to the capsule. These cells are small, forming a syncytial tissue fragment
with nuclei depicting a typical salt & pepper chromatin pattern.
Fig. 6.74. Goblet cell carcinoid of the appendix metastatic to the Fig. 6.75. Amelanotic malignant melanoma in pleural effusion. A
peritoneum. The neuroendocrine morphology of these malignant small single cell pattern as demonstrated here is just one of the many
cells (arrows) is not evident. The cytologic diagnosis is based on faces of malignant melanoma. Without a history of the tumor or in the
histologic findings. absence of melanin pigment, this case may be interpreted as possible
malignant lymphoma. These cells were immunoreactive to HMB-45.
be differentiated from poorly differentiated carcinomas high-grade lymphomas generally present no diagnostic dif-
on a cytologic basis (Figs. 6.61 and 6.75). ficulties but, at times, must be differentiated from malignan-
cies exfoliating as small, single cells (Table 6.12; Figs. 6.55
and 6.60). Hodgkin lymphoma with mononuclear Hodgkin
LYMPHOPROLIFERATIVE DISORDERS
cells can also be a diagnostic challenge (Fig. 6.77). Multiple
myeloma is occasionally seen in the effusions, and charac-
Lymphoma and Leukemia
teristic myeloma cells in various stages of differentiation
Malignant lymphomas and leukemias frequently cause (Figs. 6.78A and B) are easily recognized. Acute leukemias,
serous effusions (Figs. 6.76 to 6.80). The cytologic pattern whether lymphoblastic or granulocytic, are readily identi-
of malignant cells is dependent on the type of lymphoma fied in the serous fluids (Figs. 6.79A and B and 6.80).
or leukemia. Since clinical history indicates the primary
lesion in most instances, the cytologic diagnosis is not a
EXTRAMEDULLARY HEMATOPOIESIS
problem. Rarely, effusion may be the presenting sign.
The low-grade lymphomas or chronic lymphocytic Extramedullary hematopoiesis may involve the serous
leukemias may present diagnostic difficulties. Immunophe- cavities. The presence of megakaryocytes, megakaryo-
notyping and DNA ploidy analysis may be required to dif- blasts, and myeloid/erythroid precursor cells (e-Fig. 6.21;
ferentiate them from reactive lymphocytosis (Fig. 6.76). The Fig. 6.81) is diagnostic.
Lymphoproliferative and Hematopoietic Disorders (See Figs. 6.76 to 6.87)
Fig. 6.76. Malignant lymphoma in pleural effusion. The cells are Fig. 6.77. Hodgkin lymphoma in effusion fluid showing mononu-
immature lymphoid type and monomorphic. A wet-mount diagno- clear Hodgkin cells.
sis of such specimens will allow ancillary studies such as flow cy-
tometry to be done expeditiously.
A B
Figs. 6.78A and B. Multiple myeloma. A: These small cells with eccentric nuclei may be misinterpreted as adenocar-
cinoma such as gastric or lobular breast carcinoma. B: Multiple myeloma. These myeloma cells are much larger and
pleomorphic.
A B
Figs. 6.79A and B. Acute lymphoblastic leukemia. A: Papanicolaou stain. B: Romanowsky stain.
Fig. 6.80. Chronic granulocytic leukemia in pleural fluid. Fig. 6.81. Extramedullary hematopoiesis. The megakaryocytes may
be mistaken for tumor giant cells. The background shows cells of
myeloid and erythroid precursors.
SMALL ROUND CELL TUMORS

OF CHILDHOOD
Most small round cell tumors are seen in the pediatric age
group and include malignant lymphomas, neuroblasto-
mas, nephroblastomas (Wilms’ tumor), Ewing’s sarcoma/
primitive neuroectodermal tumor, alveolar and embryo-
nal rhabdomyosarcomas, and desmoplastic small cell
tumors (Figs. 6.82 to 6.85). Their cytopathologic features
are described in Chapter 25.
SARCOMAS
Various types of sarcomas involve the serous membranes,
examples of which have been reported in the literature. In
general, sarcomas do not exfoliate easily and are seen on Fig. 6.82. Desmoplastic small cell tumor in peritoneal fluid. The
extremely rare occasions (Figs. 6.86 and 6.87). neoplastic cells are small with scant cytoplasm, forming syncytial
tissue fragments without any architectural patterns.
A B
Figs. 6.83A and B. A: Metastatic neuroblastoma. B: Metastatic Ewing’s sarcoma. The malignant cells are small,
undifferentiated, presenting similar morphology, and can represent any of the small round cell tumors of childhood.
Clinical, radiologic data and ancillary tests are essential for proper diagnostic evaluation.
Fig. 6.84. Pleural effusion in a youngster with a history of Wilms’ Fig. 6.85. Metastatic embryonal rhabdomyosarcoma.
tumor.
Fig. 6.86. Metastatic carcinosarcoma of the lung. The sarcomatous Fig. 6.87. Hemangioendotheliosarcoma. The patient presented first
component usually does not exfoliate. The smear shows large, ana- with a massive pleural effusion. The malignant cells are small epi-
plastic epithelial component. thelioid with a pseudoglandular pattern. The diagnosis was estab-
lished by ultrastructural examination.
2. The mechanical stripping of the mesothelium along

PERITONEAL/PELVIC WASHINGS with underlying collagenous tissue presents as three-
dimensional structures simulating a tissue fragment of
adenocarcinoma cells with an acinar pattern, referred
Peritoneal or pelvic washings are routinely performed
to as collagenous cores (e-Fig. 6.4).
during any exploratory laparotomy for gynecological dis-
3. Large tissue fragments of mesothelium dislodged during
eases. Peritoneal involvement by a malignant tumor may
washing fold upon themselves, mimicking a syncytial
be grossly invisible but can be detected by a cytologic
arrangement. This feature, along with well-preserved
evaluation of the washings. This information is critical in
crisp nuclei, serves as an interpretative trap leading to
cancer staging and adjunct therapy.
the misdiagnosis of carcinoma.
Cytologic presentation of peritoneal/pelvic washings
4. Tissue fragments of epithelium originating from
differs from spontaneous effusions in many respects.
endosalpingiosis constitute important diagnostic pit-
1. The washings are always intensely bloody and con- falls because of crowded, overlapped, hyperchromatic
taminated with fat and debris. The cytoprepara- nuclei, and the frequent presence of psammoma bodies.
tory technique must be excellent for proper evalu- Endosalpingiosis must be differentiated from ovarian
ation; otherwise, a false negative diagnosis may be or endometrial carcinoma, endometriosis, and although
rendered. rare, granulosa cell tumor.
5. The recognition of cells originating from poorly dif- TABLE 6.11 CYTOPATHOLOGIC FEATURES OF
ferentiated gynecological malignancies is easy because ENDOSALPINGIOSIS
of their obvious malignant characteristics.
● Varying-sized tissue fragments of small cells in syncytial
arrangement; complex branching ⫹/⫺; no architectural
FEMALE PERITONEUM patterns; ragged edges
● Component cells with poorly defined cell borders and
The Müllerian system derived from the celomic epithe- scant cytoplasm
lium develops into the female genital tract. The female ● Cilia ⫹/⫺
peritoneum is also derived from celomic epithelium and ● Nuclei round to oval; uniform with coarsely granular
retains the embryonic potential to differentiate into vari- chromatin; nucleoli ⫹/⫺; high N/C ratios; nuclear atypia
ous types of Müllerian duct derived epithelia, manifested uncommon
● No mitoses; no necrosis
by metaplastic and neoplastic lesions such as endosalpin-
● Psammoma bodies in variable numbers; naked or
giosis, endometriosis, and neoplasms (e.g., serous papil- incorporated in the epithelial tissue fragments
lary tumors). ● Not associated with hemosiderin-containing macrophages
or glandular structures
Endosalpingiosis ● No collagenous cores; no Call-Exner bodies
● Differential Diagnoses
Endosalpingiosis, also known as Müllerian inclusions, Mesothelial tissue fragments
is described as the presence of glandular inclusions Endometriosis
lined by (fallopian) tubal-appearing epithelium. Endos- Implants of ovarian serous papillary borderline tumor
alpingiosis is found in the superficial layers of the peri- Adenocarcinoma
toneum or in the pelvic or para-aortic lymph nodes. Granulosa cell tumor
These are often identified as simple acinar or papil-
lary structures with or without cilia and psammoma
bodies (e-Figs. 6.27A and B). Although they primarily
resemble tubal epithelium, they may show morphologic toneal endosalpingiosis may find their way into the uterine
similarities with endometrial or endocervical glandular cavity and are recovered in cervical-vaginal smears (see
cells. Müllerian inclusions are frequent in pelvic peri- Chapter 5). Endosalpingiosis remains a common diag-
toneum and are encountered in peritoneal/pelvic wash- nostic pitfall since it morphologically resembles a serous
ings. Failure to identify them as Müllerian inclusions papillary carcinoma of low malignant potential (e-Figs.
has resulted in a false positive diagnosis of adenocar- 6.30A and B).
cinoma. This diagnostic difficulty is enhanced by the The differential diagnosis of endosalpingiosis includes
fact that the incidence of these Müllerian inclusions is lesions that are composed of small cells. Their differenti-
increased in patients with adenocarcinoma of the ovary ating features are listed in Table 6.12.
or malignant serous tumors (primary or metastatic) of
the peritoneum (see e-Figs. 6.31A to C). When both
types of cells are present, correct identification may ENDOMETRIOSIS
present a diagnostic problem because of overlapping
The peritoneum may be involved by endometriosis. The
features.
involvement can be diffuse. The washings may demon-
strate endometrial stromal tissue and tubular endometrial
Cytopathologic Features of Endosalpingiosis. Endosalp-
glands or the tissue fragments of endometrial glandular
ingiosis is characterized in pelvic/peritoneal washings by
cells (e-Figs. 6.32A to C). Hemosiderin-containing mac-
the presence of tissue fragments of small cells with poorly
rophages are often present.
defined cell borders, indiscernible or scant cytoplasm, and
high N/C ratios (Table 6.11; e-Figs. 6.28A to E). Their
nuclei have coarsely granular chromatin without con-
spicuous nucleoli. The tubal-type epithelium, being pseu-
GRANULOSA CELL TUMOR
dostratified, always appears in a syncytial arrangement. Granulosa cell tumor is an uncommon ovarian neoplasm.
These syncytial tissue fragments vary in size and can be Its involvement of the peritoneum is still uncommon but
present in large dimensions with branching. Psammoma occasionally encountered. Granulosa cell tumors are
bodies in varying numbers are often present within these composed of small uniform cells with bland chromatin
epithelial tissue fragments. Cilia may rarely be identified (e-Figs. 6.33A to C) and a characteristic nuclear groove
(Fig. 6.29). with the appearance of a coffee bean. The diagnostic fea-
On very rare occasions, tissue fragments of tubal-type ture of granulosa cell tumor is the presence of Call-Exner
epithelium with psammoma bodies originating from peri- bodies (e-Fig. 6.33A).
TABLE 6.12 DIFFERENTIAL DIAGNOSES OF SMALL CELL LESIONS IN PERITONEAL/PELVIC WASHINGS
Diagnostic Clues/
Disease Entity Clinicopathologic Features Cytopathologic Features Ancillary Tests
Mesothelial tissue Mechanical stripping during Two-dimensional sheets, cells with well- Folded sheets may
fragments peritoneal/pelvic washing defined cell borders, uniform round appear syncytial;
to kidney-shaped nuclei; crisp nuclear focus up and down,
membranes, evenly dispersed finely epithelial markers ⫺
granular chromatin; micronucleoli;
appreciable, pale cytoplasm; low N/C
ratios, collagenous cores ⫹/⫺
Endometriosis Frequent occurrence but not Tissue fragments of endometrial cells; Well-preserved
usually encountered in closely packed, overlapped poorly tubular glands, no
washings defined cell borders; compact chromatin; psammoma bodies
inconspicuous nucleoli; high N/C ratios;
aggregates of endometrial stromal cells;
hemosiderin-containing histiocytes
Endosalpingiosis Frequent occurrence, often Tissue fragments of epithelial cells with Cilia, psammoma
(Müllerian in the presence of or without acinar or papillary pattern; bodies
inclusions) malignancy cells small with scant cytoplasm; high
N/C ratios; nuclei round to oval,
containing coarsely granular chromatin;
inconspicuous nucleoli; cilia present on
luminal borders; psammoma bodies very
common; either naked or incorporated
within the tissue fragments
Implants of ovarian SBT accounts for 10–20% Malignant cells generally small, large Operative findings
serous borderline of all ovarian epithelial in syncytial tissue fragments with or supporting the
tumor (SBT) neoplasm; occurs in slightly without acinar to papillary pattern; presence of ovarian
younger women; usually smooth external contour; cells, small, tumor; no cilia
staged when diagnosed; generally uniform; scant cytoplasm,
length of survival longer high N/C ratios; nuclei round to oval;
compared to invasive; nuclear membrane smooth to irregular;
recurrence may be as late as chromatin fine to coarsely granular
20 years or more after with parachromatin clearing; nucleoli
diagnosis conspicuous; cytoplasmic vacuoles
uncommon; isolated malignant cells
infrequent or few; mitoses infrequent;
psammoma bodies common
Granulosa cell Very uncommon; peritoneal Malignant cells in small to large tissue History of granulosa
tumor washings positive with fragments; cells small with poorly cell tumor
disseminated spread to the defined cell borders; high N/C ratios;
peritoneum nuclei round to oval with frequent
grooves; finely granular, evenly dispersed
chromatin; micronucleoli ⫹/⫺;
cytoplasm pale, scant; Call-Exner bodies
⫹/⫺
PAPILLARY SEROUS TUMORS OF THE with pseudostratifi ed nuclei, which are oriented perpen-
PERITONEUM dicular to the basement membrane. Less-differentiated tu-
mors tend to have more pleomorphism and more crowd-
Borderline and malignant serous tumors can occur as sin-
ing of the cells than in mesotheliomas. Unlike lung and
gle or multifocal primary tumors in the peritoneum in the
breast adenocarcinomas, which are usually strongly CEA
absence of a tumor in the ovary or the rest of the female
positive, the majority of serous tumors are CEA nega-
genital tract. Serous tumors are the most common type
tive or only weakly to focally positive. LeuM1 and B72.3
and represent tumors with tubal differentiation. Primary
broaden the sensitivity for the identifi cation of serous
serous tumors of the peritoneum are histologically, immu-
adenocarcinomas. Mucin stains, likewise, may be nega-
nohistochemically, and ultrastructurally indistinguishable
tive or positive but are helpful when positive. Like in the
from their ovarian counterparts. Serous tumors involving
pleura, it is important to correlate the cytologic or histo-
the peritoneum, primary or metastatic, pose a slightly dif-
logic fi ndings with that of clinical history and the distri-
ferent problem in their differentiation from malignant
bution of the tumor. In general, the mesotheliomas tend
mesothelioma (Fig. 6.24).
to be more diffusely distributed and occur uncommonly
In general, well-differentiated serous tumors have
in women.
more distinct papillary structures lined by columnar cells
SUGGESTED READINGS
Allen KA. A Guide to Cytopreparation. Raleigh, North Carolina: Ordonez N. Immunohistochemical diagnosis of epithelioid meso-
American Society for Cytotechnology, 1998. thelioma. An update. Arch Pathol Lab Med 2005;129:
Beasley M. Immunohistochemistry of pulmonary and pleural neo- 1407–1414.
plasia. Arch Pathol Lab Med 2008;132:1062–1072. Selvaggi SM. Diagnostic pitfalls of peritoneal washing cytology
Churg A, Cagle PT, Roggli VL. Tumors of the serosal membranes. and the role of cell blocks in their diagnosis. Diagn Cytopathol
AFIP Atlas of Tumor Pathology, series 4. Washington DC: 2003;28:335–341.
American Registry of Pathology, 2006. Shidham VB, Atkinson BF. Cytopathologic Diagnosis of Serous
Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia, Fluids. Philadelphia, PA: Saunders, 2007.
PA: Churchill Livingstone, 2006. Smith-Purslow MJ, Kini SR, Naylor B. Cells of squamous carci-
Greenstreet P, Purslow MJ, Kini SR. Color Atlas of Pulmonary noma in pleural, peritoneal and pericardial fluids. Origin and
Cytopathology. New York, NY: Springer-Verlag, 2002. morphology. Acta Cytol 1989;33:245–253.
Grigoriu BD, Grigoriu B, Chahine T, et al. Clinical utility of diag- Sneige N, Fanning CV. Peritoneal washing cytology in women:
nostic markers for malignant pleural mesothelioma. Monaldi Diagnostic pitfalls and clues for correct diagnosis. Diagn
Arch Chest Dis 2009;71:31–38. Cytopathol 1992;8:632–642.
Naylor B. The exfoliative cytology of diffuse malignant mesothe- Stevens MW, Leong AS-Y, Fazzalari NL, et al. Cytopathology of
lioma. J Pathol Bacteriol 1963;86:293–298. malignant mesothelioma: A stepwise logistic regression analy-
Naylor B. The pathognomonic cytologic picture of rheumatoid sis. Diagn Cytopathol 1992;8(4):333–340.
pleuritis. Acta Cytol 1990;34:465–473. Wick MR, Moran CA, Mills SE, et al. Immunohistochemical
Naylor BN. Pleural, peritoneal, and pericardial fluids. In: Bibbo M, differential diagnosis of pleural effusions on malignant
ed. Comprehensive Cytology. 3rd ed. Philadelphia, PA: WB mesothelioma. Curr Opin Pulm Med 2001;7:187–192.
Saunders, 2008:515–577.
APPENDIX
CYTOPREPARATION OF SEROUS
EFFUSION FLUIDS
Body cavity fl uids present the cytopathology laboratory several available methods, the Saponin® technique
with challenges that are not found in the processing of offers the best results when properly carried out.
most of the other types of cytologic specimens. There are d. To anticipate the necessity of ancillary tests in situ-
no shortcuts if an ideal preparation is desired. The liquid- ations such as unusual malignancy, a diagnostically
based preparation is considered an alternative method diffi cult case, or unknown malignancy; childhood
for specimen processing, while the manual methods are round blue cell tumors; and malignant mesothe-
tedious and time consuming but yield excellent prepara- lioma. Wet mount interpretations allow prepara-
tions. The advantages are several. tions of additional smears/cell block, lymphoma
There are several methods of specimen collection and protocol, flow cytometry, and electron microscopy.
cytopreparation. The following guidelines are diligently 5. Preparation of a cell block, provided the specimen is
followed at the author’s laboratory: adequate or if a spontaneous clot is present. A cell
block is complementary to the smear evaluation and
1. Immediately submit unfixed fresh specimens to the
also allows histochemical and immunochemical stains.
cytopathology laboratory. There are no minimum
A spontaneous clot should be squeezed out of excess
requirements for the amount of effusion fl uid to be
fluid and can be processed as the cell block.
submitted. Fixation in 50% ethyl alcohol interferes
6. Quality enhancing techniques that enhance the technical
with the adherence of the cellular material onto the
quality of the final product of cytopreparation such as
glass slides. Alcohol also lyses the blood; the proteins
those described below may be carried out. They are used
thus released cause background eosinophilia.
whenever deemed necessary by the cytotechnologist.
2. Gross characteristics of the fluid should be noted. The
These techniques are extremely rewarding. Please refer
chylous fluid, or the sandy sediment and milky appear-
to the literature (Greenstreet et al., 2002) for details.
ance in alveolar proteinosis, or a brownish-black dis-
a. Wash technique when the protein content of the
coloration in malignant melanoma. Mucoid consis-
fluid is very high.
tence in pseudomyxoma peritonei is another example
b. Removal of blood from the specimen.
that requires the planning of special procedures.
c. Consolidation of the specimen.
3. Immediate processing (the specimen may be refriger-
Consolidation of the specimen is recommended
ated if a delay is anticipated).
when the amount of effusion fluid submitted is very
4. Toluidine blue staining of the sediment (wet mount
large, the cellularity is extremely poor for wet-film
technique1) is highly recommended.
technique, and malignancy is suspected. The entire
The advantages of the wet mount are as follows: specimen is usually centrifuged in large capacity
tubes (250 ml).
a. Rapid diagnosis of malignancy. The malignant spec-
7. Smear preparations
imens are processed and stained separately to pre-
There are several techniques for preparing the
vent cross-contamination.
direct smears from the sediments (please refer to the
b. Accurate assessment of the cellularity of the speci-
literature). Whichever method is employed, the final
men. Hypercellular specimens, even if benign (meso-
product should be a monolayered cell spread. Smears
thelial proliferation, lymphocytic effusion), and
for a Romanowsky-type stain are fixed by air-drying.
malignant effusions can be processed and stained
8. Cytocentrifugation and cytospin preparations
separately to prevent cross contamination. Poorly
Cytospin® preparation is the method of choice
cellular samples may be processed by cytocentrifu-
for harvesting poorly cellular samples. Cytocentrifu-
gation or a membrane filter technique.
gation allows the concentration of cells on a glass slide
c. Need to remove excess blood if the sediment is very
by way of collecting them over a filter placed on the
bloody, so that an appropriate technique for remov-
well etched on a special glass slide manufactured for
ing the red blood cells may be performed. Of the
the procedure. It produces a monolayer of cells within
a clearly defi ned area. The specimen should be non-
1
mucoid or else it will clog the fi lter. The addition of
Wet mount technique: One drop of sediment and one drop of Tolu-
idine blue solution (0.5 mg Toluidine blue, 20 ml 95% ethyl alcohol,
Saccomanno fixative to the specimen when the Papani-
80 ml distilled water). colaou stain is used will prevent air-drying. The pro-
cedure recommended by the manufacturer should be of background material such as blood, mucus, or debris
closely followed. obscuring the cellular details.
MEMBRANE FILTER TECHNIQUE CELL BLOCK TECHNIQUE
Membrane fi lter technique is a method whereby the Cell block refers to the examination of sediment, blood
specimen is filtered through specially manufactured filters clots, or grossly visible fl ecks of tissue from cytologic
made out of cellulose or polycarbonate plastic. They are specimens that are processed by paraffi n embedding and
useful in salvaging sparsely cellular specimens. The reader staining by Hematoxylin & Eosin. Small tissue flecks
may refer to the literature for procedures. must be wrapped in tissue paper and then placed in the
cassette. Sediments can be embedded in either HistoGel®
or agar. Cell blocks are complementary to the smears and
allow extra slides to be cut for ancillary tests. Several
AUTOMATIC THIN-PREP PROCESSOR methods exist for processing the cell blocks such as agar,
HistoGel, and plasma-thrombin. The reader should refer
Automatic processors are being utilized to prevent cell to the literature.
loss and to provide a monolayer of cells that is devoid
7 RESPIRATORY TRACT:
EXFOLIATIVE AND ASPIRATION CYTOPATHOLOGY
The cytopathology of the respiratory system is quite formed routinely for staging lung cancers. The goal in
unique and versatile. No other system in the body offers examining multiple specimen types is to increase the
such a variety of specimens for cytopathologic evalua- diagnostic yield for detecting lung cancer. While evalu-
tion (Table 7.1). Their combined use offers a high diag- ating varied specimen types, one must keep the follow-
nostic yield. Each type of specimen has its own merits as ing in mind:
well as limitations. The optimal use of different types of
● Depending on the specimen type, the cytomorphology
specimens is dependent on clinical and radiologic data
of lung cancers differs to some extent. For example,
as well as the physician’s preferences. The best results
spontaneously exfoliated cells identified in sputum
are obtained when the specimens are collected and sub-
samples often show degenerative changes with poor
mitted to the laboratory as per the protocol set by the
cellular details, while the diagnostic cells are better
laboratory, which in turn, is completely responsible for
preserved in bronchial brushings and aspiration biopsy
using optimal cytopreparatory techniques and stain-
specimens. Similarly, cells in direct smears of the bron-
ing. A summary of specimen processing is described in
chial brushings often show better cytomorphology
Appendix I.
than those present in washings.
● Respiratory epithelial cells may be present in large
numbers in transbronchial FNA biopsies. In their
reactive state, they constitute a potential diagnostic
DIAGNOSTIC ISSUES IN RESPIRATORY
pitfall.
PATHOLOGY
● Mesothelial tissue fragments are often seen with a per-
cutaneous transthoracic approach and not in trans-
Although specimens from the respiratory tract are bronchial aspiration biopsy specimens.
also utilized for the diagnostic evaluation of suspected ● In a patient treated with radiation, transbronchial
inflammatory processes, the main indication remains aspiration biopsy may yield atypical squamous cells
the detection of malignancy. The diagnostic yield for and are diffi cult to separate from recurrent squamous
cancer detection depends on the type of specimen exam- cancer.
ined and is stated to be 64.5% for sputum, 81% for ● Submucosal lesions in the bronchi may not be acces-
bronchial brushings/washings, 84% for transbronchial sible to the brushings. However, squamous metaplasia
aspiration biopsy, 88% for percutaneous transthoracic overlying these lesions may be brushed and the meta-
biopsy, and 81.7% for bronchial forceps biopsy. Using plastic cells with atypia may result in a misdiagnosis of
a combination of the above-mentioned specimen types, squamous cancer. On the other hand, it will also result
the diagnostic yield can be as high as 95.7%. In the in a false negative diagnosis. Submucosal lesions gen-
last decade or two, the types of specimens selected for erally do not yield diagnostic cells in sputum or bron-
cytopathologic evaluation have shifted more toward chial brushings/washings unless the overlying mucosa
radiologically guided fine needle biopsies. The use of is ulcerated.
sputum has declined considerably and is only rarely ● Some lung cancers show more than one morphologic
submitted for cytologic evaluation. Bronchial brush- pattern. The cytologic interpretation depends on the
ings and washings and bronchoalveolar lavage (BAL) sampled area and may not be representative of the
are the main diagnostic modalities. Fine needle aspira- main histologic pattern.
tion (FNA) biopsy is a popular technique performed ● Several nonneoplastic diseases involving the lower
either via a transthoracic route or via endoscopy. The respiratory tract elicit various types of cellular
endoscopic bronchial ultrasound (EBUS) guided biop- responses with cytologic changes that are often alarm-
sies of the mediastinal lymph nodes are currently per- ing enough to simulate malignant neoplasia. These
191
TABLE 7.1 TYPES OF RESPIRATORY SPECIMENS

FOR CYTOLOGIC EVALUATIONa ANATOMY/HISTOLOGY/CYTOLOGY
● Sputum The lungs are paired intrathoracic organs, divided into

• Spontaneous lobes by fi ssures. The right lung has three lobes—upper,
• Induced middle, and lower—while the left lung has two lobes—
● Bronchial brushings/rinsings and washings
upper and lower. The lingula—a portion of the superior
● Bronchoalveolar lavage
● FNA biopsy
segment of the upper lobe—represents the middle lobe
• Transthoracic percutaneous (parenchymal or for the left lung. Each lobe is further divided into bron-
pleural-based lesions) chopulmonary segments. The segmental lung anatomy is
• Transbronchial important in precisely designating tumor location. The
1. Parenchymal lungs are enveloped by two layers of pleura. The layer
2. Hilar/mediastinal lymph nodes with or without in contact with the lung is visceral, while the one lining
ultrasound guidance the thoracic cavity is the parietal layer. The two are sepa-
● Transtracheal biopsy of mediastinal masses and rated by a space—the pleural cavity—containing a small
lymph nodes amount of fl uid, which helps to facilitate the smooth
• Pleural effusion fluid movements of the lungs. The pleura are lined by a single
• Pulmonary arterial catheter-derived blood
layer of flattened squamoid cells—the mesothelium (e-Fig.
• Trachea
• Brushings of endotracheal lesions 7.1). The trachea—a cylindrical tube measuring roughly
• Tracheostomy tube 4.5 cm in length and 2 to 2.5 cm in diameter—extends
• Ventilator tube from the lower part of the larynx, bifurcating into two
main stem bronchi—right and left. The point of division
a
Modified from Kini SR. Color Atlas of Pulmonary Cytopathology. is referred to as the “carina.” Each main stem bronchus
New York: Springer-Verlag Inc., 2002.
enters its lung at the hilum, branching into major bronchi.
Hilum refers to the depression in the medial surface of
the lung that forms the openings through which the bron-
chus, blood vessels, and nerves pass. The major bronchi
cellular alterations constitute important diagnostic pit- divide into segmental and subsegmental bronchi. The tra-
falls and can be categorized according to the epithelial chea and bronchi both have muscular walls and circular,
type and the type of malignancy they mimic: incomplete cartilaginous plates that prevent them from
• Reactive/reparative or metaplastic squamous cells collapsing. The bronchi continue to divide into bronchi-
and radiation-/chemotherapy-induced changes ver- oles, which are less than 1 mm in diameter and lack car-
sus squamous carcinoma. tilage. The bronchioles further divide, ending in terminal
• Hyperplastic bronchial epithelial cells and atypical bronchioles, extending into the respiratory bronchioles,
type II pneumocytes versus adenocarcinoma. which have alveoli budding from their walls (e-Fig. 7.2).
• Follicular bronchitis and reserve cell hyperplasia The trachea, bronchi, and bronchioles are lined by
versus small cell carcinoma and other neuroendo- pseudostratified ciliated columnar cells with goblet cells
crine tumors. interspersed (e-Figs. 7.3 to 7.5). The respiratory epithe-
• Reactive/hyperplastic/hypertrophic mesothelium ver- lial cells appear singly or in tissue fragments, often as
sus malignant mesothelioma or adenocarcinoma. strips (e-Figs. 7.6A to C). The individual cells are tall
• Malignant neoplasms such as keratinizing squamous columnar with broad luminal borders containing cilia
carcinomas or even large bulky neoplasms have a on the luminal borders. Their tapered ends rest on the
tendency to cavitate and should be differentiated basement membrane, and they contain a round nucleus
from cavitary infectious lesions. exhibiting finely granular, evenly dispersed chromatin
• Although well-differentiated squamous or adenocar- and one or more micronucleoli. Goblet cells are mucus-
cinomas are cytologically typed accurately, diagnos- producing (e-Fig. 7.6D) nonciliated columnar cells with
tic problems are encountered with poorly differenti- cytoplasm distended by pale pinkish mucin and a ba-
ated neoplasms. sally located nucleus similar to that of the ciliated co-
• Differentiating a primary malignancy from a meta- lumnar cell. The mucin secretion is usually noted above
static one frequently presents problems that require the nucleus and toward the lumen. Adjacent to the base-
the support of ancillary tests. ment membrane, rest basal or reserve cells (e-Figs. 7.7
• Diagnosis of neuroendocrine tumors. and 7.8). These small undifferentiated cells are progeni-
• Differential diagnosis of lesions composed of small tors of the ciliated columnar and goblet cells. Alveolar
cells. histiocytes reside in alveolar spaces and are referred
• Diagnosis of a sarcomatous type of malignant to as “dust cells” since they frequently contain carbon
mesothelioma. particles (Figs. 7.9 and 7.10). Also present within the
Chapter 7: Respiratory Tract: Exfoliative and Aspiration Cytopathology 193
mucosa are Kulchitsky or neuroendocrine cells, which NONCELLULAR (INANIMATE) ENTITIES IN

cannot be recognized in routine H&E sections or Pa- RESPIRATORY SPECIMENS
panicolaou stained smears. These neuroendocrine cells
are argyrophilic and, ultrastructurally, demonstrate neu- Mucus
rosecretory granules.
Mucus is a normal accompaniment of respiratory speci-
The respiratory epithelium rests on the basement
mens that are obtained via the airways (e.g., sputum,
membrane (e-Figs. 7.3 and 7.4). A thin layer of fibro-
bronchial brushings and washings, and BAL). Mucus
vascular lamina propria containing collagen and elastic
appears as a pale, thin translucent shroud or as strings
fibers occupies the area between the respiratory epithe-
stained with varying intensity and with enmeshed cellular
lium and the hyaline cartilage. A smooth muscle layer
elements (e-Figs. 7.9 and 7.17). Inspissated mucus appears
encircles the thin connective tissue of the lamina pro-
as darkly stained blobs.
pria. Between the cartilage and smooth muscle layers is
the submucosa containing seromucinous salivary-type Curschmann Spirals
glands (e-Fig. 7.3). The hyaline cartilage is arranged in
discontinuous plates. Curschmann spirals are casts of bronchioles formed by
The bronchioles differ in structure from bronchi in inspissated mucus plugging their lumina. They are coiled
several respects: 1) bronchioles lack cartilage in their or corkscrew-shaped structures of variable lengths, some-
walls; 2) the lamina propria is replaced by a smooth mus- times with complex branching. Curschmann spirals have
cle layer; 3) the lining epithelium is non-stratified ciliated, a characteristic morphology with a dense-staining central
but low columnar to cuboidal; 4) they have fewer goblet core and pale-staining lateral extensions like a transpar-
cells that subsequently disappear; and 5) salivary-type ent shroud (e-Fig. 7.17).
glandular tissue is absent.
The terminal bronchioles are lined by nonciliated Charcot-Leyden Crystals
cuboidal cells (e-Fig. 7.5) called “Clara cells,” often show- Charcot-Leyden crystals have been reported in aspiration
ing cytoplasmic spouting at the apical surface. Clara cells biopsies of parasitic granulomas and in conditions asso-
are taller than the ciliated cuboidal cells in the terminal ciated with eosinophilia such as allergic disorders (e.g.,
airways. They are rich in endoplasmic reticulum and bronchial asthma, chronic myeloid leukemia, or eosino-
mitochondria and have a prominent Golgi apparatus. philic granuloma). They are slender rhomboid-shaped
Their cytoplasm contains apical large secretory granules. orangeophilic structures seen isolated (e-Fig. 7.18) and in
Clara cells serve as reserve and reparatory cells in small aggregates, being derived from the breakdown products
airways. of eosinophil cell granules.
The alveoli are lined by two types of cells or pneu-
mocytes. Type I refers to the flattened cells functioning in Ferruginous Bodies
the alveolar exchange of air and blood gases. The type II
Asbestosis generally results from exposure to dust con-
pneumocyte is a cuboidal cell, secretes cytoplasmic pul-
taining mainly chrysotile (magnesium silicate) and other
monary surfactant, and ultrastructurally, shows charac-
forms of asbestos fibers. The inhaled filamentous particles
teristic lamellar bodies. They may be identified in sputum
of asbestos as well as some other metals get coated with
or bronchial washings/BAL specimens as well as aspira-
protein and iron in the lung parenchyma, assuming a
tion biopsy specimens from a reactive lesion (e-Fig. 7.11).
characteristic appearance that is referred to as “ferrugi-
Mesothelium covering the pleura is often seen as large
nous bodies.” Ferruginous bodies may be seen in all types
monolayered tissue fragments in specimens obtained by
of respiratory specimens. They occur both extracellular
percutaneous FNA biopsy (e-Fig. 7.12).
and within alveolar histiocytes, varying in size from 4 to
Several other types of cells are occasionally identi-
5 nm to over 200 nm. They are generally dumbbell-shaped
fi ed in respiratory specimens, such as cells derived from
with a central translucent fiber core surrounded by layers
the hematopoietic system (e.g., lymphocytes (e-Fig. 7.13),
of a material containing minerals (iron and calcium) and
eosinophils, and megakaryocytes [e-Figs. 7.14A and B])
mucopolysaccharides. The color of ferruginous bodies
or occasionally cells of mesenchymal origin. The latter
is variable from a pale golden yellow to dark brown or
include leiomyocytes and fi broblastic cells (e-Figs. 7.15
black (e-Fig. 7.19). The outer coat tends to be segmented
and 7.16). The histologic and cytologic features of nor-
and to exist at right angles to the axis of the fiber. Asbes-
mal constituents of the lower respiratory tract are listed
tos fi bers may be identifi ed by digesting the tissues with
in Table 7.2.
chlorine. They appear as very slender refractile fibers.
In addition to these normal cellular components, re-
spiratory specimens may contain noncellular or inanimate
Corpora Amylacea
objects as described below (e-Figs. 7.17 to 7.25). These
are of no diagnostic signifi cance and represent cytologic Corpora amylacea are spherical noncalcified bodies con-
curiosities. taining glycoprotein. They occur in conditions such as
TABLE 7.2 CYTOHISTOMORPHOLOGY OF NORMAL CELLS OF THE LOWER RESPIRATORY TRACTa
Cell Type Location Histologic Features Cytologic Features
Ciliated Columnar cells Pseudostratified columnar to Columnar, elongated cells with tapering end housing
in bronchi and cuboidal, ciliated bronchial lining the round to oval nucleus; broad luminal border is
cuboidal cells in cells; each cell has approximately thicker (terminal bar) with attached tufts of cilia; tissue
bronchioles 250 cilia at the apical surface and fragments exhibit syncytial-like arrangement due to
each cilium is approximately 6 m pseudo-stratification; nucleus with finely granular,
long evenly dispersed chromatin; one or two micronucleoli;
when seen on end, the cells line up like a picket fence;
cytoplasm pale; cuboidal cells smaller in size
Goblet Bronchi, more Columnar mucus-secreting cells; Oblong to columnar, nonciliated; basally located,
numerous contain mucus glycoprotein that round nucleus with finely granular chromatin and
proximally; discharges apically micronucleoli; cytoplasm abundant, pale, lacy, pink,
small numbers distending the cytoplasm; may contain large vacuoles
in bronchioles
Basal or reserve Bronchi; rare in Short cells with relatively little Small, round to cuboidal cells with indiscernible or
bronchioles cytoplasm; orient along the scant thick rim of cyanophilic cytoplasm; high N/C
basement membrane; do not ratios; nucleus round with dark compact chromatin
reach the luminal surface of the
epithelium
Neuroendocrine Bronchi; rare in Basally oriented cells Not seen in routine preparations
cells (Kulchitsky bronchioles
or K-cells)
Squamous Bronchi and Stratified squamous epithelium Mature cells exfoliate singly, are polygonal with clear
bronchioles as an abnormal reaction transparent, abundant cytoplasm; well-defined cell
replacing normal pseudostratified borders; central, small nucleus with evenly dispersed
respiratory epithelium granular chromatin; nucleoli absent
Clara Predominantly Columnar nonciliated bronchiolar Not seen in routine preparations

in bronchioles cells; protuberant apical cytoplasm
Type I alveolar Alveoli Large, flat, squamous alveolar lining Not seen in routine preparations
pneumocytes cells; cover some 93% of alveolar
surface area; incapable of division
Type II alveolar Alveoli Columnar alveolar lining cells Cuboidal; roughly 15 m in diameter; large, round
pneumocytes comprising 16% of the lung to oval nucleus with smooth nuclear membrane;
parenchyma; microvillus surface; finely granular, evenly dispersed chromatin;
synthesize and secrete surfactant; micronucleoli present as monolayered sheets or in a
capable of division linear arrangement
Alveolar Alveoli Discrete or aggregates of round Round to oval; 10–25 m in diameter or more;
histiocytes to oval cells; well-defined cell well-defined medium-sized; cytoplasmic well-defined
(dust cells) borders; nucleus round, oval to borders; nucleus oval, round, or kidney-shaped,
kidney-shaped; binucleation/ central or eccentric; crisp nuclear membrane; finely
multinucleation frequent; granular chromatin; nucleoli /; binucleation
phagocytic cytoplasm frequent; cytoplasm variable, pale, carbon particles;
multinucleation /
Mesothelium Lining of lungs A single layer of squamous cells Present in tissue fragments as two-dimensional
and chest wall with underlying thin layer of sheets with a honeycomb arrangement; cell borders
collagenous tissue well-defined; nuclei central maintaining the
polarity; round, oval, occasionally kidney-shaped;
nuclear grooves /; nuclear membrane sharp;
finely granular chromatin; uniformly distributed
micronucleoli; cytoplasm moderate, dense
a
Modified from Colby TV, Koss MN, Travis WD. Tumors of the Lower Respiratory Tract. Washington DC: AFIP, 1995:10, with permission.
194
chronic bronchitis, heart failure, emphysema, infarction, Amyloid

atelectasis, and pneumonia. Corpora amylacea vary in
Amyloid represents a group of fi brillary proteins that is
size from 30 to 200 m in diameter, staining pink with
deposited in tissues in various conditions, staining pale to
hematoxylin and eosin stain and in Papanicolaou stain,
dense cyanophilic to eosinophilic material (e-Figs 7.38A
magenta with PAS stain, and blue with Masson’s trichrome
and B), at times with foreign-body giant cell reaction.
stain. They are morphologically characterized by concen-
Amyloid stains positively with Congo red, appearing
tric rings, radial striations, and sometimes inclusions in
apple green under polarized light. It is fluorescent under
the center. Corpora amylacea are either free floating in the
ultraviolet light when stained with thioflavin T.
alveoli or are surrounded by a ring of macrophages (e-Fig.
7.20) and are birefringent in polarized light.
Contaminants
Psammoma Bodies (Calcospherites) Specimens from the respiratory tract are subject to con-
tamination at any time from their procurement, dur-
Psammoma bodies are nonrefractile calcified concretions
ing cytopreparation and staining, to coverslipping. The
with concentric lamellations, sometimes found in associa-
sources are limitless. Only a few are described below.
tion with papillary adenocarcinoma, both primary and
Specimens, particularly sputum contaminated by food,
metastatic. They may also be seen in the absence of any
contain cells of animal and/or plant origin (e-Figs. 7.25A and
tumors and have been described in a condition known
B). The presence of skeletal muscle fibers suggests the for-
as pulmonary microlithiasis. Psammoma bodies appear
mer. Many of the cells of plant origin depict a morphologic
either naked or incorporated in a tissue fragment of
resemblance to several nonneoplastic entities as well as ma-
malignant cells when associated with malignancy. They
lignant neoplasms. Vegetable cells with deep orangeophilic
stain deep basophilic in H&E stain and amphophilic or
cytoplasm and dense-staining nuclei may be misinterpreted
basophilic in Papanicolaou stain (e-Fig. 7.21).
as cells of squamous carcinoma. Certain plant cells appear
as sheets of squamous cells, while some resemble virocytes;
Calcium Oxalate Crystals
still others with pale voluminous cytoplasm appear remark-
Calcium oxalate crystals are birefringent, plate-like, and ably similar to cells of adenocarcinoma. The features that
present by themselves or within giant cells. They are fre- help differentiate plant cells include thick cellulose walls,
quently associated with Aspergillus infection. smudgy nuclei lacking morphologic details, the presence of
storage vacuoles, extraordinarily large size, regular spatial
Schaumann Bodies arrangement, a variety of colors distributed throughout the
cytoplasm, and a hyper-refractile appearance.
Schaumann bodies are calcified structures, lamellated, and
Other contaminants identifi ed in respiratory speci-
often cracked; they are present in multinucleated foreign
mens include pollen, glove powder, fungal spores, micro-
body–type giant cells associated with granulomas result-
bial flora from the oral cavity, and mites, to name a few.
ing from diverse causes (e-Fig. 7.22).
Pollen are round structures that stain golden to am-
ber, have double walls and homogenous centers, and must
Asteroid Bodies
be differentiated from fungal spores. Starch granules from
Asteroid bodies represent a star-like array of crystallized glove powder are small, round, oval to polygonal, yellow
protein and present either extracellularly or within the refractile structures with a characteristic Maltese cross
multinucleated foreign body–type giant cells in a variety appearance under polarized light. Alternaria is fungi and
of granulomatous processes (e-Fig. 7.23). plant pathogens that are infrequently identified in re-
spiratory samples. They form elongated brown conidia,
Hyaline Cartilage roughly 30 m in length with a segmented structure and,
on rare occasions, demonstrate hyphae.
Hyaline cartilage may occasionally be present in speci-
mens obtained by transbronchial or transtracheal aspirates
(e-Fig. 7.24). NONNEOPLASTIC EPITHELIAL
ALTERATIONS
Elastin Fibers
Elastin fibers are refractile, elongated, curved, and often The epithelial lining cells of the tracheobronchial tree and
frayed, poorly stained structures frequently occurring in alveoli exhibit a wide array of morphologic changes in
bundles. Their presence signifi es tissue destruction (e.g., response to various types of stimuli, insults, or injuries.
acute necrotizing infl ammation, abscess, infarct, bron- The cellular alterations can be due to infectious agents,
chiectasis, and carcinomas with necrosis). In necrotic mechanical trauma such as instrumentation, smoking, en-
debris, the elastin fi bers may be mistaken for filamen- vironmental toxins, dust, immunological diseases, radia-
tous fungi such as Aspergillus. Unlike fungi, they lack cell tion, drugs, oxygen toxicity, and so on (Table 7.3; e-Figs.
walls, septation, and cytoplasm. 7.26 to 7.34; Figs. 7.1 to 7.15). The resulting changes may
TABLE 7.3 CYTOPATHOLOGIC FEATURES OF NONNEOPLASTIC EPITHELIAL CHANGES
Diagnostic Entity Cytopathologic Features See Fig(s).

Nonspecific Occur due to a wide variety of insults; changes nonspecific, may not involve all of the 7.1A and B
changes or epithelial cells uniformly; variable cell morphology within epithelial tissue fragments;
irritation forms cytokaryomegaly; fine to coarsely granular chromatin, smooth nuclear membrane; nucleoli
multiple, prominent; loss of cilia /; ciliocytophthoria /; multinucleation with uniform
mirror image nuclei; cytoplasm variable, pale to dense; mitoses rarely seen
Proliferative Seen in chronic bronchitis, bronchiectasis; bronchial asthma; chronic infections; morphologic 7.2A and B
and hyperplastic findings include: large numbers of tissue fragments of respiratory epithelium varying in
changes dimensions from small to large; the spontaneously exfoliated tissue fragments have smooth
contours and may curl up; abraded or forcibly removed epithelial tissue fragments have
irregular, jagged edges; being pseudostratified, respiratory epithelium presents a syncytial
pattern; variably enlarged nuclei with uniformly dispersed, finely granular chromatin;
prominent micronucleoli; mitoses /; secretory vacuoles /; degenerative changes /;
no necrosis; luminal borders with or without cilia; goblet cell hyperplasia /
Reserve cell Occur in response to chronic irritants; reserve cells proliferative and precede squamous 7.6
hyperplasia metaplasia. Proliferating reserve cells occur in small tissue fragments as small cells with 7.7
and squamous insignificant cytoplasm and deep-staining compact nuclei; mostly seen in bronchial brushings
metaplasia and washings; immature squamous metaplasia consists of round to oval medium-sized
squamous cells with dense cytoplasm; low N/C ratios
Epithelial repair/ Predominantly in tissue fragments; discrete cells or aggregates rare; flat, two-dimensional 7.11A and B
regeneration sheets with well-defined cell borders; low N/C ratios; abundant cytoplasm; round to oval 7.12A and
nuclei; smooth crisp nuclear membranes; chromatin finely granular with micronucleoli or B
macronucleoli; mitoses /; inflammatory background 7.43
Radiation-induced Involve squamous cells, columnar epithelial cells, and alveolar lining cells; direct effects 7.8A and
changes of radiation include marked cytokaryomegaly with pleomorphic bizarre forms; low N/C B
ratios, frayed cytoplasmic borders; abundant cytoplasm with multiple vacuoles or excessive 7.9A and
keratinization; nuclear enlargement with pleomorphism; binucleation to multinucleation, B, 7.10A
smudgy to pyknotic nuclei with intranuclear degenerative vacuoles; karyorrhexis, karyolysis; and B
associated changes include: irritation forms; repair/regeneration; squamous metaplasia with 7.11A and
or without atypia; keratinization B, 7.12A
and B
Goblet cell Occur in response to acute injuries and in chronic bronchitis, bronchiectasis; bronchial 7.5
hyperplasia asthma; chronic infections; goblet cells contain hyper distended vacuoles pushing the nucleus e-Fig.
toward the basement membrane 7.26
Drugs-induced Most severe damage is induced by chemotherapeutic drugs; may cause acute injury to alveolar e-Figs.
changes lining cells and acute respiratory distress syndrome; drugs such as amiodarone cause injury to the 7.34A and
lung as manifested by bilateral pulmonary infiltrate due to accumulation of phospholipids; BAL B
show a large number of foamy histiocytes containing lamellar bodies on ultrastructural exam
Hyperplastic and Cells isolated, in aggregates, or in tissue fragments; generally small in size, may be three- 7.13A and
reactive Type II dimensional; scalloped borders frequent; open petal pattern similar to that seen in cells of BAC; B, 7.14A
pneumocytes occasionally show small acinar-like structures with nuclei placed away from the center of the and B,
tissue fragment presenting a hob-nail pattern; tissue fragments contain acellular dense material 7.15A and B
with biphasic staining at the center, probably representing fragments of hyaline membranes e-Figs.
in cases of ARDS; hyaline membrane fragments may also be present in the background; cells 7.29 to
pleomorphic in size; small to large; round to oval; cell borders well-defined to fuzzy; abnormal 7.33
cells vary in numbers, generally few; nuclei variable in size; round to oval; low to high nuclear/ e-Figs.
cytoplasmic ratios; eccentric with hobnail pattern; nuclear membrane smooth, occasionally 7.27A
irregular; chromatin coarsely granular may be smudgy, no parachromatin clearing; prominent and B
nucleolus; cytoplasm variable, scant to abundant; bubbly to vacuolated simulating a signet-ring e-Fig. 7.28
pattern; sometimes dense; background containing inflammatory cells
(continued)

Cytologic changes Hyperplasia of ciliated columnar epithelium; goblet cell hyperplasia in bronchioles; shedding 7.3A and
associated with of large numbers of ciliated columnar cells, isolated and in tissue fragments in sputum; B
bronchial asthma papillary-like architecture of mucosal tissue fragments (Creola bodies); Curschmann’s 7.111B
spirals; eosinophils & Charcot-Leyden crystals; clean background; may be misinterpreted as
adenocarcinoma which lack cilia
Cytologic changes Infected cells with morphologic alterations seen in sputum, bronchial brushings and e-Fig.
associated with washings, and in BAL; cells seen isolated, in loosely cohesive groups, or in tissue fragments; 7.55
herpes simplex normal-sized to giant forms; nucleus single to multinucleation; nuclear chromatin e-Fig.
virus infection ground glass; pale; margination of the chromatin with a beaded appearance of the 7.56,
nuclear membrane; nuclei within multinucleated cells show molding of apposing margin; 7.38
intranuclear eosinophilic inclusions with peri-inclusion clearing; inflammatory background; 7.80
cellular debris /; associated changes: irritation forms; repair/regenerative changes
A B
Figs. 7.1A and B. Irritation forms. Bronchial brushings, direct smears showing pleomorphic respiratory epithelial
cells with mild nuclear enlargement and loss of cilia.
A B
Figs. 7.2A and B. Irritation forms. Bronchial brushings—direct smears. The tissue fragments of bronchial epithelium
are large with jagged edges due to brushings. They appear syncytial and folded upon themselves. Nuclei are mildly
enlarged, crowded and overlapped. Some cells have prominent nucleoli.
A B
Figs. 7.3A and B. A: Hyperplastic bronchial epithelium. Bronchial washings: This tissue fragment of respiratory epi-
thelium has smooth outline, indicating spontaneous exfoliation. The nuclei are mildly pleomorphic with prominent
nucleoli. These are referred to as “Creola bodies” are seen frequently in patients with bronchial asthma. B: Reactive/
hyperplastic bronchial epithelium in bronchial brushings. The tissue fragment of bronchial mucosa has scalloped
edges and syncytial architecture.
Fig. 7.4. Respiratory epithelial cells in sputum. The cells are crowd- Fig. 7.5. Bronchial brushings, direct smear: Tissue fragments of re-
ed with pleomorphic mildly enlarged nuclei and contain modest spiratory epithelium with goblet cell hyperplasia.
amount of cytoplasm. Elsewhere in the smear, cytologic changes of
herpes virus infection were apparent.
Fig. 7.6. Reserve cell hyperplasia: Bronchial washings. This three- Fig. 7.7. Sputum: Tissue fragment of benign metaplastic squamous
dimensional cell ball is composed of tightly packed small cells with epithelium.
poorly defi ned cell borders, insignificant cytoplasm, nuclei with
compact chromatin, and high N/C ratios. These cells may be mis-
taken for small cell carcinoma or a carcinoid tumor.
198
Figs. 7.8A and B. Bronchial brushings post radiation. These respi-

ratory epithelial cells are markedly atypical and pleomorphic with
A B enlarged nuclei and containing prominent nucleoli. These must be
differentiated from squamous carcinoma.
A B
Figs. 7.9A and B. Bronchial brushings, post radiation. Pleomorphic bronchial epithelial cells with radiation
changes.
A B
Figs. 7.10A and B. Bronchial brushings, postradiation showing squamous epithelial cells with nuclear enlargement
and hyperchromatic nuclei.
A B
Figs. 7.11A and B. Bronchial brushings, postradiation for squamous carcinoma. These squamous cells have
pleomorphic, enlarged nuclei, and are difficult morphologically to differentiate from squamous carcinoma.
A B
Figs. 7.12A and B. Bronchial washing, post radiation, showing reactive respiratory epithelial cells. The tissue frag-
ments show syncytial architecture with crowded and mildly atypical nuclei. At the periphery, where the cells are less
crowded, the nuclear chromatin appears uniform.
A B
Figs. 7.13A to B. Bronchial alveolar lavage from a patient with bilateral pulmonary infiltrate and on respirator as-
sistance. A: Tissue fragment of type II pneumocytes with scalloped borders and anisonucleosis. The fragment contains
acellular material (arrow) in the center representing the hyaline membrane. Note the discrete, enlarged type II pneu-
mocytes with the prominent nucleoli. Inflammation in the background favors a reactive process. B: A discrete tissue
fragment of reactive type II pneumocytes with scalloped borders. (continued)
C D
Figs. 7.13C to D. (continued) C: Pleomorphic discrete and tissue fragment of reactive type II pneumocytes in an
inflammatory background. Note the fragment of hyaline membrane in the center (arrows). D: This three-dimensional
tissue fragment of reactive type II pneumocytes with scalloped borders is difficult to differentiate from
bronchoalveolar carcinoma.
A B
Figs. 7.14A and B. Bronchial lavage from a patient on respirator. These syncytial tissue fragments of type II pneu-
mocytes, have a syncytial architecture and scalloped borders with nuclei located toward outer edges. Their nuclei are
variably enlarged and pleomorphic. Their cytoplasm is vacuolated. These cells are difficult to differentiate from an
adenocarcinoma.
Fig. 7.15. Bronchioloalveolar lavage showing florid hyperplasia of

type II pneumocytes. The patient had chemotherapy for Hodgkin
lymphoma. The large tissue fragments of type II pneumocytes with
smooth to scalloped borders contain enlarged hyperchromatic nu-
clei and mimic BAC.
be mild and reversible or severe enough to mimic neopla- delicate, are generally destroyed. Type II cells are the pro-
sia, causing a great potential for diagnostic errors. The genitors of type I cells; thus, they respond to the injury in
extent of cytomorphological alterations is dependent on an attempt to repair/regenerate and may undergo prolifera-
the type of cell injury or the etiologic agent, the intensity tion, hyperplasia, and hypertrophy. Their response can be
and the duration of the injury, the anatomic site and, most focal or diffuse, mild to extremely worrisome, mimicking
important, the immune status of the host. The cellular malignant neoplasia. Regardless of the type of injury, the
changes can be specific and pathognomonic of the disease morphologic response is similar but may vary in intensity.
process or nonspecific such as proliferative/hyperplastic The focal response is seen along the perimeter of parenchy-
changes or repair/regenerative and degenerative changes mal lesions such as granulomas, neoplasms, infarcts, local-
with or without cell death. Overlap of various nonspecific ized infections, and abscess (e-Fig. 7.28). Diffuse alveolar
features in a given disease process is not unusual. damage is more likely to be caused by systemic factors (e.g.,
The morphologic alterations may be seen in all sepsis, shock, or widespread exposure of lung parenchyma
types of epithelium (e.g., pseudostratified ciliated co- to toxic agents). The alveolar responses in the latter situa-
lumnar, goblet cells, reserve cells, alveolar lining cells tions are often florid and diffuse (e-Figs. 7.27A and B).
and squamous epithelial cells [native epithelium lining When the reaction is diffuse, the abnormal cells are re-
the trachea or the metaplastic squamous type lining the covered in sputum, bronchial washings, and in bronchoal-
bronchial tree]). veolar lavage. With localized lesions, abnormal type II pneu-
The epithelial changes can be fl orid and atypical, mocytes are usually present in aspiration biopsy specimens.
strongly mimicking malignancy. The milder and revers- The cytologic changes of altered type II pneumocytes
ible changes are referred to as “irritation forms.” Some of are similar to those described for diffuse alveolar damage
the common examples of epithelial changes include hy- in cases of adult respiratory distress syndrome (see below;
perplasia of the pseudostratifi ed columnar epithelium in Table 7.4; e-Figs. 7.29 to 7.33; Figs. 7.91 to 7.95).
chronic bronchitis, bronchiectasis, and bronchial asthma,
reactive and hyperplastic changes in infectious processes
Adult Respiratory Distress Syndrome (ARDS)
(e.g., herpes simplex virus infection), squamous metapla-
sia with atypia in chronic infections caused by bacteria Diffuse alveolar damage may be associated with a condi-
and fungi, radiation- and chemotherapy-induced changes tion referred to as Adult Respiratory Distress Syndrome
in columnar and squamous epithelium as well as alveo- (ARDS) characterized by the extensive destruction of the
lar lining cells. Depending on the type of the epithelium alveolar lining cells leading to severe hypoxia, reduced
involved, the diagnostic possibilities vary. For instance, lung compliance, reduced lung volume, and high mortal-
alterations in the columnar lining cells may mimic an ity. Diffuse alveolar damage has been divided into two
adenocarcinoma while squamous metaplasia with atypia overlapping stages: acute and organizing. The acute
may be mistaken for a squamous carcinoma. Chronic lo- exudative stage follows the initial insult lasting approxi-
calized infections with abscess formation may mimic a mately 7 days, characterized by massive interstitial edema
cavitary carcinoma. Radiation and chemotherapy may and hyaline membrane formation (e-Figs. 7.27A and B).
induce bizarre cellular changes causing great difficulties The proliferative or organizing stage consists of inter-
in differentiating from malignancy. Reactive/hyperplas- stitial infl ammation and fibrosis. Alveolar hyperplasia
tic type II pneumocytes are often difficult to differentiate develops 3 to 7 days following injury, persists through the
from adenocarcinomas. organizing stage, and eventually disappears. The type II
pneumocytes become enlarged and proliferate into mul-
tiple layers. They present a hobnail appearance when they
REACTIVE/HYPERPLASTIC TYPE II
protrude into the alveolar spaces. These hypertrophic and
PNEUMOCYTES
hyperplastic cells have abundant cytoplasm, large nuclei
One of the diagnostically difficult areas in respiratory cyto- with clumped chromatin, and prominent macronucleoli.
pathology involves the altered type II pneumocytes. Inju- Clinically, most patients show rapidly progressive pul-
ries with damage to the alveolar lining cells can result from monary dysfunction with tachypnea, dyspnea, decreased
a multitude of causes (e-Figs. 7.27 to 7.34), which include arterial oxygen tension, and variable diffuse interstitial and
infections, sepsis, shock, toxic inhalants, inspired high oxy- alveolar infiltrate on chest X-rays. Sepsis remains a common
gen saturations (oxygen toxicity), thermal injury, narcotics underlying cause. The findings may also entertain a differ-
overdose, radiation injury, drug reactions including che- ential diagnosis of malignancy. BAL is performed to identify
motherapeutic agents, smoke inhalation, ingested toxins, the infectious causes and also to rule out a malignancy.
chronic interstitial pneumonitis, granulomatous inflamma-
tions, pulmonary thromboembolism, industrial exposures,
and pulmonary fibrosis. The extent of alveolar damage is
dependent on several factors such as the causative agent, Whether the alveolar cell response is localized or gen-
severity of the injury, and its duration. Type I cells, being eralized, the morphologic alterations are similar. The
TABLE 7.4 CYTOPATHOLOGIC FEATURES OF ATYPICAL TYPE II PNEUMOCYTES IN ARDS
Presentation Cells isolated, in aggregates, or in tissue fragments; generally small in size, may be three-dimensional; scalloped
borders frequent; open petal pattern similar to that seen in cells of BAC; occasionally show small acinar-like
structures with nuclei placed away from the center of the tissue fragment presenting a hob-nail pattern
Cells Pleomorphic in size; small to large; round to oval; cell borders well-defined to fuzzy; abnormal cells vary in
numbers, generally few
Nucleus Variable in size; round to oval; low to high nuclear/cytoplasmic ratios; eccentric with hobnail pattern; nuclear
membrane smooth, occasionally irregular; chromatin coarsely granular may be smudgy, no parachromatin
clearing; prominent nucleolus
Cytoplasm Variable, scant to abundant; bubbly to vacuolated simulating a signet-ring pattern; sometimes dense
Background Inflammatory; neutrophils; macrophages with or without hemosiderin, fragments of hyaline membrane either
incorporated within tissue fragments of alveolar lining cells or dispersed in the background /
Immunoprofile Cytokeratin ; B72.3 ; PE-10
Ultrastructure Lamellated bodies; whorled myelin figure arrangement; numerous short surface microvilli; intercellular
junctions
Modified from Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer Verlag Inc., 2002.
abnormal cells representing hyperplastic/reactive type II forms. Mitotic figures are not a feature of hyperplastic/
pneumocytes exfoliate in sputum, bronchial washings, reactive type II pneumocytes. The background is often
and in BAL but are not encountered in direct smears of inflammatory with neutrophils and cellular debris along
bronchial brushings (e-Figs. 7.29 to 7.33; Figs. 7.13 to with hemosiderin-containing macrophages. In BAL from
7.15). They may also be seen in FNA biopsy specimens patients with ARDS, fragments of hyaline membrane may
from localized lung lesions. be identified (Table 7.4; see Figs. 7.13A and C).
The altered type II pneumocytes occur singly, in groups, In aspiration biopsy specimens, the cytomorphology
or in tissue fragments, generally in small numbers. These is usually well-preserved. The pneumocytes may be pres-
cells demonstrate considerable pleomorphism in their size ent in flat two-dimensional sheets, in syncytial tissue frag-
and shapes. They may be small or large, round, oval to ments, or occur singly and in groups. Their nuclei may be
polyhedral with well to poorly defined cell borders. The very bland with uniformly distributed chromatin or pres-
tissue fragments are usually small in size, and do not reach ent morphology similar to that seen in exfoliated cells.
the large dimensions of hyperplastic bronchial epithelium
or that of adenocarcinomas. The tissue fragments of ab-
Differential Diagnoses of Reactive/Hyperplastic/
normal type II pneumocytes are syncytial with ragged or
Hypertrophic Type II Pneumocytes
knobby contours. An open petal or cartwheel arrangement
is often noted. Although syncytial, these tissue fragments Atypical type II pneumocytes have great potential for mis-
lack the extreme depth of focus that is so characteristic of interpretation on account of their strong resemblance to
bronchioloalveolar carcinoma (BAC). Their nuclei are vari- adenocarcinoma cells. Their separation from an adenocar-
ably enlarged and round with smooth nuclear membranes. cinoma may be extremely difficult if the judgment is based
Binucleation and occasional multinucleation may be pres- purely on cytomorphology. The clinical history of an acute
ent. The nuclei may be central or eccentric with coarsely respiratory event, pulmonary dysfunction with symptoms
granular, deep-staining chromatin that sometimes appears of ARDS or a history of lung injury from any cause, or res-
smudgy. A single macronucleolus may be prominent and pirator assistance should serve as a caution against making
conspicuous. The nuclei in a tissue fragment with a cart- a malignant diagnosis. Features that favor a benign process
wheel pattern tend to be located at the periphery, away are listed in Table 7.12. Great caution must be exercised in
from the center. The nuclear to cytoplasmic ratios are vari- interpreting abnormal-appearing cells as malignant with
able depending on the amount of cytoplasm that ranges a history of an acute event or if a patient is on respirator
from scant to abundant. Qualitatively, the cytoplasm may assistance or with a history of toxic exposure and in the
stain pale to dense, bubbly or vacuolated with distended absence of a lung mass. These changes do regress in the
vacuoles indenting the nucleus and producing signet-ring event of recovery, while neoplastic cells will persist.
WHO classification is based on cytohistologic criteria ap-

PRIMARY LUNG CANCERS preciated only by light microscopy on routinely stained
preparations. Most squamous, adeno, and small cell carci-
Lung cancers are the most commonly diagnosed malig- nomas are readily recognized. Some poorly differentiated
nant tumors throughout the world causing considerable adenocarcinomas and squamous carcinomas are lumped
morbidity and high mortality. It is the number one cause into the group referred to as “non-small cell carcinomas”
of cancer death in the USA among both sexes with more when differentiation is not readily made.
than 178,000 new lung cancers every year and 166,000
deaths annually. Similar problems exist worldwide.
AGREEMENT BETWEEN HISTOLOGIC
Cigarette smoking is the single most notable cause of
AND CYTOLOGIC DIAGNOSIS
lung cancer. Additional causes include asbestos exposure,
radiation, and exposure to several toxic elements and car- Cytologic and histologic interpretations on specimens
cinogens. Some other factors described in carcinogenesis obtained simultaneously match in a substantial number
include lung scarring, alveolar epithelial hyperplasia, and of cases. In one study, there was 75% concordance. In
previous lung cancers. the remaining 25% of the cases, the biopsy or cytology
alone was diagnostic in an equal number of cases leading
to the conclusion that both methods used in combination
INCIDENCE, SIGNS, AND SYMPTOMS
are superior to either one used by itself. In another study,
Carcinoma of the lung affects primarily adults over the the concordance rates between histologic and cytologic
age of 45 years and is more prevalent among males than diagnosis were 85% for squamous carcinomas, 79% for
females, although there has been a dramatic increase in adenocarcinomas, 30% for large cell carcinomas, and
lung cancers among women in the past two decades. 93% for small cell carcinomas.
Among the subtypes, adenocarcinoma has surpassed
squamous carcinoma as the most common type of lung
DIAGNOSTIC PITFALLS, FALSE POSITIVE,
cancer.
AND FALSE NEGATIVE ERRORS
Signs and symptoms of lung cancers are generally re-
lated to the direct and indirect effects of the tumor. Over Reactive cells of the upper and lower respiratory tract can
80% of the patients harboring lung cancer are symptom- exhibit alarming degrees of atypia in a variety of con-
atic. The direct effects are dependant on the location of the ditions, simulating malignancy. Such changes are easy to
tumor, whether central or peripheral, or may be related to assess in histologic sections since the overall architecture
the metastatic lesions. Indirect effects that are nonmeta- is preserved and differentiating benign reactivity from
static in nature are referred to as “paraneoplastic” and malignancy is relatively easily accomplished. This is not so
include those caused by ectopic hormone production. in cytologic specimens. The diagnostic distinction between
atypical reactive epithelium and well-differentiated car-
cinomas rests on subtle morphologic clues (e.g., degree
MORPHOLOGIC DIAGNOSIS, TYPING
of atypia, number of abnormal cells, and proper clinical
OF LUNG CARCINOMAS, AND THEIR
setting). Diagnostic diffi culties are also faced in the pres-
HETEROGENEITY
ence of inadequate specimens and poor cytopreparation.
Morphologic examination of respiratory material (Table Immunostains are usually of no help in differentiating a
7.1) contributes substantially to the diagnosis and patient benign process from a malignant one. The distinction must
management. The diagnostic yield and accuracy varies be made on routinely stained preparations. False positive
with the specimen type. The choice is influenced by per- diagnoses are rendered when benign, reactive changes are
sonal preference, patient status, location of the lesion, and interpreted as malignant. False negative diagnosis occurs
the differential diagnostic possibilities. either because of sampling or because of an interpretative
Lung cancers are known for their heterogeneity. error. Pathologists/cytopathologists must be cognizant
Many carcinomas show more than one morphologic type of settings where such diagnostic errors can potentially
in different areas of the tumor. Even if this is not appreci- occur. To quote one famous cytopathologist, “most diag-
ated under light microscopy, at the ultrastructural level, nostic errors occur either because of inadequate specimen
it is not uncommon to fi nd more than one type of dif- or inexperience.”
ferentiation. Only a third of carcinomas were found to be WHO classification (Appendix II) broadly divides lung
homogeneous in one study. The diagnosis and typing of cancers into two major categories: non-small cell carcino-
carcinomas depend on the area of the tumor sampled and mas and small cell carcinomas. Non-small cell carcinomas
also on the quantity of the specimen. Specimens submit- include squamous carcinomas and adenocarcinomas in-
ted for cytologic evaluation represent only a tiny area of cluding bronchioloalveolar and large cell carcinomas. The
the neoplasm. It is quite conceivable that the cytologic clinicopathologic features of the major types of cancers
typing could differ from the histologic diagnosis. The are listed in Table 7.5.
TABLE 7.5 CLINICOHISTOMORPHOLOGIC FEATURES OF MAJOR TYPES OF LUNG CANCER
Bronchogenic Adenocarcinoma Bronchioloalveolar Large Cell Undifferentiated

Squamous Carcinoma (Conventional) Carcinoma (BAC) Small Cell Carcinoma Carcinoma (LCUC)
Incidence of 30% 35% 1–5% 12–18% 10%
Lung Cancers
Sex Common in males Common in females Equalin males & females Common in males; Not well-documented
M:F 10:1
Age Over 40 years of age; sixth Over 40 years of age Over 40 years of age 32–79 years; median age Median age 60
decade common 60
Association Strong Not strong Not strong Strong Strong

with Smoking
Signs & Generally symptomatic; Often asymptomatic Often asymptomatic (75%); Symptomatic short Symptoms due to local effect,
Symptoms related to local and/or discovered as an incidental duration, cough, dyspnea, may present paraneoplastic or
direct spreads; cough, finding on chest X-ray; wheezing, hemoptysis, endocrine syndrome
dyspnea, wheezing, stridor, cough, dyspnea, excessive chest pain, obstructive
hemoptysis, chest or back mucoid expectoration in pneumonia; superior
pain, obstructive pneumonia late stages, chest pain, venacaval syndrome
with or without cavitation; weight loss
endocrine symptoms 10%
Radiologic Mass lesion in lung or at the Mass lesion in the lung or at the Solitary peripheral nodule 5% no radiologic Central or peripheral
Features hilum hilum or multiple nodules; diffuse evidence; 70% as
infiltrate; pneumonic perihilar mass
consolidation, bilateral
involvement
Location of the Generally central 64%; General peripheral 65%; central Peripheral Frequently central 74%; Peripheral 6%; central 42%;
Tumor perihilar 29%; hilar 40% 5%; hilar/perihilar mass 17%; present as hilar/perihilar cavitation 4%
cavitation 5% cavitation 2% mass 78%; cavitation 0%
Local Spread Hilar lymph nodes; pleural Hilar lymphadenopathy 19%; Spread within air spaces Hilar lymph nodes 61%; Hilar lymphadenopathy 32%;
chest wall involvement; mediastinal nodes 5%; pleural characteristic along mediastinal lymph nodes mediastinal 10%; pleural chest
mediastinal nodes 5% chest wall 14% intact alveolar walls; 14%; pleural 5% wall 2%
hematogenous lymphatic,
pleural spread infrequent
(continued)
Bronchogenic Adenocarcinoma Bronchioloalveolar Large Cell Undifferentiated

Squamous Carcinoma (Conventional) Carcinoma (BAC) Small Cell Carcinoma Carcinoma (LCUC)
Gross and Small, endobronchial Well-circumscribed, often with Gray-white foci of Size variable; Generally large necrotic; may
Histologic obstructive tumors to large overlying pleural fibrosis or consolidation without extensive necrosis invade overlying pleura and other
Features cavitated masses that can puckering; size 1 cm to large necrosis or hemorrhagic; with hematoxyphilic hilar structures; considerably
replace an entire lung; gray- bulky; gray-white pigmentation; may be associated with encrustation of the pleomorphic in size, polygonal
white to yellowish; necrosis lobulated with central scarring; central or pneumonic blood vessels; histologic in shape, large nuclei with
and hemorrhage common; hemorrhage and necrosis; consolidation; papillary types include small cell prominent nucleoli; variable
soft to firm extensive pleural seeding; mostly fronds; nuclei round with intermediate and mixed cytoplasm clear, foamy, giant
unrelated to bronchus; micro bland chromatin pattern; types (WHO); with to spindle cell pattern; growth
tubular acinar or papillary; psammoma bodies /; palisading of nuclei at pattern is nests and sheets; stroma
varying amounts of cytoplasm; no necrosis, no hemorrhage the periphery of nest and absent to extensive
pale, foamy to vacuolated to or pleural involvement; anastomosing masses;
dense; with or without mucin aerogenous spread; high mitotic rate
vacuoles mucinous and nonmucinous
types
Spread of Hilar, mediastinal lymph Hilar/mediastinal lymph nodes; Spread within air Hilar and mediastinal Hilar and mediastinal lymph
Tumor nodes; pleura, chest wall pleura, chest wall; widespread spaces characteristic; lymph nodes frequent, nodes; pleura, chest wall;
metastasis hematogenous, lymphatic, pleural involvement; widespread metastasis
and pleural spread widespread metastasis
infrequent
Prognosis Poor Poor Better than other types Dismal Poor
Five Year 5% 19.2% 42% 0.05% 11.4%

Survival Rate
Cellularity Variable Variable Variable (uncommon Variable Variable

in bronchial brushings
but present in bronchial
washing or lavage and
sputum)
Presentation Malignant cells isolated, in Malignant cells isolated, in Cells isolated, in loose Malignant cells isolated, Malignant cells isolated, in
loosely cohesive groups, or loosely cohesive groups, or aggregates, or in syncytial in loosely cohesive loosely cohesive groups, or in
in syncytial tissue fragments in syncytial tissue fragments tissue fragments; three- groups, or in syncytial syncytial tissue fragments without
without any architectural with or without acinar pattern; dimensional ball; papillary tissue fragments without any architectural pattern
pattern; squamous pearls in papillary configuration with tissue fragments with open any architectural pattern
well-differentiated types three-dimensional presentation; flower pattern
smooth borders
Cells Markedly pleomorphic in Large round, polygonal to Cells small to medium-sized, Small (3–3.5 times the Small to large, cuboidal, round
well-differentiated; round, columnar, well to poorly defined round, cuboidal, columnar; size of lymphocyte); to polygonal, giant and spindle
polygonal, spindle-shaped cell borders; N/C ratios increased well to poorly defined round, oval to fusiform; forms may be present; high N/C
to caudate; well-defined cell borders; N/C ratios poorly defined cell ratios
cell borders; N/C ratios increased borders very high N/C
moderately to markedly ratios
increased; anucleated
squames
Nucleus Central, round, smooth Central to eccentric; large Central to eccentric; round Central, round to Central; multinucleation;
to irregular nuclear round to oval; smooth to with smooth to irregular ovoid; fusiform; smooth smooth to irregular nuclear
membranes; chromatin fine irregular nuclear membranes; nuclear membranes; to irregular nuclear membranes; fine to coarsely
to coarsely granular with finely granular chromatin; powdery to finely granular membranes; chromatin granular chromatin; excessive
excessive parachromatin micronucleoli to prominent chromatin; micronucleoli to coarsely granular to parachromatin clearing;
clearing; prominent micro/ macronucleoli; nuclear grooves prominent macronucleoli; compact, densely stained; prominent micro/macronucleoli
macronucleoli; pyknotic / nuclear grooves and nucleoli inconspicuous to
nuclei frequent in well- intranuclear inclusions absent; nuclear molding
differentiated lesions; characteristic; mitoses
mitoses / frequent; karyorrhexis
Cytoplasm Variable, scant to abundant; Generally abundant, clear, pale, Scant to moderate, pale, Scant to indiscernible Variable, scant to abundant, clear,
excessive keratinization foamy to dense; mucin vacuoles foamy to vacuolated; cytoplasm pale to dense
in well-differentiated /; psammoma bodies / secretory vacuoles;
types; cyanophilic to dense psammoma bodies /
refractile orangeophilic
Background Clean to necrotic Necrosis frequent Clean, no necrosis Necrotic Clean to necrotic
Histochemistry Not applicable Mucin / Mucin /; apical PAS ; Mucin Mucin
PAS intranuclear inclusion
glycogen
Immunoprofile CK ; TTF1 -; p63 EMA ; CEA ; TTF-1 ; EMA ; CEA ; TTF-1 ; Neuroendocrine markers
CK7 ; CK20 ; AE1/AE3, and CK7 ; CK20 ; AE1/AE3, ; cytokeratin (CAM5.2
CAM5.2 and CAM5.2 , PE10 and CK7 ; TTF-1
CK20
MOLECULAR BIOLOGY The development of carcinoma occurs over a pro-

longed period of time specifi cally in chronic tobacco
Predictive Markers smokers. The cytopathologic changes representing the
pre-invasive phases of squamous carcinoma may be de-
Lung cancer has been a formidable opponent for oncolo- tected in sputum several months prior to the clinical
gists and surgeons in achieving long-term remission and manifestation of an invasive lesion during the screening
long-term survival remains poor. Advances in under- of high-risk patients. The pre-invasive and early invasive
standing the molecular genetics of lung adenocarcinoma changes typically involve large airways and segmental
revealed that a dramatic response to tyrosine kinase inhib- bronchi and are not detected radiologically. Patients are
itor (TKI) gefitinib strongly correlated with the presence often asymptomatic but may present with cough and he-
of mutations in the tyrosine kinase domain of the EGFR moptysis. Early invasive cancers that are not detected ra-
gene. Since then, testing for hotspot mutations in exon 19 diographically are referred to as “occult carcinomas.”
and 21 of the EGFR gene, which accounts for approxi-
mately 90% of the mutations in patients with lung adeno-
carcinoma, is a standard of practice in a clinical setting INVASIVE SQUAMOUS CARCINOMA
for selecting patients for targeted therapy. This test can
be performed on DNA extracted from FNA samples or Squamous carcinomas comprise roughly 30% of all lung
pleural effusion smears or cell block in cases where cytol- carcinomas and are strongly associated with a prolonged
ogy is the only sample available. The smears may be used history of cigarette smoking. Once the most common type
to identify the tumor cell proportion and macrodissected of lung cancer, squamous carcinomas are now surpassed
to enrich the tumor DNA. In cases with wild type EGFR, by adenocarcinomas and occur predominantly in males
mutation in KRAS (codons 12, 13) predicts resistance to beyond the fifth decade of life, although they may be seen
TKI. In some institutions, in cases with wild type EGFR for in younger patients.
hotspot mutations, KRAS mutation testing is performed as The majority of squamous carcinomas are located
reflex testing. In approximately 2 to 3% of lung adenocar- centrally, arising in the main stem, lobar, or segmental
cinomas, BRAF V600E mutation is observed, which also bronchi, often causing obstructive symptoms such as
predicts resistance to TKI inhibitor therapy. They provide cough, dyspnea, hemoptysis, wheezing, stridor, or pneu-
a potential target for MEK inhibitor or BRAF inhibitor monia. One-third of squamous carcinomas occur in a
therapy. Thus, molecular diagnostics provide important peripheral location, and the patients may remain asymp-
information for targeted therapy for lung adenocarcinoma. tomatic for a long time. Chest radiographs show various
There are other mutations observed in low frequency (e.g., patterns ranging from a solitary nodule, peripheral or
ERBB2[Her2/neu], Alk-EML4 fusion, PIK3CA), which central mass, hilar and perihilar mass, cavitation, and me-
provide further possible molecular targets. diastinal lymphadenopathy.
Metastasis to regional and distant lymph nodes as
well as to other organs is very frequent and often present
Diagnostic Markers for Lung Cancers at the time of diagnosis. The prognosis is generally not
Lung adenocarcinomas usually stain positive for cytoker- favorable and mortality remains high.
atin 7, thyroid transcription factor-1 (TTF-1), and PE-10
(surfactant protein); these serve as a useful immunohis- Gross and Histologic Features
tochemistry marker panel. Squamous carcinoma, on the Grossly squamous carcinomas vary considerably in size,
other hand, stains positive for cytokeratin 5/6, p63 and ranging from small endobronchial obstructive tumors to
negative cytokeratin 7, TTF-1, and PE-10. Small cell car- large cavitary lesions replacing an entire lobe of the lung.
cinoma and tumors with neuroendocrine differentiation The tumor may extend into the mediastinum. Squamous
stain positive for neuroendocrine markers such as synap- carcinomas appear grayish-white with yellow specks.
tophysin, chromogranins, and CD56 (N-CAM) in addi- Necrosis and hemorrhage are frequent, leading to cavi-
tion to cytokeratin stain. Small cell carcinomas also stain tation that may become secondarily infected. Some car-
with TTF-1 in many cases. cinomas are fi rm to hard in consistency as a result of
desmoplasia.
Based on the degree of differentiation, squamous
SQUAMOUS CARCINOMA
carcinomas are graded as well, moderately, and poorly
Squamous carcinomas of the lung develop through phases differentiated. Well-differentiated squamous carcinomas
of morphologic alterations involving the pseudostratified consist of large nests and islands of polygonal cells, well-
ciliated columnar epithelium of the bronchial tree. These defined cell borders, and abundant eosinophilic cytoplasm
changes cover a wide spectrum that includes squamous with varying degrees of keratinization, intercellular bridg-
metaplasia, varying degrees of dysplasia, carcinoma in situ, es, and keratin pearl formations. Keratinization is very
and early invasion, similar to those seen in uterine cervix. evident in the center of masses of cancer cells containing
layers and layers of lamellated keratin. The islands of tion. Their nuclei demonstrate obvious features of malig-
carcinoma cells often exhibit peripheral palisading of the nancy. The neoplastic cells occur singly, in aggregates, and
nuclei. Foreign-body giant cell reaction to keratin may be in syncytial type tissue fragments (Figs. 7.22 and 7.23).
present. These differentiating features are less prominent Poorly differentiated squamous carcinomas offer few,
in moderately differentiated squamous carcinomas. The if any, features of squamous differentiation (Table 7.6; Figs.
malignant cells exhibit tendency toward squamous differ- 7.24 to 7.26). The cytologic samples are usually very cel-
entiation with dense cytoplasm and intercellular bridges. lular consisting of malignant cells in syncytial tissue frag-
Cytoplasmic keratinization may be focally seen or may be ments without any architectural patterns. The cell size is
insignificant. Poorly differentiated carcinomas show only variable with large nuclei and high nuclear to cytoplasmic
focal squamous differentiation. The neoplastic cells tend ratios. Nuclear chromatin is fine to coarsely granular with
to be discohesive and are often mixed with inflammatory parachromatin clearing, micro- and macronucleoli, and
cells. Squamous carcinomas may exhibit different grades numerous mitotic figures. Pleomorphism in cell size and
in different parts of the tumor. The foci of spindle cell and/ shape may be a prominent feature with bizarre, polygonal,
or giant cell pattern and clear cell change may be present. spindle and giant forms, multinucleation, and emperipole-
Stromal desmoplasia can be present and extensive. sis. The cytoplasm of the malignant cells is usually scant,
providing no clue to their identity. The only indication
leading to squamous differentiation may be an occasional
anucleated cell with dense cytoplasm and well-defined rig-
The majority of squamous carcinomas are centrally id cell borders or an intracytoplasmic keratin blob.
located and readily exfoliate cells in the airways; thus, they
are easily identified in sputum samples. Centrally located Morphologic Variants of Squamous Carcinomas
squamous carcinomas are accessible to the bronchial
brush and can be sampled with a high diagnostic yield. Morphologic variants of squamous carcinomas include
FNA biopsies are used for diagnosing peripheral tumors Well-differentiated papillary or verrucous type
as well as metastatic lesions involving the lymph nodes. Small cell variant
The cytomorphologic features of squamous carcino- Basaloid type
mas (Table 7.6; Figs. 7.16 to 7.26) depend on the degree Clear cell type
of histologic differentiation. Well-differentiated keratiniz-
ing squamous carcinomas are characterized by very pleo- Well-Differentiated Papillary or Verrucous Type. These
morphic cells, occurring mostly singly (Fig. 7.18), in loose tumors are infrequent, occur in older people, and offer a
groupings, and in small tissue fragments. The malignant better prognosis. They are generally intrabronchial pap-
squamous cells exhibit considerable variation in their size, illary lesions with minimal pleomorphism, little or no
ranging from small to large with frequent giant forms and necrosis, and minimal or no stromal invasion. Cytohisto-
in shapes from round, polygonal, caudate, spindle, and logically, these bland neoplastic cells may offer consider-
fi ber to tadpole forms. Elongated cells with or without able difficulty in recognizing the lesions as malignant.
keratinization may be seen in fascicles. The malignant Small Cell Variant. The small cell variants of squamous
cells possess well-defi ned cell borders and contain vari- carcinoma are poorly differentiated neoplasms consisting
able, excessively keratinized cytoplasm, staining deep or- of small cells forming nests and varying-sized islands with
angeophilic to cyanophilic, and sometimes, bright yellow a high mitotic rate and necrosis. In cytologic specimens,
with a hyaline gloss (Figs. 7.19 to 7.21). Their nuclei are the malignant cells are small, round to oval and have
central, round to oval, and variable in size with smooth to well-defined cell borders. Their nuclei are large with very
irregular nuclear membranes and coarsely granular chro- high nuclear to cytoplasmic ratios. The nuclear chromatin
matin, parachromatin clearing, and prominent micro- or is coarsely granular and nucleoli are prominent. Mitotic
macronucleoli. Large structureless pyknotic nuclei are fi gures may be frequent. The background often shows
quite characteristic. The background may show keratin necrosis. There are considerable morphologic similarities
debris and pleomorphic anucleated cells with or without between small cell variant of squamous carcinomas and
dyskeratosis (Figs. 7.16 and 7.17). Keratin pearls may be small cell carcinoma making the differentiation between
present. With necrosis and infl ammation, the malignant the two extremely difficult without the immunostains. The
cells may be obscured by neutrophilic and cellular debris cells of small cell variant do not exhibit nuclear molding
making their identification difficult. and do not demonstrate stretch artifacts. Unlike small cell
Moderately differentiated squamous carcinomas (Table carcinoma, the cells of small cell variant possess well-de-
7.6) exhibit some squamous differentiation in the form of fi ned cell borders, nucleoli and a thin rim of cytoplasm.
endo-/ectoplasmic demarcation and ringing within the cy- Squamous differentiation may be appreciated focally.
toplasm. The malignant cells are medium to large-sized and
round to polygonal with well-defined cell borders and vari- Basaloid Type Squamous Carcinoma. Basaloid squamous
able, dense cytoplasm that occasionally shows keratiniza- carcinomas are newly described morphologic variants of
TABLE 7.6 CYTOPATHOLOGIC FEATURES OF WELL-DIFFERENTIATED (KERATINIZING)

SQUAMOUS CARCINOMA & MODERATE TO POORLY DIFFERENTIATED (NONKERATINIZING)
SQUAMOUS CARCINOMAa
Moderate to Poorly Differentiated

Well-Differentiated (Keratinizing) Squamous Carcinoma (Nonkeratinizing) Squamous Carcinoma
Cellularity Variable, sparse to overwhelmingly cellular Variable
Presentation Cells mostly discrete, in loosely cohesive groups, or in syncytial Cells isolated, in loosely cohesive groups,
tissue fragments; keratin pearls / or in syncytial tissue fragments without any
architectural pattern; large syncytia often
present in washings, BAL, and in needle
aspirates; cytokeratin pearls absent; single cells
may be obscured by inflammatory cells
Cells Markedly pleomorphic in size and shape; cells small, medium Generally round to polygonal, may be
to large with frequent giant forms; shapes range from round, spindle-shaped, or bizarre giant forms; small
polygonal, fiber, spindle, caudate to tadpole forms; spindle resembling small cell carcinoma to medium or
cells often in parallel bundles; well-defined, rigid cell borders; large cell type; well-defined cell borders
intercellular bridges may be seen in tissue fragments; anucleated
excessively keratinized, pleomorphic forms
Nucleus Great variation in size, central location; multinucleation in Round, central with high N/C ratios;
giant forms; round with smooth to irregular nuclear borders; multinucleation /; nuclear borders smooth
chromatin fine to coarsely granular with parachromatin to irregular; chromatin fine to coarsely
clearing; karyopyknosis frequent; nucleoli variable in size and granular with parachromatin clearing; multiple
shape; multiple micronucleoli to single macronucleolus; mitoses micronucleoli/macronucleoli; karyopyknosis;
infrequent; N/C ratios variable mitoses /; necrosis /
Cytoplasm Variable, scant to abundant; varying degrees of keratinization; Variable, generally scant; dense, individual cells
cytoplasm may stain deep orange, cyanophilic, or yellow with may demonstrate squamous differentiation
refractile quality; emperipolesis / with endoplasmic/ectoplasmic demarcation,
ringing of the cytoplasm; individual cell
keratinization /; emperipolesis /
Background Clean to necrotic; inflammatory debris /; keratin debris Inflammation /; necrosis / keratin
debris not present
Differential Degenerating respiratory columnar cells (pseudoparakeratosis) Poorly Differentiated Adenocarcinoma

Diagnoses Degenerating squamous cells originating from upper (both Primary and Metastatic)
aerodigestive tract, including Pap cells LCUC
Florid squamous metaplasia with atypia and keratinization Small Cell Carcinoma
Tracheostomy site Malignant Non-Hodgkin Lymphoma
Chronic bronchitis and bronchiectasis Soft Tissue Tumors
Chronic infections Malignant Melanoma
Cavitary lesions Thymic Carcinoma
Post radiation, chemotherapy, and laser therapy Germ Cell Tumors
Epithelium overlying submucosal neoplasms
Diffuse alveolar damage in the vicinity of pulmonary infarcts
Repair/regeneration
Mesothelium with atypical nuclei in transthoracic aspiration
biopsies
Food contaminants (vegetable cells)
Severe dysplasia and carcinoma in situ
Squamous carcinoma arising in the upper aerodigestive tract
and esophagus
a
Modified from Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer-Verlag Inc., 2002.
Cytopathologic Features of Squamous Carcinoma (See Figs. 7.16 to 7.26)
Fig. 7.16. FNA of squamous carcinoma. A smear showing exces- Fig. 7.17. FNA of squamous carcinoma showing pleomorphic
sively keratinized, discrete squamous cells with enlarged pyknotic squamous cells with keratinization.
nuclei. Note the keratin debris in the background.
Fig. 7.18. Sputum: Marked exfoliation of discrete, malignant Fig. 7.19. Squamous carcinoma. Direct smears of bronchial brush-
squamous cells with pleomorphic shapes and excessive keratiniza- ings showing a tissue fragment of malignant squamous cells which
tion. Note the spindle forms. are large, round to polygonal with abundant keratinized cytoplasm.
Fig. 7.20. Squamous carcinoma. Direct smears of bronchial brush- Fig. 7.21. Squamous carcinoma. Direct smears of bronchial brush-
ings depicting very pleomorphic keratinized malignant squamous ings showing a well-differentiated squamous carcinoma with a gi-
cells. ant form.
Fig. 7.22. Moderately differentiated squamous carcinoma. Direct Fig. 7.23. Bronchial brushings, direct smear showing moderately
smears of bronchial brushings, showing syncytial tissue fragment differentiated nonkeratinizing squamous carcinoma.
of large malignant cells with variable cytoplasm and pleomorphic
nuclei.
Fig. 7.24. Bronchial brushings, direct smear showing poorly differ- Fig. 7.25. FNA of a lung nodule depicting poorly differentiated
entiated squamous carcinoma cells. The malignant cells are medium- squamous carcinoma.
sized, discrete and loosely cohesive, and possess scant cytoplasm. An
occasional cell shows keratinization.
squamous carcinomas. The tumors can occur in pure form

or in association with squamous carcinoma or large cell
undifferentiated carcinoma (LCUC). This tumor behaves
aggressively.
Histologically, basaloid squamous carcinomas are
characterized by a solid, lobular, or anastomosing trabecu-
lar pattern growing invasively in a finger-like fashion. The
malignant cells demonstrate peripheral palisading with
radial arrangement. The small, cuboidal to fusiform cells
have moderately hyperchromatic nuclei without nuclear
molding and demonstrate a high rate of mitosis. Nucleoli
are not prominent. The cytoplasm is scant. There are foci of
centrilobular coagulative necrosis. Cytopathologic findings
have rarely been reported. The malignant cells are small
Fig. 7.26. FNA of a lung nodule depicting poorly differentiated round to short spindle-shaped with scant cytoplasm. They
squamous carcinoma. present as syncytial tissue fragments with marked nuclear
crowding and overlapping, sometimes as three-dimension- compared to mediastinal lesions, which are aspirated for
al clusters. Their nuclear to cytoplasmic ratios are high. staging bronchogenic carcinomas. Each will have different
The nuclei are deep-staining with no nuclear molding. diagnostic considerations. Food contaminants are encoun-
tered only with sputum and not with any other type of
Squamous Carcinoma with Clear Cell Change. Clear cell specimen, the exception being bronchoesophageal fistula.
change is common in squamous carcinomas and occurs The differential diagnoses of well-differentiated
in focal areas. The extent of clear cell change is variable squamous carcinoma include 1) cavitary lesions; 2) ab-
and can be extensive. Clear cell change can be appreciated normal squamous cells originating from surface epithe-
better on histologic sections than on cytologic prepara- lial reactions; 3) repair/regenerative changes; 4) radiation-/
tions. The well-defined cell borders seen in tissue sections chemotherapy-induced changes; 5) pre-invasive changes
are not visualized in smears. The cytoplasm often appears including squamous carcinoma in situ; 6) metastatic well-
pale and fibrillar and the nuclei are frequently bare. differentiated squamous carcinomas; and 7) vegetable cells
(food contaminant).
Differential Diagnoses of Squamous Carcinoma
Cavitary Squamous Carcinoma versus Cavitary Lung
Differential diagnoses of squamous carcinoma correspond Lesions. Well-differentiated keratinizing squamous car-
to its histologic grade, location, and the type of cytologic cinomas tend to cavitate (Table 7.7; see Figs. 7.32 and
specimen (Table 7.6). Differential diagnostic possibili- 7.33). In aspiration biopsy specimens of the cavitary
ties are different for peripheral squamous carcinomas as squamous carcinomas, keratin grossly appears yellow
TABLE 7.7 DIFFERENTIAL DIAGNOSES OF CAVITARY LUNG LESIONS

Tuberculosis Grossly granular, cheesy; acellular eosinophilic material; granulomas /; epithelioid cells 7.27
with comma-shaped nuclei; multinucleated giant cells (Langhans’ type); fibroblasts and
lymphocytes; calcification /; special stains required to demonstrate acid-fast bacilli
Lung abscess Purulent material; neutrophilic exudate; cellular and necrotic debris; granulation tissue /; 7.28
elastin fibers
Aspergillosis Abscess cavity may or may not communicate with the bronchus; necrotic and cellular debris; 7.41
organisms present as thick, septate hyphae, branching at 45º; calcium oxalate crystals /;
lining epithelium of the cavity with squamous metaplasia with or without mild to moderate
atypia; may cause false positive interpretation
Cavitary Squamous The aspirate may be grossly cheesy, granular, resembling caseous material from tuberculous 7.32
Carcinoma lesion; malignant cells discrete, in groups and infrequently in syncytial tissue fragments; 7.33
anucleated squames; keratin pearls /; cellular material often obscured by keratin debris;
excessively keratinized malignant cells; nuclei pyknotic and structureless; well-preserved
malignant cells are essential for the diagnosis
Cavitary poorly Sparse population of poorly differentiated malignant cells, mostly discrete or in small 7.34A and
differentiated groups, obscured by acute inflammatory infiltrate and cellular and necrotic debris; B, 35A and
carcinoma granulation tissue / B
Rheumatoid nodule Aspirate grossly granular; eosinophilic granular material obscuring cellular component
(rare occurrence) consisting of pleomorphic spindle-shaped cells; lymphocytes and multinucleated giant cells
and fibroblasts; neutrophilic infiltrate not uncommon
Histoplasmosis Infection by Histoplasma capsulatum may cause a granulomatous and necrotizing inflammation 7.29
with cavity formation. The organisms are usually present within the macrophages; small yeast
forms, 2 m, possess thin capsule, stains positive with PAS and silver stain
Blastomycosis Abscess or cavitary lesion; organisms readily identified. Yeast forms 8–15 m in diameter; 7.30
spherical, single budding with a broad base, sharply defined thick refractile walls;
granulomatous response
Differential Diagnoses of Cavitary Squamous Carcinoma (See Figs. 7.27 to7.35)
Fig. 7.27. FNA lung nodule. This cavitary lesion contained cheesy Fig. 7.28. FNA lung of an abscess showing a multinucleated for-
material. Grossly, caseating tuberculous granulomas and keratiniz- eign-body-type giant cell in a neutrophilic background.
ing squamous carcinomas both show cheesy material. The necrotic
debris seen in this image stained positively for acid-fast M. tubercu-
losis (arrows) (Ziehl-Neelsen).
Fig. 7.29. BAL from a patient with a cavitary lesion showing histio- Fig. 7.30. Patient with a diffuse pneumonic process with cavitations.
cytes containing Histoplasma organisms (arrows) (PAS with diastase). Bronchial washings showing Blastomyces organisms (arrows).
and cheesy, strongly resembling the caseating necrosis of

tuberculous lesions (Fig. 7.27). Microscopically diligent
search is often required to identify well-preserved malig-
nant cells in the background of excessive keratin. Kera-
tin also incites a foreign-body reaction. The presence of
multinucleated foreign-body giant cells and inflamma-
tory cells offer considerable diagnostic difficulties and
may favor an inflammatory process and a benign diag-
nosis (Fig. 7.28). Other cavitary lesions such as those
due to actinomyces sp, nocardia, and fungal infections
particularly caused by Aspergillus sp. (Figs. 7.29 to 7.31)
or blastomycosis (Fig. 7.30) may be associated with
extensive squamous metaplasia with atypia. Demonstra-
tion of offending microbes will help to make the correct
Fig. 7.31. FNA lung nodule: Metaplastic squamous epithelium lin- interpretation. Special stains are often required to con-
ing a cavitary lesion. There is considerable nuclear atypia which
was interpreted as suspicious for squamous carcinoma. Surgical ex-
firm their identity. It is prudent to remember that myc-
ploration revealed a cavitary lesion secondary to aspergillosis. The etomas may coexist with cavitary neoplasms since they
lining epithelium os squamous metaplastic type was very atypical. are not mutually exclusive. Necrotizing granulomas of
A B
Figs. 7.32A and B. FNA of a cavitary lesion. A: Low power showing a cellular aspirate with orangeophilic cells.
B: Higher magnification showing discrete, pleomorphic, round to spindle malignant squamous cells in the back-
ground of keratin debris and anucleated forms.
A B
Figs. 7.33A to C. FNA of a cavitary lung nodule. A: Low power

showing extensive inflammatory debris. B: Higher magnification
showing discrete, keratinizing and nonkeratinizing, small malig-
nant squamous cells, obscured by inflammatory cells. C: Another
C field showing a group of keratinized malignant squamous cells.
A B
Figs. 7.34A and B. FNA cavitary poorly differentiated adenocarcinoma. A: Low power showing extensive inflammatory
exudate. Rare epithelial cells can be seen in the background (circle). B: Higher magnification showing adenocarcinoma
cells with emperipolesis.
A B
Figs. 7.35A and B. FNA cavitary lung lesion. The malignant cells are present in small numbers and obscured by in-
flammatory debris. Such a presentation may lead to a false negative diagnosis.
rheumatoid lung disease may yield necrotic and cellular mildly enlarged nuclei in cases of chronic gingivitis may
debris containing atypical spindle-shaped cells and may be present in sputum samples and may cause some di-
constitute a potential diagnostic pitfall. In addition to agnostic concern. However, these cells are seen in the
squamous carcinomas, large and bulky adenocarcinomas background of a large number of mature squamous cells
as well as LCUCs tend to cavitate (Figs. 7.34 and 7.35). in specimens that often lack the presence of dust cells, in-
The differential diagnoses of cavitary lesions are listed in dicating an unsatisfactory specimen and confirming oral
Table 7.7. contaminant. Atypical squamous cells containing promi-
nent nucleoli, originating from an oral mucosa involved
Abnormal Squamous Epithelial Reactions. Squamous by pemphigus vulgaris, have been described as a source
epithelial atypia is encountered in a number of patho- for diagnostic errors.
logic processes as listed in Table 7.8 (see also Figs. In upper respiratory tract infections, sputum samples
7.36 to 7.46). Severe changes often mimic squamous may show small squamous cells with dark-staining nuclei,
malignancy. referred to as “Pap” cells, as they were originally described
Degenerating respiratory epithelial cells contain eo- by Dr. Papanicolaou from his own sputum examined for
sinophilic cytoplasm and pyknotic nuclei. These cells, cold. Although worrisome, small pyknotic nuclei and low
referred to as “pseudoparakeratosis,” may be misinter- N/C ratios favor a benign process (Fig. 7.37). These de-
preted as atypical squamous cells (Fig. 7.36). Contami- generating cells probably originate from inflamed laryn-
nants of buccal mucosal cells with hyperkeratosis and geal mucosa.
A tracheostomy site may undergo squamous meta- both exfoliated samples and aspiration biopsies. Common
plasia and demonstrate a remarkable degree of atypia. sources are chronic bronchitis, bronchiectasis, and chronic
Similarly, atypical metaplastic cells may originate from bacterial infections such as tuberculosis, actinomycosis, and
postlaryngectomy or tracheostomy cases and are encoun- fungal infections. The atypias seen are usually of mild to
tered in tracheobronchial aspirates. Cells in these settings moderate degree. Squamous metaplasia is frequently pres-
often show marked degenerative changes and lack malig- ent involving bronchial mucosa overlying submucosal neo-
nant criteria. plasms (Fig. 7.40) such as granular cell tumors, carcinoid
Squamous metaplasia with atypia, occurring in the tra- tumors, small cell carcinoma, malignant lymphomas, and
cheobronchial tree as well as in the lining of the parenchymal soft tissue tumors. Bronchial brushings may include only
cavitary lesions (Figs. 7.38 and 7.39), is an important source the samples of the metaplastic epithelium since the intact
of diagnostic errors. The atypical cells are encountered in mucosa will prevent the underlying neoplasm from being
TABLE 7.8 DIAGNOSTIC ENTITIES IN THE DIFFERENTIAL DIAGNOSES OF WELL-DIFFERENTIATED

SQUAMOUS CARCINOMA, CYTOPATHOLOGIC FEATURESa
Diagnostic Entity Cytopathologic Features Fig(s).

Degenerating respiratory cells Large exfoliation of respiratory epithelial cells; cytoplasm vacuolated or 7.36
(pseudoparakeratosis) eosinophilic; pyknotic nuclei
Degenerating squamous cells Mature squamous cells; low N/C ratios; may be dyskeratotic; slight increase in 7.37
from upper aerodigestive nuclear size; Pap cells polygonal to round; small in size; eosinophilic cytoplasm;
tract Pap cells deep-staining nuclei
Squamous metaplasia with Single cells in sputum; single cells, or in sheets in bronchial brushings/washings; 7.38
dysplasia pleomorphic in size and shape with well-defined cell borders; N/C ratio low to 7.39
moderately increased; nucleus round, central, smooth nuclear membrane; chromatin 7.40
fine to coarsely granular; no nucleolus; keratinization /; background clean to 7.41
inflammatory (atypia is usually mild to moderate)
Repair/regeneration Cells mostly in tissue fragment with well-defined cell borders; single cells rare; 7.43
low N/C ratios; nuclei central; nuclear border smooth; finely granular chromatin;
single/multiple, micronucleoli/macronucleoli; nucleoli may be irregular in shape;
background variably inflamed
Radiation/chemotherapy Mostly single cells, markedly pleomorphic small to large; N/C ratios variable; 7.42 to
nuclear membrane smooth; chromatin coarsely granular, clumped, smudgy; 7.46
nucleoli large, irregular; cytoplasm variable, generally abundant, delicate to dense;
vacuolated
Mesothelium Honeycomb sheets of cuboidal cells; well-defined cell borders; nuclei round with
sharp nuclear membrane; granular chromatin with prominent nucleoli; cytoplasm
dense and eosinophilic; nuclear polarity altered
Vegetable cells Food contaminant in sputum; cells relatively few in number with orangeophilic 7.25A
cytoplasm and dark pyknotic nuclei; cells are of odd diametric shapes, thick walls, and B
present singly or in monolayered, loosely cohesive
Squamous carcinoma in situ Single cells, may be few in numbers, varying in size but generally small and 7.50, 7.51
round; large nuclei with high N/C ratios; cytoplasm scant to insignificant; nuclear
membrane smooth to irregular; chromatin coarsely granular or clumped; no
parachromatin clearing; no nucleoli; background clean
Squamous carcinoma (Upper Cells isolated, in loosely cohesive groups, and in syncytial tissue fragments; keratin 7.52, 7.53
respiratory tract, esophagus), pearls / isolated cells extremely pleomorphic in size and shape with well-defined
metastatic squamous cell borders; keratinized cytoplasm, central large nucleus with irregular nuclear
membrane, fine to coarsely granular chromatin; background clean to necrotic
a
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer, 2002:88. Reproduced with permission.
Differential Diagnoses of Squamous Carcinoma (See Figs. 7.36 to 7.53)
Fig. 7.36. Degenerating squamous cells with cytoplasmic eosino- Fig. 7.37. Degenerating squamous cells in sputum with pyknotic
philia referred to as “pseudoparakeratosis.” nuclei referred to as “Pap” cells.
Fig. 7.38. Sputum: A grossly enlarged squamous cell with large

nucleus containing compact chromatin suggestive of degenerating
process. Note the intense cytoplasmic orangeophilia. Similar cells
were present in the background leading to a diagnosis of “suspi-
cious for squamous carcinoma.” Bronchial washings showed herpes
simplex virus associated changes.
A B
Figs. 7.39A and B. Tissue fragments of metaplastic squamous cells in sputum with moderate nuclear atypia and high
N/C ratios.
Fig. 7.40. Metaplastic squamous epithelium overlying a submu- Fig. 7.41. Highly atypical squamous cells originating from a cavi-
cosal lesion. Note the moderate degree of nuclear atypia. With intact tary lesion due to aspergillosis. The mucosa lining the bronchi
mucosa, the underlying neoplasm may not yield to the brushings, that lead to the cavity caused by aspergillosis showed extensive
and the atypia may result in an erroneous diagnosis of squamous squamous metaplasia with atypia.
malignancy.
A B
Figs. 7.42A and B. History of radiation. Bronchial brushings. A: An admixture of metaplastic squamous cells with
abnormal forms and columnar cells with nuclear enlargement containing micronucleoli, secondary to radiation.
B: Squamous carcinoma cells for comparison.
A B
Figs. 7.43A and B. Bronchial brushings: Monolayered tissue fragments of atypical squamous cells, some with altered
polarity, mild nuclear enlargement, and containing micronucleoli, consistent with repair/regeneration. The changes
are secondary to radiation.
A B
Figs. 7.44A and B. Bronchial brushings. A: Pleomorphic squamous cells with large nuclei containing compact
chromatin. Patient with history of chemotherapy. B: discrete malignant squamous cells for comparison. Note
the morphologic overlap which makes the separation of these cells difficult.
A B
Figs. 7.45A and B. Bronchial brushings in a patient with lobectomy for squamous carcinoma followed by radiation.
The bronchoscopy was performed to rule out a recurrent lesion. A: The squamous cells in this tissue fragment are
markedly pleomorphic with variably enlarged hyperchromatic nuclei. No single cells are present in the background.
The cytomorphology favors radiation associated changes. B: Different field showing syncytial tissue fragment of malig-
nant squamous cells with high N/C ratios. Nuclear morphology favors malignancy. Note the morphologic similarities.
A B
Figs. 7.46A to C. Bronchial brushings. A: Markedly enlarged squamous cells with pyknotic nuclei representing radia-
tion change. B, C: Squamous carcinoma cells with excessive keratinization and irregular large pyknotic nuclei appear-
ing similar to those seen in Figure 7.46A, precluding an unequivocal diagnosis of squamous carcinoma. (continued)
A B
Figs. 7.47A and B. FNA of a cavitary lesion. A: Low power showing a cellular aspirate consisting of several branch-
ing tissue fragments of spindle cells. B: Higher magnification showing spindle cells to be fibroblastic type with appre-
ciable, pale cytoplasm, uniform small nuclei with low N/C ratios. There were inflammatory cells in the background.
The cytomorphology was suggestive of an inflammatory process with granulation tissue, confirmed on histology.
brushed. Such specimens have potential for a false positive (Figs. 7.42 to 7.46). Lack of single cells, abundant cyto-
diagnosis due to cells from markedly atypical squamous plasm, and low nuclear to cytoplasmic ratios are features
metaplasia as well as potential for a false negative diagnosis favoring a benign process.
because of the absence of diagnostic cells (Fig. 7.41). Radiation, chemotherapy, and laser therapy induce
Pulmonary infarction is considered to mimic squamous cellular alterations that mimic squamous neoplasia. Cy-
carcinoma because of associated squamous metaplasia. tokaryomegaly with bizarre shapes, dyskeratosis, and
In exfoliative cytology specimens, single, highly kerati- large pyknotic nuclei are difficult to differentiate from
nized squamous cells with deep-staining degenerating true carcinoma cells (Figs. 7.44 to 7.46), particularly
nuclei may cause diagnostic concerns. In aspiration bi- when recurrent malignancy is suspected. The problem
opsy specimens, sheets of metaplastic squamous cells is compounded when both disease processes are pres-
have been described as a source of misinterpretation. Evi- ent in the same cellular sample (Figs. 7.45A and B).
dence of repair/regenerative changes in the epithelial cells Great caution must be exercised before rendering a
and hemosiderin-containing macrophages favor a benign malignant diagnosis in such cases. A history of radia-
diagnosis. tion or chemotherapy is essential to avoid diagnostic
Repair/regenerative changes in stratified squamous misinterpretations.
epithelium are an important diagnostic pitfall and cannot Squamous carcinomas with a spindle cell pattern
be overemphasized. Epithelial cells undergoing repair/re- strongly resemble the fi broblastic proliferation of gran-
generative changes may be pleomorphic in shape and pos- ulation tissue. Such an example is illustrated in Figures
sess prominent nucleoli simulating malignant neoplasia 7.47 to 7.49.
A B
Figs. 7.48A and B. FNA of a cavitary lesion, proven to be a squamous carcinoma. A: Low power of this cellular aspi-
rate showing several branching tissue fragments of spindle cells very similar to Figure 7.47A. B: Higher magnification.
The cells are of spindle type with poorly defined cell borders, crowded pleomorphic nuclei with granular chromatin,
some containing nucleoli. Inflammatory cells were present in the background. The cell block of the aspirate showed
strongly positive reactivity to cytokeratin ruling out the possibility of granulation tissue.
A B
Figs. 7.49A and B. Images to compare the cytomorphology of (A) granulation tissue and (B) squamous carcinoma.
Vegetable cells contaminating the sputum samples are

yet another source of diagnostic error (e-Figs. 7.25A and B).
Vegetable cells occur singly and in sheets; may be cuboidal to
polygonal with well-defined cell borders and pale to dense;
and have abundant cyanophilic, eosinophilic, and even or-
angeophilic cytoplasm. Their nuclei are central, small in size,
deep-staining, often pyknotic, and are readily misinterpreted
as malignant by the unwary or novice. Refractile double cell
walls, a monomorphic pattern within a fragment, a rectan-
gular boxcar type arrangement, and large cytoplasmic gran-
ules suggest the presence of vegetable cells.
Severely dysplastic squamous cells and carcinoma in
situ cells with pleomorphic cell morphology and large nu-
clei with very high nuclear to cytoplasmic ratios cannot
be differentiated from invasive carcinoma (Figs. 7.50 and Fig. 7.50. Discrete squamous carcinoma in situ cells in sputum.
7.51). The presence of nucleoli is essential to diagnose in- Some are keratinized. Presence of nucleoli is necessary for the diag-
nosis of invasive carcinoma.
vasive malignancy.
A B
Figs. 7.51A and B. Squamous carcinoma showing pleomorphic keratinized squamous cells with pyknotic nuclei and
lacking nucleoli. These cells are not diagnostic of squamous carcinoma and could represent an intraepithelial lesion.
Fig. 7.52. Sputum with malignant squamous cells originating from Fig. 7.53. FNA lung nodule in patient with a history of squamous
squamous carcinoma of the larynx. carcinoma of the uterine cervix. The squamous carcinoma is consis-
tent with metastasis.
Squamous carcinomas originating from the upper share morphologic similarities not only with poorly dif-
aerodigestive tract (Fig. 7.52) or one extending from ad- ferentiated adenocarcinomas and small cell carcinomas,
jacent organs such as the esophagus may exfoliate ma- but also with several types of non-epithelial malignancies
lignant cells in sputum. A positive sputum sample with such as various types of soft tissue sarcomas with epi-
no radiologic or bronchoscopic findings should alert the thelioid cell patterns, malignant lymphomas, and malig-
clinician to the possibility of either an occult squamous nant melanoma. The differential diagnostic possibilities
carcinoma of the lung or a malignancy in the upper also depend on the site of the biopsy. For example, in
aerodigestive tract. transbronchial biopsies of mediastinal masses, thymic
In fi ne needle aspirates of solitary parenchymal carcinomas or germ cell tumors must be considered.
lung nodules, the morphology of a well-differentiated The cytologic findings of all the diagnostic possibilities
squamous carcinoma does not allow its differentiation are discussed in detail in the section on large cell carci-
from a metastasis of squamous cancer arising in the head noma and are listed in Table 7.15. Poorly differentiated
and neck area and male or female genital tract (Fig. 7.53). squamous carcinomas with extensive necrosis show iso-
Knowledge of primary cancer elsewhere is critical. lated malignant cells often obscured by cellular debris
and inflammatory cells leading to a false negative diag-
Differential Diagnoses of Poorly Differentiated nosis (Fig. 7.33).
Squamous Carcinoma
ADENOCARCINOMAS
Poorly differentiated squamous carcinomas without
apparent squamous differentiation are usually reported Adenocarcinomas of the lung are malignant neoplasms with
as LCUC or simply as non-small cell carcinoma. They glandular differentiation, with or without mucin production.
The most recent (2004) WHO classification of lung tumors forms. The carcinomas diffusely infiltrate the surrounding
includes three major categories for adenocarcinomas: parenchyma and also demonstrate intra-alveolar spread
by fl ooding the alveoli with malignant cells. Adenocar-
● Adenocarcinoma
cinomas may also grow along the alveolar walls (lepidic
Acinar
growth pattern similar to BACs). Some adenocarcinomas
Papillary
produce abundant mucin with fragments of malignant
● Bronchioloalveolar adenocarcinoma
tissue fl oating in large pools of mucin. Poorly differen-
Nonmucinous type
tiated adenocarcinomas show masses of malignant cells
Mucinous type
with only focal or no acinar formations and tend to have
● Solid adenocarcinoma with mucin production
very pleomorphic nuclei. Mitoses are quite frequent.
Adenocarcinomas often present mixed histologic pat- Clear change within the cytoplasm may be seen. The foci
terns pertaining to any of the three major types. Accurate of giant tumor cells are not uncommon in poorly differ-
typing of an adenocarcinoma from cytologic specimens entiated adenocarcinomas. Extensive necrosis may lead to
or small biopsy specimens is often diffi cult due to sam- cavitation and heavy inflammatory infiltrate. Without ap-
pling issues. Besides the above-mentioned three subtypes, parent glandular differentiation, poorly differentiated ad-
several morphologic variants of adenocarcinomas are in- enocarcinomas are often interpreted as either non-small
cluded in the classifi cation. The incidence of these mor- cell or large cell carcinomas.
phologic variants is very low. They will not be further Adenocarcinomas with a papillary growth pattern
discussed. Precursor lesions to adenocarcinomas have consist of complex branching of fibrovascular stalks lined
been described histologically but cannot be recognized or by columnar cells exhibiting nuclear morphology similar
diagnosed from cytological specimens. to that described for acinar type adenocarcinomas. Psam-
moma bodies may be present.
Adenocarcinoma: Conventional Type Cytopathologic Features. The yield of malignant cells
Adenocarcinoma is the most frequent type of lung cancer varies in different types of specimens. In sputum, adeno-
in the USA, comprising 35% of all primary lung malig- carcinoma cells spontaneously exfoliate in variable num-
nancies. Its association with tobacco smoking is not very bers and are often present in streaks of mucus and may
strong. Adenocarcinomas are more common in women be poorly preserved. The cytomorphology of adenocar-
and in nonsmokers. cinoma cells is better preserved in direct smears of the
Patients may remain asymptomatic for a long time, bronchial brushings or washings, BAL, and fine needle
particularly with peripheral lesions. The radiologic findings aspirates (Table 7.9; Figs. 7.54 to 7.67). The malignant
include masses, nodules, and pneumonic or diffuse infil- cells occur singly, in loosely cohesive groups, and in syn-
trate. They may or may not present with pleural effusion. cytial tissue fragments with various architectural patterns
such as acinar, tubular, papillary, or three-dimensional
Gross and Histologic Features. Adenocarcinomas are fre- balls with smooth external contours.
quently located peripherally and vary in size from a few The malignant cells vary considerably in size from
centimeters to large bulky lesions replacing an entire lobe small to medium in well-differentiated adenocarcinomas
of the lung. They are often attached to the overlying pleura, to large and pleomorphic in poorly differentiated carcino-
resulting in pleural invasion with extensive seeding, form- mas. They are round, cuboidal, or polygonal with well to
ing a thick rind of tumor, simulating a malignant mesothe- ill-defined cell borders and contain variable amounts of
lioma. Adenocarcinomas also occur in middle or central cytoplasm that range from scant to abundant and are pale
zones and in endobronchial locations. Their cut surfaces and foamy to bubbly and vacuolated. Their chromatin is
appear gray-white with areas of necrosis and hemorrhage, usually finely granular with micronucleoli. Mucinous carci-
sometimes with cavitations. Adenocarcinomas with exces- nomas demonstrate large distended cytoplasmic vacuoles.
sive mucin production present a mucoid appearance. There Poorly differentiated adenocarcinomas exhibit syncy-
is often central scarring, containing carbon pigment. Car- tial tissue fragments without any architectural patterns.
cinomas with desmoplastic stroma feel firm. Cytoplasmic differentiation in terms of secretions is gen-
Histologically, well to moderately differentiated con- erally not evident. Nuclei may be uniform and bland-
ventional adenocarcinomas of the acinar type consist of appearing to clearly malignant. Mitosis may be seen fre-
glandular and tubular structures formed by malignant quently in poorly differentiated carcinomas. Intranuclear
cells that range from small to large in size and are gener- inclusions are also noted. Psammoma bodies are present
ally round, cuboidal, or polygonal with poorly defined in some cases of papillary carcinomas (Fig. 7.67). The
cell borders. Their nuclei are large and eccentric and con- background may be clean, mucinous, or necrotic.
tain fi nely granular chromatin and prominent nucleoli.
The cytoplasm is variable, moderate to abundant, pale, Differential Diagnoses of Conventional Adenocarcinoma.
wispy, foamy, and bubbly or vacuolated with signet-ring Differential diagnoses of conventional adenocarcinomas
TABLE 7.9 CYTOPATHOLOGIC FEATURES OF PULMONARY ADENOCARCINOMAS
Conventional or Usual Type BAC, Non-mucinous BAC, Mucinous
Cellularity Variable; dependent on specimen type Variable, generally vary cellular in Variable, generally vary cellular
and location of the tumor FNA specimens; exfoliate in large in FNA specimens; exfoliate
numbers in sputum or bronchial in large numbers in sputum or
washings or lavage; bronchial bronchial washings or lavage;
brushings often negative due to bronchial brushings often
peripheral location of the tumor negative due to peripheral
location of the tumor
Presentation Cells isolated; in loosely cohesive groups, Cells isolated, in loosely cohesive Cells isolated, in loosely
or in syncytial tissue fragments with groups, or in syncytial tissue cohesive groups, or in
monolayered, acinar, tubular or papillary fragments; extreme crowding and syncytial tissue fragments;
configuration; as three-dimensional overlapping with depth of focus; extreme crowding with depth
spheres with smooth, external contours smooth outline; acinar pattern, or of focus not seen; papillary
or without any architectural patterns; an open petal pattern, papillary pattern, open petal pattern not
often present in mucus streaks in sputum configuration; monolayered or present; monolayered or two-
two-dimensional dimensional tissue fragments
Cells Variable in size; small, medium to large; Small, round to cuboidal; cell Larger, round to columnar; cell
giant and multinucleated forms may be borders poorly defined; N/C borders poorly defined; N/C
present; cell borders generally poorly ratios high ratios low
defined; N/C ratios variable
Nucleus Round to oval; usually eccentric; Round to oval, generally very Round to oval, generally very
smooth to irregular nuclear membranes; uniform; central to eccentric; uniform; variation in size
lobulated forms /; chromatin multinucleation not present; /; pleomorphism only in
finely granular; coarse/granularity in nuclear membranes sharp less differentiated tumors;
poorly differentiated tumors; multiple and crisp; chromatin finely binucleation/multinucleation
micronucleoli and/or prominent granular, powdery, grooves /; present; nuclear membranes
macronucleoli; intranuclear inclusions micronucleoli or macronucleoli; sharp, crisp, chromatin pale,
/; mitoses / intranuclear cytoplasmic finely granular to powdery;
inclusions /; mitoses-; nuclear micronucleoli; grooves /;
pleomorphism unusual; hobnail intranuclear inclusions-;
pattern / hobnail pattern
Cytoplasm Variable in quality and quantity; pale Scant to moderate; pale, lacy Abundant, foamy, vacuolated,
to dense; scant to abundant; lacy, pale lacy
vacuolated, wispy, single, large vacuoles
indenting the nucleus; emperipolesis /
Psammoma / / /

Bodies
Background Clean to necrotic; mucin / Clean; necrosis ; mucin (may Necrosis ; large amounts
be present in mixed carcinomas); of mucin in FNA specimens;
no muciphages muciphages
Histochemistry Alcian blue ; PAS diastase sensitive and PAS diastase resistant granules PAS diastase resistant
diastase resistant in apical portion (Clara cells) or
in the nucleus (type II)
Immunoprofile Epithelial markers Alcian blue Alcian blue

CK7 Mucicarmine Mucicarmine
CK20 Glycogen Glycogen
TTF-1
Origin of Cells Surface microvilli; intracytoplasmic Clara cells Goblet cells

lumina, tight junctions, secretory granules Type II pneumocytes
Morphologic Spectrum of Adenocarcinoma (See Figs. 7.54 to 7.67)
Fig. 7.54. Sputum: Discrete and syncytial tissue fragments of round Fig. 7.55. Sputum depicting a large syncytial tissue fragment
malignant cells with scant cytoplasm and occasional vacuoles, diag- comprised of adenocarcinoma cells.
nostic of adenocarcinoma.
Fig. 7.56. Sputum: Tissue fragments of adenocarcinoma cells with Fig. 7.57. Sputum: Branching tissue fragments of adenocarcinoma
an acinar pattern. cells. Note the acinar pattern.
Fig. 7.58. Bronchial brushings: Direct smears showing syncytial Fig. 7.59. Bronchial brushings, direct smears depicting syncytial
tissue fragments of medium-sized malignant cells with poorly de- tissue fragments of adenocarcinoma cells with an acinar pattern.
fined cell borders and scant cytoplasm. The N/C ratios are high. The
nuclear chromatin is finely granular with multiple micronucleoli.
Fig. 7.60. Bronchial washings with syncytial tissue fragment of me- Fig. 7.61. FNA lung mass. Adenocarcinoma showing syncytial tis-
dium-sized malignant cells showing poorly defined cell borders and sue fragments of malignant cells pleomorphic in size and contain-
insignificant cytoplasm. No acinar pattern is present. The cytomor- ing variable, scant to moderate pale cytoplasm, forming an acinar
phology is consistent with poorly differentiated adenocarcinoma. pattern.
These cells may be diagnosed as non-small cell carcinoma.
Fig. 7.62. FNA lung nodule. Adenocarcinoma. The malignant cells Fig. 7.63. FNA lung nodule. The cellular aspirate consists of tissue
are loosely cohesive and occasionally form an acinus. fragments of malignant cells with variable pale to dense cytoplasm
with a suggestion of acinar formation, consistent with poorly dif-
ferentiated adenocarcinoma.
A B
Figs. 7.64A and B. FNA hilar mass. Adenocarcinoma. A: The aspirate is very cellular consisting of malignant cells in
thin branching cords with anastomosis suggesting a pattern of growth along the alveolar walls (low power).
B: Higher magnification showing large malignant cells containing abundant cytoplasm.
Fig. 7.65. Papillary adenocarcinoma. FNA of lung nodule showing Fig. 7.66. Higher magnification of Figure 7.65. The malignant cells are
branching papillary tissue fragments (low power). round to short columnar with uniform nuclei and scant cytoplasm.
TABLE 7.10 DIFFERENTIAL DIAGNOSES OF

WELL TO MODERATELY DIFFERENTIATED
CONVENTIONAL AND BACa
NonNeoplastic
Foamy macrophages
Alveolar histiocytes
Alterations in respiratory epithelium (irritation forms)
Hyperplastic/proliferative changes
Goblet cell hyperplasia
Fig. 7.67. Transbronchial FNA showing a papillary adenocarcino-

Repair/regeneration
ma. Note the psammoma body (arrow).
Post radiation/chemotherapy
Hyperplasia of type II pneumocytes
cover a broad range of disease processes (Tables 7.10 Acute lung injury; infections, toxic exposures,
and 7.11) that include a host of benign nonneoplastic Pulmonary infarct, localized inflammatory lesions
conditions that mimic neoplasia and several types of
malignant neoplasms (Figs. 7.76 to 7.112). Factors Benign mesothelium
such as histologic growth pattern and grade, the loca- Neoplastic
tion of the tumor, and the specimen type all have an
Benign Neoplasms
impact on cytologic interpretations and differential
diagnoses. Diagnostic possibilities vary, being depen- Sclerosing hemangioma
dant on the type of specimen and location of the lesion
Malignant Neoplasms
in cases of aspiration biopsy. Adequate clinical data is
absolutely essential for proper cytologic evaluation and Metastatic adenocarcinoma
interpretation.
Some well to moderately differentiated conventional Carcinoid tumors
adenocarcinomas have morphology similar to that of Adenoid cystic carcinoma
BACs. The distinction between the two is not always pos-
sible on cytology. Because of the morphologic overlap, al- Malignant mesothelioma
most all the differential diagnostic entities listed in Table
7.11 for well to moderately differentiated adenocarcino- Malignant lymphoma
mas also hold true for BACs and are discussed together a
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer,
with BAC. 2002:87. Reproduced with permission from Springer Science Business Media.
TABLE 7.11 DIFFERENTIAL DIAGNOSES OF WELL TO MODERATELY DIFFERENTIATED

ADENOCARCINOMA (CONVENTIONAL) AND BAC, CYTOPATHOLOGIC FEATURESa
Adenocarcinoma Cells variable in size, small, medium to large; isolated, in loosely cohesive groups, or in syncytial 7.54 to
(conventional) tissue fragments; monolayered with or without acinar and papillary patterns; three-dimensional 7.67
cell balls with smooth external contours; nuclei variable in size; mostly eccentric but can be central;
smooth to irregular nuclear membranes; chromatin fine to coarsely granular; micronucleoli or
macronucleoli; mitoses /; cytoplasm variable, scant to abundant; pale, bubbly, lacy, vacuolated,
or dense; signet-ring forms /; psammoma bodies /; background clean to necrotic; mucin /
Bronchioloalveolar Cells variable in size, generally small to medium in nonsecretory types, medium to large in 7.68 to
carcinoma secretory types; cells isolated, in loosely cohesive groups, or in syncytial tissue fragments with 7.75
various architectural patterns (e.g., small tight three-dimensional arrangements with depth of
focus); cartwheel pattern, syncytial with monolayered tissue fragments or papillary
Nonneoplastic Altered epithelial cells usually in tissue fragments of various dimensions; lack smooth contour; 7.80 to
alterations in single cells rare; cells enlarged but modestly; nuclear enlargement variable; round to oval 7.90
respiratory nuclei with smooth nuclear membranes; fine to coarsely granular chromatin; micronucleoli/
epithelial cells macronucleoli; mitoses /; multinucleation /; cytoplasm variable; pale to dense to
vacuolated, sometimes biphasic; background: clean to inflammatory
Alveolar Discrete, no tissue fragments, medium-sized; well-defined cell borders; central to eccentric; 7.76
Histiocytes round to oval nucleus; smooth nuclear membrane; finely granular chromatin; micronucleoli; no
mitoses; cytoplasm variable; pale, bubbly to vacuolated
Goblet cell Cells discrete or in tissue fragments variably enlarged; well to poorly defined cell borders; 7.114
hyperplasia eccentric, round to oval nucleus, often pushed to the periphery with signet-ring pattern; smooth
nuclear membranes; finely granular chromatin; micronucleoli ; no mitoses; no necrosis;
cytoplasm variable; moderate to abundant
Muciphage Discrete; large; well-defined cell borders; eccentric round to oval nucleus; smooth nuclear 7.116
membranes; finely granular chromatin; micronucleoli ; cytoplasm moderate to abundant;
bubbly vacuolated with signet-ring forms; extremely difficulty to differentiate from mucin
producing adenocarcinoma cells
Lipophage Discrete; large cells; well-defined cell borders; central to eccentric, round to oval nucleus; smooth 7.118
nuclear membrane; micronucleoli ; cytoplasm abundant and vacuolated, bubbly; oil red O
Benign Tissue fragments of various sizes, large ones fold upon themselves with syncytial appearance; 7.97
mesothelium (only well-defined cell borders with a honeycomb pattern; nuclei central; generally uniform, oval to
in TTFNA*) round, occasionally kidney-shaped with finely granular chromatin; micronucleoli; cytoplasm
pale; moderate to abundant; necrosis
Malignant Variable cellularity, generally high; malignant cells isolated, in loosely cohesive groups, and in 7.166 to
mesothelioma syncytial tissue fragments with various architectural patterns such as monolayer with windows 7.168
epithelial type in between, papillary or trabecular, pseudoacinar, three-dimensional; knobby to smooth
(only in TTFNA) contours; size: medium, uniform, well-defined cell borders; N/C ratios variable but high; nuclei
uniform, round to oval, central; crisp and smooth nuclear membranes; fine to coarsely granular
chromatin; micronucleoli/macronucleoli; cytoplasm variable, dense, biphasic; psammoma
bodies /; background generally clean; Immunoprofile: vimentin ; cytokeratin ; CEA ;
calretinin ; HBME1 ; EM – bushy microvilli
Typical carcinoid Not encountered in sputum; cellularity variable; cells isolated, in loosely cohesive groups, or in 7.111A
tumor syncytial tissue fragments with any architectural pattern or in monolayer, trabeculae, pseudoacinar
or aligning capillaries; uniform to slightly pleomorphic, generally small size with admixture of
medium-sized cells; nucleus round, smooth nuclear membrane; coarse salt & pepper chromatin;
nucleoli inconspicuous; no nuclear molding; no mitoses; scant cytoplasm occasionally pale,
vacuolated, granular; background clean; Immunoprofile: neuroendocrine markers ; cytokeratin
(continued)

Adenoid cystic Mostly syncytial tissue fragments of varying sizes with pseudoacinar sieve-like pattern or tight 7.103
carcinoma groupings with depth of focus; single cells rare or not appreciated; cells small monomorphic, 7.104
round with ill-defined cell borders; high N/C ratios; scant indiscernible cytoplasm; round
to oval nucleus with coarsely granular to compact chromatin; nucleolus inconspicuous; no
nuclear molding; no mitoses; no necrosis; acellular homogenous hyaline globules within tissue
fragments or in the background; staining deep magenta with Romanowsky stain and pale blue-
green with Papanicolaou; Immunoprofile: cytokeratin ; anti-basement membrane antibody ;
S100 protein
Metastatic Malignant cells isolated, in loosely cohesive groups, or in syncytial tissue fragments with or 7.99 to
adenocarcinomas without acinar pattern; three-dimensional cell balls; depth of focus /; monolayered or papillary 7.109
breast, prostate, architecture; cells small to medium-sized; cell borders poorly defined; N/C ratios variable; nuclei
thyroid, GI tract central to eccentric; round to oval nuclei; nuclear membrane smooth to irregular; chromatin finely
granular; micronucleoli/macronucleoli; intranuclear inclusions /; mitoses /; cytoplasm scant
to abundant; pale, lacy, bubbly, vacuolated to dense; psammoma bodies /; Immunoprofile:
epithelial markers (for typing, antibodies specific for the site are necessary)
Hyperplastic Abnormal cells variable in numbers; few to moderate; isolated, in aggregates, and in tissue 7.13 to
reactive type II fragments; usually small in size; architecture of the tissue fragments range from monolayered 7.15
pneumocytes sheets with papillary or acinar pattern, open-petal or cartwheel pattern; cells pleomorphic in 7.91 to
size; small, medium to large; N/C ratios variable; nuclei round to oval, variable in size; irregular 7.94
to smooth nuclear membranes; fine to coarsely granular chromatin; micronucleoli; cytoplasm
variable, scant to abundant, pale, dense or vacuolated; mitoses ; intranuclear inclusions ; no
psammoma bodies; background inflammation and necrosis in patients with ARDS
Sclerosing Variable cellularity; cells usually in large syncytial tissue fragments with our without papillary 7.98
hemangioma (in architecture; tissue fragments may be intersected by stromal tissue or enclosed vascular
TTFNA only) spaces; cells small to medium-sized with poorly defined cell borders; N/C ratios low; uniform
found to oval eccentric nuclei; smooth nuclear membranes; finely granular evenly dispersed
bland chromatin; indistinct nucleoli; intranuclear inclusions /; moderate to abundant,
pale eosinophilic cytoplasm; histiocytes with and without hemosiderin in the background;
inflammatory cells /; Immunoprofile: epithelial markers ; Clara cell antigen ;
antisurfactant apoprotein
a
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer, 2002:87. Reproduced with permission from Springer Science Business Media.
*TTFNA–Trans thoracic fine needle aspiration.
Morphologic Spectrum of Bronchioloalveolar Carcinoma (BAC) (See Figs. 7.68 to 7.75)
A B
Figs. 7.68A and B. BAC cells in sputum. Syncytial tissue fragments of small malignant cells with smooth external contour and papillary-like
architecture. The cells have poorly defined cell borders, high N/C ratios and vacuolated cytoplasm.
Fig. 7.69. BAC cells in sputum. A syncytial tissue fragment of small Fig. 7.70. BAC. FNA of a lung mass showing syncytial tissue frag-
malignant cells with a papillary-like architecture. The cells are small ments of malignant cells forming three-dimensional structures with
with ill-defined borders and high N/C ratios. The nuclear chromatin a depth of focus. Note the smooth external contours.
is finely granular with prominent nucleoli.
Fig. 7.71. Bronchial washings. A large population of discrete, medium- Fig. 7.72. BAC. Discrete BAC cells in bronchial washings mimick-
sized cells with eccentric nuclei and vacuolated cytoplasm. These cells ing histiocytes.
are bland and may be interpreted as alveolar histiocytes.
Fig. 7.73. FNA of BAC. A syncytial tissue fragments of small ma- Fig. 7.74. FNA of BAC. The aspirate is cellular consisting of closely
lignant cells with indiscernible cytoplasm. The nuclei are monomor- packed small cells with poorly defined cell borders, scant cytoplasm,
phic, containing very pale, finely granular chromatin and prominent and high N/C ratios. The nuclear chromatin is finely granular with
macronucleoli. prominent nucleoli.
A B
Figs. 7.75A to C. BAC mucinous type. FNA of a lung mass. A: Low

power view showing large branching tissue fragments of epithelial
cells. B, C: Higher magnification showing syncytial tissue fragments
C of columnar epithelium with abundant mucinous cytoplasm.
Differential Diagnoses of Adenocarcinomas (Conventional and Bronchioloalveolar Type) in Respiratory Specimens

(See Figs. 7.76 to 7.90)
Fig. 7.76. Medium-sized histiocytes in aggregates, containing scant Fig. 7.77. Sputum. Adenocarcinoma cells in a mucus streak. Note
cytoplasm, and lacking carbon particles mimic adenocarcinoma the morphologic similarity to histiocytes in Figure 7.76.
cells in sputum preparation.
Fig. 7.78. Bronchial washings. Adenocarcinoma cells are loosely Fig. 7.79. Transbronchial FNA containing degenerating respiratory
cohesive, and discrete. Note that they resemble degenerating respi- epithelial cells mimicking adenocarcinoma.
ratory columnar cells depicted in Figure 7.79.
Fig. 7.80. Sputum. A large tissue fragment of reactive respiratory Fig. 7.81. Bronchial washings showing syncytial tissue fragment of
epithelium with syncytial architecture. Elsewhere in the smear, there epithelial cells with features suspicious for adenocarcinoma. Nuclear
were cells diagnostic of herpes virus infection. An important fact inclusions were identified in cell block preparations and confirmed
to remember is that the respiratory epithelial cells, infected by her- as herpes virus infection by immunostains to the virus antibody.
pes virus, demonstrate marked hyperplasia and nuclear atypia with
prominent nucleoli before developing nuclear inclusions.
Fig. 7.82. Bronchial washings containing adenocarcinoma cells for Fig. 7.83. Transbronchial FNA. Patient with the history of radiation.
comparison with Figure 7.81. The tissue fragment of respiratory epithelium showing marked atypia,
posing difficulties in interpretation. However, note the jagged edges of
the tissue fragment and normal pattern of the cells at the periphery.
Fig. 7.84. Bronchial brushings with respiratory epithelium exhibit- Fig. 7.85. Bronchial brushings containing large branching tissue
ing marked nuclear atypia. The patient had a history of radiation. fragments of markedly reactive respiratory epithelium mimicking
adenocarcinoma. No single cells are seen.
Fig. 7.86. Bronchial brushings showing adenocarcinoma. Compare Fig. 7.87. Bronchial brushings showing large tissue fragments of
with Figure 7.85. There is an admixture of reactive epithelial cells reactive/hyperplastic respiratory epithelial cells, which can be easily
and malignant cells. interpreted as adenocarcinoma. The nuclei are smaller and uniform.
Compare to adenocarcinoma in Figure 7.88.
Fig. 7.88. Bronchial brushings containing syncytial tissue fragments Fig. 7.89. Bronchial brushings yielding large branching tissue frag-
of adenocarcinoma cells. ments of reactive/hyperplastic respiratory epithelium that can be
misinterpreted as adenocarcinoma. Features against malignancy are
jagged edges of the tissue fragments instead of smooth contours,
lack of single cells, uniform nuclear pattern at the periphery where
cells are better visualized.
Fig. 7.90. FNA showing a papillary adenocarcinoma. Compare

with Figure 7.89 to appreciate morphologic overlap.
Atypical Reactive/Hyperplastic/Hypertrophic Type II Pneumocytes versus Adenocarcinoma (See Figs. 7.91 to 7.98)
A B
C D
Figs. 7.91A to D. Reactive/hyperplastic type II pneumocytes. Bronchial lavage showing discrete and syncytial tissue
fragments of pleomorphic epithelial cells. The cells are variable in size with enlarged eccentric nuclei. The cytoplasm
is vacuolated. The background is inflammatory. These cells strongly resemble adenocarcinoma. Such abnormal cells
are usually present in small numbers, in the background of inflammatory cells and are present for a short duration
of time.
A B
Figs. 7.92A and B. Reactive/hyperplastic/hypertrophic type II pneumocytes in BAL. A: The cells are arranged in a
cartwheel fashion with peripherally located nuclei. N/C ratios are high. Note the cytoplasmic vacuole. B: These cells
are smaller, more uniform forming a syncytial tissue fragment with a cartwheel pattern and cannot be differentiated
from the cells of bronchoalveolar carcinoma.
A B
Figs. 7.93A and B. Type II pneumocytes versus adenocarcinoma. A: Sputum: type II pneumocytes. B: Sputum
showing cells of BAC.
A B
Figs. 7.94A and B. Type II pneumocyte versus bronchioloalveolar carcinoma. A: Syncytial tissue fragment of type II
pneumocytes in bronchial washings forming a three-dimensional cluster with a depth of focus. The external contour
is smooth. B: Syncytial tissue fragment of BAC cells in bronchial washings depicting the cytomorphology very similar
to type II pneumocytes seen in Figure 7.94A.
A B
Figs. 7.95A and B. A: Atypical type II pneumocytes in bronchial washings. B: Adenocarcinoma cells in bronchial
washings. Note the morphologic overlap.
A B
Figs. 7.96A and B. Reactive respiratory epithelial cells versus adenocarcinoma. A: Bronchial brushings: tissue frag-
ment of reactive respiratory epithelium with mildly enlarged nuclei, granular chromatin and micronucleoli. These
cells resemble BAC cells. B: Bronchial brushings showing a well-differentiated adenocarcinoma resembling reactive
epithelial cells.
A B
Figs. 7.97A and B. Reactive mesothelial cells versus adenocarcinoma in FNA specimens. A: Transthoracic
FNA of lung nodule showing a tissue fragment of mesothelium which is folded upon itself appearing syncytial,
mimicking a well-differentiated adenocarcinoma. B: The aspirate of the same lung nodule showing
adenocarcinoma cells.
Fig. 7.98. FNA of sclerosing hemangioma. The cellular aspirate

with large branching tissue fragments of type II pneumocytes may
be interpreted as BAC in cytologic specimen. (Courtesy of Bernard
Naylor, M.D., professor emeritus of pathology, University of Michi-
gan, Ann Arbor, Michigan.)
Metastatic Adenocarcinoma (See Figs. 7.99 to 7.112)
Fig. 7.99. FNA of metastatic mammary duct carcinoma. The malig-

nant cells are small, uniform, forming syncytial architecture with an
acinar pattern strongly resembling BAC.
Fig. 7.100. Bronchial brushings, in a patient with a history of breast Fig. 7.101. FNA lung nodule. Patient has a history of breast carci-
carcinoma and an endobronchial lesion. These malignant cells are noma. These malignant cells in a syncytial tissue fragments are di-
large with abundant pale to vacuolated cytoplasm and may repre- agnostic of adenocarcinoma. However, the differentiation between
sent either a primary lung adenocarcinoma or a metastatic carci- a primary pulmonary adenocarcinoma and a metastatic lesion is not
noma. Immunostains are required to confirm a metastatic breast possible without immunostains.
malignancy.
A B
Figs. 7.102A and B. FNA. Metastatic adenocarcinoma of colon. The malignant nature of these cells is clearly
apparent. However, without immunostains, the primary site cannot be confirmed. Colonic carcinoma cells will react
positively to CK20 and negatively to CK7 and TTF-1, opposite results for primary lung adenocarcinoma.
A B
Figs. 7.103A and B. FNA lung nodule. Metastatic adenoid cystic Fig. 7.104. FNA of lung nodule showing another example of meta-
carcinoma. Note the typical pseudoacinar pattern formed by small static adenoid cystic carcinoma with a syncytial architecture lacking
uniform cells with scant cytoplasm and bland nuclei and basement a pseudoacinar pattern.
membrane material within the pseudoglandular spaces.
Fig. 7.105. Sputum. Metastatic gastric adenocarcinoma. The pri- Fig. 7.106. FNA of lung nodule. Metastatic adenocarcinoma of the
mary site cannot be determined from morphology alone. prostate. The nuclei characteristically demonstrate prominent ma-
cronucleoli. The metastatic process must be supported by elevated
PSA levels and positive immunoreactivity to PSA antibody.
Fig. 7.107. Sputum. Metastatic papillary thyroid carcinoma. The Fig. 7.108. Bronchial brushings. These are clearly malignant cells
malignant cells exhibit typical cytologic features of thyroid papil- with a follicular (acinar) pattern. The patient had a history of fol-
lary carcinoma but this pattern is also presented by BAC and must licular variant of papillary thyroid carcinoma. The metastatic na-
be confirmed by thyroglobulin stain. ture must be conformed by Thyroglobulin stain since both primary
adenocarcinoma and papillary thyroid carcinomas will react posi-
tively to TTF-1.
Fig. 7.109. Bronchial brushings in a patient with history of endo- Fig. 7.110. FNA lung nodule in a patient with a history of renal cell
metrial adenocarcinoma. These malignant cells were strongly im- carcinoma. The morphology of the malignant cells is consistent with
munoreactive to CA125. metastatic clear cell carcinoma.
A B
Figs. 7.111A to B. Adenocarcinoma versus carcinoid tumor. A: FNA of lung nodule showing a tissue fragment of
carcinoid cells. B: Sputum showing a tissue fragments of hyperplastic respiratory epithelium (creola body in a patient
with bronchial asthma) mimicking adenocarcinoma. (continued)
C
Figs. 7.111C. (continued) C: FNA of mediastinal lymph node with Fig. 7.112. FNA of mediastinal lymph node with metastatic small cell
primary papillary adenocarcinoma of the lung. All of the three sam- carcinoma. Note the morphologic overlap with adenocarcinoma.
ples appear morphologically similar.
Differential diagnostic possibilities for poorly dif- cretory BACs manifest as gray–white foci of consolidation,
ferentiated adenocarcinomas include several poorly dif- sometimes with central scarring and often associated with
ferentiated epithelial and non-epithelial neoplasms. Their anthracitic pigment. Hemorrhage and necrosis are lacking.
cytologic features are described in the section on LCUCs Peripheral carcinomas may demonstrate pleural puckering
(see Table 7.15). and fibrosis may be evident. Pleural invasion is unusual.
Mucinous or secretory BACs are often larger and
multifocal, their usual presentation being in the form of
BRONCHIOLOALVEOLAR CARCINOMA (BAC)
lobar pneumonia. The entire lobe of the lung may be re-
BACs are adenocarcinomas that present a distinctive placed by glistening mucinous consolidation.
morphologic pattern formed by cylindrical tumor cells Histologically, BACs present two main subtypes. The
that grow along the preexisting alveolar walls without majority is formed by nonmucinous or nonsecretory type
tissue destruction. The incidence of BAC has remarkably and is derived from Clara cells or alveolar type II pneu-
increased in the last three decades from 3 to 14.7%. BACs mocytes. The less common mucinous or secretory type
are more common in females with a female to male ratio is derived from goblet or mucin-producing bronchiolar
of 4:1 and are not associated with cigarette smoking. They cells. A small proportion of BACs show a combination of
generally occur in an older age group but have also been both patterns.
reported in younger individuals. The majority of patients The key feature of BACs is their growth pattern.
are asymptomatic since BACs tend to be located peripher- Well-differentiated cuboidal or columnar cells grow along
ally in the lungs and are detected as incidental findings. intact alveolar walls either as a single layer or occasion-
They frequently run a protracted course with slow growth ally with a papillary pattern with the papillae projecting
for several years without dissemination, while others rap- into the alveolar spaces. Discrete cells, acini, or papillary
idly develop satellite nodules, which spread to the opposite tissue fragments are often seen lying free in the alveolar
lung. Symptoms range from cough, copious watery spu- spaces. The cells of nonmucinous BACs are generally very
tum (bronchorrhea), dyspnea, chest pain, and weight loss. uniform, more cuboidal than columnar, and have a bright
Radiographically, BACs show either solitary or multiple eosinophilic cytoplasm. Their nuclei are hyperchromatic
nodules, the latter simulating a pattern of metastatic disease. and nucleoli are prominent. Clara cell differentiation may
They may also present radiologically as lobar pneumonia. be evident by the presence of apical cytoplasmic snouting.
The nuclei of the neoplastic cells often project into the
apical snouts, presenting a hobnail pattern. Mitotic fig-
Gross and Histologic Features
ures or necrosis are not features of BACs. An infiltrating
Bronchoalveolar carcinomas present several different pattern is also not frequent.
forms, such as a large solitary mass, multiple nodules, as The mucinous type of BAC is composed of tall co-
foci of consolidation, or as lobar pneumonia. They are lumnar cells with abundant, grayish, clear to foamy cyto-
more often located peripherally but can also occur cen- plasm. Their nuclei are round to oval, pale and uniform,
trally; they are not related to bronchi. BACs are well- lacking the hyperchromasia of the nonmucinous type
demarcated with no gross evidence of tissue destruction or BAC cells. Some exhibit nuclear clefting. In less differenti-
invasive features. The nodules of nonmucinous or nonse- ated BACs, hyperchromasia and prominent nucleoli may
be present. Mucinous BACs produce copious amounts II differentiation demonstrate positive reactivity to anti-
of mucin, distending the alveoli with groups and nests surfactant antibody (P10).
of malignant cells fl oating in pools of mucin that often
contain neutrophils and muciphages. Both types of BACs Ultrastructure
may show a papillary pattern and psammoma bodies.
Ultrastructurally, BAC cells exhibit the usual features of
an adenocarcinoma. Those with Clara cell differentiation
contain apical electron-dense granules of 600 to 1500 m
The cytomorphology of BACs (Table 7.9; Figs. 7.68 to and a few microvilli. BAC with type II differentiation con-
7.75) depends on whether the carcinoma is the mucinous tains cytoplasmic lamellar bodies and nuclear inclusions
or nonmucinous type with considerable variations among with branching microtubules.
different types of respiratory specimens. Since the tumors
are usually peripheral, bronchial brushings are often non-
diagnostic. The cytomorphology of exfoliated cells is gen- DIFFERENTIAL DIAGNOSES OF WELL
erally similar in sputum, bronchial washings, and BAL. TO MODERATELY DIFFERENTIATED
FNA biopsy specimens are very cellular exhibiting excel- CONVENTIONAL ADENOCARCINOMAS AND
lent cellular preservation and characteristic morphology. NONMUCINOUS (NONSECRETORY) BACS
The BACs exfoliate malignant cells in large numbers
As mentioned earlier, the cytomorphology of well to mod-
as single cells, in aggregates, or in syncytial tissue frag-
erately differentiated adenocarcinomas and BAC overlap
ments with smooth external contours (Figs. 7.68 and
and are difficult to differentiate. Accurate typing is depen-
7.69). Some tissue fragments appear three-dimensional,
dent on histologic characteristics such as growth patterns,
presenting considerable depth of focus with marked
invasive characteristics, and tissue destruction that favor
crowding and overlapping of nuclei. Another charac-
conventional adenocarcinomas. These features are not
teristic presentation is an open petal arrangement or a
evident in cytologic preparations. Because of the mor-
cartwheel pattern with scalloped borders—a pattern seen
phologic overlap, their differential diagnoses include the
also with reactive type II pneumocytes (see Figs. 7.93 and
same disease entities and, therefore, are discussed together
7.94). The nonmucinous BAC cells are small, round to
(Tables 7.10 and 7.11; Figs. 7.76 to 7.112).
cuboidal with poorly defined cell borders, scant, and have
Alveolar histiocytes (Fig. 7.76) appear remarkably
pale to dense cytoplasm and high nuclear to cytoplasmic
similar to the single cells of BAC and are difficult to dif-
ratios. Tiny cytoplasmic vacuoles are sometimes noted.
ferentiate from them. Enlarged, isolated, and discrete re-
The round to oval nuclei are uniform, with smooth nucle-
active/hyperplastic/hypertrophic type II pneumocyte with
ar membranes, occasionally with slight irregularities and
large nuclei and prominent nucleoli with cytoplasmic vac-
containing powdery to fi nely granular chromatin. The
uoles mimic adenocarcinoma cells (Fig. 7.77).
nucleoli may be single and large and prominent or small
Varied morphologic alterations in respiratory epitheli-
and multiple. Single cells of nonmucinous BACs bear a
um resulting from a multitude of causes, as discussed earlier
strong resemblance to alveolar histiocytes (Figs. 7.71 and
in the section on nonneoplastic epithelial alterations are fre-
7.72). The tissue fragments of BAC may show a papillary
quent sources of diagnostic misinterpretations. The changes
pattern with tissue fragments containing central fibro-
referred to as irritation forms, hyperplastic/proliferative re-
vascular cores, lined by cuboidal to columnar cells, con-
actions, repair/regenerative changes, or those secondary to
taining fi nely granular chromatin, micronucleoli, nuclear
radiation and chemotherapy, all mimic neoplasia (Figs. 7.78
grooves, and intranuclear inclusions.
to 7.96).
The cells of mucinous type BAC are much larger, con-
Hyperplastic respiratory epithelium is a great source
taining abundant pale, foamy to vacuolated cytoplasm
of potential diagnostic errors (Figs. 7.80, 7.83 to 7.90). It
and occur singly or in syncytial tissue fragments. The sin-
is seen in a variety of conditions such as chronic bronchi-
gle cells appear similar to goblet cells and lipophages.
tis, bronchiectasis, asthma, and viral infections. Epithelial
The mucinous type BAC exhibits cells that are large,
tissue fragments generally exfoliate in significant num-
tall columnar with abundant, foamy, vacuolated pale cy-
bers and are of large dimensions. In the specimens ob-
toplasm containing eccentric small uniform, pale nuclei.
tained by bronchial brushings or washings, the epithelial
The architectural confi guration of the syncytial tissue
tissue fragments may have irregular contours with jagged
fragments may or may not be papillary. Large amounts of
edges. The component nuclei are variably enlarged with
mucin may be present in an otherwise clean background.
coarsely granular chromatin and prominent nucleoli.
There may be crowding and overlapping of the nuclei.
Immunoprofile
These tissue fragments do not present the three-dimen-
The immunoprofile of BAC cells is similar to that of con- sional pattern or the depth of focus that is so typical
ventional adenocarcinoma, showing positive reactivity to of BAC. In patients with bronchial asthma, large tissue
CEA, EMA, and Leu M1. In addition, BAC cells with type fragments of respiratory epithelium are shed, which curl
upon themselves, acquiring smooth external contours, Focusing on the cells at multiple levels will reveal their
resembling the papillary tissue fragments of adenocarci- true nature. Also, the branching or acinar patterns of the
nomas. The presence of cilia in these fragments favors a tissue fragments seen in adenocarcinomas are not seen
benign process (Fig. 7.87). with mesothelial tissue fragments.
Instrumentation, infection, or radiation therapy may Sclerosing hemangioma (e-Figs. 7.44A to D; Fig.
be followed by repair/regenerative changes in bronchial 7.98)—a very rare benign neoplasm of the lung—presents
epithelium. Bronchial brushings, washings, and BAL of- cytomorphology very similar to that of nonmucinous
ten yield large tissue fragments of respiratory epithelium BAC. Its differentiation from BAC may be extremely dif-
with mild nuclear atypia and prominent nucleoli (Figs. ficult from cytology alone.
7.87 to 7.90). These changes may mimic neoplasia.
A potentially grave problem is the presence of reac-
tive and hyperplastic/hypertrophic type II alveolar pneu-
METASTATIC MALIGNANCY VERSUS
mocytes in sputum, bronchial washings, or BAL and in
PRIMARY ADENOCARCINOMAS
aspiration biopsy specimens (Table 7.12; Figs. 7.91 to
7.95) in a variety of situations. The cytomorphology of
these cells can be alarming, leading to a misinterpreta- Metastatic adenocarcinomas of the lungs from several
tion of malignancy. Such instances are common, partic- extrapulmonary sources (Figs. 7.99 to 7.112) are known
ularly when patients have episodes of acute lung injury for diffi culties in differentiating them from primary lung
and develop ARDS. Cytopathologic evaluation of the re- adenocarcinomas. Most present similar cytopathologic
spiratory specimens is requested if these patients are in features. For example, metastatic adenocarcinomas from
acute respiratory distress and chest radiographic changes the breast (Figs. 7.99 to 7.101), the prostate (Fig. 7.106),
include malignancy in the differential diagnosis. Distin- the gastrointestinal tract/colon (Figs. 7.102 and 7.105),
guishing reactive, abnormal alveolar lining cells from and the kidney (Fig. 7.110) may be interpreted as primary
adenocarcinoma cells may be extremely diffi cult as both lung cancer in the absence of pertinent clinical data and
show similar cytomorphologic patterns. The number of immunostains. Papillary thyroid carcinomas (Figs. 7.107
abnormal cells is generally small in reactive processes. An and 7.108) share several morphologic features with both
open petal pattern of the tissue fragments with scalloped papillary lung adenocarcinomas and BAC. Finely granu-
borders, conspicuous nucleoli, and secretory vacuoles are lar to powdery chromatin, micronucleoli, nuclear grooves,
seen in both entities. Intranuclear cytoplasmic inclusions and intranuclear inclusions are seen, particularly in BAC.
are generally not seen in reactive type II pneumocytes. Psammoma bodies are present in both lung and thyroid
Features that favor a reactive process are an inflammatory papillary carcinomas and both react positively to TTF-1.
background and considerable variations in the morphol- Thyroglobulin will, however, distinguish papillary thy-
ogy of the abnormal cells, degenerative nuclear changes, roid cancer from BAC. Metastatic follicular thyroid carci-
windows between the cells, and a typical hobnail pattern. nomas with a microacinar pattern (Fig. 7.108) resemble a
Also, the reactive cells disappear once the underlying pro- well-differentiated conventional lung adenocarcinoma.
cess resolves (Table 7.12; Figs. 7.91 to 7.94). Adenoid cystic carcinoma (Figs. 7.103 and 7.104)
Reactive changes in alveolar lining cells occur along presents syncytial tissue fragments that have a charac-
the perimeter of localized nonneoplastic lung lesions such teristic sieve-like pattern and globules of basement mem-
as chronic granulomatous lesions or infarcts. Aspiration brane-like material, allowing easy recognition. However,
biopsies may yield such cells with abnormal cytomor- its solid variant, which comprises small uniform cells with
phology that are diffi cult to differentiate from malignant a three-dimensional pattern, depth of focus, and absence
cells. Cells illustrated in e-Figures 7.28 and 7.33 represent of basement membrane-like material, may be difficult to
alveolar lining cell hyperplasia along the margin of an in- distinguish from BAC or adenocarcinoma.
farct, which clinically and radiologically was interpreted Carcinoid tumors with uniform small cells present
as possible neoplasm. Bronchial washings contained reac- cellular features that overlap with BAC (Figs. 7.111A
tive type II cells diagnosed as suspicious for adenocarci- to C). Some carcinoid tumor cells contain appreciable
noma. Pulmonary wedge resection revealed an infarct. cytoplasm, thus, resembling an adenocarcinoma (see
Trapped alveolar lining cells in nonneoplastic or be- Fig. 7.130). Neuroendocrine markers are positive in
nign neoplastic lesions may be aspirated leading to a mis- these cases. In fi ne needle biopsy specimens, carcinoid
diagnosis of malignancy. tumor cells aligning the capillaries or forming tight tis-
Tissue fragments of benign mesothelium (Figs. 7.97A sue fragments strongly resemble cells of adenocarcino-
and B) may be aspirated during a transthoracic FNA mas and are diffi cult to differentiate without the aid of
biopsy procedure. These fragments tend to be of large immunocytochemistry.
dimensions and often fold upon themselves. The honey- Small cell carcinoma cells (Fig. 7.112), particularly in
comb pattern that is normally so characteristic of meso- bronchial brushing smears, may resemble cells of adeno-
thelium gets distorted, imparting a syncytial appearance. carcinomas when the former are well-preserved and the
TABLE 7.12 DIFFERENTIATING FEATURES BETWEEN HYPERPLASTIC/REACTIVE TYPE II

PNEUMOCYTES & ADENOCARCINOMA CELLSa
Reactive/Hyperplastic/Hypertrophic Type II
Pneumocytes Adenocarcinoma
Type of Specimen Sputum, bronchial washings, BAL, and FNA; not Sputum, bronchial washings, BAL, FNA, and in
Harboring the seen in direct smears of bronchial brushings direct smears of bronchial washings
Cells
Cellularity Scant to moderate Scant to overwhelmingly cellular
Cells Very pleomorphic in size; small to large; N/C ratios Monomorphic to pleomorphic in size; N/C ratios
variable variable
Presentation Cells isolated, in loosely cohesive groups, and in Cells isolated, in loosely cohesive groups, and in
tissue fragments either as two-dimensional sheets syncytial tissue fragments, either monolayered,
or with syncytial arrangement; lack depth of focus; two-dimensional, or three-dimensional with depth
tissue fragments with open petal or with cartwheel of focus; smooth contour; open petal pattern with
patterns; varying-sized cells; windows between cells; uniform-sized cells; windows not seen between cells;
hobnail pattern ; knobby contour; tissue fragments hobnail pattern /; knobby contour /; tissue
generally small in size; irregular fragments of hyaline fragments may be very large in size
membrane within the tissue fragments or in the
background in patients with ARDS
Nucleus Single or bi-nucleated; rarely multinucleated; central Generally single, central to eccentric; size uniform
to eccentric; round to oval; variable size; smooth to pleomorphic, round to oval; nuclear membrane
nuclear membranes; chromatin fine to coarsely smooth to slightly irregular; chromatin finely
granular, often smudgy, dense-staining; nucleoli may granular; macronucleoli; intranuclear cytoplasmic
be prominent; intranuclear cytoplasmic inclusions inclusions /; nuclear grooves /
absent; nuclear grooves
Cytoplasm Scant to abundant; pale to dense or vacuolated Scant to moderate, pale to dense or vacuolated,
distending the cell, indenting the nucleus indenting the nucleus
Psammoma Not present /

Bodies
Background Inflammatory; cellular debris (in patients with Clean to necrosis

ARDS)
Features Favoring Clinical history of an acute event or toxic exposure No clinical history of an acute event or toxic
Reactive Process History of respirator assistance exposure
Inflammatory background with cellular debris History of respirator assistance
common Inflammatory background with cellular debris
Number of abnormal cells usually small present with necrotic tumors
Variability in morphology from cell to cell common Number of abnormal cells usually large
Syncytial tissue fragments, lack depth of focus; Variability in morphology from cell to cell not
present a cart-wheel pattern with scalloped common
borders Syncytial tissue fragments with depth of focus;
Coarsely granular chromatin, micronucleoli /; may present a cart-wheel pattern with scalloped
cytoplasmic vacuoles / borders
Irregular fragments of acellular biphasic staining Finely granular chromatin, micronucleoli ;
material representing hyaline membrane, either cytoplasmic vacuoles /
within the tissue fragments or in the background Irregular fragments of acellular biphasic staining
Resolution of the inflammatory process with absence material representing hyaline membrane, either
of abnormal findings in follow-up bronchoscopy within the tissue fragments or in the background
not present
No resolution; changes persistent
a
nuclear chromatin is not deeply stained. Lack of nuclear entiated from hyperplastic goblet cells (Fig. 7.114); histi-
molding favors adenocarcinoma. ocytes distended with mucin, muciphages (Fig. 7.115), or
An oft-encountered diagnostic dilemma involves the lipophages as seen in lipoid pneumonia (Fig. 7.118); and
differentiation of pulmonary adenocarcinomas from epi- reactive type II alveolar pneumocytes (Fig. 7.116). The
thelial type malignant mesotheliomas. This is particularly bland nuclear morphology of secretory type BAC cells is
true when patients present with either pleural effusion or extremely difficult to distinguish from each of these four
with a pleural based mass with no documented history of benign cell types. They have potential for both a false
primary lung cancer. The cytologic features of malignant positive and a false negative diagnostic error. Foamy his-
mesothelioma and their differentiation from adenocarci- tiocytes are also characteristic of atypical mycobacterial
noma in serous fl uids are already discussed in Chapter 6 infection, malakoplakia, and toxicity due to certain drugs
on serous effusions. Later in this chapter, the aspiration such as amiodarone (Figs. 7.117 to 7.119); see Table 7.13
biopsy cytology of malignant mesothelioma is discussed for differential diagnoses of foamy macrophages in respi-
in the section on primary pleural malignancy. ratory specimens.
Metastatic adenocarcinomas, particularly from the
gastrointestinal tract, that produce excessive mucin are
practically impossible to differentiate from cells of mu-
CONVENTIONAL ADENOCARCINOMA WITH
cinous type BAC or a mucin-producing adenocarcinoma.
MUCIN PRODUCTION AND MUCINOUS BAC
Colorectal adenocarcinomas often metastasize to lungs
The cells of mucinous BACs (Fig. 7.113) as well as those of as a solitary nodule—a pattern more in keeping with
adenocarcinomas with mucin production must be differ- primary lung cancer. Both carcinomas reveal excessive
Differential Diagnoses of Foamy Histiocytes in Respiratory Specimens (See Figs. 7.113 to 7.119)
Fig. 7.113. Bronchial washings. Mucinous carcinoma showing dis-

crete malignant cells with vacuolated cytoplasm.
Fig. 7.114. Bronchial brushings showing goblet cells containing Fig. 7.115. Sputum. Vacuolated reactive respiratory epithelial cells.
large cytoplasmic vacuoles.
A B
Figs. 7.116A and B. Reactive type II pneumocytes. The cells are pleomorphic in size with occasional large
cytoplasmic vacuoles.
Fig. 7.117. FNA of a lung lesion proven to be atypical mycobacte- Fig. 7.118. BAL showing lipid containing large macrophages. The
rial infection showing a foamy macrophage (also see e-Fig. 7.54). patient had lipid pneumonia.
Fig. 7.119. FNA of a lung lesion histologically confirmed as mala-

koplakia. The cellular aspirate shows a large number of macrophag-
es with abundant pale cytoplasm. Presence of Michales–Guttmann
bodies both intracytoplasmic and extracellular will support the di-
agnosis (also see e-Figs. 35A to C).
mucin production distending the cells and have bland nu-

SOLID ADENOCARCINOMA WITH MUCIN
clei. Without immunostains the differentiation of primary
PRODUCTION
from metastatic lung cancer is not possible. Adenocarci-
noma of the lungs is TTF-1 and CK7 positive and CK20 In cytologic preparations, solid adenocarcinomas pres-
negative, while colorectal adenocarcinomas are CK20 ent as either syncytial tissue fragments of malignant
positive and CK7 and TTF-1 negative. cells without any architectural confi gurations or discrete
TABLE 7.13 DIFFERENTIAL DIAGNOSES OF FOAMY MACROPHAGES IN RESPIRATORY SPECIMENSa
Cell Type & Associated Conditions & See

Disease Process Specimen Type Cytopathologic Features Confirmatory Tests Fig(s).
Lipophage Seen in cases of lipoid Round to oval, enlarged in size with giant Special stains: oil red 7.118A
pneumonia; present forms; well-defined cell borders; abundant O for intracytoplasmic and B
in sputum, bronchial pale, foamy bubbly cytoplasm; nucleus lipid
washings, BAL, and FNA small, central to eccentric
Mycobacterium Infection present Very large to giant forms, distended with Special stains: acid-fast 7.117;
Intracellular predominantly in HIV abundant foamy cytoplasm; rod-like stain, positive: bacilli e-Fig.
Avium (MIA) infected patients; present unstained images both intracellular and in with beaded appearance 7.56
infected cells, in sputum, bronchial extracellular location, in air-dried Giemsa
(pseudo washings, BAL, FNA stained preparations; negative images may
Gaucher’s cells) be seen in Papanicolaou stained smears
with overwhelming infections
Foamy Seen in AIDS patients Thick rhomboid crystals that dissolve Acid-fast stain: —
histiocytes treated with clofazimine during processing leaving negative images negative, red colored
containing for MIA infections, may in both Romanowsky and Papanicolaou crystals in unstained
clofazimine coexist with MIA infected stained preparation; crystals stain red in preparation
cells unstained preparations and are birefringent
Amiodarone Patients with respiratory Large foamy macrophages EM: lamellar bodies e-Fig.
drug toxicity insufficiency resulting within histiocytes; 7.34
from anti-arrhythmic drug history of drug therapy
toxicity; foamy alveolar
histiocytes in BAL
Reactive type II Patients with ARDS or Foamy cells, variable in size; cell borders Acid-fast stain: 7.116
pneumocytes acute lung Injury, assisted poorly defined, variable, sometimes negative; history of 7.91C
respiration, localized abundant foamy vacuolated cytoplasm; acute lung injury or
lesions such as infections, nucleus central to eccentric; chromatin artificial ventilation;
infarcts, benign neoplasms; bland to granular; nucleoli ; in company abnormal chest
abnormal cells recovered of cells or tissue fragments of cells radiographs; surfactant
from sputum, bronchial diagnostic of type II pneumocytes protein
washings, BAL and FNA
Malakoplakia Localized inflammatory Variably sized but generally large, round Special stains for 7.119;
lesion caused by to oval, uninucleated to multinucleated coccobacilli; Brown e-Fig.
Rhodococcus equi in cells (Von Hansemann cells); abundant & Brenn, Gomori’s 7.35
patients with AIDS; present foamy cytoplasm containing coccobacillary Methenamine silver,
in bronchial brushings, organisms seen with Romanowsky stained acid-fast; Michaelis–
BAL and FNA; may be preparations; Michaelis–Gutmann bodies Gutmann bodies stain
caused by other bacteria with targetoid centers both intracellular positive with PAS
and extracellular; inflammatory diastase resistant and
background Von Kossa
Goblet cells Chronic bronchitis and Large round to oval cells; poorly defined Mucin stain 7.114
hyperplasia asthma; present in sputum, cell borders; eccentric nuclei; abundant
bronchial brushings, lacy, foamy, bubbly cytoplasm; nucleus
bronchial washings, and central to eccentric; finely dispersed bland
BAL chromatin; micronucleoli
Mucin- Seen in all types of Size variable, medium to large; round Mucin stains 7.72
producing respiratory specimens to oval; poorly defined cell borders; Alcian blue 7.95
adenocarcinoma eccentric nucleus; powdery to finely PAS with diastase
granular chromatin; nuclear membrane
smooth to slightly irregular; micronucleoli/
macronucleoli
(continued)
247
Cell Type & Associated Conditions & See

Disease Process Specimen Type Cytopathologic Features Confirmatory Tests Fig(s).
Vegetable cells Seen in sputum Very large discrete cells with voluminous e-Fig.
contaminated with food foamy bubbly to reticular cytoplasm; well- 7.25A
defined refractile cell borders; central small
nuclei with compact chromatin; enormous
size, very small structureless nucleus;
multivacuolated cytoplasm; cytoplasmic
granulations /
Muciphage Associated with Variable size; abundant bubbly cytoplasm; 7.116

mucin producing low N/C ratio; nuclei may be pushed to
adenocarcinomas the periphery but not indented; nuclear
chromatin finely granular; very difficult
to differentiate from carcinoma cells with
cytoplasm distended with mucin
a
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer, 2002:87. Reproduced with the permission of Springer Science Business Media.
aggregates of cells with suggestions of secretory vacuoles. plasm is variable and shows no squamous or glandular
These tumors are usually interpreted simply as non-small differentiation.
cell carcinoma or LCUC.
The cells of LCUCs are present in large numbers in speci-
LARGE CELL UNDIFFERENTIATED mens obtained by bronchoscopy (bronchial brushings,
CARCINOMA (LCUC) washings, and BAL) or FNA biopsies, occurring singly,
LCUC—also called simply large cell carcinomas—are in loosely cohesive groups, and in syncytial tissue frag-
malignant neoplasms of the lung that show no squamous, ments, without any architectural pattern (Table 7.14;
glandular, or small cell (neuroendocrine) differentiation Figs. 7.120 to 7.125). Some aspiration biopsy specimens
in routinely stained sections of the tissues or smears of the may be overwhelmingly cellular with myriads of syncytial
cytologic specimens. Extensive sampling of the tumors tissue fragments in a clean background while others may
may exhibit focal differentiating features. The term non- exhibit discohesive cells in a background of cellular and
small cell carcinoma is also popularly used in order to inflammatory debris. Malignant cells vary greatly in size,
separate the neoplasm from the category of small cell car- ranging from medium to large, with frequent giant forms.
cinoma because of the distinctive management modali- They are round, oval, cuboidal to polygonal, and gener-
ties. Ultrastructurally, in the majority of cases, large cell ally possess well-defi ned cell borders. Their nuclei, large
carcinomas demonstrate squamous or glandular features with high N/C ratios, can be central or eccentric. Multi-
or both. A small proportion of these neoplasms demon- nucleation may be present. The nuclear membranes may
strate neurosecretory granules and only a few lack any be smooth or irregular and sometimes show lobulations.
differentiating features. The nuclear chromatin is fi ne to coarsely granular with
Large cell carcinomas comprise 10% of all primary parachromatin clearing. Single or multiple micro- and
lung cancers and are strongly associated with a history of macronucleoli are conspicuous and intranuclear inclu-
tobacco smoking. The patients remain asymptomatic for sions may be present. Karyorrhexis and mitotic figures
a long time or present with symptoms due to local effects may be prominent features.
or present with paraneoplastic syndrome. The cytoplasm of LCUC cells is variable, scant to
Large cell carcinomas are usually located peripher- abundant, pale, wispy, granular to dense, frequently show-
ally and spread via lymph nodes locally and to distant ing emperipolesis. There is no evidence of architectural or
organs with widespread metastases. They are usually functional differentiation demonstrated by the malignant
large, bulky with necrosis, and may invade the overly- cells. The background may be clean or necrotic.
ing pleura and hilar structures. Histologically, the carci-
Immunoprofile
noma reveals a solid growth pattern formed by medium
to large round to polygonal cells with no architectural Fifty to 75% of the cases react positively to epithelial
pattern. The nuclei are clearly malignant. The cyto- markers while some react to neuroendocrine markers.
TABLE 7.14 CYTOPATHOLOGIC FEATURES OF LCUC
Cellularity Variable; exfoliated malignant cells in sputum may be few and isolated; generally moderate to marked in
bronchial brushings and aspiration biopsy specimens
Presentation Malignant cells discrete, in loosely cohesive groups, or in syncytial tissue fragments without any architectural
pattern; dissociated pattern characteristic
Malignant Cells Very pleomorphic; small, medium, large to giant forms; round, oval to polygonal; cell borders may be well-defined
Nucleus Central to eccentric; single; bi-nucleated to multinucleation; round to irregular borders with or without
lobulations; chromatin fine to coarsely granular with parachromatin clearing; intranuclear inclusions /;
single/multiple; micronucleoli/macronucleoli; large cherry-red macronucleolus characteristic; mitotic figures /
Cytoplasm Variable, scant to abundant, pale, wispy, dense; neutrophils (emperipolesis) /
Background Clean to dirty with diathesis
Histochemistry PAS diastase resistant

Alcian blue
Immunoprofile Cytokeratin /; CEA /; vimentin /; neuroendocrine markers /
Ultrastructure Squamous differentiation: desmosomes and tonofilaments or

glandular differentiation: lumina surface microvilli, secretory granules and tight junctions or neurosecretory
granules or no differentiating features
Differential Poorly Differentiated Squamous Carcinoma

Diagnoses Poorly Differentiated Adenocarcinoma (Primary and Metastatic)
Large Cell Neuroendocrine Carcinoma (LCNEC)
Thymic Carcinoma (in Mediastinal Aspiration Biopsies)
Germ Cell Tumors (in Mediastinal Aspiration Biopsies)
Hodgkin Lymphoma
Malignant Lymphoma, Non-Hodgkin Type
Anaplastic Large Cell Lymphoma
Soft Tissue Tumors (Pleomorphic and Round Cell Type)
Malignant Melanoma
Large Cell (Undifferentiated) Carcinoma (LCUC) (See Figs. 7.120 to 7.125)
Fig. 7.120. Large cell carcinoma: Bronchial brushings. Tissue frag- Fig. 7.121. Large cell carcinoma: FNA lung mass. The malignant
ment of malignant cells, pleomorphic in size with scant to minimal cells are pleomorphic in shape and size and are loosely cohesive or
cytoplasm, lacking the differentiating features. discrete. Their cell borders are poorly defined. The scant cytoplasm
does not offer differentiating features.
Fig. 7.122. FNA mediastinal mass showing metastatic large cell Fig. 7.123. Large cell carcinoma: FNA lung nodule. Undifferenti-
carcinoma. ated, very pleomorphic, large malignant cells.
Fig. 7.124. Large cell: Bronchial brushings. Medium-sized to large Fig. 7.125. Large cell carcinoma: Bronchial brushings. Medium-
malignant cells, containing very scant cytoplasm and large clearly sized to large malignant cells containing appreciable cytoplasm that
malignant nuclei. shows no glandular or squamous differentiation.
Ultrastructure on surgical resection tend to demonstrate some cytoplas-

mic differentiation, at least in focal areas. This is often
Large cell carcinomas may demonstrate squamous or not the case with the limited quantity of cellular material
glandular differentiation and occasionally neuroendo- available in cytologic samples. In the absence of architec-
crine differentiation. Fourteen percent lack any differen- tural and functional differentiation, the host of neoplasms
tiating features. described below is interpreted as non-small cell carcino-
mas or LCUCs.
Certain benign cells may be misinterpreted as malig-
Differential Diagnoses of Large Cell Carcinoma
nant and should be considered in the differential diagno-
Most malignant neoplasms of the lung that are cyto- ses of LCUC. These are atypical epithelial cells with ra-
logically interpreted as LCUCs are poorly differentiated diation- or drug-induced changes, herpes virus–associated
neoplasms that lack any cytoplasmic characteristics for changes, and exuberant repair. Low nuclear/cytoplasmic
proper categorization into squamous, glandular, or small ratios, few or lack of single cells, and degenerating chang-
cell (neuroendocrine) carcinomas. These neoplasms share es involving both the cytoplasm and the nucleus are fea-
morphologic similarities with a wide range of non-epi- tures that favor benign lesions. Of course, clinical data is
thelial malignant neoplasms (Table 7.15), which must be absolutely essential.
considered in the differential diagnoses, particularly when Carcinomas with massive necrosis may yield large
a metastatic process is suspected. The majority of LCUCs numbers of infl ammatory cells, obscuring the few single
TABLE 7.15 DIFFERENTIAL DIAGNOSES OF LCUCS CYTOPATHOLOGIC FEATURESa
Diagnostic Diagnostic Clues/

Entity Cytopathologic Features Ancillary Tests See Fig(s).
Large cell Variable cellularity, generally cellular, malignant cells isolated, in CK , CK7 /, 7.120 to
undifferentiated aggregates, or in syncytial tissue fragments without any architectural TTF-1 / 7.125
carcinoma patterns; cells large; dissociated pattern characteristic; cells round,
oval to polygonal and occasionally spindle-shaped; cell borders
generally well-defined; nucleus central or eccentric; binucleation or
multinucleation /; nuclei round to oval; nuclear membrane smooth
to irregular; granular chromatin, parachromatin clearing; multiple
micronucleoli/macronucleoli; intranuclear cytoplasmic inclusions /;
mitoses /; cytoplasm variable, scant to abundant, pale to dense;
emperipolesis ; background clean to necrotic; no squamous, glandular,
or neuroendocrine differentiation
Poorly Variable cellularity, generally cellular, malignant cells isolated, in CK 7.23 to 7.36
differentiated aggregates, or in syncytial tissue fragments without any architectural p-63
squamous patterns; cells small to large with well-defined cell borders; N/C ratios
carcinoma variable; shape round to polygonal; central large nucleolus; nuclear
membrane smooth, irregular, or scalloped; granular chromatin; irregular
chromocenters /; parachromatin clearing; nucleoli prominent;
mitoses /; cytoplasm scant to abundant, pale to dense, squamous
differentiation in some cells /; (endo-ectoplasmic demarcation; rigid
cell borders); necrosis /; emperipolesis /
Poorly Variable cellularity, generally cellular, malignant cells isolated, in Epithelial markers 7.63, 7.64
differentiated aggregates, or in syncytial tissue fragments without architectural patterns; (see Table 1.3)
adenocarcinoma cells uniform to widely pleomorphic, small to large with giant forms;
primary or cell borders well to poorly defined; nuclei central to eccentric, round
metastatic to bizarre forms; chromatin fine to coarsely granular; micronucleoli/
macronucleoli prominent; intranuclear inclusions /; mitoses /;
cytoplasm scant to abundant, clear, pale to dense, occasional cell may
show cytoplasmic vacuoles; emperipolesis /; necrosis /
Large cell Variable cellularity; malignant cells pleomorphic in size, small to Neuroendocrine 7.139
neuroendocrine medium with frequent giant forms, round, oval to fusiform; cell borders markers
carcinoma poorly defined; N/C ratios high; nuclei round oval; molding /;
chromatin granular; nucleoli ; cytoplasm scant; mitoses very frequent;
karyorrhexis ; necrosis ; stretch artifacts
Thymic Variable cellularity; malignant cells pleomorphic in size, small to CK (HM wt) 17.34
carcinoma (in medium with frequent giant forms, round, oval to fusiform; cell borders USb tonofilaments
transbronchial poorly defined; N/C ratios high; nuclei round oval; molding /; around the nucleus
fine needle chromatin granular; nucleoli ; cytoplasm scant; mitoses very frequent;
biopsies only) karyorrhexis ; necrosis ; stretch artifacts
Germ cell Highly cellular, dispersed cell pattern, markedly pleomorphic malignant AFP 17.29
tumors cells with frequent giant forms; irregular nuclei with coarsely granular PLAP 17.33
(embryonal clumped chromatin with parachromatin clearing; single/multiple BHCG /
carcinoma) prominent nucleoli; intranuclear cytoplasmic inclusions; mitoses ; CEA
necrosis ; variable cytoplasm CK
Large cell Medium-sized cells; nuclei larger than histiocytic nucleus; finely Kappa/lambda / 14.13
lymphomas granular chromatin; one or more nucleoli; distinct rim of cytoplasm; LCA (CD45), 17.28
immunoblastic: large cells with eccentric nucleus; paranuclear clearing, CD19,
central prominent nucleolus; basophilic cytoplasm (Romanowsky stain); CD20
high mitotic rate; lymphoglandular bodies, cellular debris CD5 /
CD10 /
High K167
expression
(continued)
251
Diagnostic Diagnostic Clues/

Entity Cytopathologic Features Ancillary Tests See Fig(s).
Hodgkin Variable cellularity, discrete, medium-sized, round to oval, mononuclear Presence of Reed- 17.27
lymphoma Hodgkin cells; well-defined cell borders; large nucleus with granular Sternberg cells
chromatin and prominent nucleoli; scant cytoplasm; high N/C ratios History of Hodgkin
lymphoma
CK
CD20
CD45
Malignant Very cellular; pleomorphic, round to spindle cells; large nuclei; high N/C LCA / 14.16
lymphoma ratio; coarsely granular chromatin; micronucleoli; large cells, round to CD30 14.17
anaplastic large horse shoe-shaped nuclei; multinucleation; Reed-Sternberg-like cells; CK
cell type cytoplasm variable, scant to abundant; vacuolated /; mitoses /;
erythrophagocytosis rarely present
Soft tissue Generally very cellular, malignant cells isolated, in aggregates, or in Vimentin 24.34
tumors syncytial tissue fragments; cells mild to markedly pleomorphic in size 24.35
and shape; well-defined cell borders; binucleation/ multinucleation
frequent; nuclei large, round to irregular, lobulated with giant forms;
coarsely granular chromatin; prominent nucleoli; intranuclear
cytoplasmic inclusions ; variable cytoplasm
Malignant Highly cellular individually dispersed large round to polygonal cells, HMB-45 11.9
melanoma variable in size; well-defined cell borders; large pleomorphic nuclei with S100 protein 11.29
(amelanotic) binucleation and multinucleation; granular chromatin, parachromatin Melan-A
clearing; multiple micronucleoli/macronucleoli; intranuclear
cytoplasmic inclusions variable; pale to dense cytoplasm; mitoses /;
necrosis /
a
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer, 2002:120–121. Reproduced with the permission of Springer Scientific Business
Media.
b
US—Ultrastructure.
dispersed malignant cells that are easily overlooked and are. Not all are identified in cytologic specimens, par-
present the potential for a false negative diagnosis (Figs. ticularly the pre-neoplastic neuroendocrine lesions that
7.34 and 7.35). are included in the most recent WHO/IASLC classifica-
Morphologic variants of large cell carcinomas tion of the lung tumors. This chapter will focus only on
include neoplasms that are more frequently encountered, which
include 1) typical carcinoid tumor; 2) atypical carcinoid
● Large cell neuroendocrine carcinoma (LCNEC)
tumor; 3) LCNEC; and 4) small cell carcinoma. These
● Basaloid cell carcinoma
four neoplasms present a spectrum of morphologic fea-
● Lymphoepithelioma-like carcinoma
tures ranging from benign-appearing uniform cellular
● Clear cell carcinoma
patterns to highly anaplastic ones. Their biologic behav-
● Large cell carcinoma with rhabdoid features.
ior likewise ranges from that of a benign protracted
These carcinomas are of rare occurrence and will not course in a typical carcinoid to an aggressive one with a
be discussed further. fatal outcome, as seen in large cell neuroendocrine and
small cell carcinomas. Table 7.16 summarizes their salient
features. Despite the differences, pulmonary neuroendo-
crine tumors, as these are referred to, share several prop-
NEUROENDOCRINE TUMORS
erties such as morphologic features, growth patterns, the
presence of cytoplasmic secretory granules, the expres-
The spectrum of pulmonary neuroendocrine tumors sion of broad-spectrum neuroendocrine markers, and the
encompasses several diagnostic entities. Their classifica- expression of specific peptide hormones and amines. The
tion is quite complex, as is the terminology. Some neo- neuroendocrine neoplasia in general is discussed in detail
plasms are encountered more frequently than others in Chapter 10.
TABLE 7.16 CLINICOPATHOLOGIC FEATURES OF PULMONARY NEUROENDOCRINE TUMORS
Large Cell Small Cell

Typical Carcinoid Atypical Carcinoid Neuroendocrine Tumor Carcinoma
Clinical Findings
Incidence 1–2% of all primary lung 0.01–0.02% 2–3% of all pulmonary 12–18%
tumors cancers
Age: Range 23 to 70 years 21 to 67 years 35 to 75 years 45 to 64 years
Average 46 years 64 years 52 years
Sex M:F 2:3 2:1 4:1 2:1
Smoking History / / 100% 100%
Presenting Dependent on location Often detected as an Dependent on tumor Obstructive

Symptoms and centrally located cause incidental finding, usually location; ectopic symptoms;
Signs hemoptysis, dyspnea, post asymptomatic hormone production hemoptysis;
obstructive pneumonia; not observed in reported superior venacaval
often asymptomatic; may be cases syndrome; pleural
related to ectopic hormone effusion /;
production or associated symptoms may be
with MEN I or Cushing’s related to ectopic
syndrome hormone production
Radiographic Solitary nodule Solitary nodule Chest mass, variable in Hilar/mediastinal

Findings size mass
Location 30% central; 30% mid zone; 50% central; 50 peripheral Central or peripheral; Predominantly
30% peripheral may replace the lung central; 5%
peripheral
Biologic Behavior Indolent; regional node More aggressive than Very aggressive; fatal Very aggressive;
metastasis; up to 15%; typical carcinoid; regional fatal
metastasis at the time of node involvement 40–
presentation: none; 2–7% 45%; metastasis at the
demonstrate carcinoid time of presentation: 20%;
syndrome with 86% liver 5-year disease free survival
metastasis; 5-year disease 69%; 10-year disease free
free survival 100%; 10-year survival 52%
disease free survival 87%
Metastasis at Hilar lymph nodes 20% Hilar lymph nodes 40%; Hilar/mediastinal lymph Local and distant
the Time of liver metastasis 20% nodes metastases
Presentation
Gross Features
Tumor Size 0.7–3.5 cm; average 1.5 1.5–12 cm; average 2.4–4 cm; average Data not available
cm; smooth surface; no 4.5 cm; necrosis and 3.2 cm; necrosis and (surgical resections
hemorrhage or necrosis hemorrhage on cut surface hemorrhage are infrequent);
/ necrosis and
hemorrhage
(continued)
Large Cell Small Cell

Typical Carcinoid Atypical Carcinoid Neuroendocrine Tumor Carcinoma
Histomorphology Neuroendocrine growth Neuroendocrine growth Neuroendocrine growth Large masses of
pattern: nests, trabeculae with pattern; disruption of pattern; large nests and compactly arranged
or without anastomosing the architecture /; islands with peripheral cells
pattern; rosettes, acinar, peripheral palisading of palisading
papillary very uniform nuclei in large islands
Cell Size and Small round to uniform Small to medium-sized; Large round, oval Small round, oval
Shape monomorphic; well-defined round to oval; uniform to fusiform; very to fusiform; poorly
cell borders; lower N/C to pleomorphic; well to pleomorphic; well to defined cell borders;
ratios poorly defined cell borders; poorly defined cell high N/C ratios; less
low to high N/C ratios borders; lower N/C pleomorphic
ratios
Nucleus Nuclei round to oval; smooth Nuclei round to oval; Nuclei round to oval Nuclei round, oval
nuclear membrane; stippled smooth nuclear membrane; fusiform; smooth to fusiform; intense
coarsely granular salt & chromatin coarsely nuclear membrane; hyperchromasia;
pepper chromatin pattern; granular stippled to dense; typical stippled salt nucleoli absent;
nucleoli inconspicuous; nucleoli may be prominent; & pepper chromatin mitotic rate
mitoses none; karyorrhexis mitoses up to 10/10HPF; pattern; nucleoli high; nuclear
none; nuclear molding none; nuclear molding /; prominent frequent molding always;
stretch artifacts none karyorrhexis /; stretch giant forms; very high karyorrhexis
artifacts / mitotic rate 22/hpf; always; stretch
nuclear molding /; artifacts always
karyorrhexis frequent;
stretch artifacts
Cytoplasm Scant to modest; Variable, scant to modest Modest Insignificant

eosinophilic; granular
Azzopardi Effect None Very rare Not common Very common
Necrosis None Punctate, small foci to Large infarct-like areas Large infarct-like
large areas of necrosis areas of necrosis
PULMONARY CARCINOID ing’s syndrome due to the ectopic production of ACTH.

TUMORS (NEUROENDOCRINE Hilar lymph nodes are involved in roughly 20% of the
CARCINOMA, GRADE I) cases and five-year disease free survival is reported to be
100%. In general, carcinoid tumors follow an indolent
Typical carcinoid tumors or well-differentiated neuroen-
course.
docrine carcinomas of grade I are neoplasms with low
malignant potential, accounting for 1 to 2% of all pri-
mary lung tumors.
Pulmonary carcinoid tumors occur more frequently
in women, at any age, with a mean of 55 years. The Carcinoid tumors are equally located centrally, in the mid
majority of patients harboring carcinoid tumors are as- portion of the lung, and peripherally. Central carcinoids
ymptomatic. Those with centrally located tumors may frequently present as a large endobronchial exophytic
present with hemoptysis, dyspnea, and post-obstructive fl eshy, polypoid mass with a smooth surface protruding
pneumonia. Roughly 2 to 7% of patients with carcinoid into the bronchial lumen. The tumor infiltrates the under-
tumors develop carcinoid syndrome resulting from in- lying tissues beyond the cartilage plates into the surround-
creased production of serotonin. The majority of the ing parenchyma. The cut surface may appear tan–yellow
patients with carcinoid syndrome have hepatic metasta- to red. Gross necrosis and hemorrhage are not features of
sis. Some patients with carcinoid tumors develop Cush- a typical carcinoid tumor.
Peripheral carcinoid tumors are situated in the sub- are smooth and regular. Nucleoli are inconspicuous and
pleural parenchyma and, anatomically, are not related to nuclear molding, stretch artifacts, karyorrhexis, or mi-
a bronchus or a bronchiole. They are circumscribed, non- totic figures are not present. The cells of typical carcinoid
encapsulated may be multiple, and tend to be smaller in tumors in cytologic preparations generally exhibit poorly
size than the central carcinoids. defi ned cell borders and insignifi cant or scant, pale cy-
Histologically, the typical carcinoid tumor consists of toplasm in contrast to histologic sections. Occasionally,
uniform small, round to cuboidal cells with varied growth the cells may exhibit pale, somewhat bubbly cytoplasm,
patterns that are characteristic of neuroendocrine tumors resembling well-differentiated adenocarcinoma cells (Fig.
(neuroendocrine growth pattern) (see Chapter 10). The 7.130) and are distinguished by positive reactivity to neu-
neoplastic cells are compactly arranged in well-defined ag- roendocrine markers. Abundant granular cytoplasm in
gregates, nests, islands, trabeculae, and ribbons separated the oncocytic variant of a carcinoid tumor has been mis-
by delicate vascular stroma. Other morphologic patterns interpreted as a granular cell tumor. On rare occasions,
include pseudoglandular, rosettes, and sometimes palisad- carcinoid tumor cells may demonstrate a very pleomor-
ing arrangement at the periphery of the islands of tumor phic cell pattern with an admixture of plasmacytoid and
cells. Papillary pattern may rarely be encountered. The short spindle cells with cytoplasmic processes, reminiscent
nuclei of the carcinoid tumor cells are round to oval with of medullary thyroid carcinoma or a paraganglioma (Fig.
coarsely granular stippled salt & pepper chromatin with 7.129). The background is clean and necrosis is absent.
inconspicuous nucleoli. The cell borders are well-defined. A perithelial pattern with carcinoid cells attached to the
The cytoplasm is variable, scant to moderate, pale to eo- capillaries is quite characteristic in fine needle aspirates
sinophilic, and at times clear. (Fig. 7.131).
Spindle cell carcinoid tumors are unusual occurrenc- Spindle cell carcinoid tumors demonstrate short to
es, comprising 5% of all pulmonary carcinoids. They long spindle cells, discrete, in groups, or fascicles with
tend to be peripheral and are not anatomically related cytoplasmic processes (Fig. 7.132A). Their nuclei are
to the airways. Spindle cell carcinoids are well-circum- round to oblong with smooth nuclear membranes con-
scribed and non-encapsulated. Tumor nodules may infil- taining typical salt & pepper type chromatin and incon-
trate into the surrounding parenchyma. Microscopically, spicuous nucleoli. The cytoplasm is pale and variable.
spindle cell carcinoids are composed of swirling bundles Spindle cell carcinoid tumors may be associated with
of short to long spindle cells with round to oblong nu- cells presenting the cytomorphology of a typical carci-
clei containing salt & pepper type chromatin—a charac- noid (Fig. 7.132B).
teristic feature of neuroendocrine tumors. Nucleoli are
inconspicuous. The cells of spindle cell carcinoids have
indistinct cell borders and possess a modest amount of Differential Diagnoses of Carcinoid Tumors
pale eosinophilic cytoplasm. Spindle cell carcinoid tu-
The differential diagnostic possibilities of carcinoid tumors
mors may contain areas with the morphology of a typi-
include all the lesions both nonneoplastic and neoplastic
cal carcinoid tumor.
that are composed of small cells as well as other neuroen-
docrine tumors (see Table 7.20).
In specimens obtained by bronchoscopy, the cells of
carcinoid tumor must be differentiated from benign enti-
Carcinoid tumors rarely, if ever, shed cells in sputum. ties (see Figs. 7.149 to 7.152) that exhibit a small cell
Bronchial brushings, washings, BAL, and aspiration pattern such as reserve cell hyperplasia, bronchial epithe-
biopsies—both transthoracic (for peripheral carcinoids) lial cell hyperplasia, lymphocytes, and alveolar lining cells
and transbronchial (for central carcinoid tumors)—are (in washings and lavage specimens). Among the malig-
useful in establishing the diagnosis. Bronchial carcinoid nant neoplasms with a small cell pattern, the diagnostic
tumors in subepithelial locations cannot be sampled if the considerations are small cell carcinoma, malignant lym-
overlying mucosa is intact. Bronchial brushings in such phoma, adenoid cystic carcinoma, poorly differentiated
instances are often nondiagnostic. squamous carcinoma, primary and metastatic adenocar-
The cells of typical carcinoid tumors present a distinc- cinomas, malignant melanoma (see Fig. 7.164; also refer
tive pattern (Table 7.17; Figs. 7.126 to 7.134). They oc- to Fig. 11.13).
cur loosely cohesive, present a dispersed pattern, or form In addition to the above diagnostic entities, tumors
syncytial tissue fragments that vary in size forming nests, involving the mediastinal structures such as the thy-
trabeculae, and occasionally a pseudoacinar or a pseu- mus, lymph nodes, or soft tissues must be considered in
dopapillary pattern. Strikingly uniform, small, round to specimens obtained by transbronchial fine needle biopsy.
cuboidal, sometimes plasmacytoid cells with typical salt These include thymic carcinoids, thymoma, metastatic
& pepper chromatin granules are a hallmark of carcinoid malignant melanoma, and in younger patients, primitive
tumors (Figs. 7.126 to 7.128). The nuclear membranes neuroectodermal tumors (PNET).
TABLE 7.17 CYTOPATHOLOGIC FEATURES OF PULMONARY NEUROENDOCRINE TUMORS
Large Cell
Neuroendocrine
Carcinoid Tumors Atypical Carcinoid Carcinoma (LCNEC) Small Cell Carcinoma
(Neuroendocrine (Neuroendocrine (Neuroendocrine (Neuroendocrine
Carcinoma, Grade I) Carcinoma, Grade II) Carcinoma, Grade III) Carcinoma, Grade III)
Cellularity Variable, generally very Variable, generally very Variable, generally Variable, scant (e.g.,
cellular cellular cellular sputum) to overwhelmingly
cellular in direct brushings
smears or FNA
Presentation Cells dispersed, isolated, in Cells dispersed, Malignant cells discrete, Malignant cells discrete,
loosely cohesive groups, or in isolated, in loosely in loosely cohesive in aggregates, or in
syncytial tissue fragments, as cohesive groups, or groups, or in syncytial syncytial tissue fragments
cords, nests or anastomosing in syncytial tissue tissue fragments, without usually without any
ribbons with occasional fragments as cords, any architectural pattern architectural patterns;
acinar pattern; dispersed nests, or anastomosing or forming trabeculae crush artifacts may be
pattern more frequent in ribbons, occasional and occasionally rosette extensive in direct smears
brushings and washings; acinar pattern or formation; stretch of brushings or FNA;
perivascular location with rosettes; perivascular artifacts , peripheral often present as single
cells lining capillaries in FNA arrangement of cells in palisading of nuclei in cells or in groups of 2 and
specimens fine needle aspirates tissue fragments / 3 cells in a mucus streak
Cells Small, round to cuboidal; Small, round to Small to medium-sized; Small, round, 3–3.5
cell borders well to cuboidal; well to pleomorphic with times the size of a resting
poorly defined; uniform, poorly defined cell frequent giant forms; lymphocyte to slightly
monotonous pattern with borders; high N/C round, oval to polygonal, larger to oval to short
occasional large pleomorphic ratios; uniform to occasionally fusiform; spindle-shaped 3.5–4
forms; short to long spindle varying degrees of N/C ratios high; cell times the lymphocyte; cell
cells in some spindle cell pleomorphism borders poorly defined borders poorly defined,
carcinoids often flush with the nucleus
Nucleus Round to oval in typical Round to oval with Large, round, oval, Round to oval;
carcinoids; oblong in spindle smooth nuclear occasionally fusiform; multinucleation not
cell carcinoids; smooth membrane; salt & nuclear membranes observed; N/C ratios very
nuclear borders; N/C ratios pepper chromatin sharp; chromatin stippled, high; nuclear membranes
generally high; chromatin pattern and coarsely granular; smooth; nuclear
coarsely granular, salt & inconspicuous nucleoli nucleoli /; mitoses ; chromatin very coarsely
pepper type; nucleolus /; to hyperchromatic karyorrhexis ; naked granular to compact and
no nuclear molding; no nuclei with nuclear nuclei /; nuclear deep-staining; nucleoli
karyorrhexis; mitoses absent; molding and nucleoli; molding inconspicuous; nuclear
no stretch artifacts mitoses /; molding ; mitoses ;
karyorrhexis /; no karyorrhexis ; stretch
specific cytologic criteria artifacts
Cytoplasm Scant to moderate; pale Variable, scant Scant, indiscernible to Indiscernible to very
occasionally foamy insignificant to moderate, pale scant; paranuclear
(mimicking adenocarcinoma), moderate amount vacuoles in Romanowsky
rarely oncocytic stained preparations
Background Clean Clean to necrosis Necrosis Dirty; necrosis;

fragmented forms
Immunoprofile Neuroendocrine markers ; Neuroendocrine Neuroendocrine markers Neuroendocrine markers

cytokeratin (CAM5,2 and markers ; cytokeratin ; cytokeratin (CAM5,2 ; cytokeratin (CAM5,2
CK7) ; TTF-1 CK20 , (CAM5,2 and CK7) and CK7) ; TTF-1 ; and CK7) ; TTF-1 ;
CD56 ; TTF-1 ; CK20 , CK20 −, CD56 CK20 , CD56
CD56
Ultrastructure Membrane-bound Membrane bound Neurosecretory granules Membrane bound

neurosecretory granules neurosecretory present; no squamous or neurosecretory granules
granules glandular differentiation
256
Pulmonary Carcinoid Tumors (See Figs. 7.126 to 7.136)
A B
Figs. 7.126A and B. Carcinoid tumor: Bronchial brushings. A: The carcinoid tumor cells are small, round, occurring
discrete and in tissue fragments. They have ill-defined cell borders, insignificant cytoplasm, and high N/C ratios. The
nuclei are remarkably uniform containing the characteristic salt & pepper chromatin. B: Another field from the same
specimen. The carcinoid tumor cells are discrete and may be misinterpreted as lymphocytes.
Fig. 7.127. Carcinoid tumor. Bronchial brushings: Syncytial tissue Fig. 7.128. Carcinoid tumor. Bronchial brushings. The carcinoid
fragments of small malignant cells. The nuclei contain salt & pepper tumor cells are mildly pleomorphic in size but present the charac-
chromatin. There is no nuclear molding. teristic salt & pepper chromatin.
Fig. 7.129. Carcinoid tumor. Bronchial brushings. The carcinoid Fig. 7.130. Carcinoid tumor. Bronchial brushings. The carcinoid
tumor cells are pleomorphic in size and shape with round, plas- tumor cells present in syncytial tissue fragments are enlarged with
macytoid, triangular and polygonal forms. The nuclei are eccentric variable cytoplasm, resembling an adenocarcinoma. The bronchial
and contain salt & pepper chromatin. This pattern is reminiscent of biopsy performed at the same time confirmed the diagnosis.
other neuroendocrine tumors such as medullary thyroid carcinoma
or a paraganglioma.
257
Fig. 7.131. Carcinoid tumor. FNA lung nodule. The carcinoid tu-
mor cells demonstrate a perivascular arrangement. The cells are at-
tached to a capillary by cytoplasmic processes.
A B
Figs. 7.132A and B. A: FNA spindle cell carcinoid tumor. The aspirate shows spindle cells that are discrete and in fas-
cicles. Their cytoplasm is scant. The nuclear chromatin is stippled, characteristic of neuroendocrine tumor. B: Another
field showing an admixture of round and spindle cells with characteristic nuclear morphology of neuroendocrine
tumor.
Fig. 7.133. FNA carcinoid tumor. The aspirate is paucicellular and Fig. 7.134. FNA carcinoid tumor. The poorly cellular aspirate con-
showed a rare tissue fragment of small, round cells with scant cyto- tained discrete small carcinoid tumor cells misinterpreted as lym-
plasm and uniform nuclei and was interpreted as benign respiratory phocytes.
cells.
The spindle cell carcinoid tumors must be differenti- 1) increased number of mitotic fi gures; 2) pleomorphism
ated from neoplasms that are composed of spindle cells or irregularity of the nuclei, prominent nucleoli, hyper-
(e.g., soft tissue tumors, squamous carcinoma with spin- chromasia, and increased nuclear:cytoplasmic ratios; 3)
dle cell pattern, metastatic medullary thyroid carcinoma, areas of increased cellularity with disorganization of the
and malignant mesothelioma with sarcomatous pattern) architecture; and 4) necrosis in either punctate, focal, or
(see Table 24.5; Figs. 24.38 to 24.48). large areas. None of these features can be appreciated in
Since the neuroendocrine tumors of the lung share cytologic preparations.
several of the morphologic features, their differential di-
agnostic possibilities are similar with some exceptions. In Cytopathologic Features
order to avoid repetition, they are discussed in the section
The cytologic recognition of an atypical carcinoid is
on small cell carcinoma (see Table 7.20).
not possible. The cytologic interpretation ranges from a
typical carcinoid to a small cell carcinoma (Table 7.17).
When tumor cell necrosis is minimal, mitotic figures
ATYPICAL CARCINOID TUMOR sparse, and the overall architecture is maintained, the
(NEUROENDOCRINE CARCINOMA, GRADE II) cytologic pattern strongly resembles that of a typical
carcinoid. With prominent nuclear atypia, mitosis, and
Atypical carcinoid tumors are uncommon neoplasms,
necrosis, the cytologic pattern resembles either a small
behave more aggressively than the typical carcinoid
cell carcinoma or a LCNEC (Figs. 7.135 and 7.136).
tumors, and comprise 11 to 24% of all pulmonary car-
There is not a single cytologic feature that is characteris-
cinoids. They are more frequent in males, occurring at
tic of an atypical carcinoid. The immunoprofile and the
an older age than typical carcinoid tumors. Roughly
ultrastructural findings are similar to that of typical car-
20% of the cases demonstrate metastasis at the time of
cinoid tumors.
presentation with regional lymph node involvement in
The differential diagnoses of atypical carcinoid tu-
40 to 48% of the cases. Five-year survival is reported
mors are the same as for other pulmonary neuroendo-
to be 69%.
crine tumors.
Grossly, atypical carcinoid tumors tend to be larger than
LARGE CELL NEUROENDOCRINE
the typical carcinoids and may reveal areas of hemor-
CARCINOMA (LCNEC, NEUROENDOCRINE
rhage and necrosis.
CARCINOMA, GRADE III)
Microscopically, atypical carcinoids show a spectrum
of fi ndings that range from patterns resembling a typical LCNECs have been fairly recently recognized as a sub-
carcinoid to one that appears very similar to small cell type of pulmonary neuroendocrine tumors, characterized
carcinoma. by their distinctive morphology such as neuroendocrine
Histologic diagnosis of atypical carcinoid is based on growth patterns, large cells with coarse nuclear chroma-
the presence of one or more of the following four criteria: tin, prominent nucleoli, large amount of cytoplasm, high
Fig. 7.135. FNA. Atypical carcinoid. The malignant cells are pleo- Fig. 7.136. FNA. Atypical carcinoid. The neoplastic cells are slightly
morphic and contain coarsely granular chromatin. This is cytologi- larger with high N/C ratios. The chromatin is stippled and extremely
cally interpreted as either a carcinoid or a small cell carcinoma. The deep-staining. Their cytoplasm is indiscernible. There is no nuclear
diagnosis is made on surgically resected specimen. molding. A small cell carcinoma is the likely cytologic diagnosis, but
confirmed histologically as atypical carcinoid.
mitotic rate, infarct-like necrosis, and neuroendocrine Cytopathologic Features

differentiation, both immunocytohistochemically and
ultrastructurally. Cytologically, LCNEC presents (Table 7.17) a wide spec-
LCNECs are uncommon with a reported incidence trum of cytomorphologic features ranging from one that
of less than 2% of all lung carcinomas. They occur in an closely resembles small cell carcinoma to LCUC. LCNECs
age range of 35 to 75 years with a median age of 64 years are frequently peripheral and better visualized in aspira-
and are more common in males with a M:F ratio of 6:1. tion biopsy specimens.
A strong association with heavy cigarette smoking is well- The aspirates are generally very cellular (Figs. 7.137
documented. LCNECs are aggressive neoplasms with a to 7.140). The malignant cells are isolated, in loosely
one-year survival rate of 58.5%. cohesive groups or aggregates, and in syncytial-type tis-
sue fragments with trabeculae that often anastomose.
Gross and Histologic Features An occasional rosette formation may be appreciated.
Stretch artifacts involving individual cells are character-
Grossly, the tumors may be centrally located but more istic both under low and high power (Fig. 7.140). The
frequently are peripheral, ranging from small to large, malignant cells are less uniform than in small cell car-
extensively replacing the lung parenchyma, often with cinoma and often display a pleomorphic pattern with
large areas of necrosis. Peripherally located tumors often cells varying in size and shape ranging from round, oval
lack lymph node metastasis and do not show evidence of to polygonal forms. Fusiform cells are less frequent. Of-
systemic spread. The tumor is well-circumscribed, non- ten interspersed, are large giant forms either with abun-
encapsulated, and may be multinodular. The cut surface dant cytoplasm (Fig. 7.137) or as naked nuclei, similar
is yellow–white to tan. to those seen in other neuroendocrine tumors such as
Histologically, LCNECs present typical neuroendo- pheochromocytomas or medullary thyroid carcinomas.
crine growth patterns with large nests or well-defined The cell borders of LCNEC are poorly defined with a
islands of cells demonstrating peripheral palisading or variable scant to appreciable amount of pale cytoplasm.
trabeculae and rosettes. The neoplastic cells are pleo- The nuclear:cytoplasmic ratios vary from high to low.
morphic in size, round, spindle-shaped to polygonal The nuclei are round, oval, and sometimes spindle-
cells with interspersed, very large forms. Their N/C shaped with regular nuclear membranes. The chromatin
ratios are variable. The nuclear chromatin is coarsely is dark-staining, coarsely granular, and at times, thready.
granular. Micronucleoli may be a prominent feature. A Nucleoli are frequently present in contrast to small cell
very high mitotic rate is highly characteristic of LCNECs carcinoma. Nuclear molding is often present, aiding in its
(22–38/10 HPF), so also the large geographic, infarct- differentiation from LCUC, but this feature is less con-
like areas of necrosis. Azzopardi effect (DNA staining spicuous than in small cell carcinomas. Mitotic activity
and hematoxylin encrustation of the vessel wall) is is brisk and conspicuous. Karyorrhexis is common with
uncommon. fragmented nuclei present within the tissue fragments.
Large Cell Neuroendocrine Carcinoma (See Figs. 7.137 to 7.140)
Fig. 7.137. LCNEC. FNA of a lung nodule. The malignant cells are Fig. 7.138. LCNEC. FNA. The malignant cells are small, loosely
very pleomorphic with an occasional giant form. Their cytoplasm cohesive with poorly defined cell borders and scant cytoplasm. The
is variable and nuclei in many cells are eccentric, pleomorphic with nuclei have deep-staining granular chromatin. Nucleoli are absent.
very coarsely granular chromatin. There are no nucleoli. There is some suggestion of nuclear molding.
Fig. 7.139. LCNEC. FNA. These malignant cells are medium-sized Fig. 7.140. LCNEC. FNA. The malignant cells are discrete, small,
to large. The nuclei have typical neuroendocrine morphology. These and may be interpreted as small cell carcinoma, but histologically
may be interpreted as large cell carcinoma. proven to be LCNEC.
Foci of acellular debris, when present, suggest tumor presents an age range of 32 to 79 years with a median age
necrosis—a characteristic feature of LCNEC. of 60 years. There is a male preponderance and a strong
association with smoking.
The majority of the patients are symptomatic with
Immunoprofile
cough, dyspnea, wheezing, hemoptysis, chest pain, or
LCNECs react positively to most of the neuroendocrine post-obstructive pneumonia. Mediastinal involvement is
markers and cytokeratin. common; small cell carcinoma may manifest as superior
venacaval syndrome, or with recurrent laryngeal nerve
paralysis. Symptoms may be related to ectopic hormone
Differential Diagnoses of LCNEC
production by the tumor cells and also due to metastatic
The differential diagnoses of LCNEC include small cell involvement of sites such as the central nervous system,
carcinoma, carcinoid tumors, large cell carcinoma, and bones, and liver. Chest radiographic findings are vari-
poorly differentiated adeno or squamous carcinomas, and able and often show a perihilar mass or mediastinal
several types of soft tissue sarcomas that present an epi- widening.
thelioid cell pattern.
The cytologic differentiation between small cell car-
cinoma and LCNEC is extremely diffi cult and to a large
extent depends on a sampling of the lesion. Both carcino- Roughly 70% of the cases of small cell carcinomas present
mas share many morphologic features. Pleomorphism of as a perihilar mass with extensive lymph node metastasis.
the cells with frequent large forms and infrequent nuclear The tumor is white–tan, soft, and friable, frequently with
molding favor LCNECs. Variable, sometimes abundant extensive necrosis. Small cell carcinoma is typically situ-
cytoplasm, conspicuous nucleoli, also suggests LCNEC. ated in a peribronchial location. Submucosal and circum-
Most often, the fi nal diagnosis is made on histologic ferential infi ltrates may occur along bronchi. Bronchial
examination. lumen may be obstructed. A small portion (5%) presents
Shared morphologic features account for difficulties in as a solitary (coin) lesion.
accurate identification of LCNEC cytologically. Its differ- Small cell carcinomas are characterized by extensive
entiation from LCUC can be extremely difficult on Papani- necrosis. Their growth patterns consist of nests, streams,
colaou staining and without immunostudies (Table 7.18). and ribbons with palisading of cells at the periphery of
the nests; occasionally, rosettes may be formed. Necro-
sis may be minimal and some tumors may show des-
moplastic reaction. Azzopardi effect is often noted. The
SMALL CELL CARCINOMA
malignant cells are small, round to fusiform, contain-
(NEUROENDOCRINE CARCINOMA, GRADE III)
ing scant cytoplasm, finely granular nuclear chromatin,
Small cell carcinomas comprising 12 to 18% of all lung and absent or inconspicuous nucleoli. Nuclear mold-
cancers are highly malignant neoplasms with a very ing is difficult to visualize in histologic sections. A very
aggressive clinical course and a high mortality rate. Most high mitotic rate, sometimes exceeding 10/single HPF is
patients have distant metastasis at the time of diagnosis. It characteristic.
TABLE 7.18 CYTOPATHOLOGIC FEATURES DIFFERENTIATING LCNEC AND LCUCa
Large Cell Neuroendocrine Carcinoma (LCNEC) Large Cell Undifferentiated Carcinoma (LCUC)
Cellularity Variable, generally cellular Variable, generally cellular
Presentation Malignant cells discrete, in loosely cohesive groups, Malignant cells discrete, in loosely cohesive
or in syncytial tissue fragments, without any groups, or in syncytial tissue fragments without
architectural pattern or forming trabeculae and any architectural pattern; stretch artifacts ;
occasionally rosette formation; stretch artifacts karyorrhexis
Cells Medium-sized; pleomorphic with frequent giant Medium to large; uniform to pleomorphic, giant
forms; round, oval to polygonal, occasionally forms /; round to polygonal, spindle cells /;
fusiform; N/C ratios high; cell borders poorly N/C ratios high; cell borders well to poorly defined
defined
Nucleus Large, round, oval, occasionally fusiform; nuclear Large, round to oval; nuclear membrane sharp,
membrane sharp; chromatin stippled, coarsely smooth to irregular; chromatin fine to coarsely
granular; nucleoli /; mitoses ; karyorrhexis ; granular with parachromatin clearing; nucleoli
naked nuclei /; nuclear molding ; micronucleoli/macronucleoli ; mitoses ;
karyorrhexis ; naked nuclei ; nuclear molding
Cytoplasm Scant, indiscernible to moderate, pale; Scant to moderate, pale, lacy to dense;
emperipolesis emperipolesis /
Background Necrosis can be extensive Necrosis large bulky tumors may be cystic
Histochemistry Alcian blue ; PAS with and without digestion Alcian blue /; PAS with and without
digestion /
Immunochemistry Positive reactivity to neuroendocrine markers Negative reactivity except in cases with
Neuroendocrine neuroendocrine differentiation
Markers
Ultrastructure Neurosecretory granules present; no squamous or Neurosecretory granules generally absent; may be
glandular differentiation present in a small population; features of squamous
or glandular differentiation
a
Small Cell Carcinoma (See Figs. 7.141 to 7.148)
Fig. 7.141. Sputum. Discrete and loosely cohesive small cell carci- Fig. 7.142. Sputum. The tissue fragment of small malignant cells
noma cells with degenerating forms. with poorly defined cell borders, indistinct cytoplasm, high N/C
ratios and deep-staining compact chromatin with no nucleoli.
Fig. 7.143. Small cell carcinoma in bronchial brushings. A large Fig. 7.144. Bronchial brushings. Syncytial tissue fragment of small
population of small undifferentiated cells with nuclear molding and undifferentiated cells without any architectural pattern. The cell
karyorrhexis. borders are poorly defined. The nuclei are round to oval with deep-
staining, compact chromatin, lacking nucleoli. There is conspicuous
nuclear molding.
Fig. 7.145. FNA. Small cell carcinoma. The cellular aspirate consists Fig. 7.146. FNA. Small cell carcinoma. The cells forming this syncy-
of discrete and loosely cohesive, small malignant cells with molded tial tissue fragment are small with poorly defined cell borders, nuclei
nuclei containing compact chromatin. Their cytoplasm is insignifi- with molding and insignificant cytoplasm. The nuclear chromatin is
cant. Some malignant cells demonstrate stretch artifacts. coarsely granular and lack nucleoli.
Fig. 7.147. FNA. Small cell carcinoma. The cellular aspirate con- Fig. 7.148. FNA. Small cell carcinoma with a spindle cell pattern.
sists of dispersed small cells with round, oval and short spindle- The nuclei demonstrate stretch artifacts. There is karyorrhexis in
shapes. The nuclei show molding and stretch artifacts. the background.
Cytopathologic Features TABLE 7.19 DIFFERENTIAL DIAGNOSES OF

SMALL CELL CARCINOMAa
The cytologic features of small cell carcinomas are
very characteristic (Table 7.16; Figs. 7.141 to 7.148). 1. Nonneoplastic
The malignant cells are small, 3 to 3.5 times the rest- a. Lymphocytes
ing lymphocyte and present as discrete cells, in groups, Follicular bronchitis and bronchiolitis
or in small to large syncytial tissue fragments without Diffuse lymphoid hyperplasia
any architectural pattern. The cells are round or oval to Pseudolymphoma
fusiform with molded nuclear borders. The nuclear chro- Reactive lymphadenitis
matin is very coarsely granular of varying intensity, even b. Reactive bronchial epithelial cells
appearing compact. Nucleoli are absent to inconspicu- c. Reserve cell hyperplasia
d. Alveolar lining cells
ous. The small cell carcinoma cells contain scant to insig-
2. Neoplastic
nificant cytoplasm with almost invisible cell borders, giv- a. Neuroendocrine tumors
ing an appearance of naked nuclei. Mitotic figures are Carcinoid tumors
frequent, as are karyorrhexis and necrotic debris in the Atypical carcinoid tumor
background. Large cell neuroendocrine carcinoma
The cells of small cell carcinoma with scant cytoplasm b. Poorly differentiated squamous carcinoma
tend to air dry quickly, losing cellular details, often mak- Small cell variant
ing cytologic interpretation very difficult. The neoplastic c. Poorly differentiated adenocarcinoma (primary or
cells are also very fragile and exhibit stretch artifacts that metastatic)
result from the smearing process. The stretch or crush ar- d. Adenoid cystic carcinoma
tifact seen in small cell carcinoma is described by some e. Malignant lymphoma
f. Malignant melanoma
as a distinctive feature, generally involving single cells
g. Thymoma
manifested by long streaks or fine strands of chromatic h. Thymic carcinoid
material extending from the nuclear membrane of oth-
erwise intact carcinoma cells. It is also seen as elongated a
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer,
nuclei with finely pointed ends. In contrast to small cell 2002:87. Reproduced with permission from Springer Science Business
Media.
carcinoma cells, the crush artifacts involving lymphoid
cells both benign and malignant, involve aggregates and
not individual cells, appearing as thick ropy strands of
chromatic material that does not extend from the nuclei
In bronchial brushings, small cell carcinomas must
of intact cells.
be differentiated from other neoplasms that are com-
posed of small cells such as carcinoid tumors and poorly
differentiated squamous carcinoma, adenocarcinomas,
Differential Diagnoses
and rarely, adenoid cystic carcinoma. Reactive and hy-
The typical cytomorphologic pattern of small cell carcino- perplastic respiratory epithelial cells may be a problem
mas offer high diagnostic accuracy provided the cytologic (Figs. 7.157 to 7.159). The presence of tissue fragments
sample is adequately cellular and properly preserved. The of reserve cell hyperplasia also constitutes a diagnostic
differential diagnostic possibilities are several and are pitfall (Fig. 7.156).
also dependant on the type of specimen. The differential In transbronchial aspirates, the differential diagnos-
diagnoses of small cell carcinoma in various specimens tic entities are several. Since most small cell carcinomas
from the respiratory tract are listed in Table 7.19. Their involve hilar lymph nodes, malignancies affecting the
differentiating features are described in Table 7.20 and lymph nodes in this area must be considered in the dif-
illustrated in Figures 7.149 to 7.164. ferential diagnoses (e.g., non-Hodgkin lymphoma, thymic
In sputum, small cell carcinomas may be mistaken carcinoid [Fig. 7.160], thymoma [Fig. 7.161], poorly dif-
for lymphocytes and vice versa (Fig. 7.151). The degen- ferentiated adenocarcinoma [Figs. 7.162 and 7.163] or
erated, discrete malignant cells may not exhibit nuclear squamous carcinoma with a small cell pattern, LCNEC,
molding and must also be differentiated from the py- and malignant melanoma [Fig. 7.164] and neuroectoder-
knotic nuclei of respiratory epithelial cells. However, mal tumors).
there are not too many malignant neoplasms whose In transthoracic aspirates like transbronchial aspi-
exfoliated cells in sputum pose differentiating prob- rates, the differential diagnoses include carcinoid tumors,
lems from small cell carcinoma. Diagnostic difficulties atypical carcinoids, large cell neuroendocrine tumors,
may be experienced with malignant lymphoma (see Fig. malignant lymphoma, pseudolymphoma, poorly dif-
7.152)—a rare occurrence in sputum—and with cells of ferentiated carcinomas, and infrequently, metastatic ad-
poorly differentiated squamous carcinomas with a small enoid cystic carcinomas with a solid pattern originating
cell pattern. from salivary glands. Large cell neuroendocrine tumors,
TABLE 7.20 DIFFERENTIAL DIAGNOSES OF SMALL CELL CARCINOMA, CYTOPATHOLOGIC FEATURESa
Small cell carcinoma Neoplastic cells present isolated, in loosely cohesive groups, and in syncytial tissue 7.14
fragments without any architectural patterns; malignant cells often present in 7.144
mucus streaks in sputum; size small, 2–2.5 times the lymphocytes; high N/C ratios;
nucleus round, oval to fusiform; coarsely granular deep-staining chromatin; nucleoli
inconspicuous to absent; nuclear molding characteristic; stretch or crush artifacts of
nuclei; karyorrhexis; mitoses ; indiscernible cytoplasm; necrosis in the background
/; surface markers; Immunoprofile: cytokeratin ; neuroendocrine markers ;
LCA
Benign
Follicular bronchitis, Mature lymphocytes in sputum in mucus streaks or a polymorphic lymphoid cell 7.151,
pulmonary lymphoid population with follicular center cells, tingible body histiocytes, and plasma cells 7.152
hyperplasia; in other types of respiratory specimens; no nuclear molding, no karyorrhexis or
pseudolymphoma; hilar/ necrosis; Immunoprofile: LCA , polyclonal
mediastinal reactive
lymphadenopathy (TBNA)
Reactive/hyperplastic Cells predominantly in tissue fragments; round to cuboidal when viewed en face and 7.149A
bronchial epithelial columnar on profile; variable cytoplasm; N/C ratios high; round to oval nuclei with and B
(columnar) cells smooth nuclear membranes; finely granular chromatin; micronucleoli/ macronucleoli; 7.158
no nuclear molding; no stretch artifacts; mitoses rare; no karyorrhexis
Reserve cell hyperplasia Only in tissue fragments; single cells are difficult to identify; often attached to 7.156A
columnar cells; compactly arranged, poorly defined cell borders; indiscernible and B
cytoplasm with high N/C ratios; minimal nuclear molding; dense-staining compact
chromatin; nucleoli ; no mitoses; no karyorrhexis; no stretch artifacts
Alveolar lining cells In tissue fragments, usually easily recognized because of uniformity and monolayer; 7.157
small cell size; scant cytoplasm; no nuclear molding or stretch artifacts; high N/C
ratios; no mitoses; no necrosis; nucleoli /; granular chromatin
Malignant
Pulmonary carcinoid tumor Carcinoid tumor cells generally do not exfoliate in sputum; cells discrete, in loosely 7.159
typical cohesive groups, or in syncytial tissue fragments, in cords, in nests, ribbons, or with
acinar pattern; cells strikingly uniform, small, round to cuboidal with occasional
binucleation and giant forms; nuclei round to oval with smooth nuclear membrane,
stippled salt & pepper chromatin pattern; nucleoli /; no stretched out nuclear
material; no molding; cytoplasm variable, generally scant, clear to pale; mitoses
absent; no karyorrhexis; no necrosis; Immunoprofile: neuroendocrine markers ; CEA
; cytokeratin
Atypical carcinoid Cytomorphology ranges from that of a typical carcinoid tumor to small cell 7.135
carcinoma; diagnosis made on histology criteria; Immunoprofile: cytokeratin ; 7.136
neuroendocrine markers ; LCA
Large cell neuroendocrine Most often encountered in FNA specimens; cells isolated, in loosely cohesive groups, 7.138,
carcinoma (LCNEC) and in syncytial tissue fragments usually with no architectural patterns; occasional 7.140
rosette formations or palisading of nuclei at the periphery; cells variable in size,
generally larger than those of small cell carcinomas; at times considerable variation
in cell and nuclear size with occasional giant forms; variable cytoplasm but scant;
high N/C ratios; nuclei round, oval to fusiform; coarsely granular chromatin;
nucleoli frequent; nuclear molding ; mitoses frequent; karyorrhexis ; necrosis
prominent −; stretch artifacts ; Immunoprofile /; neuroendocrine markers ;
cytokeratin
(continued)

Poorly differential Cells isolated, in loosely cohesive groups, or in syncytial tissue fragments, no 7.150
squamous carcinoma or architectural patterns; cells round, small in size, similar to or slightly larger than
small cell variant small cell undifferentiated carcinoma; mild pleomorphism; scant cytoplasm; high N/C
ratios; smooth to irregular nuclear membranes; coarsely granular chromatin; nucleoli
often conspicuous; no molding; no stretch artifacts; mitoses frequent; necrosis /;
Immunoprofile: neuroendocrine markers ; TTF-1 ; cytokeratin
Poorly differentiated Cells isolated, in loosely cohesive groups, or in syncytial tissue fragments, no 7.162
adenocarcinoma, architectural patterns; cells round, small in size, similar to or slightly larger than 7.163
primary or metastatic small cell undifferentiated carcinoma; mild pleomorphism; scant cytoplasm; high N/C
ratios; smooth to irregular nuclear membranes; coarsely granular chromatin; nucleoli
often conspicuous; mitoses frequent; necrosis /; Immunoprofile: CEA ; CK7 ;
TTF-1
Adenoid cystic carcinoma Cells mostly in tissue fragments with three-dimensional pattern with or without 7.112
enclosed spaces presenting a sieve-like pattern; spaces contain acellular material,
bright magenta in Romanowsky stained preparation; cells very small, tightly packed;
poorly defined cell boarders; scant, indiscernible cytoplasm; high N/C ratios; nuclei
round to oval; monomorphic; no nuclear molding; smooth nuclear membranes;
granular chromatin; nucleoli /; background clean, may contain acellular material;
Immunoprofile: CEA ; cytokeratin ; S100 protein
Malignant lymphoma Discrete, immature lymphoid cells; no follicular center cells or tingible body 7.153
histiocytes; finely granular chromatin with micronucleoli/macronucleoli; no nuclear 7.154
molding; karyorrhexis ; mitoses ; necrosis /; Immunoprofile: LCA ; CEA ;
monoclonal surface immunoglobulin
Thymoma Differential diagnosis to be considered only transbronchial FNA of mediastinal 7.161

lesions; large population of mature lymphoid cells obscuring neoplastic epithelial
cells occurring singly, in groups, or tissue fragments; poorly defined cell borders;
pale cytoplasm and bland nuclei; ultrastructural findings of perinuclear garland of
tonofilaments; Immunoprofile: cytokeratin
Thymic carcinoid Differential diagnosis to be considered in transbronchial FNA of mediastinal lesions; 7.160
cytopathologic features similar to pulmonary carcinoid tumors
Malignant melanoma Cells discrete, small size with or without tailing of the cytoplasm; fine brownish 7.164
dusting of the cytoplasm /; scant cytoplasm; high N/C ratios; granular
chromatin; nucleolus prominent; no nuclear molding; mitoses /; necrosis /;
Immunoprofile: neuroendocrine markers ; CEA ; cytokeratin ; S100 protein ;
HMB-45
a
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Springer, 2002:87. Reproduced with permission from Springer Science Business Media.
although of infrequent occurrence, are often difficult to ties. Reactive lymphadenitis involving the mediastinal
differentiate from small cell carcinomas. The same is true lymph nodes or follicular bronchitis are also diagnostic
with atypical carcinoid tumors. challenges.
A diagnostic challenge that is often faced in the
practice of cytopathology is differentiation between
malignant lymphoma and small cell carcinoma, par-
COMBINED SMALL CELL CARCINOMA
ticularly in fine needle aspirates. Immunocytochemical
studies and flow cytometry are essential. Currently, mo-
lecular studies can be of diagnostic value. In transbron- Combined small cell carcinomas consist of a variable com-
chial aspirates, reactive or hyperplastic epithelium or ponent of squamous carcinoma or an adenocarcinoma,
reserve cell hyperplasia may cause diagnostic difficul- generally comprising less than 5% of the carcinoma. The
Differential Diagnoses of Small Cell Carcinoma (See Figs. 7.149 to 7.165)
A B
Figs. 7.149A and B. Bronchial brushings. Small cell carcinoma versus respiratory epithelium. A: The brushings smear shows small cell car-
cinoma cells with poorly defined cell borders, insignificant cytoplasm and molded nuclei. The chromatin is however finely granular and the
nuclei mimic respiratory epithelial cells. Bronchial biopsy confirmed a small cell carcinoma. B: Bronchial brushings with benign respiratory
epithelial cells that are uniform and round with granular chromatin. These cells mimic either small cell carcinoma or a carcinoid tumor.
Fig. 7.150. Small cell carcinoma versus poorly differentiated Fig. 7.151. Small cell carcinoma versus lymphocytes. Sputum. These
squamous carcinoma. The sputum sample shows syncytial tissue discrete lymphocytes in a mucus streak mimic small cell carcinoma.
fragments and discrete small cells with morphology consistent with There is no nuclear molding or stretch artifacts.
small cell carcinoma. There is karyorrhexis in the background. The
bronchial biopsy and subsequently lobectomy revealed a poorly dif-
ferentiated squamous carcinoma, a small cell variant.
Fig. 7.152. Small cell carcinoma versus follicular bronchitis. Bron- Fig. 7.153. Small cell carcinoma versus malignant lymphoma. FNA.
chial washings containing a large population of lymphocytes. Discrete malignant lymphoma cells without nuclear molding or
stretch artifacts. Immunostains and flow cytometry are required for
confirmation of the diagnosis.
267
Fig. 7.154. Small cell carcinoma versus chronic lymphocytic leukemia. Fig. 7.155. Small cell carcinoma versus small histiocytes. Sputum
BAL showing discrete small cells containing hyperchromatic round smear showing aggregates of small histiocytes, scant cytoplasm and
nuclei with compact chromatin. There is no nuclear molding or stretch nuclei with compact chromatin, probably representing degenerative
artifacts. Patient has a history of chronic lymphocytic leukemia. changes, mimicking small cell carcinoma.
A B
Figs. 7.156A and B. Small cell carcinoma versus reserve cells. Bron- Fig. 7.157. Small cell carcinoma versus alveolar type II pneumo-
chial washings. Tissue fragments of reserve cells, mimicking small cytes. Sputum smear containing a syncytial tissue fragment of hyper-
cell carcinoma. plastic/reactive type II pneumocytes in an inflammatory background.
The absence of nuclear molding, scant cytoplasm and knobby exter-
nal contour do not support the diagnosis of small cell carcinoma.
Fig. 7.158. Small cell carcinoma versus hyperplastic respiratory epi- Fig. 7.159. Small cell carcinoma versus carcinoid tumor. FNA of
thelial cells. Bronchial brushings containing a tissue fragment of hy- hilar mass showing a tissue fragment of carcinoid tumor cells. Note
perplastic respiratory epithelium resembling small cell carcinoma. the typical salt & pepper chromatin.
Fig. 7.160. Small cell carcinoma versus thymic carcinoid in me- Fig. 7.161. Small cell carcinoma versus thymoma. FNA mediasti-
diastinal mass FNA. The cytomorphology of these discrete small nal mass showing a syncytial tissue fragment of thymic epithelial
cells with hyperchromatic nuclei include a differential diagnosis of cells with scant cytoplasm, high N/C ratios, mimicking small cell
carcinoid tumor, small cell carcinoma and malignant lymphoma. carcinoma.
Immunostains are required for correct diagnosis. Surgical excision
confirmed a thymic carcinoid.
Fig. 7.162. Small cell carcinoma versus adenocarcinoma with a Fig. 7.163. Small cell carcinoma versus metastatic adenocarcinoma
small cell pattern. Bronchial brushings. The malignant cells are with a small cell pattern. FNA of a lung nodule in patient with
small with poorly defined cell borders, high N/C ratios and scant to history of a breast adenocarcinoma. The malignant cells are small,
insignificant cytoplasm. The nuclear chromatin is however granular. forming a syncytial tissue fragment. Granular chromatin, micronu-
There is no nuclear molding. The morphology is consistent with an cleoli and lack of nuclear molding favor an adenocarcinoma.
adenocarcinoma.
Fig. 7.164 Small cell carcinoma versus metastatic malignant mela-

noma. FNA of a lung nodule. The malignant cells are small with
insignificant cytoplasm, high N/C ratios. Granular chromatin and
nucleoli should rule out a small cell carcinoma. History of malig-
nant melanoma in this case prompted special stains, which were
positive for melanoma.
A B
C D
Figs. 7.165A to D. Combined small cell and adenocarcinoma. A: Bronchial brushings depicting a tissue fragment of
small cell carcinoma exhibiting typical cytomorphology. B: Lobectomy showing a small cell carcinoma (H&E). C: A
different fold from bronchial brushings showing malignant cells forming a syncytial tissue fragment with glandular
pattern, consistent with adenocarcinoma. D: Adenocarcinoma in lobectomy specimen (H&E).
combined small cell carcinomas are rare with a reported logically, grossly, and cytohistologically and are referred
incidence of 1 to 3% of all squamous carcinomas. The clin- to as “tumor-like lesions.”
ical characteristics are the same as those for pure small cell
carcinomas. Histologically, these tumors exhibit small cell
PULMONARY TUMOR-LIKE LESIONS
carcinoma with either adenocarcinoma or squamous carci-
noma (Figs. 7.165A to D). Tumor-like lesions, as the name implies, present as soli-
The cytologic diagnosis depends on the sampling of tary mass lesions and, clinically as well as radiologically,
the respective component(s) (Figs. 7.165A to D). mimic malignancy. They are usually detected as inciden-
tal fi ndings. Since these lesions need to be differentiated
from primary or metastatic lesions in patients with a his-
tory of malignancy, they are often subjected to fine needle
UNCOMMON LESIONS AND NEOPLASMS
biopsies. Some of the more common tumor-like lesions
include
Besides the major types of carcinomas comprising the
● Malakoplakia
vast majority of lung malignancies, there exists an impres-
● Pulmonary amyloidoma
sive list of several uncommon and unusual types of both
● Inflammatory pseudotumor
benign and malignant tumors, seldom encountered in
● Bronchial inflammatory polyps
the routine practice of surgical pathology and still more
● Extramedullary hematopoiesis
rarely in cytopathology. Nevertheless, they do make their
● Endometriosis
appearance every now and then. In addition to these infre-
quently occurring neoplasms, some nonneoplastic disease The cytohistologic features of these lesions are listed
processes in the lungs mimic neoplasia, clinically, radio- in Table 7.21 and illustrated in e-Figures 7.35 to 7.40.
TABLE 7.21 TUMOR-LIKE LESIONS OF THE LUNGS
Diagnostic Entity Clinical/Histocytologic Features See Fig(s).

Malakoplakia An uncommon chronic granulomatous infection; often associated with E. coli infection and 7.119
occasionally MAI; higher incidence of Rhodococcus equi as an opportunistic infection in e-Figs.
immunosuppressed patients such as AIDS; frequently affects urinary bladder; may occur in 7.35A
other organs (e.g., lungs); the lesions grossly appear as yellowish raised plaques or as cavitary; to C
cytologic findings include a mixed inflammatory infiltrate, consisting of characteristic large
foamy histiocytes with abundant granular to foamy to vacuolated cytoplasm, containing
Michaelis-Guttmann (M-G) bodies, about 3–20 m in diameter; PAS positive, diastase
resistant; coccobacilli are seen with Romanowsky stain; necrotic debris in the background;
the differential diagnoses include disease entities that demonstrate foamy histiocytes
Bronchial A fibroinflammatory polyp consisting of inflammatory stroma and lined by respiratory e-Figs.
inflammatory epithelium with or without squamous metaplasia; a polypoid lesion simulating a neoplastic 7.36A to E
polyp growth; brushings yield large tissue fragments of respiratory epithelium with or without
reactive/hyperplastic changes; single cells is not a feature
Inflammatory Also known as plasma cell granuloma; exceedingly rare lesion; mostly seen in young adults; e-Figs.
pseudotumor consists of inflammatory infiltrate comprised of plasma cells, lymphocytes and histiocytes, 7.37A and
(plasma cell along with proliferating myofibroblasts; spindle-shaped cells present isolated or in aggregates; B
granuloma) can be short and plump, or elongated with round to oblong; the latter may predominate
forming a storiform pattern and be mistaken for a soft tissue neoplasm; plasma cells may
be present in abundance; the spindle cell nuclei are round to elongated with finely granular
chromatin and micronucleoli; nuclear atypia /; the histiocytes may contain foamy
cytoplasm and are referred to as “xanthoma cells”; differential diagnosis depend on the
predominant component and includes malakoplakia, soft tissue tumor or granulomatous
inflammation
Endometriosis Rare occurrence in lung; may present as intrapulmonary mass and also involve the pleura; e-Figs.
the nodular lesion is referred to as “endometrioma”; may cause catamenial (menstrual) 7.39A and
hemoptysis; FNA specimens reveal endometrial glands and the stroma B
Extramedullary Extramedullary hematopoiesis occurs in a variety of hematologic disorders such as leukemia, e-Figs.
hematopoiesis myeloproliferative disorders or incases where bone marrow is replaced by fibrosis or 7.40A and
(EMH) metastases; usually seen as microscopic finding but occasionally present in macroscopic form; B
FNA specimens will contain hematopoietic cells with erythroid, myeloid and megakaryocytic
cell lines
Pulmonary A nodular lesion of the lung consisting of various mesenchymal elements and epithelial e-Figs.
hamartoma cells, native to bronchus; these elements such as cartilage, smooth muscle adipose tissue and 7.41A to D
respiratory epithelium are present in a haphazard fashion; an uncommon lesion, presents
as a coin lesion; cytologic features include an admixture of hyaline cartilage, fragments of
fibroconnective and adipose tissue, smooth muscle and tissue fragments of benign respiratory
epithelium
Amyloidosis/ Amyloidosis can be generalized or localized; primary or secondary, occurring in association e-Figs.
amyloidoma with autoimmune disorders, chronic infections, plasma cell dyscrasias; in localized form, it 7.38A and
is characterized by extracellular deposition of amyloid which clinically and radiologically B
simulates malignancy; amyloid nodule grossly appears as waxy, gritty, white-tan with calcified
surface; amyloid deposits appear as amorphous eosinophilic acellular material and may be
associated with chronic inflammatory cells and foreign body–type giant cells; differential
diagnoses in lung include disease entities that contain fluffy alveolar exudate (see Table 7.31)
BENIGN NEOPLASMS OF THE LUNGS The differential diagnoses of granular cell tumor and
clear cell tumors are listed in Tables 7.23 and 7.24,
respectively.
The lungs are sites for several benign neoplasms. They
are not commonly encountered in routine cytopathology
practice. The following neoplasms are occasionally sub-
jected to fine needle biopsy procedures: UNCOMMON MALIGNANT NEOPLASMS
OF THE LUNGS
● Granular cell tumor
● Sclerosing hemangioma
● Pulmonary hamartoma ADENOSQUAMOUS CARCINOMA
● Solitary fibrous tumor/hemangiopericytoma
Adenosquamous carcinomas are uncommon, aggressive
● Clear cell (sugar) tumor
malignant neoplasms comprising 0.4 to 4% of all lung
The cytohistologic features of the above-mentioned cancers. There is a strong association with smoking.
neoplasms are listed in Table 7.22 (e-Figs. 7.41 to 7.44). Adenosquamous carcinomas are more common in males.
TABLE 7.22 BENIGN TUMORS OF THE LUNG
Diagnostic Entity Clinical and Cytohistologic Features See Fig(s).

Granular cell tumor Also known as granular cell myoblastoma; this tumor, considered as Schwann cell e-Figs.
origin occurs rarely in respiratory tract as endobronchial, submucosal nodules with 7.42A to C
pseudoepitheliomatous hyperplasia of the overlying bronchial epithelium; cytologic samples
demonstrate large round to polygonal cells with well to poorly defined cell borders, 20–50 m
in diameter; occasionally as large as 200 m; cytoplasmic processes /; abundant, coarsely
granular cytoplasm; granules surrounded by clear zones; low N/C ratios; nuclei small, round,
central to eccentric; PAS ; S100 protein ; differential diagnoses include: oncocytoma
arising from salivary gland type tissue; metastatic Hürthle cell carcinoma to the bronchus
Solitary A rare benign neoplasm occurring in older age group; often discovered as an incidental e-Figs.
fibrous tumor/ finding; usually seen in peripheral location; cytopathologic features include: variable 7.43A to D
hemangiopericytoma cellularity with a benign spindle cell population and variably collagenized stromal tissue
fragments; trapped mesothelial tissue fragments may be present; positive immunoreactivity
to vimentin and CD34; differential diagnoses include: soft tissue tumors, spindle cell
mesothelioma; malignant melanoma
Sclerosing Synonym–papillary pneumocytoma; exceedingly rare, benign neoplasm, commonly seen in 7.98
hemangioma women; encountered as an incidental finding; various histologic patterns: solid, papillary, e-Figs.
sclerotic and hemorrhagic; thought to be arising from primitive respiratory epithelium; 7.44A to D
consists of two cell types: round stromal cells and cuboidal surface cells with morphology
of bronchiolar or type II pneumocytes; cytopathologic features: cellular aspirate; dual cell
population; tissue fragments with monolayered arrangement or papillary configurations; small
to medium-sized cells (hyperplastic type II pneumocytes) line the vascular cores; uniform
nuclear pattern; bland nuclei with finely granular chromatin and micronucleoli; nuclear
grooves /; pseudo inclusions /; variable but scant cytoplasm; trapped tissue fragments
of mesothelium; background show hemosiderin containing macrophages; Immunoprofile: CK
/; factor VIII -; EMA ; surfactant apoprotein ; neuroendocrine markers; differential
diagnoses: conventional and bronchioloalveolar adenocarcinoma; metastatic papillary
carcinoma (thyroid, kidney, ovary); malignant mesothelioma; carcinoid tumor
Benign clear cell Also known as sugar tumor; a benign tumor of rare occurrence and of unknown origin;
tumors often detected incidentally as a coin lesion; peripheral location; no gender preference;
cytologic features: medium to large cells; present in large tissue fragments with no
architectural patterns; cells polygonal to spindle-shaped; sharp cell borders; abundant
pale to clear cytoplasm; low N/C ratios; central to eccentric nucleus with finely granular
chromatin; inconspicuous nucleoli; differential diagnoses: primary clear cell carcinoma of
the lung; metastatic renal cell carcinoma
TABLE 7.23 DIFFERENTIAL DIAGNOSES OF GRANULAR CELL TUMOR
Neoplasm Cytopathologic Features Diagnostic Clues/Ancillary Tests

Granular cell Cells round, oval to polygonal, sometimes spindle-shaped; large S100 protein
tumor size 20–50 m; discrete; in aggregates or in tissue fragments; sharp Vimentin
to poorly defined cell borders, some with cytoplasmic processes; Laminin
abundant cytoplasm containing coarse eosinophilic or cyanophilic (in Various myelin proteins
Papanicolaou stained preparations) granules with clear spaces around Neurofilament proteins −
them; central to eccentric small nuclei with very low N/C ratios; Glial fibrillar acidic protein −
granular chromatin; inconspicuous nucleoli; clean background Neuroendocrine markers −
US −
Membrane bound granules of varying
sizes, some with lamellated structure
Oncocytic Round to polygonal cells; mostly discrete but occur in loose aggregates PAS
tumor of or tissue fragments; well to poorly defined cell borders; abundant deep- S100 protein −
salivary gland staining eosinophilic to cyanophilic granular cytoplasm; low N/C ratios; PTAH
type tissue central to eccentric round to oval nucleus; finely granular chromatin; CK
(oncocytoma) nucleolus ; clean background HMB-45 −
Neuroendocrine markers −
Antimitochondrial antibody
Ultrastructure −
Abundant mitochondria
Carcinoid Medium-sized; round to polygonal cells; discrete, in loosely cohesive S100 protein −
tumor with groups, or in syncytial tissue fragments; well to poorly defined cell Neuroendocrine markers
oncocytic borders; abundant granular cytoplasm (eosinophilic, amphophilic, or CK
change cyanophilic); low N/C ratios; eccentric round to oval nuclei; granular US −
chromatin; occasional single distinct nucleolus; clean background Dense core granules and abundant
mitochondria
Metastatic Medium-sized, round, cuboidal to polygonal cells; isolated, in loosely Thyroglobulin

Hürthle cell cohesive groups, or in syncytial tissue fragments; well to poorly defined S100 protein −
carcinoma of cell borders; abundant eosinophilic, amphophilic to cyanophilic; finely US: abundant mitochondria
the thyroid granular cytoplasm; N/C ratios variable; central to eccentric, moderately
enlarged, round to oval nucleus containing granular chromatin and
prominent macronucleolus; history of thyroid tumor helpful
Their clinical and radiographic features are similar to sarcoma or sarcoma-like (spindle and/or giant cell) dif-
those of other non-small cell carcinomas. ferentiation. These malignant neoplasms are very rare,
Grossly, adenosquamous carcinomas tend to be comprising only 0.3 to 1.3% of all primary lung cancers.
bulky with necrosis and cavitation. Histologically, ad- Currently, fi ve subgroups in this category representing
enosquamous carcinomas demonstrate components of morphologic continuum are recognized:
both squamous carcinoma and adenocarcinoma with
● Pleomorphic carcinoma
each comprising at least 10% of the tumor. The cytologic
● Spindle cell carcinoma
identifi cation can be made when both components are
● Giant cell carcinoma
present in the cytologic specimens but depends on the
● Carcinosarcoma
sampling (e-Fig. 7.45).
● Pulmonary blastoma
CARCINOMAS WITH PLEOMORPHIC, Pleomorphic Carcinomas/Carcinomas

SARCOMATOID, AND SARCOMATOUS with Spindle and/or Giant Cells
ELEMENTS
These malignant neoplasms are poorly differentiated and
This group of malignant neoplasms is referred to as are composed of either an admixture of spindle and giant
“sarcomatoid carcinoma” and are poorly differentiated tumor cells or predominantly to exclusively spindle or
non-small cell carcinomas that contain a component of giant tumor cells. When the tumor contains both types
TABLE 7.24 DIFFERENTIAL DIAGNOSES OF PULMONARY CLEAR CELL TUMORS
Neoplasm Cytopathologic Features Diagnostic Clues/Ancillary Tests

Benign clear cell (sugar tumor) Medium to large cells extremely cohesive; PAS diastase sensitive
tumor of the lung predominantly in large tissue fragments with HMB-45
no architectural pattern; polygonal to spindle- Cathepsin B
shaped; sharp cell borders; abundant pale to clear Alpha-1 antitrypsin
cytoplasm; low N/C ratios; central to eccentric S100 protein /
nucleus with finely granular bland chromatin CK
pattern; nucleoli inconspicuous Oil red O
Primary clear cell carcinoma of the Medium to large cells; discrete, in loosely cohesive PAS diastase sensitive
lung groups, and in syncytial tissue fragments; poorly Vimentin −
defined cell borders; variable pale cytoplasm; CK
N/C ratios high; distinctly malignant nuclei with Oil red O
prominent nucleoli; bare nuclei in the background
due to disruption of the cell borders
Metastatic renal cell carcinoma, Medium to large cells; discrete, in loosely cohesive PAS diastase sensitive (glycogen )
clear cell type groups, or in syncytial tissue fragments; acinar Oil red O
pattern /; round to polygonal with well Vimentin
to poorly defined cell borders; abundant pale CK
cytoplasm; N/C ratios variable; round to oval EMA
nuclei with smooth nuclear membranes; granular CEA −
chromatin; micronucleoli/macronucleoli; bare LeuM1
nuclei in the background; history of nephrectomy B72–3
helpful BerEP4
of cells, it is referred to as “pleomorphic carcinoma” with benign and malignant neoplasms similar to those arising
spindle and giant cell pattern. Pleomorphic carcinomas are in major and minor salivary glands. The incidence of these
very uncommon, accounting for less than 0.3% of lung tumors is extremely low. The most common amongst these
cancers. They are usually squamous or adenocarcinomas are mucus gland adenomas, adenoid cystic carcinomas, and
or large cell carcinomas containing a spindle and/or giant mucoepidermoid carcinomas. Tumors such as pleomorphic
cell component amounting to 10% or more of the tumor. adenomas, acinic cell carcinomas, epithelial-myoepithelial
Cytohistologically, giant cell carcinomas are character- carcinoma, and oncocytomas occur very rarely.
ized by huge, bizarre, pleomorphic, uni- to multinucleated Mucoepidermoid carcinomas are rare, comprising
malignant cells of up to 700 to 800 m with well-defined less than 1% of all lung cancers. They are slightly more
cell borders (e-Figs. 7.46A to C). Their nuclei are irregular common in males and can occur at any age. Grossly, they
and lobulated with prominent nucleoli. Their cytoplasm is are well-circumscribed, often present as a polypoid lesion
variable with frequent emperipolesis. Spindle cell carcino- in the trachea or bronchi, have a smooth or ulcerated
mas are also referred to as “sarcomatoid carcinomas.” They surface, and can reach large dimensions. Cystic change is
are very rare in incidence. In the absence of a squamous or frequent. Histologically, they present three grades: low-
an adeno component, these tumors must be differentiated grade, intermediate-grade, and high-grade (e-Figs. 7.48A
from other spindle cell tumors (e-Figs. 7.47A to C). and B). Their cytologic presentation (e-Figs. 7.48C to E)
Carcinosarcomas are malignant tumors with a mix- is similar to that seen in mucoepidermoid carcinomas in
ture of carcinoma and differentiated sarcomatous ele- salivary glands (see Chapter 15).
ments. Pulmonary blastoma is a biphasic tumor contain- Adenoid cystic carcinomas are the most common pri-
ing a primitive epithelial component and a malignant mary tumor in trachea but can also arise in bronchi. The
glandular and sarcomatous component (see e-Figs. 7.52A histologic and cytologic fi ndings (e-Fig. 7.49) of adenoid
to D). Both these neoplasms are exceptionally rare. cystic carcinomas are described in great detail in Chapter
15 on salivary gland tumors.
TUMORS OF THE SALIVARY
GLAND-TYPE TISSUE PULMONARY SOFT-TISSUE TUMORS
Salivary type glandular tissue is present in tracheal and Primary soft tissue sarcomas of the lung are exceedingly
bronchial walls, both of which are known to be sites for rare, comprising less than 0.5% of lung cancers. This is
in sharp contrast to the higher incidence of pulmonary cation. The patients are almost always symptomatic.
involvement by metastatic soft tissue sarcomas. The vari- Grossly, DLBCL presents as varying-sized fleshy nod-
ous types of primary pulmonary soft tissue sarcomas ules with and without necrosis. The growth pattern is
include solid consisting of large masses of poorly differentiated
lymphoid cells.
● Malignant fibrous histiocytoma
● Leiomyosarcoma
● Fibrosarcoma Cytopathologic Features
● Peripheral malignant nerve sheath tumor The correct recognition of malignant non-Hodgkin lym-
● Synovial sarcoma phoma depends on its type (e-Figs. 7.53A to D). The diag-
● Vascular tumors nostic cells can be recovered mostly in bronchial brush-
• Angiosarcoma ings, washings, or bronchial lavage and aspiration biopsy
• Hemangioendothelioma samples. The presence of malignant lymphoma cells in
• Hemangiopericytoma/solitary fibrous tumor sputum is exceedingly rare (e-Fig. 7.53D). The MALT
• Kaposi’s sarcoma lymphomas usually involve the bronchi, in which case the
● Miscellaneous brushings demonstrate a large number of lymphoid cells,
The cytopathologic features, whether primary or sec- which can be a small cell type or a heterogeneous, poly-
ondary, of soft tissue tumors are similar. They may be en- morphic type (e-Figs. 7.53A and B). MALT lymphomas
countered in all types of respiratory specimens including must be confi rmed by fl ow cytometry. The DLBCL cells
bronchial brushings, washings, and more commonly, in can be identifi ed without much diffi culty (e-Figs. 7.53C
aspiration biopsy specimens. Their presence in sputum is and 7.53E), and their diagnosis should be supported by
exceedingly rare (e-Fig. 7.50). Soft tissue tumors can pres- ancillary studies.
ent with spindle cell pattern, round cell pattern, or mixed
with pleomorphic cell pattern (e-Figs. 7.50, 7.51A and B). PRIMARY EFFUSION LYMPHOMA
Those with a round cell pattern resemble large cell carci-
nomas as well as malignant melanomas, and sometimes, Primary effusion lymphoma is a large B-cell lymphoma
malignant lymphomas. The cytomorphology of soft tissue that presents as serous effusion without detectable
tumors is described in detail in Chapter 24. tumor masses. It is associated with the human herpes
virus 8 (HHV8)—Kaposi’s sarcoma-associated herpesvi-
rus (KSHV)—usually occurring in the setting of immu-
PRIMARY MALIGNANT LYMPHOMAS nodeficiency, with a higher incidence in individuals with
OF THE LUNGS AIDS. There is no associated lymphadenopathy or orga-
Primary non-Hodgkin lymphomas are rare in the lungs, nomegaly. The effusion fluid examination will reveal the
comprising less than 1% of all primary malignancies and presence of lymphoma cells.
less than 10% of extranodal lymphomas. Generally, three
types are recognized: 1) Marginal zone B-cell lymphoma
LESIONS OF THE TRACHEA
of the mucosa-associated lymphoid tissue (MALT) type;
2) diffuse large B-cell lymphoma (DLBCL); and 3) lym- Tracheal lesions are similar to those involving the bronchi
phomatoid granulomatosis. and lungs. The only difference is a lower incidence for the
Primary marginal zone B-cell lymphoma of the MALT neoplasms.
is an extranodal lymphoma, consisting, morphologically, Specimens for the cytopathologic evaluation of tra-
of a heterogeneous lymphoid cell population represented cheal lesions are
by small B-cells (centrocytes), monocytoid B-cells, scat-
● Tracheal aspirates
tered immunoblasts and centroblast-like cells, and vari-
● Tracheal brushings and washings
able numbers of plasma cells. Histologically, the infiltrate
● Aspirates from ventilator tubes or tracheostomy tubes
is present in the marginal zone of reactive follicles and
extends into the interfollicular areas as well as colonizes Inflammatory lesions that are encountered in tracheal
the follicles. They typically infiltrate the bronchial mucosa cytopathology include tracheobronchitis of viral or fun-
and form lymphoepithelial lesions. gal origin. This is particularly the case in patients who
Primary pulmonary diffuse B-cell non-Hodgkin are intubated and risk the development of viral infection
Lymphoma (DLBCL) is a diffuse proliferation of large or colonization by fungi. Tracheal brushings, washings,
neoplastic B-lymphoid cells with nuclear size equal to or tracheal aspirates may demonstrate microorganisms.
or exceeding normal macrophage nuclei or more than Other conditions that necessitate cytologic evaluation are
twice the size of normal lymphocyte. DLBCL com- cases of bronchopulmonary dysplasia in neonates. Tra-
prises approximately 10 to 20% of primary pulmonary cheal brushings are also reported in the diagnosis of amy-
lymphomas. The tumors are typically peripheral in lo- loid deposits.
PRIMARY TRACHEAL TUMORS The cytopathologic features (Figs. 7.166 to 7.168) of epi-
thelial type are similar to those seen in effusion specimens.
Primary tracheal tumors are rare, and only a few series Mesotheliomas may be extremely cellular, lacking
are available for review. Cytologic findings are still rarely stroma or show extensive desmoplasia. The sarcomatoid
reported. Tracheal tumors tend to be exophytic and may types are less frequent and exhibit considerable variation
not be clinically evident if they are small. Symptoms in morphology. They are composed of spindle-shaped
include breathing difficulties that worsen at night in pros- cells appearing bland to pleomorphic with frequent mi-
trate positions. The majority of the tumors occur in adults tosis and necrosis. Sarcomatoid mesotheliomas may re-
and are malignant. Eight percent of tracheal tumors occur semble a soft tissue tumor such as fibrosarcoma or a leio-
in children and are mostly benign. The malignant tumors myosarcoma or a malignant fibrous histiocytoma (MFH).
in children are usually sarcomas. Cartilaginous or osseous metaplasia has been described.
A variety of tumors are known to occur in trachea. Mixed mesotheliomas present both epithelial and sarco-
Benign tumors are exceedingly rare, with the most com- matoid components in varying proportions.
mon being papillomas. The sarcomatoid mesotheliomas are diagnostically
Among the malignant tumors, squamous carcinoma difficult lesions (Figs. 7.169 to 7.171). This is particularly
is most common. It runs an aggressive course, is more true with the desmoplastic variant, as they resemble re-
frequent in older males, and is strongly associated with active pleural tissue, seen in chronic pleuritis caused by
a history of tobacco smoking. Squamous carcinomas of organizing empyema and asbestosis. They are also diffi-
the trachea are usually exophytic and ulcerated. Almost cult to differentiate from solitary fibrous tumor. The lym-
a third of the patients have pulmonary metastasis at the phohistiocytoid variants are rare and diagnostically chal-
time of diagnosis. Cytologic presentation is similar to lenging, being misinterpreted as inflammatory lesions.
squamous carcinomas elsewhere. Small cell carcinomas The diagnosis of a desmoplastic variant of sarcomatoid
and adenocarcinomas may also arise from the trachea. mesotheliomas is very challenging. First, these neoplasms
The second most common tumor is adenoid cystic usually do not exfoliate cells in the effusion fluids, render-
carcinoma arising from salivary gland type tissue. These ing the cytologic examination of the fluids nondiagnostic.
tumors are slow-growing, occurring equally in both sexes. Secondly, the pleural biopsy may show only fibrotic areas
Adenoid cystic carcinomas have a long survival rate in and wide sampling is necessary for a correct diagnosis.
spite of spreading submucosally and perineurally. Mu- The most striking and defi nable feature of desmoplastic
coepidermoid carcinomas occur rarely in the trachea. For malignant mesothelioma (DMM) is a twisting, whorled,
cytologic fi ndings, please refer to the section on salivary paucicellular fibrotic lesion produced by distinct uniform
gland type tumors in this chapter. fibers of collagen with a storiform pattern. Differentiation
Other types of neoplasms that may arise in the tra- of DMM from fibrous pleuritis may be extremely difficult.
chea include carcinoid tumors, soft tissue tumors, carti- The diagnosis of DMM is most often a histologic one;
laginous tumors, and granular cell tumors. the cytologic diagnosis may be suggested on aspiration
biopsy samples if the right areas are sampled. Histologic
PRIMARY PLEURAL MALIGNANCY criteria that are helpful in differentiating DMM from fi-
brous pleuritis include 1) invasion of the chest wall or
Malignant mesothelioma represents the most common pri- the underlying lung; 2) foci of bland necrosis; 3) frankly
mary malignant neoplasm of the pleura and is an aggres- sarcomatoid foci; and 4) distant metastases.
sive tumor and has a strong association with asbestos
exposure. They are more common in males and occur in Cytopathologic Features
older individuals. Most malignant mesotheliomas present
with chest pain and pleural effusion. Cytologic examina- The epithelial type malignant mesotheliomas exfoliate
tion of the pleural fluid and pleural biopsy are commonly readily in effusion fluid and can be identified in cytologic
used diagnostic techniques offering accurate diagnosis in a preparations. Their characteristic morphology aided by
significant number of cases (see Chapter 6). However, 20% ancillary studies lends itself to correct diagnosis in most
of patients with malignant mesothelioma do not develop instances (Table 7.25). The sarcomatoid type, on the
effusion at the time of presentation and may have atypical other hand, does not exfoliate in the effusion fluid. Con-
radiologic appearances with intrapulmonary or mediastinal sequently, the cytologic examination of the effusion fluids
extension. Aspiration biopsy is indicated in such instances, is nondiagnostic. Pleural-based masses are thus subjected
and in the majority of cases, the lesion can be identified to FNA biopsy. The aspirates of the epithelial type malig-
accurately, particularly with the aid of ancillary tests. The nant mesotheliomas are generally very cellular and can
most important differential diagnoses include mesothelial be diagnosed from cytologic samples. The diagnosis of
proliferation and adenocarcinoma, in epithelial type and epithelial type malignant mesotheliomas must be differ-
spindle cell tumor in sarcomatoid type. The differential entiated from adenocarcinoma (Figs. 7.166 and 7.167).
diagnosis of a mixed type depends on the area sampled. The aspiration biopsies of the sarcomatoid type, on the
Aspiration Cytopathology of Malignant Mesothelioma (See Figs. 7.166 to 7.171)
A B
Figs. 7.166A to C. FNA. Malignant mesothelioma, epithelial type.

A: The neoplastic cells are small, forming a syncytial tissue frag-
ment, containing a psammoma body. B: Different field containing
syncytial tissue fragments composed of small cells with a pseudoaci-
nar pattern. C: Different field showing a syncytial tissue fragment
of medium-sized cells containing moderate amount of eosinophilic
cytoplasm and uniform nuclei with granular chromatin and micro-
nucleoli. These cells do not present a typical morphology of malig-
C nant mesothelioma and resemble an adenocarcinoma.
A B
Figs. 7.167A and B. A: Pleural fluid with a syncytial tissue fragment of small cells with a pseudoacinar pattern. The
background is inflammatory and necrotic. The case was interpreted as adenocarcinoma. B: FNA of the pleural nod-
ule, same patient. The aspirate revealed syncytial tissue fragments of pleomorphic malignant cells with scant cyto-
plasm. Surgical biopsy confirmed a malignant mesothelioma. It is not unusual for malignant mesothelioma to present
cytomorphology mimicking an adenocarcinoma.
A B
Figs. 7.168A to C. FNA of a cervical lymph node with metastatic

malignant mesothelioma. A, B: The aspirate shows discrete and tis-
sue fragment of medium-sized to large cells with well-defined cell
borders, appreciable dense cytoplasm and uniform nuclei. Patient
had a history of malignant mesothelioma. C: Metastatic adenocar-
cinoma for comparison. Note the malignant cell nuclei, one clearly
malignant as compared to bland nuclear pattern of malignant me-
C sothelioma cells.
A B
Figs. 7.169A to C. Malignant mesothelioma with a mixed spindle

and epithelial cell pattern. FNA of pleural mass. A: Low-power view
showing large tissue fragment of spindle cells. B: Higher magnifica-
tion showing cells with poorly defined cell borders with round, oval
to spindle-shaped nuclei. The nuclear chromatin is granular with
uniform. C: Syncytial tissue fragment with no architectural pattern.
Nuclei are uniform with granular chromatin. Diagnosis of mesothe-
C lioma was confirmed by positive reactivity to calretinin stain.
278
A B
Figs. 7.170A and B. FNA. Pleural based mass. Mesothelioma with a spindle cell pattern. A: Low-power view show-
ing large tissue fragments of spindle cells. B: Higher magnification showing a mixed spindle and epithelial pattern.
A B
Figs. 7.171A to C. FNA. Pleural based mass. Spindle cell vari-

ant of malignant mesothelioma. A: A syncytial tissue fragment of
short spindle cells embedded in a collagenous stroma. Their nu-
clei are pleomorphic in size with granular chromatin and nucleoli.
B, C: These discrete spindle cells present in the background contain
pleomorphic nuclei containing prominent nucleoli. Pleural biopsy
and positive reactivity to calretinin confirmed malignant mesothe-
C lioma.
other hand, tend to be paucicellular, where the cellular- the final diagnosis is made on the basis of clinical, radio-
ity is dependant on the stromal content. The neoplastic logic data and ancillary studies, which are described in
cells are spindle-shaped, occurring singly or in tissue the relevant section (see Chapter 24 on soft tissue tumors;
fragments. Based on morphology alone, the diagnosis of Table 24.5). The cytologic diagnosis of mixed type malig-
sarcomatoid mesothelioma is diffi cult both cytologically nant mesotheliomas is variable since it depends greatly
and histologically. A number of diagnostic possibilities on exfoliated cells as well as the sampling of the cellular
representing spindle cell lesions must be considered, and areas with fine needle biopsies (Figs. 7.169 to 7.171).
TABLE 7.25 CYTOPATHOLOGIC FEATURES OF MALIGNANT MESOTHELIOMA IN

ASPIRATION BIOPSY SPECIMENS
Cytologic Feature Epithelial Type Sarcomatoid Type

Cellularity Generally very cellular Paucicellular
Presentation Cells isolated, in loosely cohesive groups, in sheets Cells mostly isolated or in loosely cohesive groups
or in syncytial tissue fragments with crowding and or in tissue fragments which are usually few in
overlapping; no specific architectural pattern numbers; tissue fragments of collagenous tissue
usually present
Cells Variable in size; medium to large; round, Variable in size; pleomorphic; round, spindle-
cuboidal to polygonal; well-defined cell borders; shaped or elongated with cytoplasmic processes;
characteristic features of mesothelial lineage cell borders well to poorly defined; characteristic
present features of mesothelial lineage not present
Nucleus Central to eccentric; enlarged in size; bi- to Central to eccentric; round, elongated to spindle-
multinucleation /; round with crisp nuclear shaped; variably sized but enlarges; granular
membranes; finely granular chromatin with micro/ chromatin; micro/macronucleoli
macronucleoli
Cytoplasm Variable in amount; can be abundant; pale to Variable; mostly scant

dense; foamy or occasionally vacuolated; biphasic
staining /
Psammoma Bodies May be present Not present
Background Clean to inflammatory Clean; tissue fragments of collagenous stroma
Differential Diagnoses Adenocarcinoma Spindle cell lesions
METASTATIC MALIGNANCY 1. Multiple nodules

2. Lymphangitic
3. Endobronchial
Extrapulmonary malignancies metastasize more fre- 4. Embolic
quently to the lungs than any other organ in the body. The 5. Solitary nodule
reported incidence of lung metastases in autopsy studies 6. Pleural
on patients dying of extrapulmonary cancers range from
20 to 54%, while lungs may be the only organs involved Some patterns are more frequent, while others are
in 15 to 20% of the cases. Virtually any type of malig- unusual and uncommon. Certain presentations are more
nancy from any site or organ in the body can metasta- characteristic of certain types of malignancies; others
size to the lungs. However, certain malignancies are more present very few clues to their origin.
prone to involve the lungs. These are uterine choriocarci- In general, metastatic adenocarcinomas outnumber
noma and malignancies occurring in the breast, the colon, all other types of metastatic lung cancers. However, most
the kidneys, the stomach, the pancreas, the prostate, soft adenocarcinomas and squamous carcinomas do not allow
tissues, and the male and female genital tracts. Clinically, the detection of the primary site without adequate clinical
patients with metastatic lung cancers may present with data and, frequently, without the help of immunostains.
signs and symptoms related to pulmonary involvement or
may be asymptomatic. PROBLEMS ENCOUNTERED IN THE
CYTOLOGICAL DIAGNOSIS OF METASTATIC
PATTERNS OF METASTATIC INVOLVEMENT MALIGNANCY
The tumors spread to the lungs via lymphatics, blood The cytologic identification of a metastatic neoplasm
vessels, and by direct extension from adjacent organs or to the lung from respiratory specimens is usually made
sites (e.g., esophagus, mediastinum, chest wall, and dia- without any difficulties. Most often, a history of primary
phragm). Several patterns of metastatic involvement of extrapulmonary malignancy is available, and the met-
the lungs have been described (Table 7.26): astatic process is supported by clinical and radiologic
TABLE 7.26 METASTATIC MALIGNANCY TO Multiple lung nodules usually signify a metastatic pro-
LUNGS: PATTERNS OF INVOLVEMENT cess; however, lung cancers can also manifest in simi-
lar fashion. If the cytohistomorphology of the primary
Type of Involvement Characteristics and metastatic lung tumors is different, diagnosis is not
Solitary May reach large dimensions; referred a problem. However, a similar morphologic presenta-
May be necrotic to as “cannon balls”; frequent with tion such as adenocarcinoma or a squamous carci-
and cavitary malignancies of renal cell carcinoma noma becomes the source of diagnostic problems. This
Must be differentiated from a new is because a primary origin of these tumors cannot be
primary lung in a patient with the determined by morphology alone and requires ancillary
history of malignancy tests. As far as squamous carcinomas are concerned,
May represent, benign tumor- even ancillary tests are not helpful.
like lesion, benign tumor or
inflammatory lesion. Best
APPROACH TO SOLVING
diagnosed by FNA
DIAGNOSTIC PROBLEMS
Multiple nodules, Frequent pattern of metastatic When confronted with any of the above stated diagnostic
unilateral or bilateral spread; must be differentiated from problems, the following guidelines may be helpful:
inflammatory processes, oxygen
toxicity or alveolar damage ● Review of clinical history and radiographic findings
Best diagnosed by FNA, BAL ● Review of previous cytologic and histologic material
whenever available
Endobronchial Infrequent; 1–2% of ● Ancillary tests
bronchoscopically identified • Histochemistry
malignancies; common primary • Immunocytohistochemistry
source include: breast, colon, soft • Ultrastructural studies
tissue tumors, kidney; malignant
• Flow cytometry
melanoma; colon; best diagnosed by
• Molecular studies
bronchial brushings
Diagnostic possibilities can often be narrowed down
Lymphangitic spread Most frequent with breast by the presence of morphologic features specific to a
adenocarcinoma; diffuse group of neoplasms. Ancillary tests will then help to es-
intrapulmonary spread; often tablish the correct diagnosis.
a ssociated with effusion; exfoliation
Some examples of commonly encountered diagnostic
of malignant cells low
dilemmas:
Embolization of the Common with kidney tumors, ● Metastatic adenocarcinomas with acinar pattern ver-
blood vessels choriocarcinomas, breast, gastric and sus well-differentiated lung adenocarcinoma. Meta-
hepatocellular carcinomas; involve static adenocarcinomas originating from breast,
small-sized arteries prostate, gastrointestinal tract, thyroid, and adenoid
cystic carcinomas share cytomorphologic features
Pleura, direct Associated with pleural effusion
with well-differentiated adenocarcinomas of lung.
extension or via Best diagnosed by cytologic
lymphatics examination of the effusion fluid
All demonstrate small to medium-sized cells with
and without acinar or follicular architecture. His-
tochemical stains may confirm the adenocarcinoma
but will not determine the primary source of the
findings. Diagnostic difficulties are encountered under tumor. Immunostains with certain specific antibodies
certain circumstances such as unusual growth patterns, are essential to establish the diagnosis. For example,
metastases in unusual locations, multiple lung nod- positive reactivity to ER/PR will support the breast
ules, or malignant cells in pleural effusion fluid with primary while positive reactivity to TTF-1 will con-
an unknown primary. Examples of unusual growth firm lung primary in a patient with a history of breast
patterns include a solitary nodule or a coin lesion in a adenocarcinoma.
patient with a history of extrapulmonary malignancy. ● Mucin producing adenocarcinomas. Metastatic adeno-
Since primary lung cancer usually manifests as a solitary carcinomas with excessive mucin production include
nodule, it must be ruled out first. The same holds true those arising from the gastrointestinal tract, particu-
for endobronchial lesions, which are common manifes- larly the colon and the rectum, and are extremely diffi-
tations of primary lung cancers. Although metastases cult to differentiate from mucin-producing lung adeno-
in these locations are extremely rare, they occur with carcinomas. Antibodies such as villin, CK7, and CK20
certain malignancies more frequently than with others. are very useful.
● Papillary carcinomas. Papillary carcinomas originating ration biopsy yields acellular amorphous cheesy material
from the thyroid, the kidney, and the ovary and epithe- and rarely epithelioid and giant cells. Special stains may
lial mesothelioma with a papillary pattern may offer identify mycobacteria (Fig. 7.27; e-Figs. 7.54A to C).
considerable diagnostic diffi culties in their differentia- The differential diagnoses of lesions yielding necrotic
tion from primary lung adenocarcinomas. All present granular material include tuberculosis, infection by atypi-
similar cytomorphology. Lung adenocarcinomas, not cal mycobacteria, actinomyces, keratinizing squamous
uncommonly, present initially as malignant pleural carcinoma, lung abscess, and cavitary fungal lesions (e.g.,
effusion with papillary architecture; the above-men- Aspergillosis).
tioned tumors are considered in differential diagnoses.
Exuberant mesothelial hyperplasia may pose diagnos- PULMONARY VIRAL INFECTIONS
tic difficulties.
● Spindle cell tumors. Spindle cell carcinoma or sarco- Viral infections of the respiratory tract are very common
matoid carcinoma of the lung may present diagnostic occurrences, particularly in the pediatric age group. The
difficulties in its differentiation from several neoplasms majority of these episodes are self-limiting, causing very
that demonstrate a spindle cell pattern. little morbidity and extremely low mortality in healthy
individuals. However, some viruses are opportunists and
cause serious infections in immunocompromised patients,
resulting in considerable morbidity and mortality.
PULMONARY INFECTIONS The viruses that cause frequent respiratory infections
include influenza, parainfl uenza, adenovirus, respiratory
syncytial virus, measles, Epstein–Barr virus, herpes sim-
The lung is a frequent site for infectious processes caused plex, and cytomegalovirus. Documented cytopathologic
by a wide range of bacterial, viral, fungal, and parasitic changes are most frequently identifi ed in infections with
agents. Cytologic examination of various types of speci- the herpes family of viruses.
mens from the respiratory tract has been used to detect The clinical presentations of viral infections vary
many of these organisms. Confi rmation of the specific widely and are often complicated by underlying condi-
microbial agent must be done by appropriate studies. tions. Radiographically, the changes appear as a focal
Discussions on various infectious diseases are beyond the or diffuse infi ltrate. Pulmonary involvement manifests
scope of this atlas. Only a few of the infectious processes in several different forms such as necrotizing bronchitis
that are commonly encountered in cytologic specimens or bronchiolitis, interstitial pneumonitis, diffuse alveolar
will be described in this section. damage with hyaline membrane formation, and focal in-
flammatory changes with bronchopneumonia.
PULMONARY BACTERIAL INFECTIONS The infl ammatory response may consist of nonspe-
cifi c changes or specifi c morphologic changes. The non-
Cytopathologic evaluation of respiratory specimens for specific changes include 1) ciliocytophthoria; 2) bronchial
the most common bacterial infections is not warranted. epithelial and alveolar lining cell hyperplasia; 3) repair/
The majority of bacteria do not produce any specific regenerative changes involving bronchial epithelial cells;
cytopathologic changes. The application of cytopathol- and 4) specifi c changes characterized by multinucleation
ogy is limited but may be helpful in certain types of infec- and intranuclear inclusions (e.g., herpes virus infection
tions such as those caused by mycobacteria, actinomyces, or cytomegalo virus infection) (Table 7.28; Figs. 7.55 to
Nocardia, Rhodococcus equi, and Legionella. Only the 7.57). The cytopathic effects are quite often specific for a
first three will be discussed (Table 7.27). given virus.
Even when the morphologic changes strongly suggest
Pulmonary Tuberculosis a diagnosis of viral infection as well as the viral type, spe-
Mycobacterial infections include tuberculosis caused by cific identification must come from the virology laborato-
Mycobacterium tuberculosis and atypical mycobacterial ry. The viral types are established by isolation in culture,
infections. demonstration of antigens, or nucleic acids in clinical
Bacterial infections causing granulomatous lesions specimens, serologic tests, and DNA probes.
and presenting as solitary nodules are frequently due
to M. tuberculosis. Lately, infections by Mycobacterium PULMONARY MYCOTIC INFECTIONS
avium intracellular have been on the rise in patients with
AIDS. Histologically, the lesions show a granulomatous Pulmonary fungal infections occur as a result of inhala-
response with central caseating necrosis, peripheral col- tion of aerosolized fungal elements from environmental
lection of epithelioid cells, and multinucleated Langer- sources. Fungi causing pulmonary infections are grouped
hans type giant cells. Granulomas are bordered by a into two categories 1) Primary or true pathogens and
fibroblastic proliferation and lymphocytic infiltrate. Aspi- 2) opportunistic pathogens. Primary pathogens affect
TABLE 7.27 PULMONARY BACTERIAL INFECTIONS
Mycobacterium Tuberculosis Atypical Mycobacterial Actinomyces
Causative Mycobacterium tuberculosis; an Mycobacterium avium Actinomyces Israeli

Organism acid-fast organism, slender, slightly intracellular (MAI); acid-fast
curved, beaded; obligatory aerobic organisms
Geographic Worldwide; endemic in Worldwide; present in soil Occur as commensals in mouth, throat,
Distribution underdeveloped countries; airborne gastrointestinal tract and vagina;
infection opportunist; invade injured tissues
Clinicopathologic Immunocompetent and Frequent in An endogenous infection; results

Features immunosuppressed hosts; primary immunocompromised hosts; from aspiration of infectious material
infection occurs early in life; also occur in patients with or direct extension of cervicofacial
heals with fibrosis but results in underlying lung disease; infection; fever, chills, night sweats,
development of sensitization to cause cavitary lung disease weight loss; small abscesses in lungs;
tuberculin protein; re-infection with formation of thin- contain actinomycotic colonies of
results in destruction of lung walled cavities; caseating sulphur granules, which are tangled
parenchyma and cavitation, military granulomas; histiocytes masses of bacteria; Splendore–Hoeppli
spread can occur with primary filled with organisms and phenomenon; may cause sinus tract to
infection or secondary infection; appear globoid with foamy chest wall; squamous metaplasia with
granulomas formation with cytoplasm or without atypia of the lining of the
caseating necrosis cavities or bronchi
Morphology Beaded; rod-shaped Organisms slender, Anaerobic; microaerophilic;

beaded, intracellular and filamentous gram-positive organism;
extracellular large basophilic masses; numerous
thin filamentous branching structures,
1 m in width; radially oriented;
branching at right angles
Organisms All types of respiratory specimens, BAL; FNA, bronchial Discharge from sinuses; BAL, FNA
Recovered gastric washings washings, sputum
Cytopathologic Epithelioid cells; granulomas, Mononuclear infiltrate Acute inflammatory with or without
Features multinucleated giant cells of with large histiocytes abscess formation organisms seen as
Langhans’ type, amorphous debris containing abundant foamy branching filaments
cytoplasm; negative images
of the bacilli particularly in
Romanowsky type stains
(pseudo-Gaucher’s cells)
Useful Stains Not visualized in H&E or Acid-fast; Romanowsky Visualized in H&E stained slides;
Papanicolaou stains; stains with type Papanicolaou, Brown & Brenn, GMS
Ziehl-Neelsen or auramine-
rhodamine
Differential MAI infection, nocardia, M. tuberculosis; nocardia; Mycotic infections

Diagnoses sarcoidosis; other caseating clofazimine crystals; for
granulomas due to fungi; necrotic foamy histiocytes: Gaucher’s
squamous carcinoma cell; Amiodarone drug
toxicity; malakoplakia;
lipoid pneumonia mucin
producing adenocarcinoma
Confirmatory Culture Culture Culture

Tests
TABLE 7.28 PULMONARY VIRAL INFECTIONS
Herpes Simplex Cytomegalovirus
Occurrence Any age; immunocompromised and Any age, immunocompromised; more common
immunocompetent hosts in transplant recipients; often associated with
PCP infection in AIDS
Types of Specimens Sputum; tracheal, bronchial brushings and washings, Sputum; bronchial brushings and washings;
BAL BAL FNA
Tissue Response Ulcerative tracheobronchitis; interstitial pneumonitis; Interstitial pneumonia; diffuse alveolar damage,
diffuse alveolar damage with hyaline membrane hyaline membrane; hemorrhagic pneumonia
Cytopathologic Cell enlargement, multinucleation, ground-glass Cytomegaly and karyomegaly; large basophilic
Features nuclei; intranuclear inclusions intranuclear inclusion, clearing around
inclusion, multiple small cytoplasmic inclusions
Associated Features Reactive/hyperplastic epithelial changes, necrosis None, no necrosis
Differential Diagnoses CMV infection; adenocarcinoma Herpes virus infection; adenocarcinoma
Diagnostic Tests Immunocytohistochemical stains; culture Culture, molecular probes, transbronchial

biopsy, immunostain
immunocompetent individuals, the incidence being ous multinucleated giant cells often containing budding
very low. Opportunistic infections occur in immuno- organisms (e-Fig. 7.58) with a clear mucin capsule. The
compromised patients. Although several types of fungal latter may be stained by PAS or mucicarmine.
infections of the lung are encountered, only the most Other mycotic infections include histoplasmosis,
common ones will be described in this chapter (Table blastomycosis, and coccidioidomycosis. The reader may
7.29). Special stains are often required to confirm refer to the literature for more information.
their presence, even though most fungal organisms are Blastomycosis, coccidioidomycosis, histoplasmosis,
visualized in routine H&E and Papanicolaou-stained and phycomycosis are some of the fungi that can cause
preparations. necrotizing and cavitary lesions. Table 7.29 summarizes
the salient features.
Aspergillosis
Aspergillosis is the most common opportunistic infec- Pneumocystosis
tion frequently occurring in immunologically compro- Pneumocystosis is caused by the organism Pneumocystis
mised patients. These fungi have the capacity to invade jiroveci, formerly known as Pneumocystis carinii, which
normal lung tissue causing infiltrates, eventually masses, was considered to be a protozoan. However, it possesses
and may undergo cavitation. Aspergillus organisms certain properties that some believe puts Pneumocystis in
may also invade pre-existing cavities (abscess, cavitary the family of fungi.
malignant lesion). The organisms initially cause acute P. jiroveci organisms are ubiquitous, affecting 75%
inflammatory or a purulent response and, in the chronic of children by the age of four years. The infection is ac-
form, a granulomatous response. The organisms (e-Fig. quired via the respiratory tract, remaining latent and
7.59) are characterized by thick septate hyphae branch- asymptomatic in healthy or immunocompetent indi-
ing at 45°. Crystals of calcium oxalate may be present viduals. It may be reactivated in immunocompromised
in some cases. patients. P. jiroveci infection has become life threaten-
ing in immunocompromised patients, particularly those
Cryptococcosis (Torulosis)
with AIDS.
The infectious agent, Cryptococcus neoformans, fre- The clinical presentation of P. jiroveci pneumonia
quently causes widespread infection in immunocompro- varies. Symptoms are often nonspecifi c, such as fever,
mised or debilitated patients. In lungs, it causes a periph- malaise, or weight loss or the patient could be acutely ill
eral nodular lesion or multiple nodules with necrosis or running a fulminant course with respiratory failure.
and a granulomatous response. The lesions show numer- Chest X-rays show bilateral, symmetrical, and interstitial
TABLE 7.29 PULMONARY MYCOTIC INFECTIONS
Aspergillosis Blastomycosis Histoplasmosis Cryptococcosis Phycomycosis Coccidioidomycosis
Causative Aspergillus fumigatus, Blastomyces Histoplasma capsulatum Cryptococcosis neoformans Phycomycetes, Coccidioides immitis
Organism Aspergillus niger, dermatitides Zygomycetes
Aspergillus flavus
Geographic Worldwide; common North America; a Americas, particularly Worldwide; saprophytic in Worldwide, North American
Distribution household mold; soil saprophyte; Ohio and Mississippi soil, most abundant in avian saprophytic in soil deserts; dimorphic
saprophytic in soil dimorphic fungus valleys; dimorphic habitat, unimorphic fungus; widely
fungus, present in soil, in distributed in soil
areas with large amounts
of bird droppings
Clinicopathologic Predominantly affect Infection results Affect both Commonly affect Most fulminant Pulmonary mycosis;
Features immunocompromised from inhaling the immunocompetent and immunocompromised and invasive form dissemination
host; can affect spores; may cause immunosuppressed hosts; may infect occurs in patients rare; affects both
immunocompetent acute or chronic hosts; infection results immunocompetent with diabetic immunocompromised
host by colonizing pre- granulomatous from inhaling airborne hosts; often coexist ketoacidosis; and
existent cavities; present and suppurative; infectious spores; may with PCP infection; progressive immunocompetent
a spectrum of pulmonary infection of the result in asymptomatic marked predilection pulmonary infiltrate; hosts; endemic
infections: lung; affect both infection, leading for cerebromeningeal signs and symptoms in the western
1) perivascular and immunocompetent to multiple calcified dissemination; portal of of pulmonary hemisphere; majority
peribronchial and nodules; can cause acute entry-lungs; clinically present infarct; propensity of the cases clinically
suppurative infection; immunocompromised pulmonary infection with cough, low-grade fever, of organisms to inapparent, silent and
2) chronic granulomatous hosts; Splendore- or chronic pulmonary non-pleuritic chest pain involve pulmonary resolve; nonspecific
or chronic necrotizing Hoeppli phenomenon granulomatous infection malaise, weight loss, mucoid vasculature; arterial symptoms,
aspergillosis; in the granulomatous or cavitary lesions, sputum; alveolar and/or thrombosis; x-ray radiographic
3) invasive aspergillosis lesions; clinically, infection may get interstitial infiltrate on chest chest-solitary or features may suggest
involving arteries signs and symptoms disseminated; clinically x-ray, may cause single or multiple areas of acute pneumonia,
and veins resulting resemble those of and radiologically multiple nodules, mimicking consolidation, inflammation
in thrombosis, tissue pulmonary neoplasia; resembles tuberculosis neoplasia; segmental patchy hemorrhagic and suppuration,
infarction and systemic blood streaked or lobar consolidation; infiltrate; rarely cavitation;
dissemination; sputum, hemoptysis, granulomatous response, hemorrhagic granulomatous
4) allergic cough, chest pain, intense local inflammatory infarct; suppurative inflammation
bronchopulmonary fever, weight loss; reaction with suppuration; pneumonitis;
aspergillosis; bilateral dense diffuse interstitial or military haphazard
5) asymptomatic irregular shadows on infiltrate; host response distribution of
colonization of chest radiographs may be absent in severely hyphae throughout
cavitary lesion (e.g., immunocompromised the lesions and the
tuberculosis, infarcts, patients walls of the blood
bronchiectasis, cavitary vessels
carcinomas); may
induce squamous
metaplasia with atypia
(continued)
Aspergillosis Blastomycosis Histoplasmosis Cryptococcosis Phycomycosis Coccidioidomycosis
Morphology Organisms represent as Yeast forms 8–15 m Yeast forms, small Yeast forms 4–15 m; Hyphae up to Non-budding,
septate hyphae, 3–6 m in diameter; spherical, budding 2–4 m; budding with narrow base 10–30 m, in width, encapsulated spherule
in width; parallel walls; single budding with intracellular within resembling tear drops; broad ribbon-like, 15–100 m; thick
characteristic dichotomous a broad base, sharply organisms have rigid round to oval; thick irregular shapes; refractile walls,
branching at 45°; often defined thick refractile cell walls; retraction of mucopolysaccharide capsule; branching at right contains numerous
present as tangled masses walls the cytoplasm cerates a thin cell wall; extracellular angles; delicate; small endospores, 2–5
of hyphae; mycelial clear space or halo giving pauci septate; often m; stains basophilic
growth in pre-formed a false impression of twisted, folded,
cavities forming fungus capsule wrinkled uneven
ball or aspergilloma; when contours due to
in contact with air, form variation in width
fruiting bodies or conidia;
may exhibit irregular
bizarre shapes and
varicose dilatations; black
pigment with infection by
Aspergillus niger; calcium
oxalate crystals
Organisms Sputum, bronchial All types of FNA Sputum, bronchial washings, All types of Sputum, bronchial
Recovered brushings/washings; BAL, respiratory specimens BAL, FNA respiratory washings, BAL, FNA
FNA specimens
Useful Stains Papanicolaou, H&E, PAS, Papanicolaou, H&E, H&E, GMS, PAS- Papanicolaou, H&E, India Papanicolaou, H&E, Papanicolaou, H&E,
GMS, Gram, Giemsa, PAS, GMS negative, mucicarmine- ink, PAS for cell walls, GMS, GMS PAS negative, GMS
Toluidine blue negative Alcian blue, mucicarmine,
immunostain
Differential Mucor, candida hyphae, Cryptococcosis, Cryptococcosis, Histoplasmosis, Aspergillosis Pollen grains,
Diagnoses elastin fibers Histoplasmosis, Blastomycosis, Blastomycosis, vegetable cells,
Coccidioidomycosis Coccidioidomycosis Coccidioidomycosis Cryptococcosis,
Blastomycosis
Confirmatory Culture, fluorescent Culture Culture, serology Culture Culture, direct

Tests antibody immunofluorescence,
latex agglutination
to capsular
polysaccharide
antigen complement
fixation
infiltrates in the majority of cases. Other patterns include tive, diastase resistant proteinaceous material that is rich
unilateral infiltrates, nodules, and cavities. in lipids.
PAP occurs in association with various situations
Gross and Histologic Features. Gross appearance of such as exposure to dust or toxic chemicals, pulmo-
Pneumocystis pneumonia (PCP) is not diagnostic and may nary infections, immunodeficiency states, hematologic
resemble bacterial pneumonia or diffuse alveolar dam- abnormalities, or in patients receiving chemotherapy.
age. Histological manifestations of PCP are highly vari- The disease also occurs in newborns. Patients with PAP
able. The most frequent pattern is pneumonia with alveoli usually present with progressive dyspnea, low-grade
filled with foamy eosinophilic casts, accompanied by vari- fever, dry cough, hemoptysis, and pleuritic chest pain.
able degrees of lymphoplasmacytic interstitial infiltrate. Chest radiographs demonstrate fine diffuse feathery
There may be alveolar damage with hemorrhage and hya- to vaguely nodular bilateral infiltrates with a fluffy
line membrane formation. Unusual presentations include appearance.
abscess-like lesions, epithelioid granulomas affecting lung
parenchyma and hilar lymph nodes, and cavitary lesions Gross and Histologic Features
with or without pleural effusion. The fluffy alveolar casts
Grossly, the lungs are extremely heavy and solid. Viscid,
demonstrate multiple small clear spaces within them—a
white, milky fl uid exudes from their cut surfaces, which
pattern so characteristic of PCP infection—which repre-
show multiple fi rm yellow–tan to gray–white nodules
sents the cysts of the organisms. The latter are not stained
ranging from a few millimeters to 2 cm.
by either H&E stain or Papanicolaou stain. With silver
Histologically, the most dominant feature is the fill-
stain, the cyst walls are stained black. The cysts themselves
ing and distension of the alveoli with eosinophilic, fluffy,
appear round, cup-shaped, or crescent-shaped measuring
granular, acellular material. The alveoli remain intact. The
5 to 7 m in diameter. The frothy material itself does not
intra-alveolar material is PAS positive, diastase resistant,
stain with silver. Within the cysts are 5 to 8 sporozoites,
and negative for mucin. The intra-alveolar material is rich
each measuring 1 to 2 m and are not stained by silver
in lipid, staining positively with oil red O, and occasion-
but are visualized in Romanowsky-stained preparations.
ally contains cholesterol crystals. Peripherally, the alveoli
The cysts demonstrate autofluorescence in Papanicolaou-
show hyperplasia of type II lining cells.
stained smears. Other useful stains include toluidine blue,
Gram-Weigert, and PAS.
BAL has been successful as a therapeutic procedure in
Cytopathologic Features. Cytologic samples for identi-
patients with PAP. The lavage fl uid presents very charac-
fication of Pneumocystis organisms include induced spu-
teristic gross, cytologic, histochemical, and ultrastructural
tum since the cough in AIDS patients is often nonproduc-
findings, offering an accurate diagnosis.
tive, bronchial washings, BAL, aspiration biopsies, and
The lavage fluid is grossly opaque, milky white to
imprints of bronchial or transbronchial tissue biopsies.
gray with granular white sediment. The smears show
BAL is by far the best type of respiratory specimen offer-
(Table 7.32) sparsely cellular, fluffy to amorphous granu-
ing a high diagnostic yield. The eosinophilic fluffy exudate
lar debris, containing a few mononuclear cells. The latter
with round negative images of the trophozoites and cysts
probably represent alveolar histiocytes, occurring singly
is characteristic enough to be identified in Papanicolaou-
or in aggregates. Rarely, a tissue fragment of alveolar
stained smears (Table 7.30; e-Figs. 7.60A and B). Monoclo-
lining cells is present. The amorphous material stains
nal antibodies have been used for confirming the diagnosis
eosinophilic or cyanophilic with Papanicolaou stain (e-
of PCP. The organisms have not been isolated by culture.
Figs. 7.61A to C). Another characteristic feature is the
presence of varying-sized dense eosinophilic globules
Differential Diagnoses. Differential diagnoses of PCP within the granular material. Cholesterol crystals have
with the granular precipitate (Table 7.31) include condi- been identified.
tions that are characterized by the presence of intra-alve-
olar eosinophilic fl uffy exudates that are seen in respira- Ultrastructural Findings
tory specimens from disease processes such as pulmonary
Ultrastructurally, the fluid sediment shows a large number
alveolar proteinosis, amyloidosis, and lysed red blood
of multi-lamellated bodies within the amorphous mate-
cells (e-Fig. 7.62).
rial (e-Figs. 7.61F and G).
PULMONARY ALVEOLAR PROTEINOSIS
The differential diagnoses of the fluffy, eosinophilic, acel-
Pulmonary alveolar proteinosis (PAP) is a rare condition lular material in the Papanicolaou-stained smear include
characterized by the fi lling of the alveoli with PAS posi- alveolar casts seen in P. jiroveci pneumonia, pulmonary
TABLE 7.30 CYTOPATHOLOGIC CHARACTERISTICS OF FOAMY ALVEOLAR CASTS IN

PNEUMOCYSTITIS CARINII PNEUMONIA IN RESPIRATORY SPECIMENS
● Well-demarcated, three-dimensional extracellular structures

● Globular shape
● Size, range of typical or distended lung alveoli 80–340 m in longest dimension
● Pale eosinophilic to cyanophilic with negative imaging as multiple round clear spaces due to nonstaining of cysts in
Papanicolaou stains
● Special stains required to confirm the presence of organisms
TABLE 7.31 DIFFERENTIAL DIAGNOSES OF FLUFFY, GRANULAR, OR AMORPHOUS ACELLULAR MATE-

RIAL IN RESPIRATORY SPECIMENSa

Pneumocystis carinii Fluffy, granular, eosinophilic precipitate appearing as three-dimensional e-Fig. 7.60
pneumonia (may be seen extracellular structures; round, small ‘ghost’ shadows of cysts; often have
in sputum, BAL, bronchial globular shapes ranging from 80–340 m; pale eosinophilic to cyanophilic
washings) stained with negative imaging as multiple, round, clear spaces due to non-staining
of the cysts in Papanicolaou staining; sliver stain shows cyst 8–10 m, either
spherical, crescent-shaped, or crinkled; trophozoites within the cysts 0.5–1 m
appear as dots
Alveolar proteinosis (may Fluffy granular eosinophilic precipitate, almost acellular to poorly cellular; may e-Fig. 7.62
be seen in BAL, bronchial show macrophages, reactive alveolar type II lining cells and multinucleated
washings) foreign-body-type giant cells; PAS positive with or without diastase; mucin stain
negative; silver stain negative; ultrastructural exam: presence of lamellated bodies
Pulmonary amyloidosis (may Amorphous, fluffy, granular to dense eosinophilic or cyanophilic acellular e-Fig. 7.38
be seen in BAL, bronchial material; may be associated with giant cell reaction; plasma cells present when
washings, or aspirates) associated with plasmacytoma or multiple myeloma; require special stains to
confirm the amyloid
Alveolar hemorrhage with Eosinophilic granular precipitate with rounded ‘ghost’ shadows of lysed red e-Fig. 7.63
lysed red blood cells (may blood cells; pale center, darker borders; negative with silver stains
be seen in BAL, bronchial
washings)
Kayexalate aspiration* Kayexalate is a drug used to treat hyperkalemia; aspiration of this drug may
(sodium polystyrene sulfonate) be seen as alveolar casts without any tissue reaction; the casts are described as
(may be seen in BAL, various-sized basophilic acellular material with parallel laminations
bronchial washings, FNA)
a
Idowu M, Mudge M, Ghatak NR. Kayexalate (sodium polystyrene sulfonate) aspiration. Arch Path Lab Med 2005;129:125.
TABLE 7.32 CYTOPATHOLOGIC FEATURES OF PULMONARY ALVEOLAR PROTEINOSIS IN BAL
Gross Lavage fluid opaque, milky-white to gray; granular to sandy sediment
Microscopic Amorphous, fluffy to granular debris staining eosinophilic or cyanophilic with Papanicolaou stain and
basophilic with Romanowsky stains; sparsely cellular with alveolar macrophages; multinucleated giant
cells and reactive alveolar type II pneumocytes; dense eosinophilic globules of varying sizes; cholesterol
crystals /
Histochemistry Granular material PAS , diastase resistant; alcian blue and mucicarmine ; oil red O
Ultrastructure Large numbers of multi-lamellated bodies in extracellular location

amyloidosis, and lysed red blood cells in aggregates. Dif- Histologic Features
ferentiating features are listed in Table 7.31.
Histologically, the lungs initially exhibit lymphocytic inter-
stitial pneumonitis followed by formation of noncaseating
granulomas. The latter are also seen in submucosal loca-
GRANULOMATOUS INFLAMMATION tions in bronchi and bronchioles as well as hilar lymph
nodes. The granulomas may be discrete or confluent, non-
Several disease processes affecting the lungs provoke a caseating, composed of aggregates of epithelioid cells with
granulomatous response. Most are of infectious origin, elongated nuclei and Langhans type multinucleated giant
such as bacterial or fungal infections, with tuberculosis cells, which lack phagocytized debris and possess dense
being the most common. The rest include granulomas cytoplasm with nuclei arranged peripherally or clustered
secondary to foreign-body, occupational exposure, and at one pole and may contain Schaumann (e-Fig. 7.22) or
idiopathic lung diseases to name a few. The inflammatory asteroid bodies (e-Fig. 7.23) within their cytoplasm.
response may result in localized nodular lesions or cause
diffuse parenchymal and interstitial involvement. Chest Cytopathologic Features
radiographic patterns vary accordingly. Granulomatous The cytopathologic findings of sarcoidosis are only infre-
inflammation, in general, is characterized by aggregates of quently documented in respiratory specimens, particularly
epithelioid cells, multinucleated giant cells, lymphocytes, in sputum and bronchoscopic specimens. These findings
plasma cells, and fi broblasts. Epithelioid cells are altered include the presence of granulomas (e-Fig. 7.63) multi-
macrophages presenting pleomorphic shapes ranging nucleated giant cells and aggregates of epithelioid cells in
from round, elongated to oblong forms with variable, a clean background, lacking necrotic and cellular debris
pale to foamy cytoplasm that is devoid of tingible ingested (e-Fig. 7.49). The giant cells are large, 50 to 500 m in
material such as carbon particles. They are seen isolated size, round, oval, or elongated, containing dense cyano-
or in aggregates. The epithelioid cell nuclei are very pleo- philic cytoplasm with poor to sharply defined cell borders.
morphic in shape and size. They can be round, elongated, They are often sticky and seen in aggregates in mucus
spindle-shaped, comma-shaped, boomerang-shaped, or streaks in sputum. Their nuclei vary in numbers, either
deeply indented and clefted, producing footprint shapes. distributed randomly within the cytoplasm or clustered at
Multinucleated giant cells within the granulomas one pole or arranged along the perimeter. The cytoplasm
present different morphologic patterns in the arrange- of these cells does not contain phagocytized debris and
ment of their component nuclei. Some multinucleated gi- may house asteroid or Schaumann bodies. The epithelioid
ant cells are specialized and are associated with specific cells are round, oval, polygonal or spindle-shaped, occur-
types of inflammations while others are nonspecific. The ring singly, or in aggregates and contain pale to dense
giant cells may contain microorganisms, foreign bodies, cytoplasm. Their nuclei display a great variation in their
keratin, or collagen. Granulomas may show necrosis. In shapes consisting of oval, oblong elongate, curved, carrot,
cases of tuberculous granulomas, the necrotic material boomerang, kidney, and some with multiple indentations
appears yellow, greasy, and is referred to as “caseation” resembling footprints and twisted forms. It is this varia-
(cheese-like). Granulomas may be discrete or conflu- tion in nuclear shapes and the haphazard arrangement
ent, may be walled off by fibrosis, and may be calcified. of nuclei within the cytoplasm that is so characteristic
The granulomas can be brushed only if they involve the of epithelioid cells. Lymphocytes may be present in large
bronchi and extend through the mucosa. They may be numbers, particularly in BAL specimens. In fact, a differ-
encountered in bronchial washings and BAL. Granulo- ential count of infl ammatory cells in BAL has been used
mas that cause localized lesions and appear as a solitary to support the diagnosis of sarcoidosis as well as in moni-
nodule often enter the differential diagnosis of neopla- toring the response of drug therapy. Lesions of sarcoidosis
sia and are subjected to FNA biopsies. The morphology are more likely to be encountered in fine needle aspirates
of granulomas is often well-demonstrated in cell block particularly the transbronchial ones rather than sputum
preparations. or bronchoscopic specimens.
SARCOIDOSIS Differential Diagnoses

Sarcoidosis is a granulomatous disease of unknown eti- The differential diagnoses include other granulomatous
ology with multi-system involvement, affecting mostly diseases of which tuberculosis strongly resembles the
young or middle aged patients, particularly women. Pul- lesions of sarcoidosis. The diagnosis of sarcoidosis is
monary involvement is extremely common and is asso- made only after excluding the causes for other granu-
ciated with hilar lymphadenopathy. The disease is com- lomatous disease processes by special stains and micro-
monly encountered in transbronchial fine needle aspirates biologic studies to rule out acid-fast organisms, fungi, or
of mediastinal lymph nodes. any other organisms.
tomas accounting for 4%. Identifi cation of a broncho-

DIFFERENTIAL DIAGNOSES OF SOLITARY genic carcinoma presenting as a solitary nodule is impor-
PULMONARY NODULES tant to enable potentially surgically curable lesions to be
treated appropriately and to minimize the thoracotomies
A solitary lung nodule may be the primary malignant for non-surgical malignant lesions or benign lesions.
tumor in approximately one-third of cases, while 4% rep- Bronchogenic carcinomas and metastatic lesions have
resent metastatic lesions. The majority are benign lesions been discussed earlier.
predominantly representing granulomas with hamar-
SUGGESTED READINGS
Bibbo M, Wilber D, eds. Comprehensive Cytopathology. 3rd ed. Travis WP, Brumbilla E, Muller-Hermelink HK, et al. World Health
Philadelphia, PA: Saunders, 2008. Organization Classification of Pathology and Genetics of
Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia, Tumors of the Lung, Pleura, Thymus and Heart. Lyon, France:
PA: Churchill Livingstone, 2006. IARC Press, 2004.
Elkus R, Miller M, Kini S, Kvale PA. A comparison of withdrawn Yasufuku K, Nakajima T, Fujiwara T, et al. Role of endobronchial
and nonwithdrawn brushes in the diagnosis of lung cancer. ultrasound-guided transbronchial aspiration in the management
J Bronchol 1994;1:269–275. of lung cancer. Gen Thoracic Cardiovas Surg 2008;56:268–276.
Erozan YS, Ramzy I. Pulmonary cytopathology. In: Rosenthal DL, Zander DS, Farver CF. Pulmonary pathology. In: Goldblum JR,
ed. Essential in Cytopathology. New York, NY: Springer, 2009. ed. Foundations in Diagnostic Pathology. Philadelphia, PA:
Kini SR. Color Atlas of Pulmonary Cytopathology. New York: Churchill Livingstone, 2008.
Springer-Verlag, 2002.
Krishna G, Gould MK. Minimally invasive techniques for the diag-
nosis of peripheral pulmonary nodules. Curr Opin Pulm Med
2008;14:282–286.
APPENDIX I
the diagnostic work-up of a patient with diffuse lung

SPECIMEN PROCESSING infections and has provided excellent results in the
detection of P. carinii infections in AIDS patients. BAL
As listed in Table 7.1, the respiratory system provides sev- has also been used in parenchymal diseases to study
eral types of specimens for cytologic evaluation. Many of the response to drugs by performing a differential cell
these specimens require different methods of processing. count.
Their diagnostic yield also varies. A synopsis of specimen
processing is described below. Detailed information can
be obtained from the literature. FINE NEEDLE BIOPSY
FNA biopsy of lung masses is performed both via per-

SPUTUM cutaneous transthoracic route under radiologic guidance
and as transbronchial biopsy via fiberoptic broncho-
Cytologic evaluation of sputum offers higher diagnostic scope. Indications for each type of biopsy procedure are
yields for centrally located cancers such as squamous cell different.
and small cell carcinomas. Sputum examination performed
over three to five consecutive days enhances the detection
rate. Early morning samples should be submitted fresh or TRANSTHORACIC FINE NEEDLE
fixed in 2% polyethylene glycol in 50% ethyl alcohol (Sac- BIOPSY (TTFNA)
comanno fixative). A three-day pooled specimen collected
in Saccomanno fixative is equally effective in cancer screen-
INDICATIONS
ing or diagnosis. Sputum may be spontaneously coughed or
induced. A twenty-four hour unfixed sample is not suitable ● Clinically or radiologically suspected lung cancer,
for cytologic evaluation. A sputum sample is considered located peripherally and not accessible to fiberoptic
satisfactory when it contains alveolar macrophages (e-Fig. bronchoscopy.
7.9). The use of sputum has declined over the years.
To identify a new lesion in a patient with a history of
treated lung cancer.
BRONCHIAL BRUSHINGS AND To confirm a metastatic lesion from a known
primary.
WASHINGS (BB/BW)
To differentiate malignant from infectious cavitary
processes; FNA biopsy also allows microbiologic stud-
Specimens obtained at bronchoscopy produce a higher ies in case of infectious processes.
diagnostic rate for lung cancers since the fiberoptic bron- For pleural-based lesions to differentiate carcinomas
choscopes are fl exible and can visualize smaller bronchi, from malignant mesothelioma.
rendering the lesions accessible to the sampling device.
In unresectable tumors, for morphologic support prior
The normal cellular components include respiratory
to radiation/chemotherapy.
columnar cells and goblet cells. Bronchial washings also
contain alveolar histiocytes. On patients with medical disease contraindicating
Following the brushing of the endobronchial lesions, bronchoscopy.
smears are prepared directly by rolling the brush on the
glass slide over a small area (size of a nickle or a quar-
ter) in a circular motion and wet-fixed immediately. The
rinsing of the brush in a balanced salt solution after the TRANSBRONCHIAL FINE NEEDLE
smears have been made can be processed in the same BIOPSY (TBFNA)
fashion as bronchial washings.
Transbronchial fine needle aspiration (TBFNA) biopsy
BRONCHOALVEOLAR LAVAGE (BAL) involves inserting a needle into the lesion, through a flex-
ible fiberoptic bronchoscope, penetrating the bronchial
wall between the cartilaginous plates and aspirating
BAL is performed via fiberoptic bronchoscope and, at cytologic material. It is either directed toward the paren-
times, via endotracheal tube. BAL is often a part of chymal nodules or the hilar–mediastinal lymph nodes. It
is popularly used for a peripheral nodule that cannot be Note: Choice of fi xation of the smears (air-drying or wet
visualized by bronchoscopy but can be accessed under fi xation) and staining (Romanowsky or Papanicolaou
radiologic guidance. The newer bronchoscopic meth- or H&E) as well as specimen processing (conventional
ods utilizing electromagnetic navigation system provide methods or liquid-based techniques) varies from one lab-
lung access beyond third or fourth generation airways. oratory to another.
TBFNA is primarily used for obtaining material from
mediastinal or hilar lymph nodes in staging bronchogenic SPECIMEN ADEQUACY
carcinoma and other metastatic carcinomas. The newer
technology with endoscopic endobronchial ultrasound Following adequacy guidelines are recommended by the
guided (EBUS) needle biopsies of the mediastinal lymph Papanicolaou Society of Cytopathology. “When an aspi-
nodes have been very popular in staging the lung can- rate yields cellular material representative of a specific
cer and provide high diagnostic accuracy. TBFNA is also pathologic entity, the specimen is deemed satisfactory or
ideally suited for submucosal and for necrotic nodules. adequate. A specimen composed of benign respiratory cells,
The use of TBFNA is also extended to diagnose benign macrophages, alveolar lining cells, and inflammatory cells
lesions involving mediastinal or hilar lymph nodes (e.g., in the presence of a significant clinical and/or radiographic
granulomas). lesion is designated ‘nondiagnostic,’ despite the presence of
abundant cellular material.” For TBFNA, directed at hilar/
mediastinal lymph nodes for staging purposes, the pres-
ence of lymphocytes is essential. Bronchial epithelial cells
TRANSTRACHEAL FINE NEEDLE do not make the FNA satisfactory. Absence of lympho-
ASPIRATION BIOPSY cytes indicates that the target organ is not biopsied.
Very few cells should render a specimen inadequate.
Transtracheal needle aspiration biopsy is useful in the However, there are no guidelines for an unsatisfactory or an
diagnosis of hilar, paratracheal, and subcarinal masses. A inadequate aspirate. Most often, the criteria are based on per-
high degree of sensitivity has been reported. sonal experience and are specific to individual laboratories.
APPENDIX II
WHO CLASSIFICATION OF LUNG TUMORS

Large Cell Carcinoma
MALIGNANT EPITHELIAL TUMORS Large Cell Neuroendocrine Carcinoma
Combined Lire Cell Neuroendocrine
Squamous Carcinoma Carcinoma
Papillary Basaloid Carcinoma
Clear Cell Lymphoepithelioma-Like Carcinoma
Small Cell Clear Cell Carcinoma
Basaloid Large Cell Carcinoma with Rhabdoid Phenotype
Small Cell Carcinoma Adenosquamous Carcinoma
Combined Small Cell Carcinoma Sarcomatoid Carcinoma
Adenocarcinoma Pleomorphic Carcinoma
Adenocarcinoma, Mixed Subtype Spindle Cell Carcinoma
Acinar Adenocarcinoma Giant Cell Carcinoma
Papillary Adenocarcinoma Carcinosarcoma
Bronchioloalveolar Carcinoma Pulmonary Blastoma
Nonmucinous Carcinoid Tumor
Mucinous Typical Carcinoid
Mixed Nonmucinous and Mucinous or Indeterminate Atypical Carcinoid
Solid Adenocarcinoma with Mucin Production Salivary Gland Tumors
Fetal Adenocarcinoma Mucoepidermoid Carcinoma
Mucinous (Colloid) Carcinoma Adenoid Cystic Carcinoma
Mucinous Cystadenocarcinoma Epithelial–Myoepithelial Carcinoma
Signet-Ring Adenocarcinoma Preinvasive Lesions
Clear Cell Adenocarcinoma Squamous Carcinoma In Situ
Atypical Adenomatous Hyperplasia Adenomas of the Salivary Gland Type

Diffuse Idiopathic Pulmonary Mucous Gland Adenoma
Neuroendocrine Cell Hyperplasia Pleomorphic Adenoma
Mesenchymal Tumors Others
Epithelioid Hemangioendothelioma Mucinous Cystadenoma
Angiosarcoma
Pleuropulmonary Blastoma
Chondroma LYMPHOPROLIFERATIVE TUMORS
Congenial Peribronchial Myofibroblastic Tumor
Diffuse Pulmonary Lymphangiomatosis
Inflammatory Myofibroblastic Tumor Marginal Zone B-Cell Lymphoma of the MALT Type
Lymphangioleiomyomatosis Diffuse Large B-Cell Lymphoma
Synovial Sarcoma Lymphomatoid Granulomatosis
Monophasic Langerhans Cell Histiocytosis
Biphasic
Pulmonary Artery Sarcoma
Pulmonary Vein Sarcoma MISCELLANEOUS TUMORS
BENIGN EPITHELIAL TUMORS Hamartoma

Sclerosing Hemangioma
Clear Cell Tumor
Papillomas Germ Cell Tumor
Squamous Cell Papilloma Teratoma, Mature
Exophytic Immature
Inverted Other Germ Cell Tumors
Glandular Papilloma Intrapulmonary Thymoma
Mixed Squamous Cell and Glandular Papilloma Melanoma
Adenomas
Alveolar Adenoma
Alveolar Adenoma METASTATIC TUMORS
Papillary Adenoma
8 ALIMENTARY TRACT:
ESOPHAGUS,
GASTROINTESTINAL, GALL-
BLADDER AND EXTRAHEPATIC
BILIARY TRACT (EXFOLIATIVE
AND ASPIRATION CYTOLOGY)
Fiberoptic endoscopy has greatly enhanced the ability to cardiac type gastric mucosa. Brushings of a normal esoph-
directly visualize several parts of the gastrointestinal tract ageal mucosa show mature squamous epithelial cells.
and to obtain specimens for cytohistologic evaluation. Endoscopic specimens include direct smears prepared
Over the last few years, the use of gastrointestinal cytol- at the time of brushings and smears prepared from rins-
ogy has declined due to a preference for tissue biopsies. ings of the brush.
However, cytologic evaluation is often complementary to Indications for esophageal brushings include
the histologic diagnosis.
● Ulcerative, constricting, or obstructive lesions in order
With recent advances in technology, endoscopic ultra-
to rule out a malignant process;
sound (EUS) guided needle biopsies of the gastrointestinal
● Confirmation of a diagnosis of Barrett’s esophagus and
lesions have become extremely popular for establishing
surveillance following abnormal results;
the diagnosis of mass lesions as well as for staging pur-
● Follow-up of esophageal carcinoma treated with radi-
poses. The EUS-guided biopsies can also be utilized for
ation.
the submucosal lesions of the gastrointestinal tract and
retroperitoneal lesions. Diagnostic problems include the differentiation of
Specimens for the cytologic evaluation of lesions in-
● Benign ulcers with reactive/reparative changes from
volving the various organs of the alimentary tract include
malignancy;
● esophageal, gastric, and duodenal brushings; ● Radiation-induced changes from malignancy, particu-
● colonic and rectal brushings; larly in cases of treated squamous carcinoma;
● anal smears; ● Barrett’s esophagus with epithelial atypia from adeno-
● brushings of the ampulla of Vater, common bile duct, carcinoma.
and pancreatic duct;
● fluid from the pancreatic duct and the bile ducts; NONNEOPLASTIC LESIONS OF
● bile collected from T-tube drainage, percutaneous tran- THE ESOPHAGUS
shepatic cholangiography, or retrograde cholangiopan-
creatography; and Infections
● ultrasound-guided fi ne needle biopsies of the mass
Infections of the esophagus are generally infrequent except
lesions.
in immunologically compromised patients and include
those caused by candida and herpes virus as well as Cyto-
ESOPHAGUS megalovirus. The cytologic features are the same as those
described elsewhere (e-Fig. 8.1, see also Chapter 2).
NORMAL ARCHITECTURE Reflux Esophagitis

The esophagus is lined by nonkeratinizing stratified This is an extremely common condition often resulting in
squamous epithelium with mucus glands in the submucosa. ulceration and inflammation. The brushings reveal inflam-
At the gastroesophageal junction, the mucosa changes to a matory cells and squamous epithelial cells, often with
294
Chapter 8: Alimentary Tract: Esophagus, Gastrointestinal, Gall Bladder and Extrahepatic Biliary Tract 295
TABLE 8.1 DIFFERENTIATING FEATURES BETWEEN REACTIVE/REPARATIVE CHANGES

AND SQUAMOUS CARCINOMA
Reactive/Reparative Changes Squamous Carcinoma

Cellularity Low Variable, low to high
Presentation In monolayered tissue fragments with honeycomb Single cells, in groups, and in syncytial tissue fragments
pattern; single cells not seen
Cells Slightly enlarged Considerably pleomorphic in size and shape
Nucleus Mildly enlarged; round with smooth nuclear membrane; Markedly enlarged with high N/C ratios; round with
undulation but no sharp angularity; chromatin smooth to irregular membrane with sharp angularity;
finely granular, evenly dispersed; nucleoli variable in chromatin fine to coarsely granular with parachromatin
numbers, generally few; micronucleoli/macronucleoli clearing; considerable variation in numbers; micronucleoli/
conspicuous; may be irregular; mitoses ⫹/⫺ macronucleoli conspicuous; may be irregular; mitoses ⫹/⫺
Cytoplasm Variable Scant
Background Inflammatory Inflammatory ⫹/⫺
repair/regenerative changes demonstrating enlarged nuclei in a flat or villous configuration and consists of goblet cells
with prominent nucleoli, mimicking malignancy, and con- and columnar cells. The goblet cells contain mucin that
stituting an important diagnostic pitfall (Table 8.1). stains positively with both periodic acid-Schiff (PAS) and
alcian blue at pH 2.5. The columnar cells resemble gastric
RADIATION-INDUCED CHANGES foveolar epithelium or, rarely, intestinal absorptive cells,
but they lack absorptive capability or ultrastructural find-
Radiation-induced changes are encountered in patients
ings of true intestinal absorptive cells. Therefore, the term
with esophageal carcinoma treated with radiation or in
incomplete intestinal metaplasia is applied. This epithelium
patients receiving radiation therapy for pulmonary or
may also contain Paneth cells and enterochromaffin cells.
mediastinal disease. The squamous cells show cytomegaly
Patients with Barrett’s esophagus are at an increased
and karyomegaly with vacuolated cytoplasm and nuclei
risk for esophageal adenocarcinoma. Dysplasia—the pre-
that are pale to smudgy with irregular chromatin clump-
sumed precancerous epithelial lesion—has been regularly
ing (see Figs. 15.7 and 15.10).
recognized in esophageal specimens adjacent to and dis-
tant from Barrett’s-associated adenocarcinomas. Dyspla-
BARRETT’S ESOPHAGUS
sia has been reported to occur in all three types of Barrett’s
Barrett’s esophagus is the eponym for the columnar epi- epithelia, but it is more frequently seen in the specialized
thelium-lined distal esophagus replacing the stratified type. It is unlikely that cancer ever occurs except in pa-
squamous epithelium. The presence of chronic gastroe- tients with specialized columnar epithelium.
sophageal reflux is the single most important risk factor in In cytologic preparations, the brushings from typical
the development of columnar epithelium and subsequently Barrett’s mucosa show large tissue fragments of columnar
adenocarcinoma, with a frequency of approximately 8 to epithelial cells with a honeycomb arrangement (e-Figs.
15% in some large series. Three epithelial types are found 8.2A to C). A villiform columnar configuration is often
in Barrett’s esophagus: junctional epithelium (gastric car- preserved. Single columnar cells are found more common-
dia-like), gastric fundic-type epithelium, and specialized ly in cell spreads prepared from the specimens collected
columnar epithelium (incomplete intestinal metaplasia). in the fluid rather than direct smears. Goblet cells can be
The junctional epithelium comprises glands and pits identifi ed as pale-staining globoid cells with basally ori-
that resemble the gastric cardia. These glands are lined by ented and slightly fl attened nuclei. In small epithelial tis-
mucus-secreting cells. Chief, parietal, Paneth, enterochro- sue fragments viewed en face, goblet cells appear as large
maffin, and goblet cells are not encountered. vacuoles, giving the fragment a Swiss cheese appearance.
Gastric fundic-type epithelium in Barrett’s esophagus The cardiac-type mucosa in cytologic samples show cells
is virtually identical to that of the normal gastric body of uniform size, cuboidal to round, with regular, benign
and is associated with inflammation and atrophy. appearing nuclei.
Specialized columnar epithelium, also termed incom- The dysplastic change is represented by groups, ag-
plete intestinal metaplasia, is a distinctive epithelial type gregates, or small irregular tissue fragments of epithelial
that is virtually unique to Barrett’s esophagus. It can occur cells with crowding and overlapping of nuclei. The nuclei
A B
Figs. 8.1A to C. Esophageal brushings from Barrett’s disease show-

ing tissue fragments of gastrointestinal epithelium with interspersed
C goblet cells. There is a variable degree of nuclear atypia.
Fig. 8.2. Brushings of an ulcerative lesion of the esophagus depict-

ing a well-differentiated squamous carcinoma.
are variably increased in size. The chromatin is coarsely Prognosis is poor mainly because of a contiguous
granular and nucleoli may be present (Figs. 8.1A to C). extension of the carcinoma beyond the esophageal wall
and the close relationship with the neighboring struc-
tures. Therefore, resection is difficult, but advances in
radiation therapy have significantly altered the thera-
SQUAMOUS CARCINOMA
peutic approach. These tumors have an insidious onset
and are deeply invasive and metastatic at the time of
Squamous carcinoma is the most common malignant diagnosis.
neoplasm in the esophagus. Since relatively few lym- The gross appearance of the tumor is variable: fun-
phatic vessels are present in the esophageal wall, lymph gating in 60%, ulcerative in 25%, and infiltrative in 15%.
node metastases are absent in nearly 40% of the cases. Irrespective of the growth pattern, the neoplasm generally
Fig. 8.3. Esophageal brushings depicting a poorly differentiated Fig. 8.4. Esophageal brushings depicting an adenocarcinoma. The
squamous carcinoma. The malignant squamous cells are pleomor- malignant cells are medium-sized to large, loosely cohesive with
phic with spindle forms. poorly defined cell borders containing pale vacuolated cytoplasm.
Note the prominent nucleoli.
Fig. 8.5. Esophageal brushings depicting an adenocarcinoma. The Fig. 8.6. Esophageal brushings depicting a poorly differentiated
malignant cells are medium-sized, forming a syncytial tissue frag- squamous carcinoma. The malignant cells are small with high N/C
ment with an acinar pattern. The nuclear chromatin is finely granu- ratios and scant cytoplasm. A neuroendocrine carcinoma should be
lar and micronucleoli are conspicuous. ruled out.
involves a long segment of the esophagus. The circumfer- Barrett’s epithelium. Cytologic features are character-
ential involvement is variable. istic of adenocarcinomas described elsewhere (Figs. 8.4
Histologically, in situ squamous carcinoma is often ob- and 8.5).
served at the border areas of invasive carcinoma. The junc- Small cell carcinoma (Fig. 8.6) is extremely uncom-
tion between tumor and normal epithelium is abrupt. In situ mon. A primary lesion in the tracheobronchial tree must
carcinoma that is independent of invasive tumor is a rare first be excluded.
phenomenon in the esophagus. Squamous carcinomas of the With adequate cellularity and a proper cytoprepa-
esophagus are generally well-differentiated with varying de- ratory technique, the cytologic diagnosis of squamous
grees of keratinization and are no different than squamous carcinoma is not a challenge. Diagnostic difficulties arise
carcinomas involving other body sites. Please refer to Table when the specimen is scantily cellular. Cells from the sur-
8.6 for cytopathologic features (Figs. 8.2 and 8.3). face of a keratinizing well-differentiated carcinoma may
not exhibit malignant criteria and are difficult to differ-
entiate from squamous cells exhibiting radiation chang-
es. Reparative/regenerative changes at ulcer margins may
OTHER MALIGNANT NEOPLASMS
present active nuclei with prominent nucleoli. However,
OF THE ESOPHAGUS
these cells lack the unequivocal criteria of malignancy.
Furthermore, reparative/regenerative cells are generally
Adenocarcinoma of the esophagus accounts for 10% present in tissue fragments and not in isolated forms
of esophageal cancers. Most are believed to arise in (Figs. 8.7 to 8.11).
A B
Figs. 8.7A and B. A: Brushings of an esophageal ulcer showing reactive squamous cells. The nuclei are enlarged and
contain prominent nucleoli. B: A different field from the same case showing a tissue fragment of reactive squamous
cells with prominent micronucleoli.
Fig. 8.8. Ulcers caused by herpes virus infection may show consid-
erable nuclear atypia prior to the appearance of nuclear inclusions
and are potential diagnostic pitfalls.
A B
Figs. 8.9A to B. Esophageal brushings. A, B: Herpes virus infection. Discrete squamous cells containing enlarged
nuclei with compact chromatin. Typical nuclear inclusions are not apparent. These cells can be misinterpreted
malignant squamous cells. (continued)
C D
Figs. 8.9C to D. (continued) C, D: Brushings of a squamous carcinoma showing morphologic similarities.
Fig. 8.10. Esophageal brushings showing squamous epithelial cells

with changes, induced by radiation, that mimic malignancy.
A B
Figs. 8.11A to B. Esophageal brushings showing squamous carcinoma. Compare with nuclear changes seen in
Figure 8.10. (continued)
C Fig. 8.11C. (continued)
8.29 and 8.30; e-Figs. 8.4A and B, and 8.5). The cells
STOMACH representing reparative/regenerative changes are gener-
ally seen in tissue fragments; the presence of isolated cells
Cytologic evaluation of gastric lesions is mainly per- is not a feature, unlike malignancy.
formed to confirm a clinically or radiologically suspected Intestinal metaplasia is characterized by the presence
malignancy. Diagnostic problems include of large cytoplasmic vacuoles (goblet cells).
● Differentiation of repair/regenerative changes from

carcinoma.
● Differentiation of signet-ring cell carcinoma from MALIGNANT NEOPLASMS
malignant lymphoma. OF THE STOMACH
● Differentiation of histiocytes from individually dis-
persed malignant cells.
ADENOCARCINOMA OF THE STOMACH
Worldwide, adenocarcinoma of the stomach is the second
NORMAL GASTRIC MUCOSA most common malignant tumor particularly in Asia, but
its incidence in the United States is declining. Carcinoma
The stomach is lined by columnar epithelium that is char-
of the stomach occurs more frequently in males, in older
acteristically uniform in appearance, composed of tall
individuals with a peak in the seventh decade. Gastric
cells with basal nuclei and apical mucin (Foveolar epi-
adenocarcinomas are rare before the age of 40 years. Gas-
thelium). Goblet cells are not present. The different parts
tric adenocarcinomas are aggressive tumors with a 5-year
of the stomach contain different types of mucosal glands.
survival rate as low as 10 to 15% and are a leading cause
The cardia and pyloric antrum contain mucus glands.
of death.
Acid and enzyme secreting glands with parietal and chief
Grossly, adenocarcinoma presents various growth
cells are found in the body and fundus.
patterns: superfi cial (12%); polypoid (8%); ulcerated in-
Cytologic specimens from normal gastric mucosa
fi ltrative, shallow or deep (30–40%); fungating (30%);
contain only surface epithelium appearing as tissue frag-
and diffusely infi ltrating (12–22%). Histologically, ade-
ments with a honeycomb pattern. The epithelial cells are
nocarcinomas may be classified into two schemes, namely
columnar, have oval nuclei, uniformly distributed finely
the Lauren type and WHO classifi cation into tubular,
granular chromatin, and uniformly distributed mucin in
papillary, mucinous, and signet-ring.
the apical part of cells (e-Figs. 8.3A to C).
The Lauren type classifi cation divides gastric adeno-
carcinomas into two main groups: the well-differentiated
or intestinal type and the poorly differentiated or gastric
NONNEOPLASTIC LESIONS
type. Considerable differences are noted in their presenta-
OF THE STOMACH
tion and behavior (Table 8.2).
Chronic superfi cial gastritis, chronic gastric ulcers, and The cytologic diagnosis of intestinal type gastric ade-
atrophic gastritis with or without intestinal metaplasia nocarcinoma is generally straightforward since the malig-
may all reveal marked epithelial abnormalities that are nant cells exfoliated from these lesions are present in large
extremely difficult to differentiate from gastric adenocar- numbers and demonstrate obvious malignant criteria (Figs.
cinoma cells (see Tables 8.3 and 8.4; Figs. 8.19 to 8.25, 8.12 to 8.14). The gastric type adenocarcinomas, on the
TABLE 8.2 GASTRIC ADENOCARCINOMA
Intestinal Type Diffuse (Gastric) Type

Associated with intestinal metaplasia, may be associated Derived from glandular crypts; not associated with intestinal
with intramucosal carcinoma metaplasia and intramucosal carcinoma
Better prognosis Poor prognosis
Large bulky tumors Flat, ulcerated lesions, tend to infiltrate early and deeply
Histologically well-differentiated with acinar to papillary Poorly differentiated, small to medium cells with large cytoplasmic
growth pattern; large malignant cells vacuoles; acinar pattern not present or rare
Cytologically: malignant cells present in large numbers; Cytologically: malignant cells variable in numbers, individually
discrete, in loosely cohesive groups, or in syncytial tissue dispersed, round to oval, small to medium-sized; nucleus eccentric,
fragments with or without acinar pattern; papillary often pushed to periphery and flush with cell border; nuclear
configuration ⫹/⫺; malignant cells pleomorphic in size chromatin fine to coarsely granular; nuclear membrane smooth to
with variable pale cytoplasm; nuclei large with high N/C irregular; nucleolus ⫹/⫺; cytoplasm often abundant, pale to foamy
ratios; irregular nuclear membrane; granular chromatin or with large vacuoles
with parachromatin clearing, prominent nucleoli
Background; inflammatory, necrosis, and naked nuclei Background; inflammatory, necrosis, and naked nuclei
Differential diagnoses; repair/regeneration Differential diagnoses; histiocytes; malignant lymphoma
Fig. 8.12. Gastric brushings showing large adenocarcinoma cells in Fig. 8.13. Gastric brushings showing large adenocarcinoma cells in
a syncytial tissue fragments with an acinar pattern and represent the a syncytial tissue fragments represent the Intestinal type adenocar-
intestinal type adenocarcinoma. cinoma.
other hand, are diagnostically difficult since the malignant

MALIGNANT LYMPHOMA
cells are fewer in number, smaller in size, and have bland
nuclei (Figs. 8.15 to 8.17). They may not be recognized as The stomach is a common site for extranodal malignant
malignant cells since they very often resemble histiocytes. lymphomas that arise from mucosa-associated lymphoid
Single malignant cells with prominent nucleoli, scant cyto- tissue (MALT). Lymphomas of the stomach are associ-
plasm, and high N/C ratios morphologically resemble cells ated with Helicobacter pylori infections and autoim-
of malignant lymphoma. Gastric adenocarcinomas must mune disorders. Gastric lymphomas are more common
also be differentiated from reparative/regenerative cells in females in their fi fth to sixth decades. These are low-
from gastritis or the margins of gastric ulcers (Table 8.3) grade lymphomas and offer excellent prognosis. MALT
(see Figs. 8.18 to 8.25). lymphomas may progress into high-grade lymphomas.
Fig. 8.14. Gastric brushings showing intestinal type adenocarcino- Fig. 8.15. Gastric brushings showing signet-ring type adenocarci-
ma with large pleomorphic loosely cohesive malignant cells. noma. The malignant cells are small with vacuolated cytoplasm and
eccentric nuclei.
Fig. 8.16. Gastric brushings showing gastric type adenocarcinoma Fig. 8.17. Gastric brushings showing gastric type adenocarcinoma
with smaller cell size, scant cytoplasm. with smaller cell size, scant cytoplasm.
TABLE 8.3 CYTOPATHOLOGIC FEATURES DIFFERENTIATING GASTRIC EPITHELIAL

REPAIR AND ADENOCARCINOMA
Repair Adenocarcinoma
Cellularity Generally cellular Very cellular
Presentation Abnormal epithelial cells mostly in tissue Malignant cells isolated, in loosely cohesive groups, and in
fragments; single cells rare; generally syncytial tissue fragments with or without acinar pattern
honeycomb arrangement crowding ⫹/⫺
Cells Size variable; cell borders well to poorly Size variable; cell borders well to poorly defined; high N/C
defined; high N/C ratios ratios
Nucleus Round, size variable, mild enlargement; Round to oval, size variable; pleomorphic, crowding and
polarity maintained ⫹/⫺; smooth nuclear overlapping of nuclei with loss of polarity; smooth to irregular
membrane; finely granular chromatin; multiple nuclear membrane; fine to coarsely granular chromatin;
micronucleoli/macronucleoli; mitoses ⫹/⫺ multiple micronucleoli/macronucleoli; mitoses ⫹/⫺
Cytoplasm Variable; scant to abundant; pale, vacuolated Variable; scant to abundant; pale lacy to vacuolated
Background Inflammation; cellular debris ⫹/⫺ Inflammation ⫹/⫺; cellular debris ⫹/⫺
A B
Figs. 8.18A and B. Gastric brushings showing single signet-ring adenocarcinoma cells resembling histiocytes and may
be easily overlooked.
Fig. 8.19. Gastric brushings showing small discrete adenocarcino- Fig. 8.20. Gastric brushings. These small discrete adenocarcinoma
ma cells that morphologically resemble histiocytes. They may also cells strongly resemble malignant lymphoma cells.
be mistaken for malignant lymphoma cells.
Fig. 8.21. Gastric brushings showing discrete malignant melanoma

cells, containing melanin pigment. Note the cellularity is sparse and
can result in a false negative interpretation.
Differential Diagnoses of Gastric Adenocarcinoma (See Figs. 8.22 to 8.37)
A B
Figs. 8.22A and B. Gastric brushings. A: Gastric epithelium depicting reactive changes with prominent nucleoli.
B: Compare with gastric adenocarcinoma cells.
Fig. 8.23. Gastric brushings. These reactive gastric epithelial cells

are diagnostically difficult as they mimic malignancy. The smears
were interpreted as suspicious for adenocarcinoma. Multiple gastric
biopsies failed to confirm malignancy.
A B
Figs. 8.24A and B. Gastric brushings with discrete reactive gastric epithelial cells. These can easily be mistyped as
adenocarcinoma.
Fig. 8.25. Gastric brushings. Compare these adenocarcinoma cells

with the reactive cells.
Grossly, the lesions present with thickened rugal folds Most cancers identified in the duodenum are of pan-
that are often associated with large submucosal masses creatic and biliary tract origin and are seen in the ampul-
with ulcerations. Smears prepared from brushings show lary region in its second part. Carcinomas of the ampulla
only necrotic debris and often fail to demonstrate lym- of Vater and the bile duct are predominantly adenocarcino-
phoma cells. When present, they must be differentiated mas. These are discussed in the section on extrahepatic bil-
from reactive lymphoid processes as well as from poorly iary tract. The cytologic diagnosis is established on fine nee-
differentiated gastric carcinomas with single cell exfolia- dle biopsies performed under the guidance of ultrasound.
tion (Table 8.4) (Figs. 8.26 to 8.28).
COLORECTAL BRUSHINGS
DUODENUM
Although not a popularly used diagnostic technique, the
Normal duodenal and ampullary aspirates may include epi- cytologic evaluation of brushings of colorectal and anal
thelium that is columnar with numerous interspersed goblet lesions via colonoscopy or under direct vision has been
cells appearing as spaces or windows. They may also con- reported to be diagnostically accurate. This is particularly
tain cells from pancreatic and bile ducts but no goblet cells. suitable for patients in whom extensive biopsy sampling
TABLE 8.4 DIFFERENTIAL DIAGNOSES OF GASTRIC ADENOCARCINOMA WITH SINGLE

CELL EXFOLIATION

Histiocytes from Gastritis, Present with gastric ulcers; size variable, round to oval; well-defined 8.24A
Gastric Ulcers cytoplasm, central to eccentric; small, round, oval to reniform nucleus;
finely granular chromatin with one or more micronucleoli; low N/C ratio;
appreciable cytoplasm, pale or vacuolated, not indenting the nucleus
Signet-Ring Carcinoma Originate from carcinoma that diffusely infiltrates the gastric wall; cells 8.15, 8.18A and
Cells/Single Cell small to medium-sized; well-defined cell borders, often distended by large B, 8.19, 8.20
Exfoliation of Small secretory vacuoles indenting the nucleus; nucleus flush against the cell
Malignant Cells border and inconspicuous; cytoplasm may be indiscernible, with high N/C
ratio, or cytoplasm may be clear or foamy resembling histiocytes; nuclear
membrane smooth to irregular with finely granular chromatin; prominent
nucleoli; background may be inflammatory
Malignant Lymphoma 5% of gastric malignancies, vast majority B-cell lineage; discrete 8.26 to 8.28
Non-Hodgkin Type monomorphic immature lymphoid cells; may appear in mucus streak; no
cytoplasmic vacuoles, no nuclear indentation; high N/C ratio; prominent
nucleoli; background inflammatory, necrotic debris
A B
Figs. 8.26A and B. Gastric brushings showing an aggregate of poorly differentiated lymphoid cells consistent with
malignant lymphoma.
Fig. 8.27. Gastric brushings showing malignant lymphoma. The Fig. 8.28. Gastric brushings showing scattered lymphoma cells. An
lymphoma cells are discrete and often present in mucus streaks. accurate cytologic diagnosis of malignant lymphoma is challenging.
Fig. 8.29. Brushings of a cecal mass showing adenocarcinoma. The

malignant cells are extremely pleomorphic.
may compromise mucosal integrity (e.g., ulcerative colitis in aggregates, and in syncytial tissue fragments. The
or polyposis). neoplastic cells tend to be rounded with large nuclei,
Adenomas in brushings show large branching tis- high N/C ratios, finely granular chromatin, and mul-
sue fragments of columnar epithelium with elongated tiple nucleoli. Tissue fragments may exhibit an acinar
hyper-chromatic nuclei containing variable mucin. Sin- pattern or picket fence arrangement. The cytoplasm is
gle cells are few. The malignant lesions appear very cel- variable and may or may not contain mucin (Figs. 8.29
lular exhibiting malignant cells dispersed individually, to 8.32).
Fig. 8.30. Colonic brushings showing adenocarcinoma. Fig. 8.31. Brushings of a colonic mass showing adenocarcinoma de-
picting typical cytomorphology of colonic adenocarcinoma.
A B
Figs. 8.32A and B. Brushings from an adenocarcinoma of the rectum. The malignant cells are pleomorphic in size.
Their nuclei vary from small, round to elongated and are hyperchromatic. The cells contain abundant pale mucinous
cytoplasm.
Fig. 8.33. FNA of an anal mass histologically confirmed as a cloaco-

genic carcinoma. The aspirate is cellular consisting if small colum-
nar to basaloid cells with scant cytoplasm, and high N/C ratios.
in men. Cloacogenic carcinomas present as fungating or

CLOACOGENIC CARCINOMA
ulcerating lesions. The tumor may arise in anal ducts,
in which case it may be submucosal in location. His-
Cloacogenic carcinoma is a rare malignant tumor of the tologically, two categories have been described: poorly
anorectal region originating from the remnant of the clo- differentiated small cell type and large cell type. The lat-
acal membrane. It accounts for 2 to 3% of the anorectal ter may be transitional type (Fig. 8.33), squamous type,
carcinomas and occurs twice as often in women than or mixed.
terminology used to describe dysplasia of the anus. The

ANAL CYTOLOGY
changes are analogous to cervical intraepithelial neopla-
sia (CIN), and both are associated with HPV infection
The anal canal is lined by nonkeratinizing stratified (Figs. 8.34A and B).
squamous epithelium. The proximal transitional zone has
a variable mucosa, somewhat similar to urothelium.
Anal brushings are currently submitted for cytologic MALIGNANT MELANOMA OF THE ANUS
evaluations in individuals at high risk for developing in-
traepithelial neoplasia and squamous cancer. They are also
Malignant melanoma of the anorectum is uncommon;
utilized for ulcerative lesions such as adenocarcinomas or
however, the anorectum is the most common alimentary
melanomas.
tract site for malignant melanoma, representing 1% of col-
HPV-related changes, dysplasia, and carcinoma can
orectal malignancies. Anal malignant melanomas are fre-
involve the squamous mucosa of the anus. HPV types 6
quently polypoid. Grossly, they may be discolored brown-
and 11 are most often associated with condyloma and
ish-black. Amelanotic melanomas are great mimickers and
low-grade dysplasia while types 16 and 18 are associated
should be considered in the differential diagnosis of poorly
with carcinoma and high-grade dysplasia. In heterosexual
differentiated malignancies (Figs. 8.34C to E).
individuals, anal squamous cancer, although an uncom-
mon gastrointestinal malignancy, is more frequent in
women. The incidence of anal carcinoma has increased in
NEUROENDOCRINE TUMORS OF THE
recent years in homosexual males irrespective of immu-
GASTROINTESTINAL TRACT
nodefi ciency virus status. The risk factors are HIV infec-
tion and anoreceptive intercourse.
The use of anal cytology as a screening procedure has The gastrointestinal tract is a common site for neuroendo-
increased in recent years. Anal cytology is interpreted and crine tumors, particularly carcinoid tumors (Figs. 8.35 to
reported using the Bethesda Guidelines, modified for this 8.37). Those that involve the upper gastrointestinal tract
site. Anal intraepithelial neoplasia (AIN) is the current are generally not identifi ed by endoscopic brushings due
A B
Figs. 8.34A to C. Anal smears. A, B: Excessively keratinized pleo-

morphic squamous cells, many containing pyknotic nuclei. This
pattern is consistent with either a high-grade intraepithelial lesion
or well-differentiated keratinizing squamous carcinoma. C: Anal
brushings of an ulcerative lesion showing an aggregate of medium-
sized round to short spindle cells with poorly defined cell borders
and scant cytoplasm. The chromatin is coarsely granular and nucle-
C oli are prominent. (continued)
D E
Figs. 8.34D to E. (continued) D: Biopsy of the mass revealed a cellular neoplasm with a mixed round and
spindle cell pattern (H&E). E: Strong positive reaction with Melan-A, confirming the diagnosis of malignant
melanoma.
Fig. 8.35. Gastric neuroendocrine tumor. The neoplastic cells are Fig. 8.36. Intraoperative FNA of a peritoneal mass in a patient with
loosely cohesive, plasmacytoid with eccentric nuclei containing a history of neuroendocrine carcinoma (small cell carcinoma) of
coarse salt & pepper chromatin. Some cells exhibit cytoplasmic the colon. The malignant cells are small with poorly defined cell
processes. borders, scant indiscernible cytoplasm with high N/C ratios. There
is nuclear molding and necrosis in the background.
to their submucosal location, unless the overlying mucosa

is ulcerated. With the advent of endoscopic FNA biopsy, it
may be possible to diagnose these lesions more frequently.
Neuroendocrine tumors involving the small intestine or
appendix, although more frequent in occurrence, are not
accessible to endoscopy. Their metastasis to the liver can
be identified by FNA biopsy.
MESENCHYMAL TUMORS OF THE

GASTROINTESTINAL TRACT
Mesenchymal neoplasms of the gastrointestinal tract

Fig. 8.37. Peritoneal fluid from a patient with the history of goblet
are uncommon and represent a small proportion of gas-
cell neuroendocrine carcinoma of the appendix. Without a history, trointestinal tract neoplasms, with the most common
these malignant cells can be mistaken for an adenocarcinoma. being gastrointestinal stromal tumor (GIST). The other
mesenchymal neoplasms include smooth muscle tumor, The spindle cell variety resembles the conventional
neurogenic tumors, and vascular tumors. These tumors smooth muscle tumors; however, they possess a shorter,
are generally located in muscularis mucosa or submu- fusiform shape in contrast to the elongated cells of leio-
cosa and may lead to ulceration of the overlying mucosa, myoma/sarcoma. They have oval, centrally placed nuclei
causing bleeding. The submucosal lesions are not amena- and lightly staining cytoplasm. The spindle cells are not
ble to forceps biopsy at endoscopy. However, EUS-guided arranged in well-oriented fascicles but consist of short, ill-
fi ne needle biopsy has been extremely successful in the defined fascicles, sometimes in a storiform pattern. Nucle-
diagnosis of these tumors. ar palisading is occasionally seen. The stroma is typically
composed of mats of fi ne hair-like collagen interrupted
by a delicate vasculature. Their nuclei may be bland or
GASTROINTESTINAL STROMAL clearly malignant.
TUMORS (GIST) Other features include perivascular hyalinization as seen
in hemangiopericytomas, the presence of skeinoid fibers (ex-
tracellular collagen-containing eosinophilic globules), and
GISTs are defined as mesenchymal tumors displaying dif- extensive extratumoral hyaline change. Increased cellularity,
ferentiation toward the lines of interstitial cells of Cajal brisk mitotic activity, and nuclear pleomorphism indicate
and typically express CD117/c-kit. malignancy.
GISTs are a recently described entity, which was pre-
viously interpreted as smooth muscle tumors such as leio-
myoma, leiomyosarcoma, or leiomyoblastoma. CYTOPATHOLOGIC FEATURES
GISTs are most common in the stomach (60–70%),
followed by the small intestine (20–30%), and the colon- The fi ne needle aspirates of GIST are usually cellular,
rectum (5%), with the rest occurring in the esophagus, the composed of spindle and epithelioid cells, either exclu-
retroperitoneum, the omentum, and the mesentery. GISTs sively or in combinations (Table 8.5; Figs. 8.38 to 8.41).
typically occur in older individuals in their sixth decade The spindle cells may be short or elongated with delicate
of life with a slight gender preference for males. These processes, occurring isolated, or in fascicles separated by
tumors may be symptomatic or be detected as incidental variable stroma. The epithelioid cells may be discrete or
findings. They may behave in a benign malignant fashion. in syncytial tissue fragments without any architectural
The gastrointestinal stromal tumors are easily accessible patterns. They vary considerably in size from small,
to a fi ne needle biopsy procedure via endoscopic ultra- round, cuboidal, and plasmacytoid to large polygonal.
sound guidance. Their cell borders are well to poorly defined, and the
cytoplasm is scant to abundant and pale to eosinophilic.
Both spindle and epithelioid type cells may be present
GROSS AND MICROSCOPIC FEATURES together in a haphazard fashion. Their nuclei vary in size
with or without irregular nuclear membranes. The chro-
The gastrointestinal stromal tumors vary in size from
matin is fi ne to coarsely granular, and nucleoli may be
1 cm to larger than 20 cm. They can be submucosal, intra-
present. Bi-nucleation is also noted. Nuclear grooving and
muscular, or subserosal. They are well-defi ned, solid, or
intranuclear inclusions have been described. Mitoses are
cystic with areas of hemorrhage and necrosis. The overly-
present in malignant tumors. Their cytoplasm is variable,
ing mucosa may be ulcerated.
scant to abundant, and pale to granular. The stroma is
Histologically, GISTs are composed of two principle
variable, either collagenous or myxoid or both. The cell
cell types: namely, spindle and epithelioid forms. The
block preparations are extremely helpful, particularly for
tumors may be composed of one or the other type or
immunostains.
mixed.
The epithelioid pattern corresponds to older descrip-
tions in which the tumor consisted of round cells from
small uniform to large pleomorphic ones with abundant IMMUNOPROFILE
eosinophilic cytoplasm. In some cases, these large cells The cells of GIST react strongly and consistently to
demonstrate peripherally located multiple nuclei. An- CD117/c-kit.
other characteristic feature is the presence of cytoplasmic
vacuoles and possibly a signet-ring pattern; they can be
mistaken for liposarcoma or mucin-producing adenocar- DIAGNOSTIC DIFFICULTIES AND
cinoma. The vacuoles do not stain for fat, mucin, or gly- DIFFERENTIAL DIAGNOSES
cogen and are artifacts. The neoplastic epithelioid cells
are arranged in nests or small groups separated by a ma- The cytologic diagnosis of GIST is easily made provided
trix of loose fi brillar or dense collagen pools of stromal the cellular material is adequate for cytologic evaluation
mucin or both. and for immunostains that are either on already prepared
smears or on cell blocks. The differential diagnoses include

other mesenchymal tumors occurring in the gastrointes-
SMOOTH MUSCLE TUMORS
tinal tract and retroperitoneum. The list of diagnostic
entities for the differential diagnosis, as described in the Smooth muscle tumors arising in gastrointestinal tracts
literature, is very exhaustive and beyond the scope of this are infrequent. The most common among these are leio-
atlas. Commonly encountered differential diagnostic enti- myomas that frequently arise in the esophagus. Leiomyo-
ties are listed in Table 8.5. sarcomas of the gastrointestinal tract are also unusual.
TABLE 8.5 CYTOPATHOLOGIC FEATURES OF GASTROINTESTINAL STROMAL TUMORS
Cellularity Variable, may be marked
Presentation Dispersed, in aggregates, syncytial tissue fragments without architectural patterns, small nests or fascicles,
whorls; traversing capillaries through tissue fragments ⫹/⫺
Cells Short to elongated spindle cells, round, cuboidal, plasmacytoid to polygonal; variable in size; cell borders well
to poorly defined
Nucleus Round, oval to spindle-shaped, with smooth to irregular membranes; binucleation ⫹/⫺; eccentric nuclei; fine
to coarsely granular chromatin; micronucleoli; intranuclear inclusions ⫹/⫺; nuclear grooves ⫹/⫺; nuclear
pleomorphism mild in benign types to marked in malignant ones; mitoses in malignant variety
Cytoplasm Variable, scant to abundant; pale to eosinophilic; perinuclear clearing ⫹/⫺; delicate long wispy cytoplasmic processes
Background Variable stroma; collagenous to myxoid; elongated irregular skeinoid fibers
Immunoprofile Strong and consistent reactivity to CD117/c-kit
Ultrastructure Features of smooth muscle cells (parallel arrays of intracytoplasmic thin (actin) filaments, with or without dense
bodies, micropinocytic vesicles and discontinuous lamina; or features of neural cells with thin interdigitating
cytoplasmic processes connected by primitive junctions and containing microtubules and dense core granules
Differential Spindle Cell Type

Diagnoses neurogenic tumors; malignant fibrous histiocytoma; spindle cell carcinoma; solitary fibrous tumor; fibromatosis;
inflammatory pseudopolyp; sclerosing peritonitis; follicular dendritic cell sarcoma
Epithelioid Type
adenocarcinoma; neuroendocrine tumors; granular cell tumor; malignant melanoma; paraganglioma
Gastrointestinal Stromal Tumors (GIST) (See Figs. 8.38 to 8.42)
A B
Figs. 8.38A to B. FNA of a gastric stromal tumor. A: The cellular aspirate consists of fascicles of spindle cells
with scant cytoplasm and slender cytoplasmic processes. The nuclei are elongated with bland chromatin. Stripped
nuclei are present in the background. B: Different field containing loose aggregates of spindle cells with elongated,
serpentine, or wavy nuclei. (continued)
C D
Figs. 8.38C to D. (continued) C: Loose aggregates of cells with very long cytoplasmic processes. The nuclei are very
slender, long and thin. D: A fascicle of spindle cells (Romanowsky).
A B
C D
Figs. 8.39A to D. FNA of a gastric stromal tumor. A: The aspirate is poorly cellular depicting dispersed single
cells and their stripped oval to elongated nuclei. B: The group of scattered medium-sized oblong cells with round
of oval bland nuclei. These cells can be easily overlooked particularly in the setting of on site evaluation. C: A small
group of oval cells containing round to oval nuclei, with finely granular chromatin and sharp nuclear membranes.
They have very scant cytoplasm. D: The cell block from the case showed whorls of pleomorphic spindle and round
cells. (continued)
Fig. 8.39E. (continued) E: A strong positive staining with c-kit, a

E feature characteristic of GIST.
A B
C D
Figs. 8.40A to D. FNA of a retroperitoneal mass. A: Syncytial tissue fragments of oval to spindle cells. B: Pleomor-
phic small round to oval cells with myxoid stroma. C: A tissue fragment of large epithelioid cells in the same aspirate.
D: Cell block showing a mixed spindle and epithelioid pattern. H&E. The cells were immunoreactive to c-kit.
GALL BLADDER CARCINOMA OF THE GALL BLADDER

Carcinomas of the gall bladder are rare. They have a pre-
The application of cytologic evaluation to the lesions of dilection for women, occurring in their seventh decade of
the gall bladder is very limited except in cases of malig- life, and are often associated with cholelithiasis. Gall blad-
nancy as described below. der carcinomas are highly lethal with a 5-year survival
Fig. 8.41. Metastatic gastrointestinal stromal tumor. FNA of a cer-

vical mass with a history of gastric tumor. These cells are small,
epithelioid and contain scant cytoplasm.
A B
Figs. 8.42A and B. Carcinoma of the gall bladder. A: Patient with painless jaundice. Bile duct brushings via ERCP
showing a well-differentiated adenocarcinoma. B: Another example of adenocarcinoma of the gall bladder in
aspirated bile.
rate of 5%. Patients with gall bladder carcinoma may be and malignancy. Narrowing of the duct system may also
asymptomatic or present with anorexia, weight loss, and be caused by extrinsic tumors. Biliary duct lesions are
right upper quadrant abdominal pain. often not accessible to forceps or clamshell biopsy, and the
Grossly, the carcinomas form firm, infiltrative masses or direct brushings remain the mainstay in the diagnosis of
polyps that project into the lumen. The wall may be slightly these challenging diseases. Endoscopic retrograde cholan-
thickened and is grossly indistinguishable from chronic chole- giopancreatography (ERCP) is the procedure of choice.
cystitis. The majority of the tumors occur in the fundus. The cytologic methods used to evaluate biliary duct
Microscopically, adenocarcinomas present a typical epithelium are the brushings and washings of the bile
morphology of a conventional adenocarcinoma with or ducts obtained via ERCP and direct examination of bile.
without desmoplasia and a papillary pattern. Goblet cells The latter may be obtained through various procedures in-
may be present. Other morphologic variants include ad- cluding T-tube drainage, aspiration during ERCP, and as-
enosquamous carcinoma. piration during transhepatic cholangiography. Cytologic
The cytologic diagnosis can be provided by exam- samples may also be obtained from the stents. Diagnostic
ining the bile duct contents or the brushings of the bile difficulties include the differentiation of hyperplastic and
ducts (Fig. 8.42). reactive changes due to strictures from adenocarcinomas.
NORMAL CYTOLOGY OF THE BILE DUCTS

EXTRAHEPATIC BILIARY TRACT
Benign bile duct epithelium is seen as tissue fragments with
either a honeycomb pattern or strips with palisading of the
Abnormalities of the extrahepatic biliary tract may be nuclei (Fig. 8.43A). The nuclei are round; uniform with
caused by a multitude of etiologic factors such as inflam- finely granular, evenly dispersed chromatin, and micronu-
matory processes, parasitic infestations, calculus disease, cleoli (e-Figs. 8.6A to D). The N/C ratios are low, and cells
contain clear to vacuolated cytoplasm. Occasionally, the epithelial atypia that can lead to false positive results. The
tissue fragments display papillary configurations. When brushings usually demonstrate benign bile duct epithe-
seen on end, the lining cells are tall columnar (Fig. 8.43B). lial cells in an infl ammatory background. Inflammation
secondary to calculus disease, postcholecystectomy, or
reactive changes due to stent placements may produce a
INFLAMMATORY CONDITIONS
variable degree of cellular and nuclear atypias that may
OF THE BILE DUCTS
lead to a false suspicious or positive diagnosis (Fig. 8.44
Infl ammatory conditions of the bile ducts encompass to 8.47).
a variety of conditions, with the frequent ones that are
encountered in the practice of cytopathology being pri-
CARCINOMAS OF THE BILE DUCTS
mary sclerosing cholangitis (PCS). Common in males and
possessing a strong association with malignancy, PCS Carcinomas of the bile duct are very uncommon, com-
presents with multiple strictures of the biliary tree, giving prising 3% of all gastrointestinal malignancies, and 10
a characteristic beaded radiologic appearance. These stric- to 20% of all primary liver cancers. The incidence of bile
tures simulate malignancy and cannot be differentiated duct carcinomas is stated to have increased threefold
from it. The diagnostic difficulties are compounded by the within the last three to four decades. The carcinomas are
fact that brushings in this condition may present severe more common in males.
Extrahepatic Bile Ducts (See Figs. 8.43 to 8.53)
A B
Figs. 8.43A and B. Normal bile duct epithelium A: Bile duct brushings, showing strips and honeycomb sheets of
benign cuboidal cells. B: Brushings of the common bile duct showing tall columnar cells.
A B
Figs. 8.44A to B. A: Brushings of a bile duct showing mild nuclear atypia. The tissue fragment has maintained the
honeycomb architecture with minimal dyshesion at the periphery. There is mild nuclear enlargement. B: Different
tissue fragment of bile duct epithelium with minimal crowding and overlap. The nuclei are minimally enlarged. This
atypia is more in keeping with a reactive process. (continued)
Fig. 8.44C. (continued) C: Different case of bile duct brushings.

The honeycomb architecture for the most part is maintained. A few
C nuclei show altered polarity. The nuclei are uniform.
A B
Figs. 8.45A and B. Bile duct brushings for biliary stricture with stent placing. A: Syncytial architecture with papillary-
like pattern, and overlapped, crowded nuclei. B: These cells in a different field show monolayered configuration but
minor alteration in nuclear polarity. Note prominent nucleoli. The case was interpreted as suspicious, but proven to
be benign on biopsy.
A B
Figs. 8.46A and B. Brushings performed for a stricture of the bile duct in a patient, post cholecystectomy. There is
remarkable cellular and nuclear atypia with crowding and overlapping of variably enlarged nuclei. The case was
interpreted as suspicious but proven to be benign and inflammatory on biopsy.
A B
Figs. 8.47A to C. Brushings of the ampullary region, for bile duct

obstruction. The bile duct epithelium showing a syncytial arrange-
ment with mild nuclear atypia interpreted as suspicious. There was
an impacted stone in the common bile duct. The epithelial changes
C were reactive.
Fig. 8.48. Bile duct brushings showing malignant cells, confirmed

as adenocarcinoma of the ampulla of Vater.
Bile duct carcinomas can be intrahepatic or extrahe- may show varying degrees of differentiation. Well-differ-
patic. The term cholangiocarcinoma specifi cally refers to entiated adenocarcinoma with its bland nuclear pattern
intrahepatic adenocarcinomas. Those arising outside the is diffi cult to differentiate from reactive or hyperplastic
liver are referred to as “extrahepatic bile duct carcino- change. The latter is frequently seen in strictures due to
mas.” Carcinomas occurring at the confluence of the right chronic infl ammatory conditions or obstruction caused
and left hepatic ducts are called “hilar cholangiocarci- by lithiasis (Figs. 8.48 to 8.53). Cytologic features of ad-
nomas,” which are also known as Klatskin tumor. These enocarcinoma of the bile duct carcinoma are the same as
produce obstructive jaundice very early in the disease. those described for adenocarcinomas in general. Criteria
Carcinomas of the extrahepatic biliary tree frequently that are specifi c for bile duct brushings described in the
present with obstructive symptoms. Adenocarcinomas literature include nuclear molding, clumped chromatin,
Fig. 8.49. Brushings of ampulla of Vater. Malignant cells originat- Fig. 8.50. Bile duct brushings. Malignant cells originating from the
ing from the adenocarcinoma of the extrahepatic bile duct involving adenocarcinoma of the head of the pancreas involving the common
ampulla of Vater. bile duct.
Fig. 8.51. Bile duct brushings showing poorly differentiated malig- Fig. 8.52. Bile duct brushings showing malignant cells from adeno-
nant cells surgically confirmed as carcinoma of the bile duct. carcinoma of the bile duct.
A B
Figs. 8.53A and B. Brushings of the bile duct stricture caused by a hilar mass. A: medium power showing a papillary
malignant neoplasm. B: Higher magnification of the malignant cells. The surgical exploration revealed a papillary
carcinoma of the extrahepatic bile duct.
Malignancies in Bile Duct Brushings Other than Bile Duct Adenocarcinomas (See Figs. 8.54 to 8.56)
Fig. 8.54. Bile duct brushings. Hepatocellular carcinoma in ERCP Fig. 8.55. Bile duct brushings neuroendocrine carcinoma, in bile
specimen misinterpreted as pancreatic adenocarcinoma. A syncytial duct brushings depicting typical cytomorphology of a neuroendo-
tissue fragment of medium-sized malignant cells with no architec- crine tumor.
tural pattern. Their cell borders are poorly defined with scant cyto-
plasm and high N/C ratios. The nuclear chromatin is finely granular
and nucleoli are very prominent. No bile is seen. The malignant cells
were interpreted as adenocarcinoma. The core biopsy performed at
the same time showed features of hepatocellular carcinoma.
result of inadequate sampling, inflammatory and necrotic

debris, and excess bile obscuring the cellular material as
well as the comfort level and experience of the pathologist/
cytopathologist (Figs. 8.54 to 8.59).
Inadequate sampling has been a major factor in false
negative diagnoses. Fear of overtreatment by the clini-
cian and sequelae of unnecessary surgery will always
hold back the pathologist in making a definite malignant
diagnosis in the presence of scant samples or in the ab-
sence of obvious malignant criteria. Few malignant cells
in the background of benign cells may be overlooked.
The malignant cells may not present sufficient cytologic
criteria and be interpreted as atypical or even benign
(Figs. 8.60 to 8.62).
Fig. 8.56. Bile duct brushings. Malignant lymphoma. Discrete small Another major problem refers to the inconsistencies
cells consistent with malignant lymphoma.
in the reporting system of the bile duct brushings and the
lack of standardization—an issue that needs to be ad-
dressed among pathologists. The author’s laboratory de-
high N/C ratios. The secondary criteria included syncy-
veloped internal guidelines as listed in Table 8.6. Since
tial arrangement, anisonucleosis, irregular nuclear mem-
the development of these guidelines, interpretative errors
branes, macronucleoli, and chromatin clearing. Lesions
have declined.
other than adenocarcinomas of the biliary tree are also
Inflammatory processes of the bile ducts, stent place-
encountered; these include pancreatic carcinoma invading
ment, and primary sclerosing cholangitis all cause repair/
the bile ducts, neuroendocrine tumors, hepatocellular car-
regenerative changes that mimic malignancy. These con-
cinoma, and malignant lymphoma (Fig. 8.54 to 8.56).
stitute potential for the false suspicious and false positive
diagnoses (Figs. 8.63A to C). The differentiation between
Diagnostic Difficulties and Differential Diagnoses
the reactive processes and malignancy can be extremely
The overall sensitivity of the bile duct brushings and the difficult. The diffi culties are compounded in cases of pri-
examination of the aspirated bile are reported to be low, in mary sclerosing cholangitis since it is predisposed to the
the range of 30 to 50%. However, the specificity has been development of malignancy and may have a higher inci-
reported to be very high. The low sensitivity is often the dence of dysplasia and carcinoma.
Diagnostic Difficulties in Bile Duct Brushings (See Figs. 8.57 to 8.63)
A B
C D
Figs. 8.57A to D. The presence of a very few discrete malignant cells in the background of normal epithelium may
easily be overlooked resulting in a benign diagnosis. A: Bile duct brushings. The smear is cellular containing a large
number of benign epithelial cells. With scattered discrete malignant cells that are easy to overlook (low power).
B: Higher magnification to show single malignant cells, pleomorphic in size. Single macronucleolus is very prominent.
C: Single cell exfoliation with nuclei stripped off the cytoplasm. D: Few scattered malignant cells in a background of
blood and debris precluding a definite diagnosis of malignancy. The patient was confirmed to have a carcinoma of the
gall bladder.
A B
Figs. 8.58A to B. Bile duct brushings interpreted as suspicious. A: Malignant epithelial cells with syncytial architecture
and papillary-like pattern. The nuclei are minimally enlarged and pleomorphic. Malignant criteria are not clearly
apparent. B: Two epithelial tissue fragments: one is clearly benign, and the other one displays nuclear atypia similar to
that seen in Figure 8.58A. The cytologic impression of suspicious for malignancy was confirmed on surgery. (continued)
C D
Figs. 8.58C to D. (continued) C: Syncytial tissue fragments of duct epithelium with eccentric, mildly enlarged nuclei.
D: Different field from the same smear, showing syncytial tissue fragments of duct epithelium with crowding and over-
lapping of minimally enlarged nuclei. Obvious malignant features are not appreciated.
A B
Figs. 8.59A and B. Example of a false negative diagnosis in bile duct brushings. Poorly differentiated carcinoma cells
with high N/C ratios and nuclear molding. Note the prominent nucleoli. The cytologic interpretation was limited by
poor cellularity of the specimen.
A B
Figs. 8.60A and B. Brushings of the ampulla. The cellularity was low and showed rare tissue fragments of minimally
atypical, mildly pleomorphic nuclei and low N/C ratios. The chromatin is bland but nucleoli are prominent. The case
was interpreted as suspicious and confirmed as well-differentiated adenocarcinoma of the ampulla. The cytologic
interpretation limited by low cellularity and minimal changes.
A B
Figs. 8.61A and B. An example of a false negative diagnosis in bile duct brushings. The sample was poorly cellular
consisting of tissue fragments of mostly benign columnar epithelium and loosely cohesive atypical epithelial cells that
were interpreted as benign. Surgical exploration confirmed the malignancy.
A B
Figs. 8.62A to C. Another example of a false negative diagnosis.

Bile duct brushings showing atypical epithelial cells interpreted as
C benign.
TABLE 8.6 DIAGNOSTIC CATEGORIES FOR BILE DUCT BRUSHING
Diagnostic Categories Cytologic Features Possible Reasons See Fig(s).

Unsatisfactory Acellular, bloody, air-drying with poor Inflammatory processes; inherent
Inadequate Specimen cellular preservation; excessive necrosis, factors such as stricture or
blood or bile obscuring details or very few desmoplasia; endoscopist related
benign duct epithelial cells
Negative Benign bile duct epithelium, in honeycomb 8.43A and B

sheets or in strips; cells round to cuboidal e-Figs. 8.6A
or columnar; well-defined cell borders in and B
tissue fragments; uniform, round nuclei
with smooth nuclear membranes, finely
granular, evenly distributed chromatin;
micronucleoli ⫹/⫺
Atypical Mildly disordered architecture, nuclear Inflammatory conditions, calculus 8.44 to 8.46
atypia among scattered cells, loss of disease; stents; chronic obstruction
polarity, slight crowding, minimal due to external compression,
overlap, smooth nuclear membranes, Primary sclerosing cholangitis;
nucleoli-small single to multiple; dysplasia
normal to mildly increased N/C ratios;
mitoses ⫹/⫺ regular type; inflammation,
degeneration; necrosis ⫹/⫺
Suspicious Syncytial architecture, crowding and 8.58

overlapping; minimal pleomorphism or, 8.60
clearly malignant but very few cells
Positive Well-preserved, well-stained smears with 8.49

clearly malignant cells; syncytial tissue 8.51
fragments, in groups or isolated; high
N/C ratios; smooth to irregular nuclear
membranes, prominent nucleoli
Note: A negative diagnosis does not rule out malignancy; it can represent a sampling error or malignancy resulting from an extrinsic mass.
An unequivocal positive diagnosis in the absence of a mass lesion may result from in situ cancer.
A B
Figs. 8.63A to B. The bile duct brushings were extremely cellular consisting of A: Large papillary tissue fragments
epithelium with architectural disarray and nuclear overlapping. B: Loosely cohesive very pleomorphic epithelial cells
with enlarged nuclei containing bland chromatin interpreted as malignant. Biopsies were negative. (continued)
Fig. 8.63C. (continued) C: Several tissue fragments in the back-

ground displayed only minimal atypia. Malignancy was not con-
C firmed on biopsy.
SUGGESTED READINGS
Bardales RH, Stanley MW, Simpson DD, et al. Diagnostic value of Lack EE. Pathology of the Pancreas, Gall Bladder, Extrahepatic
brush cytology in the diagnosis of duodenal, biliary and ampul- Biliary Tract and Ampullary Region. New York: Oxford
lary neoplasms. Am J Clin Pathol 1998;109:40–48. Press, 2003.
Cohen MB, Wittchow BJ, Jolin FC, et al. Brush cytology of the Layfield LJ, Wax TD, Lee JG, et al. Accuracy and morphologic
extrahepatic biliary tract; comparison of cytologic features of aspects of pancreatic and biliary duct brushings. Acta Cytol
adenocarcinoma and benign biliary structures. Mod Pathol 1995;39:11–18.
1995;8:498–502. Parasher VK, Huibregste K. Endoscopic retrograde wire-guided
de Peralta MN, Wong DK, Purslow MJ, Kini SR. Biliary tract cytology of malignant biliary strictures using a novel scraping
cytology in specimens obtained by direct cholangiographic brush. Gastrointest Endosc 1998;48:288–290.
procedures. Diagn Cytopathol 1996;14(4):334–348. Renshaw AA, Madge RB, Rroutek M, et al. Bile duct brushing
Dong Q, McKee G, Pitman M, et al. Epithelioid variant of gastro- cytology: Statistical analysis of proposed diagnostic criteria.
intestinal stromal tumors: Diagnosis by fine needle aspiration. Am J Clin Pathol 1998;110:635–640.
Diagn Cytopathol 2003;29:55–60. Sink JD, Kramer SA, Copeland DL, et al. Cloacogenic carcinoma.
Ferrari AP Jr, Lichtenstein DL, Slivka A, Chang C, Carr-Locke Am Surg 1978;88:53–59.
DL. Brush cytology during ERCP for the diagnosis of biliary Volmar KE, Vollmer RT, Routort MJ, et al. Pancreatic and the
and pancreatic malignancies. Gastrointest Endosc 1994;40: bile duct brushing cytology in 1,000 cases. Review of findings
140–145. and comparison of preparation methods. Cancer (Cancer
Kirsch R, Gao Z, Riddell R. Gastrointestinal stromal tumors. Cytopathol) 2006;108:231–238.
Diagnostic challenges and practical approach to differential Weiss SW, Goldblum JR. Ensinger and Weiss’s Soft Tissue Tumors.
diagnosis. Adv Anat Pathol 2007;14:261–285. 4th ed. Philadelphia: Mosby, 2008.
Kocjan G, Smith AN. Bile duct brushing cytology; potential pitfalls
in diagnosis. Diagn Cytopathol 1997;16:358–363.
9 URINARY SYSTEM
Mariza
i d de Peralta-Venturina
l i • SSudha
d h R. Kini
i i
The cytologic evaluation of urine and related specimens Limitations of urine cytology arise in the following
(see Table 9.2) is second only to cystoscopy in the ini- areas:
tial diagnosis and monitoring of tumor recurrence in
● Localization of neoplasms (upper collecting system
patients with a bladder tumor. The diagnostic yield and
versus urinary bladder primary)
accuracy for urothelial neoplasms depend on several fac-
● Detection of nonaggressive neoplasms (i.e., low-grade
tors related to the tumor characteristics such as grade,
early stage tumor)
stage, and tumor load (a small lesion may not exfoli-
● Detection of some nonepithelial neoplasms such as sar-
ate enough atypical cells); sampling error (an invasive
comas or lymphomas involving the bladder wall
tumor without surface involvement); type of specimen
● Detection of urothelial neoplasms with little or no sur-
(voided urine versus instrumented specimens); and pres-
face components, although they may be deeply invasive
ence of confounding factors such as extensive cellular
● One of the problems in urine cytology that remains
degeneration and obscuring acute inflammation. Utility
unaddressed is the quality of cytopreparation. A well-
of urine cytology:
prepared cytologic preparation can provide better
● Evaluation of patients with microscopic hematuria or diagnostic results. Appendix I describes the cytoprepa-
irritative symptoms ratory technique at the author’s (SRK) laboratory.
● Screening of high-risk populations exposed to known
bladder carcinogens
● Monitoring of patients with a history of bladder can- NORMAL HISTOLOGY AND CYTOLOGY
cer for the detection of tumor recurrence
● Used in conjunction with cystoscopy in bladder cancer
patient surveillance. Urothelium or transitional epithelium lining the urinary
bladder, ureters, and renal pelvis is multilayered up to
Urine cytology is inexpensive, noninvasive, and highly seven layers thick and is composed of a superficial layer
specific. However, the overall sensitivity of urine cytology of large polygonal cells (umbrella cells) and several lay-
in detecting bladder cancer is only 40 to 60% with some ers of smaller basal cells, which are either cuboidal or
series reporting even ⬍20%. It is even less sensitive in columnar (e-Fig. 9.1). The umbrella cells, which are
the detection of low-grade bladder cancers as these share comparable to superficial squamous cells are particu-
some morphologic similarities with normal urothelial larly numerous in washings of the bladder, renal pelvis,
cells, which is further complicated in instrumented urine and ureter; may be mistaken as giant cells; and may
samples. However, urine cytology is more than 95% sen- be aneuploid (tetraploid) (see discussion on ancillary
sitive in detecting high-grade urothelial carcinoma (UC) studies). The smaller basal cells resemble the parabasal
and urothelial carcinoma in situ (CIS). One cannot reli- squamous cells in both size and configuration. Their
ably determine whether a lesion is in situ or invasive cy- cytologic features are listed in Table 9.1 and illustrated
tologically. The diagnosis of urothelial dysplasia in urine in e-Figures 9.2A to E.
specimens is not reliable as there are cytologic overlap-
ping features suggestive of a reactive as well as neoplastic
process.
TYPES OF SPECIMENS AND THEIR
Since it samples a wide area of urothelium, urine cytol-
COMPOSITION
ogy allows the detection of small foci of tumor, although
this may be limited by the number of atypical cells. The
lesion may be too small to be seen on cystoscopy and, Different types of specimens are obtained from different
thus, may not be confi rmed on biopsy. Abundant reac- sites from the urinary tract in a variety of manners, each
tive urothelial cells may obscure the few neoplastic cells, with a characteristic cellular composition. These differ-
which in turn may show varying grades of atypia. ences are summarized in Table 9.2. A brief account of
325
TABLE 9.1 CYTOPATHOLOGIC FEATURES OF UROTHELIAL CELLS
Basal-Intermediate Cells Superficial-Umbrella Cells

Presentation Single cells in presence of inflammation or Present as discrete cells
erosion; tissue fragments in instrumented
urine samples; may be tightly packed/
crowded and may appear papillary
Size Small to medium-sized; 7–10 ␮m in Very large to giant forms, 20–50 ␮m

diameter in diameter
Shape Round to cuboidal or columnar with Polygonal with well-defined

well-defined cell borders cell borders; sharp angulations,
scalloping impressions made by
underlying cells
Nucleus Central in round, cuboidal cells; at the Very low N/C ratio; central location;
broad end of columnar cells; round, binucleation and multinucleation
smooth nuclear membrane, finely very common; round, smooth
granular, evenly dispersed chromatin with nuclear membrane, evenly dispersed,
a tendency for peripheral condensation; finely granular chromatin;
micronucleoli inconspicuous micronucleoli
Cytoplasm Variable, pale, sometimes vacuolated Abundant eosinophilic, sometimes

vacuolated
TABLE 9.2 CELLULAR COMPOSITION OF cytopreparatory techniques for specimens from the uri-
VARIOUS TYPES OF URINARY SPECIMENS nary tract is described in Appendix.
Voided Urine Sparse cellularity; rare urothelial VOIDED URINE

cells; squamous cells from trigone
or vaginal contamination in A fresh clean-catch specimen is ideal for cytologic evalua-
females; noncellular constituents: tion. Urine provides a milieu where epithelial cells degen-
casts; crystals; corpora amylacea erate rapidly, particularly if left at room temperature. The
and sperm in males 24-hour specimen or fi rst morning voided samples are
unsatisfactory due to the degeneration of cells. Normal
Catheterized Urine Cellularity moderate; urothelial urine contains very few urothelial cells and noncellular
cells superficial and basal material such as casts, crystals, and corpora amylacea
intermediate type; isolated and in
in males. Single or multiple eosinophilic inclusions may
tissue fragments
be present in degenerating urothelial cells and are of no
signifi cance. Squamous cells may be seen in urine, par-
Bladder Wash Highly cellular; urothelial
cells of various sizes and ticularly in females, originating from the trigone of the
shapes; superficial and basal/ bladder or as a contaminant from the vulva, the vagina,
intermediate type; varying-sized or the uterine cervix. Although less commonly seen in
tissue fragments; well-preserved men, squamous cells may originate from the terminal
cytomorphology portion of the urethra. Renal tubular cells may be seen
in urine samples, particularly in patients with medical
Ureteral and Renal Pelvic Highly cellular; dispersed cells renal diseases, and are often found associated with renal
Brushings and large tissue fragments; casts. These are often degenerated and may resemble mac-
increased numbers of large rophages, although their epithelial nature is evident. Occa-
multinucleated umbrella cells sionally, cells of prostatic and seminal vesicle origin may
also be seen in men and endometrial cells and squamous
Ileal Conduit Moderate cellularity; columnar
cells with human papilloma viral cytopathic change pre-
to round mucin producing
sumably of cervical origin can be seen in women. Mucus-
cells; nuclei dark, eccentric,
degenerating type secreting columnar cells derived from cystitis cystica and
cystitis glandularis may also be seen.
Chapter 9: Urinary System 327
CATHETERIZED URINE 70 years of age, and is three times more common in men
than women. Risk factors include genetic and molecular
This type of specimen is generally more cellular than the
factors, chemical and environmental exposures (aromatic
voided urine, due to traumatic exfoliation of urothelial
amines, aniline dyes, nitrites and nitrates, and most impor-
cells. The composition is similar to bladder wash.
tantly, cigarette smoking), and chronic irritation (indwell-
ing catheters, Schistosoma hematobium infestation, and
BLADDER WASH pelvic irradiation). The most common presenting symptom
of bladder cancer is gross or microscopic hematuria—the
Bladder washings are highly cellular, composed of urothe-
latter may be intermittent. Other symptoms include unex-
lial cells of both the superficial umbrella type and deeper
plained urinary frequency, urgency, or irritative symptoms.
cells varying in size and shape, either isolated or in tissue
More than 90% of cases are urothelial (transitional
fragments. The cells are well-preserved.
cell) carcinoma. Less common are squamous, adenocar-
cinoma, small cell carcinoma, and other tumors. Up to
URETERAL AND RENAL PELVIC 20% of high-grade urothelial cell carcinomas contain foci
BRUSHINGS AND WASHINGS of squamous differentiation and up to 7% show glandu-
lar differentiation.
These specimens are generally highly cellular, composed
The classification of papillary urothelial (transitional
of isolated pleomorphic urothelial cells and small to large
cell) neoplasms has been a long-standing source of contro-
tissue fragments. The umbrella cells, which are present
versy. In the 1973 WHO classification of urothelial tumors,
in large numbers, are strikingly large (up to 50 ␮m) and
papillary urothelial neoplasms were separated into 4 catego-
multinucleated with up to 50 nuclei. The cytomorphology
ries: papilloma and carcinoma grades 1 to 3 based on the
is well-preserved. Finely granular chromatin with micronu-
degree of nuclear anaplasia. In 1998, the International So-
cleoli and papillary configuration of tissue fragments may
ciety of Urologic Pathologists (ISUP) proposed a classifica-
result in a false positive diagnosis of urothelial carcinoma.
tion (Fig. 9.1), which has 4 categories: papilloma, papillary
urothelial neoplasm of low malignant potential (PUN-LMP)
ILEAL BLADDER (CONDUIT) SPECIMEN (e-Fig. 9.5), low-grade carcinoma (e-Fig. 9.6), and high-grade
carcinoma (e-Figs. 9.7 and 9.8). This is now known as ISUP/
Cytologic evaluation of ileal bladder urine is performed to
WHO 2004 classification of bladder neoplasms. This pro-
monitor the patient following cystectomy for muscle inva-
posed classification includes a detailed histologic description
sive, often high-grade, bladder cancers. The specimen usu-
of the various grades employing specific cytology and histo-
ally contains a large population of poorly preserved intesti-
logic criteria. The terminology used in this classification is
nal epithelial cells (e-Fig. 9.3). They may appear columnar
more or less consistent with what is used in urine cytology.
or round with mucus-producing transparent cytoplasm and
small, round, eccentric, often degenerating nuclei. Eosino-
philic intracytoplasmic inclusions are commonly seen.
CONTAMINANTS IN URINE
The commonly encountered contaminants in the urinary
tract specimens include cells from the cervix and vagina in
females including endometrial cells (e-Fig. 9.4) and cells
of squamous intraepithelial neoplasia. In males, the con-
taminants include cells of seminal vesicles and corpora
amylacea. Urine may also contain various types of casts
and lubricant.
NEOPLASMS OF THE URINARY BLADDER
Urinary bladder cancer is the second most common gen-

itourinary malignant disease in the USA; it is the fourth
most common malignancy in men and the seventh most
Fig. 9.1. Relationship of WHO 1973 to WHO/ISUP 2004 classifi-
common cancer worldwide. In 2008, there were 69,000 cation of papillary urothelial tumors. (Epstein JI, Amin M, Reuter,
newly diagnosed cases and 14,000 deaths. The incidence V. Bladder Biopsy Interpretation. Lippincott Williams & Wilkins,
of bladder cancer rises with age, peaking between 50 to 2004;40. Reproduced with permission.)
It should be emphasized that there is no one to one trans- TABLE 9.4 PAPILLARY UROTHELIAL NEOPLASM
lation between the 1973 WHO classification and the WHO/ OF LOW MALIGNANT POTENTIAL (PUN-LMP)
ISUP 2004 classification except for papilloma (same criteria (WHO/ISUP 2004) (EQUIVALENT TO MOST GRADE
for both classifications) and the 1973 WHO Grade 3 tu- 1 TCC WHO 1973)
mors, which, by definition, are high-grade carcinomas ac-
Clinical Mean age 65 years; M:F 5:1; most cases
cording to WHO/ISUP 2004. A new category, PUN-LMP,
are solitary and 1–2 cm; tumor recurrence
in the 2004 ISUP/WHO corresponds to some but not all of in up to 35% and disease progression in
the tumors classified as Grade 1 with the 1973 WHO clas- 4–8%
sification (see e-Fig. 9.5) This category is created to avoid
labeling a patient as having cancer; although not benign, Gross Often exophytic, may have inverted
since these can recur, they have a very low-risk of progres- features
sion. Both classifications will be used in this chapter.
The majority of patients (70%) present with superfi- Histology Thicker urothelium compared to
cial low-grade papillary tumors while the remaining 30% papilloma; no architectural abnormalities
of cases present as muscle-invasive disease. The superficial (no loss of polarity); rare mitoses limited
tumors tend to recur (50–70%) but 10 to 20% of cases will to the basal layer
progress to muscularis propria invasive disease. Although
the tumor stage is the most important prognostic factor, Cytopathology May be difficult to differentiate from
normal urothelial cells due to absence
it is closely correlated with histologic grade. In terms of
of nuclear atypia; may see prominent
progression, PUN-LMPs and low-grade carcinomas have
umbrella cells
similar risks (about 8–11%) compared with significantly
higher risk with high-grade carcinomas (51%). Low and Molecular Diploid with low proliferation; FGFR3
high-grade carcinomas had similar risks of recurrence mutation in 85%
(56% and 64%) in contrast with a lower risk of recur-
rence with PUN-LMP (33%). Aside from tumor stage and
grade, other pathologic prognostic factors include multi-
focality, tumor size, and the presence of associated CIS.
TABLE 9.5 LOW-GRADE PAPILLARY UROTHELIAL
UROTHELIAL NEOPLASMS CARCINOMA (WHO/ISUP 2004) (EQUIVALENT TO
SOME GRADE 1 TCC AND SOME OF GRADE 2 TCC
General characteristics of urothelial neoplasms are listed WHO 1973)
in Tables 9.3 to 9.6. Their cytologic features illustrated in
Figures 9.2 to 9.13. Clinical Mean age 70 years; M:F 2.9:1; most
cases are solitary but multiple in 22%;
tumor recurrence in up to 50% and
disease progression in 10–13%
TABLE 9.3 CHARACTERISTICS OF UROTHELIAL
PAPILLOMA (WHO 1973 AND WHO/ISUP 2004) Gross Often exophytic, may have inverted
Clinical ⬍1% of all bladder tumors, occur typically features
in younger patients (⬍50 years old); may be
associated with prior or concurrent history of Histology Orderly appearance with minimal
other urothelial tumors; once resected usually variation in architecture and/or
does not recur or progress cytological features; Slender papillae
with frequent branching, minimal
Gross Usually solitary and relatively small (⬍1.0 cm), fusion and variations in nuclear
often exophytic, may be inverted polarity, size, shape and chromatin
pattern; infrequent mitoses
Histology Delicate fibrovascular cores covered by normal-
looking urothelium with intact umbrella cells Cytopathology Variable cellularity; cohesive
groups with or without papillary
Cytology Scant cellularity, cannot be reliably identified configuration; minimal nuclear atypia;
on urine cytology as cells resemble normal may see small nucleoli; more granular
urothelial cells; umbrella cells present which may chromatin than normal but evenly
show atypia; may see papillary tissue fragments dispersed; difficult to differentiate from
instrumentation artifact
Molecular Normal (diploid) with low proliferation; FGFR3
mutation in 75% Molecular Maybe diploid or aneuploid
A B
C D
E F
Figs. 9.2A to F. A: Urothelial cells in voided urine with high N/C ratios and notches in the nuclear membrane. B: A
tissue fragment of mildly pleomorphic transitional cells with granular chromatin and high N/C ratios. These cells may
represent either PUN-LMP or a low-grade papillary urothelial carcinoma. C, D, E, F: Bladder washings. The abnor-
mal urothelial cells are small, discrete and in tissue fragments with high N/C ratios but with bland chromatin pattern
and micronucleoli. Note the nuclear notch in 9.2B (arrow). These cells may represent either PUN-LMP or a low-grade
papillary urothelial carcinoma.
Fig. 9.3. Voided urine. Low-grade carcinoma cells with scant to

dense cytoplasm.
Low-Grade Papillary Urothelial Carcinoma (Grade 2 TCC of 1973 WHO Classification) (See Figs. 9.4 to 9.8)
Fig. 9.4. Voided urine with numerous, discrete, pleomorphic tran- Fig. 9.5. Bladder washings containing a large number of urothe-
sitional cells, variable, pale cytoplasm, and deep-staining but finely lial cells, present as discrete, and in loosely cohesive groups. Note
granular chromatin and prominent nucleoli. The morphology of considerable pleomorphism, high N/C ratios and prominent nu-
these cells is consistent with low-grade urothelial carcinoma and cleoli. The morphology of these cells is consistent with low-grade
corresponds with grade 2 TCC of 1973 classification. urothelial carcinoma and corresponds with grade 2 TCC of 1973
classification.
Fig. 9.6. Bladder washings containing large papillary tissue frag- Fig. 9.7. Bladder washings: A large population of dispersed urothe-
ments. Atypical urothelial cells cover the central cores. lial cells with high N/C ratios and prominent nucleoli. The cytomor-
phology is consistent with low-grade urothelial carcinoma. (They
correspond to Grade 2 TCC of 1973 WHO classification.)
Fig. 9.8. Bladder washings containing very pleomorphic urothelial

cells with spindle cell nuclei, consistent with low-grade urothelial
carcinoma. (They correspond to Grade 2 TCC of 1973 classifica-
tion.)
High-Grade Papillary Urothelial Carcinoma (Include Some Grade 2 TCC of 1973 WHO Classification) (See Figs. 9.9 to 9.14)
Fig. 9.9. Bladder washings. The malignant cells are more pleomor- Fig. 9.10. Bladder washings, high-grade urothelial carcinoma. The
phic with high N/C ratios coarsely granular, deep-staining chro- malignant cells are readily recognized, more pleomorphic with
matin and multiple nucleoli, scant cytoplasm and are easily readily coarsely granular, deep-staining chromatin and multiple nucleoli.
recognized as malignant.
A B
Figs. 9.11A to B. Bladder washings. A: Marked exfoliation of malignant urothelial cells with squamous differentiation.
B: Higher magnification showing obvious malignant features. (continued)
C
Fig. 9.11C. (continued) C: Small malignant cells in a syncytial tis- Fig. 9.12. Bladder washings. Malignant urothelial (transitional)
sue fragment. cells with irregular nuclei.
A B
Figs. 9.13A and B. Bladder washings. Pleomorphic malignant cells in tissue fragments, consistent with high-grade
urothelial carcinoma (Grade 3 TCC of 1973 WHO Classification).
TABLE 9.6 HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA (WHO/ISUP 2004)

(EQUIVALENT TO SOME GRADE 2 TCC AND ALL OF GRADE 3 TCC WHO 1973)
Clinical Progression in stage and death due to disease in up to 65% of patients
Gross Papillary to nodular/solid single or multiple tumors
Histology Disorderly appearance due to marked architectural and cytological abnormalities, recognizable at low magnification;
Papillae are frequently fused; easily recognizable architectural and cytologic atypia; mitoses frequent
Cytology Variable cellularity; single cells and syncytial tissue fragments; marked pleomorphism; hyperchromatic nuclei,
prominent nucleoli; may see atypical mitoses; may see squamous or glandular differentiation
Molecular Most cases are aneuploid

mately four to five times that of a mature lymphocyte and

INTRAEPITHELIAL NONINVASIVE are intensely hyperchromatic with smudged chromatin.
LESIONS OF THE BLADDER These often show moderate to abundant eosinophilic cy-
toplasm. Marked cellular degeneration is often noted, and
UROTHELIAL CARCINOMA IN SITU bare intensely hyperchromatic nuclei with loss of chro-
matin details are common. Some types of large cell CIS
Urothelial carcinoma in situ (CIS) is a nonpapillary (i.e., may not show marked pleomorphism and instead show
flat lesion) in which the epithelium contains cells that dem- uniform cells, but the high-grade cytologic atypia diag-
onstrate severe cytologic atypia (nuclear anaplasia) (e-Fig. nostic of CIS is evident. The small cell variant of CIS is
9.9). Full thickness change is not essential, although it is characterized by small hyperchromatic nuclei with scant
usually present. It can occur less frequently as primary (de cytoplasm. The cells in the clinging and pagetoid/under-
novo) CIS, which comprises 1 to 3% of urothelial neo- mining CIS types do not have specific cytologic features
plasms or more frequently (secondary CIS) in association but show the same nuclear atypia although the tumor cells
with invasive bladder tumors. Primary CIS is less likely to may be admixed with more numerous benign urothelial
progress to invasive disease than secondary CIS (7–15% cells. CIS cells do not differ from those of invasive high-
vs. 45–65%). grade urothelial carcinoma and cannot be differentiated
Clinically, patients with CIS complain of dysuria, su- as such (Fig. 9.14). Umbrella cells may be present in the
prapubic pain, nocturia, and frequency of urination. Most background.
have gross or microscopic hematuria. However, similar
signs and symptoms occur in a variety of processes, in-
cluding infections and interstitial cystitis. CIS is difficult UROTHELIAL DYSPLASIA
to localize endoscopically but may be seen as patches of
erythema or roughening. Dysplasia is defin ed as an intraepithelial lesion (e-Fig. 9.10)
Histologically, several patterns have been described, with appreciable cytologic and architectural changes felt
including Pagetoid pattern (individual neoplastic cells to be preneoplastic but which fall short of CIS. Its pres-
scattered amidst normal urothelium), so-called “denud- ence may indicate urothelial instability and is a marker
ing cystitis” type pattern (resulting in positive urine for recurrence of progression. Dysplasia is seen most
cytology but biopsy may be negative due to complete commonly in 22 to 86% of patients with bladder neo-
surface denudation), clinging pattern (few single cells at- plasia. Little is known about de novo dysplasia, but the
tached to the surface), small cell CIS, and large cell CIS. few published studies indicate that 5 to 19% of patients
It may be a focal process or diffuse and multicentric; it may progress to have urothelial neoplasia (Figs. 9.15
may involve von Brunn’s nests and the foci of cystitis to 9.18).
cystica. Histologically, there is a loss of polarity and mild
Despite the various patterns of CIS, the common fea- to moderate nuclear atypia with cellular abnormalities
ture is the marked nuclear atypia. The most easily recog- that are restricted to the basal and intermediate cell
nized pattern is that of large cell CIS with pleomorphism. layers.
In this pattern, there is a marked variation in nuclear There is irregular nuclear crowding, slight hyperchro-
shape and size. The nuclei are often large at approxi- masia, and irregularity of nuclear contours with notching
A B
Figs. 9.14A and B. The urothelial cells are discrete with markedly hyperchromatic large nuclei showing high N/C
ratios. Follow-up revealed carcinoma in situ. Malignant cells exfoliating from urothelium with carcinoma in situ tend
to be discrete.
Urothelial Dysplasia (See Figs. 9.15 to 9.25)
Urothelial dysplasia is a histologic diagnosis. Cytologically, the abnormal cells originating from dysplastic urothelium cannot be
differentiated from papillomas, papillary urothelial neoplasm of low malignant potential (PUN-LMP), and some low-grade urothe-
lial carcinomas. The abnormal cells in Figures 9.15 to 9.18 were variably interpreted as abnormal or suspicious for carcinoma.
Their follow-up revealed dysplasia of the urothelium.
A B
Figs. 9.15A and B. The urothelial cells are atypical, fewer in number and resemble grade 1 urothelial cell carcinoma.
A B
Figs. 9.16A to C. The urothelial cells are atypical, fewer in number

C and resemble grade 1 urothelial cell carcinoma.
A B
Figs. 9.17A to C. The urothelial cells are

atypical, fewer in number and resemble
C grade 1 urothelial cell carcinoma.
A B
Figs. 9.18A and B. The urothelial cells are atypical, fewer in number and resemble grade 1 urothelial cell carcinoma.
of cell borders. Their chromatin is more granular than as well as CIS (Table 9.7). Distinction between these
normal but is evenly distributed. Micronucleoli may be various diagnostic entities is not possible from cytol-
identified in well-preserved specimens. Umbrella cells are ogy. Urothelial dysplasia is a histologic diagnosis. The
usually present. cells vary in size, have high N/C ratios, coarsely granular
The dysplastic urothelial cells may exfoliate in urine chromatin, and often display nuclear membrane irregu-
or can be obtained via instrumentation. Their exfolia- larity such as notches. The features are identical to cells
tion is not consistent. The cytomorphology resembles re- originating from PUN-LMP or a low-grade urothelial
active urothelial cells, low-grade urothelial carcinomas, carcinoma.
TABLE 9.7 DIFFERENTIATING FEATURES BETWEEN REACTIVE, DYSPLASTIC UROTHELIUM,

AND UROTHELIAL CARCINOMA IN SITU
Reactive Urothelium Urothelial Dysplasia Urothelial Carcinoma In Situ

Cellularity Variable, may be high Low Often high
Presentation Cells mostly in monolayered tissue Cells mostly isolated or in groups Numerous isolated or syncytial tissue
fragments; often with umbrella fragments
cells; isolated cells infrequent
Cells Uniformly enlarged; slight to Slightly enlarged; mildly Often large with marked
moderate increase in N/C ratios pleomorphic with nuclear crowding pleomorphism
Nucleus Round, smooth nuclear Round; nuclear membrane Marked variation in size and shape,
membrane; evenly dispersed, smooth or with notches and hyperchromatic coarsely granular
finely granular chromatin; single creases; granular chromatin; chromatin; irregular nuclear outline;
prominent nucleolus micronucleoli ⫹/⫺ micro and micronucleoli
Cytoplasm Variable, pale, lacy Scant, homogenous Variable
Background Often see inflammatory cells Clean Debris and marked cellular degeneration
Immunoprofile
CK20 Basal cell staining Variable Full thickness staining
IHC: CD44 Full thickness staining Basal/parabasal staining Basal/parabasal staining
IHC: P53 Negative Variable Full thickness staining
Molecular Diploid ? Aneuploid
the remaining one-third arises from urachal remnants.

OTHER NEOPLASMS OF
They may show different histologic patterns including
THE URINARY BLADDER
enteric (colonic) type, adenocarcinomas that are not other-
wise specified (NOS) (Fig. 9.21), mucinous (colloid) type,
SQUAMOUS CARCINOMA signet-ring cell type, clear cell type (Fig. 9.22), hepatoid
type, and mixed forms. When the foci of typical urothelial
Pure primary squamous carcinomas represent less than
carcinoma—either CIS or papillary—is present, the tumor
5% of bladder cancers. These are usually associated with
should be classified as urothelial carcinoma with glandu-
chronic inflammatory conditions (e.g., calculi, diverticu-
lar differentiation rather than adenocarcinoma, which is
lum, and parasitic infections such as schistosomiasis). This
reserved for tumors with almost 100% glandular differ-
parasitic infestation accounts for the high incidence of
entiation. Adenocarcinomas must be differentiated from
squamous cell cancers of the bladder in the Middle East (up
carcinomas extending from the neighboring organs such
to 40%). The cytologic changes are typical of squamous
as prostate (Fig. 9.23) or endometrium (Fig. 9.24).
cell cancers described elsewhere. When the foci of typical
urothelial carcinoma including urothelial CIS are present,
the tumor should be classified as urothelial carcinoma with
NEUROENDOCRINE CARCINOMA
squamous differentiation rather than squamous carcinoma,
which should be reserved for tumors with almost 100% Neuroendocrine or small cell undifferentiated carcino-
pure squamous differentiation (Figs. 9.19 and 9.20). mas of the urinary bladder are very rare neoplasms with
cytologic patterns similar to those described elsewhere.
Coexisting nonsmall cell carcinoma components are seen
ADENOCARCINOMA
in a majority of the cases. The presence of neuroendocrine
Adenocarcinomas account for less than 2% of the bladder carcinomatous component has therapeutic relevance;
carcinomas. Two-thirds arise in the bladder proper while thus, its recognition is important.
Fig. 9.19. Primary squamous carcinoma of the urinary bladder. Fig. 9.20. Primary squamous carcinoma of the urinary bladder.
Fig. 9.21. Primary adenocarcinoma of the urinary bladder. Fig. 9.22. Clear cell adenocarcinoma of the urinary bladder.
Fig. 9.23. Adenocarcinoma cells originating from prostatic adeno- Fig. 9.24. Endometrial adenocarcinoma cells exfoliated (contami-
carcinoma extending into the bladder. nation) in urine.
adults and children (see Chapter 25), respectively. Myo-

SPINDLE CELL LESIONS OF THE
fi broblastic proliferations including inflammatory myofi-
URINARY BLADDER
broblastic tumor and postoperative spindle cell tumor are
Primary soft tissue tumors of the urinary bladder are very often included in the differential diagnosis of mesenchy-
rare; leiomyosarcoma and rhabdomyosarcoma are the mal bladder tumors because of their spindled morphology.
most common malignant mesenchymal bladder tumors in Recognizing these spindle cell lesions and differentiating
TABLE 9.8 DIFFERENTIAL DIAGNOSES OF UROTHELIAL CARCINOMA
Diagnostic Entity Cytopathologic Features Mistaken for See Fig(s).

Instrumentation Cellularity high; cells isolated, in aggregates, and in tissue fragments; Low-grade 9.2C,
Effect monolayered with one margin smooth, lined by umbrella cells; infolding of urothelial 9.25C
the tissue fragments may impart syncytial pattern; cells very pleomorphic carcinoma
in size and shape with numerous multinucleated umbrella cells in renal,
pelvic, or ureteral specimens; uniform, round nuclei with smooth nuclear
membrane; finely granular, evenly dispersed chromatin; micronucleoli ⫹/⫺;
no necrosis; pale, lacy cytoplasm
Urolithiasis or Same as above; inflammation in the background; nucleoli may be Low-grade 9.28
Cystitis prominent; poor cellular preservation 9.29
Nephrogenic Cellularity variable, cells mostly in tissue fragments; monolayered; single cells Low-grade 9.35
Adenoma infrequent; round to cuboidal cells, uniform with round central nuclei; smooth
nuclear membrane; finely granular, evenly dispersed chromatin; nucleoli may
be prominent; mitoses ⫺; necrosis ⫺; cytoplasm variable pale to lacy
Cystitis Cystica/ Low cellularity; small tissue fragments of benign appearing transitional Low-grade 9.30
Cystitis Glandularis epithelium; ciliated mucus-containing epithelial cells with peripheral nuclei 9.31
and clear cytoplasm (cystitis glandularis)
Systemic Variable cellularity, cells predominantly isolated, very pleomorphic in shape High-grade 9.38
Chemotherapy and size with considerable cytomegaly and karyomegaly; nuclei eccentric,
(Cyclophosphamide irregular nuclear membrane; marked hyperchromasia; coarsely granular
and Busulfan) chromatin to pyknosis; nucleoli when present may be multiple and
irregular; cytoplasm vacuolated, frayed with long tails
Intravesical Variable cellularity, affected cells are of enlarged superficial type; High-grade 9.36A and B
Therapy with moderately enlarged nuclei; irregular, wrinkled nuclear membrane; 9.37A and B
Mitomycin C and granular to smudgy chromatin; multinucleation frequent; nucleoli present;
Thiotepa cytoplasm vacuolated, frayed borders
Radiation Induced Variable cellularity, changes mostly involve superficial cells present as High-grade 9.39
Changes isolated; marked cellular enlargement; nuclei increased in size but have
low N/C ratios; granular to smudgy chromatin; nucleoli and intranuclear
vacuoles; multinucleation; cytoplasmic vacuoles; polychromasia and frayed
cell borders
Polyoma Virus Variable cellularity; generally low isolated small round cells; high N/C High-grade 9.33
Induced Changes ratios; enlarged central nucleus; nuclear membrane may be beaded; CIS 9.34
structureless smudgy chromatin; scant to indiscernible cytoplasm;
background clean; positive staining with Mab/BK T.1
them from sarcomatoid carcinoma is important because

the therapeutic and prognostic implications are different. DIAGNOSTIC PITFALLS
Diagnostic pitfalls in urinary cytology are encountered in

METASTATIC MALIGNANCY
a number of situations (Table 9.8; Figs. 9.26 to 9.39) and
Carcinomas of the prostate (Fig. 9.23), colon-rectum, uter- mostly revolve around diffi culties in differentiating low-
ine cervix, and endometrium (Fig. 9.24) may involve the grade urothelial carcinomas from benign urothelium, par-
urinary bladder by direct extension and exfoliate in urine. ticularly in instrumented specimens or the ones dislodged
Other malignant neoplasms that involve the urinary blad- as a result of lithiasis and infl ammation (Figs. 9.27 to
der include malignant lymphoma and melanoma. Renal 9.29). Identifi cation of urothelial carcinoma in the back-
cell carcinomas shed cells late in the disease and are only ground of acute infl ammation is very difficult when the
infrequently identified. malignant cells are sparse and obscured by neutrophils
A B
C D
Figs. 9.25A to D. Ureteral brushings yielding an extremely cellular specimen with several tissue fragments of normal
urothelium that might be misinterpreted as low-grade urothelial cell carcinoma.
Diagnostic Pitfalls in Urinary Cytopathology (See Figs. 9.26 to 9.40)
A B
Figs. 9.26A and B. Bladder washings from a patient with hematuria interpreted as low-grade urothelial carcinoma.
Cystoscopy and biopsy revealed papillary urothelial hyperplasia (see e-Fig. 9.11).
(see Figs. 9.27 and 9.28). Papillary hyperplasia/cystitis may clusters and cellular clusters with papillary configuration
present similar problems (Fig. 9.26; e-Fig. 9.11). Reactive that may be misinterpreted as low-grade transitional cell
changes with the presence of nucleoli in the latter settings carcinoma (Fig. 9.35). Very infrequently, epithelium from
may enhance the diagnostic difficulties. Nephrogenic lesions such as cystitis cystica or cystitis cystica glandu-
adenoma has been noted to exfoliate cells in small loose laris may be present in the instrumented specimen, causing
A B
Figs. 9.27A and B. Urothelial carcinoma cells are difficult to identify in the background of acute inflammation. The
isolated malignant cells often show degenerative changes and obscured by the inflammatory cells.
A B
Figs. 9.28A and B. Bladder wash with large tissue fragments in the inflammatory background in a patient with hema-
turia and calculi. A: Low power. B: Higher magnification showing atypical urothelial epithelium.
A B
Figs. 9.29A and B. Reactive urothelium due to calculi. A: Low power view showing a large branching tissue fragment
of urothelium in an inflammatory background. B: Higher magnification showing transitional epithelium with mild
nuclear atypia. The urinary bladder contained a large calculus.
A B
Figs. 9.30A and B. A group of slightly atypical urothelial cells. Bladder biopsy showed cystitis cystica.
Fig. 9.31. Cystitis cystica. A tissue fragment of mildly atypical Fig. 9.32. Herpes virus infection. Voided urine. The urothelial cells
urothelial cells, suspected of low-grade carcinoma. Follow-up bi- contain nuclei with typical morphology of herpes simplex virus in-
opsy showed cystitis cystica. fection.
Fig. 9.33. Polyoma virus (BK virus) infection. Voided urine. Cel-
lular changes associated with polyomavirus infection which may be
misinterpreted as high-grade urothelial carcinoma or urothelial car-
cinoma in situ. The infected cells are discrete with scant cytoplasm,
high N/C ratios. The nuclei are hyperchromatic and dense.
diagnostic difficulties (Figs. 9.30 and 9.31). Problems may chemotherapy involve mostly superficial or umbrella cells
also be encountered in cases with virus-induced changes and, at times, cause difficulties in differentiation from the
that may be mistaken for high-grade urothelial neoplasms pleomorphic bizarre cells of high-grade neoplasms (Figs.
including urothelial CIS. Radiation-induced changes (Fig. 9.36 and 9.37). The differential diagnostic problems are
9.39) and cellular alterations due to systemic or topical discussed below in detail.
A B
Figs. 9.34A and B. Polyoma virus infection. Voided urine. A: Cellular changes associated with polyoma virus
infection which may be misinterpreted as high-grade urothelial carcinoma or urothelial carcinoma in situ.
B: Positive immunostaining with Mab/BK T.1.
A B
Figs. 9.35A and B. Nephrogenic adenoma. Voided urine. Atypical urothelial cells from a patient with nephrogenic
adenoma. The cytomorphology is similar to that of a low-grade urothelial carcinoma.
A B
Figs. 9.36A and B. Effects of local treatment with Thiotepa. Voided urine. A: Atypical cellular changes in umbrella cells
due to thiotepa topical therapy. B: High-grade urothelial carcinoma for comparison. Note that malignant cells have
nuclei with irregular, coarse chromatin, and multiple nucleoli.
A B
Figs. 9.37A and B. Effects of local treatment with Thiotepa. Voided urine. The tissue fragments of urothelial cells
appear syncytial with pleomorphic hyperchromatic but structureless dense nuclei.
Fig. 9.38. Atypical changes in urothelial cells due to systemic che- Fig. 9.39. Atypical changes in urothelium due to radiation. Voided
motherapy. Voided urine. The urothelial cells are in syncytial tissue urine. The umbrella cell is gigantic in size with degenerative changes
fragment, containing hyperchromatic nuclei. seen as multiple vacuoles in the cytoplasm with inflammatory cells
and pleomorphic pyknotic, structureless nuclei.
INSTRUMENTATION EFFECT The samples obtained by retrograde catheterization

are characterized by hypercellularity, large umbrella cells
Urothelial papilloma, PUN-LMP, and low-grade papillary
containing up to 50 perfectly benign-appearing nuclei
urothelial carcinomas are extremely difficult to differenti-
and basal intermediate type urothelial cells, isolated and
ate from urothelial cells that are dislodged as a result of
in tissue fragments (Fig. 9.25). Cytologic distinction be-
instrumentation. The urothelial cells are present in large
tween neoplastic urothelial cells derived from urothelial
numbers, either singly or in tissue fragments that vary in
papilloma and low-grade papillary urothelial carcinoma
size and configuration. They may form honeycomb sheets
(Fig. 9.40) cannot be made from benign urothelial cells in
with well-defi ned cell borders and polarized nuclei, or
instrumented specimens.
they may be arranged in large strips that curl up, lend-
ing the appearance of a papillary configuration. One edge
of these fragments is often smooth convex, representing
REACTIVE/REGENERATIVE
umbrella cells. Single urothelial cells may be round, cuboi-
UROTHELIAL CELLS
dal, or columnar—the last housing the nuclei at the broad
end or luminal side. The nuclei of the benign urothelial Large tissue fragments of urothelial cells with reactive
cells are small with smooth nuclear membranes, and changes may be seen in patients with lithiasis or cystitis
evenly distributed, fi nely granular chromatin. Their vari- (Figs. 9.28 and 9.29). The nuclei within the tissue frag-
able cytoplasm is pale and may be vacuolated, in contrast ments exhibit only slight enlargement but show low N/C
to neoplastic cells whose cytoplasm appears dense. ratio. Although a prominent nucleolus may be a striking
A B
Figs. 9.40A and B. Ureteral brushings. Low-grade urothelial carcinoma cells. Note the hyperchromatic and slightly
pleomorphic nuclei. An unequivocal diagnosis of low-grade carcinoma is very difficult in ureteral brushings/washings.
feature, the fi nely granular chromatin, smooth nuclear bladder cancer. The total effects of the drug result in degener-
membrane, lack of nuclear membrane irregularity, and ative changes characterized by frayed cell borders, enlarged
pale vacuolated cytoplasm favor a benign process. hyperchromatic but smudgy nuclei, vacuolated cytoplasm,
irregular large nucleoli, and multinucleation (Fig. 9.38).
NEPHROGENIC ADENOMA
RADIATION-INDUCED CHANGES
Nephrogenic adenoma is a reactive process characterized
by a polypoid lesion with papillary and tubular growth The urothelial cells may show striking gigantism with
pattern. A lining of single cuboidal epithelium distin- binucleation and multinucleation (Fig. 9.39). The nuclei
guishes this lesion from transitional cell carcinoma. The may be enlarged, but the N/C ratio remains low. The nuclei
epithelium may be reactive and in cytologic samples sim- may have smudgy chromatin, vacuoles, and nucleoli.
ulate low-grade neoplasms (Fig. 9.35). Cytoplasmic vacuolization and polychromasia are char-
acteristic findings. The cell borders may be frayed.
CELLULAR CHANGES DUE TO
INTRAVESICAL THERAPY VIRUS-INDUCED CHANGES
Intravesical therapy to reduce the rate of recurrence uses Urothelial cells infected with human polyomavirus have
immunomodulators BCG and interferon alpha and che- been termed decoy cells. These are degenerated cells—
motherapeutic agents such as mitomycin or thiotepa. normal to slightly increased in size—that contain enlarged
The changes caused by these chemotherapeutic drugs round nuclei and stain intensely basophilic with smudgy
are observed almost exclusively in superficial cells character- chromatin. The nuclear membranes do not exhibit irreg-
ized by marked cytomegaly with abundant, vacuolated cyto- ularities in contrast to high-grade lesions. The polyoma
plasm, containing one or more enlarged nuclei. The nuclear virus–infected cells occur isolated, in variable numbers.
chromatin is chunky, clumped, and deeply-staining or struc- These decoy cells may be misinterpreted as cells originat-
tureless and smudgy. Nucleoli may be prominent. The N/C ing from high-grade urothelial carcinoma, both invasive
ratio remains low in spite of bizarre nuclear morphology. and in situ (Figs. 9.33 and 9.34). Immunostain with Mab/
The cell borders may be frayed. These drugs do not affect BK T-1 is diagnostic.
the neoplastic cells, whose morphology remains unaltered. Other viruses that are associated with cystitis include the
Cellular changes caused by the BCG vaccine are non- herpes simplex virus and cytomegalovirus. Human Papillo-
specifi c and exhibit reactive/regenerative features (Figs. ma virus–induced changes are also encountered. Frequently
9.36 and 9.37), although granuloma formations have they represent contaminants from the vagina in females.
been described.
SUMMARY OF CYTOPATHOLOGIC FEATURES
CELLULAR CHANGES DUE TO SYSTEMIC OF UROTHELIAL CELLS IN URINARY TRACT
CHEMOTHERAPY
The spectrum of cytologic changes from reactive to
Systemically administered drugs such as alkylating agents, neoplastic, from low grade malignancy to high grade, from
cyclophosphamide, and busulfan have a marked effect on preneoplastic to neoplastic is very wide. The overlapping
the urothelium. The therapy may be associated with com- features often lead to diagnostic difficulties. Table 9.9 lists
plications such as hemorrhagic cystitis, bladder fibrosis, and the cytologic features and various diagnostic possibilities.
TABLE 9.9 SUMMARY OF CYTOPATHOLOGIC FEATURES OF UROTHELIAL CELLS IN URINARY TRACT

SPECIMENS AND THE HISTOLOGIC POSSIBILITIESa
Cellular Features Diagnostic Possibilities

Normal ● Normal
Reactive: Cells usually in tissue fragments, variably ● Inflammation
enlarged nuclei, often with nucleoli ● Nonneoplastic entities (hyperplasia, urolithiasis, cystitis cystica,
nephrogenic adenoma, therapy-associated changes)
● Urothelial papilloma
● PUN-LMP
Dysplasia (Atypical Urothelial Cells) ● Normal

Abnormal cells mostly discrete and in loosely cohesive ● Nonneoplastic entities (hyperplasia, urolithiasis, cystitis cystica,
groups; nuclei eccentric, usually at the broad end of nephrogenic adenoma, therapy-associated changes)
the transitional cells with tailing of the cytoplasm; high ● Dysplasia
N/C ratios, round to oval nuclei, often with anuclear ● Urothelial papilloma
notches; coarsely granular chromatin; nucleoli not ● PUN-LMP
apparent; number of abnormal cells few, particularly in ● Low-grade urothelial carcinoma
voided urine
Suspicious for High-Grade Urothelial Carcinoma ● Normal

● Nonneoplastic entities (hyperplasia, urolithiasis, cystitis cystica,
● Dysplasia
● PUN-LMP
● Low-grade urothelial carcinoma
● High-grade urothelial carcinoma
● Carcinoma in situ
Positive for Low-Grade Urothelial Carcinoma ● Normal

Number of abnormal cells usually high ● Nonneoplastic entities (hyperplasia, urolithiasis, cystitis cystica,
● Dysplasia
● PUN-LMP
● Low-grade urothelial carcinoma
● High-grade urothelial carcinoma
● Carcinoma in situ
Positive for High-Grade Urothelial Carcinoma ● Urothelial carcinoma high-grade

Number of abnormal cells usually high; cells ● Carcinoma in situ
isolated, in groups and in syncytial tissue fragments; ● Urothelial carcinoma low-grade
pleomorphic and clearly malignant ● Squamous carcinoma
● Adenocarcinoma
Positive for Squamous Carcinoma Squamous carcinoma
Positive for Adenocarcinoma Adenocarcinoma (primary or metastatic)

Modified from Murphy WM, Grignon DJ, Pearlman EJ. Tumors of the kidney, bladder and related urinary structures. AFIP Atlas of Tumor Pathology,
Series 4. Washington DC: American Registry of Pathology, 2004;262.
a
Note that the positive cytohistologic correlations are extremely variable and the presence of malignant urothelial cells may not be confirmed for a long time,
particularly with carcinoma in situ. Also high-grade lesions may exfoliate cells that are representative of low-grade lesions because of coexisting lesions.
UrovysionTM obtained Food and Drug Administration

ANCILLARY STUDIES
(FDA) clearance or approval.
The commercially available assays and specifics of
The limitations of cytology and the invasiveness of ureth- the assay including their sensitivities and specificities in
rocystoscopy for detecting bladder cancer have generated comparison with urine cytology are listed in Table 9.10.
much research to identify the best possible noninvasive The two most popular tests among pathologists are
urine-based assays. Bladder tumor markers can be grouped the microscope-based and FDA-approved ImmunoCyt/
into two categories: soluble urine markers and cell-based uCytTM and UrovysionTM. Both require the use of a flu-
markers based on whether urine specimens or exfoliated orescence microscope and are operator-dependent and
cells in urine are used in the assay. time consuming. The former requires at least 500 cells
The soluble urine marker assays include the hemo- while the latter requires at least 25 (for manual) or 100
globin dipstick (Hemastix), BTA stat/BTA TRAK, NMP- (for automated UrovysionTM) to call a case negative.
22, BLCA-4, Survivin, UBC test, CYFRA21, and the HA- ImmunoCyt/uCytTM is a fluorescence test which com-
HAase test. bines three monoclonal antibodies: M344 and LDQ10,
The cell-based assays are microsatellite analysis, te- labeled with fl uorescein—a green fl uorescence that has
lomerase, uCyt, DD23, UrovysionTM, and quanticyt nu- been raised against mucin-like antigens—and 19A211,
clear karyometry. Currently available point-of-care test- labeled with Texas red, which recognizes a high molecular
ing or offi ce-based dipstick tests are the Hemastix, BTA form of carcinoembryonic antigen. M344 and 19A211
stat, NMP-22, and UBC rapid while the others are sent are expressed by 71 to 91% of pTa-T1 tumors. A positive
to a central laboratory for testing. Like urine cytology, test is defi ned as the identifi cation of at least one green
these assays have high sensitivity and specificity for high- or red fluorescent urothelial cell. A major advantage over
grade bladder tumors but are low for detecting low-grade other tests is its sensitivity to detect both low-grade and
tumors. Some assays are affected by benign urologic con- high-grade tumors (79% for Grade 1, 84% for Grade 2,
ditions such as infl ammation, urolithiasis, and benign and 92% for Grade 3 tumors) but the specificity is signifi-
prostatic hypertrophy (BTA-TRAK, NMP-22, UBC, CY- cantly lower than cytology or UrovysionTM.
FRA-21, telomerase TRAP, ImmunoCyt/uCytTM) while The UrovysionTM test is a multitarget multicolor FISH
the sensitivity value of certain assays depend on the cut- assay that involves the staining of exfoliated cells from
off limit selection (BTA-TRAK and NMP-22). Currently, urine specimens with the Chromosome Enumeration
BTA stat, BTA TRAK, NMP-22, ImmunoCyt/uCytTM, and Probes (CEP) 3 (spectrum red), 7 (spectrum green), and 17
TABLE 9.10 URINARY BLADDER TUMOR MARKERS
Test Available Marker Detected Assay Type Sensitivity Specificity

Urine Cytology Tumor cells Microscopy 11–76% ⬎90%
BTA-TRAK Complement factor-H Sandwich ELISA 9.3–89% ⬎90%
NMP-22 Nuclear mitotic apparatus protein Sandwich ELISA 60–70% 60–90%
UBC CK8/18 Sandwich ELISA 35–79% 88–92%
CYFRA 21.1 CK19 Immunoradiometric assay or 75–97% 67–71%

electrochemiluminescent immunoassay
Telomerase (TRAP Enzyme activity TRAP assay 46–90% 60–70%

Assay)
ImmunoCyt/uCytTM Carcinoembryonic antigen; bladder Immunocytochemistry 38–90% 73–80%

tumor cells associated mucins
DD23 185-kDa tumor associated antigen Immunocytochemistry 73–100% 33–67.5%
UrovysionTM Alterations in chromosome 3,7 and Multicolored multiprobe fluorescent in 68–87% ⬎90%
17 and 9p21 situ hybridization (FISH)
Modified from Lokeshwar, Habuchi T, Grossman HB, et al. Bladder tumors markers beyond cytology: International consensus panel on bladder tumor
markers. Urology 2005;66(Suppl 6A):35–63.
(spectrum aqua) and the Locus Specific Probe (LSP) 9p21 in at least 12 cells. Its sensitivity is significantly lower for
(spectrum gold) and the evaluation for chromosomal gain low-grade and low-stage tumors. False positive cases may
or loss using a fluorescence microscope. This test takes be due to abundant umbrella cells particularly in upper
advantage of the high occurrence of specific chromosomal tract washing specimens as these cells may be tetrasomic
abnormalities in urothelial carcinomas. A positive test is or near-tetrasomic. Also, the LSI probe is a small probe
defined as a gain of at least two of the three CEPs in the and may be difficult to detect, leading to a false positive
same cell in at least four cells or a biallelic loss of 9p21 LSI test based on the absence of both copies of 9p21.
SUGGESTED READINGS
Bardales RH. Practical Urologic Cytopathology. New York: Montie JE, Bahnson RR, Cohen SM, et al. Bladder cancer: Clini-
Oxford University Press, 2002. cal practice guidelines in oncology. J Natl Compr Canc Netw
Bostwick DG, Cheng L. Urologic Surgical Pathology. 2nd ed. Phila- 2009;7:8–39.
delphia: Mosby Elsevier, 2008. Murphy WM. Urinary Cytopathology. Chicago: ASCP Press,
Epstein JI, Amin MB, Reuter VE. Bladder Biopsy Interpretation. 2000.
Philadelphia: Lippincott Williams & Wilkins, 2004. Murphy WM, Grignon DJ, Pearlman EJ. Tumors of the kidney,
Koss LG. Diagnostic Cytology of the Urinary Tract. Philadelphia: bladder and related urinary structures. AFIP Atlas of Tumor
Lippincott-Raven, 1996. Pathology, Series 4. Washington DC: American Registry of
Lokeshwar VB, Habuchi T, Grossman HB, et al. Bladder tumor Pathology, 2004.
markers beyond cytology: International consensus panel on Tetu B. Diagnosis of urothelial carcinoma from urine. Mod Pathol
bladder tumor markers. Urology 2005;66(Suppl 6A):35–63. 2009;22:S53–S59.
APPENDIX
CYTOPREPARATION OF URINARY
TRACT SPECIMENS
SPECIMEN PROCESSING
CYTOPREPARATION OF URINARY
TRACT SPECIMENS The specimens can be processed by using any of the fol-
lowing several techniques:
SPECIMEN TYPES ● Direct smears of the sediment—Not recommended for

routine specimen unless the sediment is visible, follow-
● Voided urine ing washing
● Catheterized urine ● Cytocentrifugation (will be referred to as cytospin
● Bladder washings preparations)
● Renal pelvic washings ● Liquid-based preparations
● Ureteral washings ● Membrane filter technique (Nucleopore, Millipore)
● Urethral washings The choice depends on the individual laboratory.
● Ileal conduit specimen
METHOD
● Pour the entire specimen into a 50-ml test tube.

SPECIMEN COLLECTION ● Centrifuge the tube for 2,500 rpm 10 minutes.
AND SUBMISSION ● Decant.
● Wash the specimen until the supernatant is clear.
Twenty-four-hour urine or first morning urine samples are ● A bloody specimen should be processed to remove the
unsatisfactory for cytologic evaluation and are rejected. blood. Saponin technique is preferred to other methods.
The random clean catch specimen should be collected in a A wet mount technique (see appendix for Chapter 6)
sterile container and delivered to the laboratory promptly. may be utilized if the sediment is significant and may require
Refrigerate the specimen if a delay is anticipated. Once that direct smears be made rather than cytocentrifugation.
received in the laboratory, it is processed within a short
period.
CYTOCENTRIFUGATION METHOD
If the specimen is to be transported to a different fa-
(CYTOSPIN PREPARATION)
cility, follow the guidelines below:
● Centrifuge the specimen at 2,500 rpm for 10 minutes. ● To the washed and decanted specimen, add 2 to 3
● Decant and discard supernatant. drops of Saccomanno fixative.
● Consolidate all the buttons (if more than one tube is ● Check the clarity of the specimen. If turbid, add one or
centrifuged). two drops of Saccomanno fixative.
● Re-suspend the button/s in 40 milliliters of cytology ● A turbid specimen will result in an excessively cellular
preservative or Saccomanno fixative. cytospin preparation and render it unsatisfactory for
evaluation.
● Prepare two cytospins as per the manufacturer’s
instructions.
● Stain by the Papanicolaou method.
WASHINGS
LIQUID-BASED PREPARATIONS
Renal pelvic, ureteral, and urethral washings are submit-
ted fresh and promptly and are handled in the same fash- Liquid-based preparations by ThinPrep have proven to be
ion as urine samples. an excellent technique for processing urine.
SECTION III: FINE-NEEDLE ASPIRATION CYTOPATHOLOGY
10 NEUROENDOCRINE SYSTEM
AND NEUROENDOCRINE
NEOPLASIA
with various different epithelial and nonepithelial neo-

EXFOLIATIVE AND ASPIRATION
plasms.
CYTOPATHOLOGY ● Within the neoplasia of the neuroendocrine system,
there are considerable similarities; at the same time,
A diffuse neuroendocrine system represents a constellation there are specifi c differences that allow their iden-
of specialized cells called neuroendocrine cells that form tification.
the entire organ such as the pituitary and parathyroid ● Neuroendocrine tumors share common markers but
glands, are present within the organs such as the pancreas also contain specific markers related to the secretion or
(islet cells), the thyroid (C-cells), and the adrenal medulla, production of specific hormones.
or are present as isolated and aggregates throughout the
body in several diverse locations (Fig. 10.1).
This chapter describes the concepts of a diffuse or
AN OVERVIEW OF A DIFFUSE
dispersed neuroendocrine system, highlights the common
NEUROENDOCRINE SYSTEM
denominators for the different components of the system,
and presents the current classifi cation and nomencla-
ture of neuroendocrine neoplasia. General cytohistologic The neuroendocrine cells are either epithelial or neural
features of various neoplasms originating from the dif- in origin and share several features/properties such as the
ferent components of the neuroendocrine system are il- presence of cytoplasmic secretory granules, the expres-
lustrated in order to appreciate the shared morphologic sion of broad spectrum neuroendocrine markers, and the
features. A brief account of histochemical properties, expression of specific peptide hormones and amines.
immunocytohistochemical stains for specific markers, ul- The understanding of neuroendocrine cells and the
trastructural findings, and molecular studies is presented. diffuse neuroendocrine system involves fascinating obser-
The various neuroendocrine tumors are discussed in de- vations and extensive research produced by several inves-
tail in the respective chapters. A glossary is provided (see tigators over the last century and a half. It is a fascinat-
Appendix) to explain certain commonly used terms in ref- ing subject that has consistently drawn the attention of
erence to the diffuse neuroendocrine system. physicians and scientists alike. The literature is rich with
vast information on the subject and comes highly recom-
mended to interested individuals.
SOME PRACTICAL CONSIDERATIONS
IN THE CYTOPATHOLOGY OF HISTORICAL PERSPECTIVE
NEUROENDOCRINE NEOPLASIA A brief history of how the neuroendocrine concept
evolved over the years certainly helps to put the neuroen-
● Neuroendocrine tumors are ubiquitous. They can be docrine system and neuroendocrine neoplasia in proper
encountered in all types of exfoliative and aspiration perspective.
biopsy specimens from every site in the body. They Heidenhain, in 1870, first described the presence of
should be considered in the differential diagnosis of a chromaffin cells in the intestine—an observation that was
large number of neoplasms from varied sources. Famil- confirmed by Kultschitzky in 1897. Masson, in 1914, ob-
iarity with the cytomorphology of various neuroendo- served that these cells were argentaffin positive. Hamperl,
crine tumors is essential. in 1932, reported a larger population of argyrophil cells
● Neuroendocrine neoplasms present an extraordinarily within the intestine, suggesting that they might be endo-
large spectrum of morphologic features that overlaps crine cells. Cells with similar histochemical properties
349
350 Section III: Fine-Needle Aspiration Cytopathology
known. Cells with APUD characteristics are now referred

to as “neuroendocrine cells.” This term does not necessarily
imply embryologic derivation from the neuroectoderm. It
reflects the presence of a shared phenotype that is charac-
terized by the expression of multiple genes encoding both
endocrine and neuronal features.
NEURAL COMPONENT OF DIFFUSE

NEUROENDOCRINE SYSTEM
The neural component of the diffuse neuroendocrine sys-

tem is represented by pheochromocytes of adrenal medulla
and paraganglia. Paraganglia are topographically dis-
persed organs characterized by the presence of morpho-
logically and cytochemically similar neuroendocrine cells
Fig. 10.1. Diffuse neuroendocrine system. Schematic overview of that are derived from the neural crest. These organs have
the diffuse endocrine system which is composed of classic endocrine varied anatomic distributions in which their characteris-
organs as well as scattered neuroendocrine cells in various organs tic cells perform different functions. For physiologic and
and tissues. These cells are characterized by specific peptides such
as chromogranin and synaptophysin, and ultrastructural evidence
pathophysiologic purposes, they may be broadly divided
of secretory granules. (Lloyd RV, Douglas BR, Young WF. Diffuse into two groups, existing in close proximity to branches
neuroendocrine system. In: Eds. King DW, Sobin LH, Stocker JT, of either the sympathetic or parasympathetic nervous sys-
Wagner B: Endocrine Diseases. Atlas of Nontumor Pathology. tems. The prototype for sympathetic paraganglia is the
Washington, DC: AFIP, 2002:259–308. Reproduced with permis- adrenal medulla, while that of parasympathetic paragan-
sion from American Registry of Pathology.)
glia is the carotid body.
The sympathetic paraganglia are referred to as “chro-
were later identified in other organs such as the lungs, maffi n cells” because of the brown discoloration with
the thymus, and the thyroid gland. Feyter and Froelich the addition of chromates, while those of the parasym-
in 1938 noted that many of these cells had a clear (HeLa pathetic paraganglia are referred to as “nonchromaffin.”
Zellen) appearance in Hematoxylin and Eosin–stained This reaction is now considered to be due to the oxida-
sections. They coined the term “diffuse neuroendocrine tion of stored catecholamines rather than the affinity for
system.” chromates.
Pearse, in the late 60s and 70s, reported that these
cells had the capacity for the uptake and decarboxyla-
HISTORY
tion of precursors of the biogenic amines, and they were
referred to as “Amine Precursor Uptake and Decarbox- Kohn, at the beginning of the twentieth century, coined
ylation” (APUD). APUD cells also contained high con- the term “paraganglia” for ganglia-like structures com-
centrations of nonspecifi c esterase and/or cholinesterase posed of chromaffi n cells and connected to the sympa-
and alpha glycerophosphate dehydrogenase. Most impor- thetic system; however, unlike true ganglia, paraganglia
tantly, they contained a peptide hormone stored within lacked axons and dendrites.
their membrane-bound secretory granules. Pearse con-
cluded that APUD cells originated from the neural crest
STRUCTURE OF THE PARAGANGLIA
because of his observation that many endocrine cells had
chemicals in common with neurons, including peptides With the exception of the Organs of Zuckerkandl and
and amines. carotid bodies, paraganglia are less than 1 millimeter
The neural crest theory was disproved, except for long. They contain two types of cells: namely, neuroendo-
C-cells and paraganglioma cells, based on embryologic crine cells and Schwann cell-like glial cells. The former is
studies of the chick–quail chimera system. The study referred to as chromaffin cells or granule-containing cells
demonstrated that the intestinal epithelial cells, including when associated with sympathetic paraganglia. Those
those that exhibit APUD characteristics, develop from associated with parasympathetic ganglia are termed glo-
multipotential stem cells within the intestinal crypts, mus cells, type I cells, or chief cells. The Schwann cell-
while pancreatic endocrine cells arise from the ductal like glial cells are referred to as sustentacular cells, type II
epithelium. cells, satellite cells, or supporting cells.
The factors responsible for the development of stem The paraganglion cells are polygonal, have abun-
cells into cells with APUD characteristics are largely un- dant cytoplasm, are small, round to ovoid, and have
Chapter 10: Neuroendocrine System and Neuroendocrine Neoplasia 351
pale-staining nucleus. The cells can be identified by silver TABLE 10.1 TRADITIONAL TERMINOLOGY FOR
stains, fluorescence methods, ultrastructure, or neuroen- NEUROENDOCRINE NEOPLASMSa
docrine markers. These cells are completely surrounded
by glial cells that contain less cytoplasm and flattened, Tumor Location Description
more deeply staining nuclei, which contain coarse chro- Pituitary Pituitary adenoma/carcinoma
matin and stain positively with S100 protein. Ultrastruc-
turally, paraganglia cells demonstrate neurosecretory Thyroid Medullary carcinoma
granules.
Lung Bronchial carcinoid; Kulchitsky-
cell tumor
THE NOMENCLATURE OF EPITHELIAL Different body sites Carcinoids, atypical carcinoid

TYPE NEUROENDOCRINE NEOPLASMS
Lung and several Oat cell/small cell undifferentiated
The nomenclature of the neuroendocrine tumors, par- different body sites carcinoma
ticularly of epithelial types, consisted of a long list of
Gastrointestinal tract; Carcinoid
designations that included terms such as apudoma,
appendix
Kulchitsky-cell tumor, argentaffinoma, and so on. They
were also referred to by the various names listed in Table Pancreas Islet cell tumor
10.1. Many of these neoplasms belonged to one category
with similar or identical morphologic pattern, shared Adrenal Pheochromocytoma, peripheral
immunomarkers, and followed a similar clinical course. neuroepithelioma
Yet, they were clinically managed differently since cer-
tain diagnostic terms implied benign behavior. In other Autonomic nervous Paraganglioma/chemodectoma
words, biologically similar lesions were designated dif- system
ferent names and resulted in different nonuniform grad-
ing systems, which did have a considerable impact on Adrenal/autonomic Neuroblastoma,
patient management. A new, simplified, and practical sys- nervous system ganglioneuroblastomas
tem was proposed, whereby the neuroendocrine tumors
were broadly divided into two major groups: epithelial Nose Esthesio (olfactory)
and neural, with the exceptions being the pituitary, the neuroblastoma
parathyroid, and the thyroid where traditional terminol-
Eye Retinoblastoma
ogy was retained. Table 10.2 lists the updated terminol-
ogy. The epithelial variety of neuroendocrine tumors
Central nervous system Medulloblastoma
that encompassed neoplasms such as typical carcinoid
tumors, islet cell tumors, atypical carcinoids, and small Central nervous system Pineoblastoma
cell carcinomas were brought under the umbrella of
“neuroendocrine carcinomas” and were subclassified into Soft tissue Peripheral neuroepithelioma
three grades. Although, tumors such as typical carcinoids (PNET)
frequently follow a benign course, they do metastasize
locally and distally and must not be considered benign as Skin Merkel cell carcinoma
they were in the past.
The neoplasms of the neural origin included tumors Parathyroid Parathyroid adenoma/carcinoma
arising from primitive neuroectodermal cells such as a
Modified from: Wick MR. Neuroendocrine neoplasia. Current concepts.
medulloblastoma and neuroblastoma, peripheral neu- Am J Clin Pathol 2000;113:331–335.
roectodermal tumors, and those arising from adrenal
medulla and paraganglia (e.g., pheochromocytoma and
paraganglioma).
as a common marker and can be further divided into
epithelial and neural subtypes on the basis of the presence
PATHOLOGIC FEATURES OF
of cytokeratins or neurofilaments, respectively. Tumors of
NEUROENDOCRINE NEOPLASMS
both groups may be associated with clinical syndromes
Neuroendocrine tumors occur in virtually all tissues and due to the overproduction of biologically active amines
organs, including those that do not normally contain neu- or peptide hormones, while others may be clinically
roendocrine cells. They can also occur as components of silent. In the later cases, amines or peptide hormones
teratomas. This family of tumors contains synaptophysin are demonstrated by immunohistochemical techniques.
TABLE 10.2 RECOMMENDED TERMINOLOGY FOR

NEUROENDOCRINE NEOPLASMS
Epithelial Type Neuroendocrine Tumors or Neuroendocrine Carcinomas; Grades I, II, III
Grade I Neuroendocrine Carcinoma (well-differentiated)

Carcinoid tumors (pulmonary, gastrointestinal or other sites),
Islet cell tumors or pancreatic neuroendocrine tumors
Grade II Neuroendocrine Carcinoma (moderately-differentiated)

Atypical carcinoid (pulmonary; gastrointestinal or other sites),
Atypical Islet cell tumors or pancreatic neuroendocrine tumors
Grade III Neuroendocrine Carcinoma (poorly-differentiated)

Small cell carcinomas
Large cell neuroendocrine carcinoma
Neural Type Neuroendocrine Tumors

Classic neuroblastoma, ganglioneuroblastoma and ganglioneuroma
Olfactory neuroblastoma
Medulloblastoma
Retinoblastoma
Pineoblastoma
Primitive neuroectodermal tumors (PNET)
Pheochromocytoma
Paraganglioma
Thyroid Medullary Carcinoma
Pituitary Adenoma
Parathyroid Adenoma/Carcinoma
Neuroendocrine tumors are also associated with several as Papanicolaou-stained preparations. Nucleoli may be
genetic syndromes. present. The high-grade neuroendocrine carcinomas cor-
respond to small cell carcinomas and are characterized by
Neuroendocrine Tumors, Epithelial Type small cells, high N/C ratios, nuclear molding, brisk mitotic
activity, and necrosis. Neuroendocrine carcinomas also
Neuroendocrine tumors of the epithelial type exhibit
coexist with other nonendocrine epithelial malignancies.
a wide range of histologic and cytologic features (Figs.
The neuroendocrine tumors arising from C-cells of
10.2 to 10.27). Common patterns include the presence
the thyroid, referred to as medullary carcinoma, present
of nests (insulae), alveoli, ribbons (trabeculae), festoons,
marked variations in their cytohistologic presentations
cords, glands, and rosettes. The tumors also demonstrate
(Figs. 10.28 to 10.33). Medullary carcinomas share mor-
solid, pseudopapillary, or fascicular growth patterns. The
phologic features with neuroendocrine carcinomas as well
neoplastic cells may be round, cuboidal, polyhedral, or
as pheochromocytomas and paragangliomas.
spindle-shaped, and cell processes may be evident. Indi-
The morphology of pituitary neoplasms and parathy-
vidual cells may be small, intermediate, or large. Their
roid neoplasms are characterized by uniform small round
cytoplasm may be granular, eosinophilic (or cyanophilic
cells with salt & pepper chromatin (see Figs. 10.49 and
with Papanicolaou stain), or amphophilic and oncocytic
10.50).
as well as vacuolated due to the accumulation of mucin or
lipid. The cytoplasm may contain melanin granules. The
Neuroendocrine Tumors, Neural Type
nuclei may be small, hyperchromatic, and intermediate to
large with coarsely granular chromatin; it is referred to Neuroendocrine tumors of the neural type include tumors
as “salt & pepper” chromatin. In fact, the salt & pepper arising from primitive small, round, and undifferenti-
chromatin is a hallmark of neuroendocrine neoplasia and ated cells resembling the germinal or matrix cells of the
can be appreciated in both the histologic samples as well embryonic neural tube; examples of these tumors include
Neuroendocrine Tumors, Epithelial Type Histologic and Cytopathologic Features of Carcinoid Tumors (Neuroendocrine
Carcinoma, Grade I) (See Figs. 10.2 to 10.7)
A B
Figs. 10.2A to C. Histomorphologic features of carcinoid tumors

(neuroendocrine carcinoma, grade I). A: Typical presentation
formed by nests and trabeculae of neoplastic cells separated by cap-
illaries. The neoplastic cells are small, round to cuboidal, uniform
with scant cytoplasm and high N/C ratios. The nuclear chromatin
is coarsely granular, evenly distributed presenting a characteristic
pattern referred to as salt & pepper chromatin (H&E). B: Trabe-
culae can be of varying thickness and may show branching (H&E).
C: Carcinoid tumors often form nests, islands, rosettes, or pseudoglan-
C dular as well as papillary patterns (H&E).
Fig. 10.3. Carcinoid tumor. Bronchial brushings depicting tissue Fig. 10.4. Carcinoid tumor. Bronchial brushings. These carcinoid
fragment of small cells with scant cytoplasm, high N/C ratios, and tumor cells are larger containing significantly more foamy cytoplasm
uniform, round nuclei containing salt & pepper chromatin. than conventional carcinoid tumor cells and may be misinterpreted
as adenocarcinoma. Nuclei, however, present typical morphology.
Fig. 10.5. Carcinoid tumor. A classic presentation of carcinoid tu-

mor cells in bronchial brushings. Note the salt & pepper chromatin
and nucleoli are prominent. These small cells can be easily mistaken
for bronchial epithelial cells or even lymphocytes.
A B
Figs. 10.6A and B. Carcinoid tumor. A: This carcinoid tumor presents spindle cell morphology, but maintaining the
nuclear characteristics (H&E). B: The cytologic presentation parallels the histomorphology.
A B
Figs. 10.7A and B. A: Pancreatic islet cell tumor or neuroendocrine carcinoma, grade I in fine needle aspirate,
demonstrating small, round cells with poorly defined cell borders, scant cytoplasm, and nuclei with salt & pepper
chromatin. Nucleoli are often seen. B: Different example of a fine needle aspirate exhibiting nuclear pattern that is
readily distinguishable as that of neuroendocrine type.
Histologic and Cytopathologic Features of Atypical Carcinoid Tumors (Neuroendocrine Carcinoma, Grade II)
(See Figs. 10.8 to 10.11)
A B
Figs. 10.8A to C. A: This tumor presents a usual pattern of neu-

roendocrine neoplasm or carcinoid tumor except for punctate
necrosis (H&E). B: This neoplasm shows larger, areas of necrosis
(H&E). C: Histomorphology of this neoplasm closely resembles
that of a small cell carcinoma and the cytologic samples from such
a tumor may be interpreted as small cell carcinoma. This neoplasm
was well-circumscribed and lacked an invasion of the surrounding
C parenchyma (H&E).
Fig. 10.9. Atypical carcinoid tumors in cytologic specimens dem- Fig. 10.10. FNA of an atypical carcinoid tumor of the stomach.
onstrate varying degrees of nuclear changes ranging from mild to The nuclei are slightly enlarged with prominent micronucleoli. This
marked resembling small cell carcinomas. Atypical carcinoid is a tumor spread widely with a fatal outcome.
histologic diagnosis, the latter based solely on histologic criteria.
FNA of a histologically confirmed atypical carcinoid tumor.
A B
Fig. 10.11. FNA of two separate examples of histologically proven atypical carcinoid tumors showing cytomorphology
mimicking small cell carcinoma.
Histologic and Cytopathologic Features of Large Cell Neuroendocrine Carcinoma (Neuroendocrine Carcinoma, Grade III)
(See Figs. 10.12 to 10.16)
A B
Figs. 10.12A and B. Neuroendocrine carcinoma, grade III. Histologically, this tumor is characterized by large geo-
graphic areas of necrosis, high proliferative activity. Spectrum of histologic pattern ranging from large round cells, to a
pleomorphic pattern to one that resembles a small cell carcinoma. A: Large cell neuroendocrine carcinoma of the lung
showing massive necrosis (H&E). B: Higher magnification (H&E).
Fig. 10.13. FNA of large cell neuroendocrine carcinoma. A: These cells Fig. 10.14. FNA of large cell neuroendocrine carcinoma showing a
are slightly larger than carcinoid tumor cells, are round with a dispersed pleomorphic cell pattern.
pattern. Their cell borders are poorly defined with scant cytoplasm.
Fig. 10.15. FNA of large cell neuroendocrine carcinoma. Note the Fig. 10.16. FNA of large cell neuroendocrine carcinoma showing a
pleomorphic cell pattern with giant forms. morphologic pattern resembling small cell carcinoma.
Histologic and Cytopathologic Features of Small Cell Carcinoma (Neuroendocrine Carcinoma, Grade III)
(See Figs. 10.17 to 10.27)
A B
C D
Figs. 10.17A to D. Histologic features of small cell carcinoma. A: Large islands of malignant neoplasm with peripher-
al palisading (H&E). B: Sheets of small to short spindle cells (H&E). C: Sheets of small to short spindle cells (H&E).
D: Higher magnification showing oblong nuclei with molding (H&E).
Fig. 10.18. Small cell carcinoma cells in sputum. Fig. 10.19. Bronchial brushings of a small cell carcinoma.
Fig. 10.20. Bronchial brushings of a small cell carcinoma showing

considerable karyorrhexis and necrosis.
A B
Figs. 10.21A and B. FNA of a small cell carcinoma of the lung. Syncytial tissue fragments of small cells with poorly
defined cell borders, indistinct cytoplasm with high N/C ratios, markedly hyperchromatic oval to oblong nuclei dem-
onstrating molding.
Fig. 10.22. FNA of a small cell carcinoma of the lung with a spindle Fig. 10.23. FNA of a primary small cell carcinoma of the parotid
cell pattern. gland.
A B
Figs. 10.24A and B. FNA of a small cell carcinoma of the parotid gland.
Fig. 10.25. Cervical (Pap) smear showing small cell (neuroendo-

crine) carcinoma.
A B
Figs. 10.26A to C. Positive Immunoreactivity of neuroendocrine

cells to: A: cytokeratin, note the dot-like staining around the
C nucleus; B: chromogranin; and C: synaptophysin.
Fig. 10.27. FNA of a Merkel cell carcinoma (neuroendocrine) of the

skin, presenting a typical cytomorphology of small cell carcinoma.
neuroblastomas and their mature congeners (ganglion- characterized by a solid growth pattern and consist of
euroblastomas and ganglioneuromas), medulloblastoma undifferentiated small cells with scant, indiscernible cy-
and peripheral neuroectodermal tumors (PNET), as well toplasm and high N/C ratios. The nuclei contain deeply
as tumors arising from the adrenal medulla (pheochro- stained chromatin with inconspicuous nucleoli. These
mocytomas) and from the paraganglia (paragangliomas) tumors often form rosettes and contain neuropile (Figs.
(Figs. 10.34 to 10.48). 10.42 to 10.48).
The neoplasms arising from the primitive cells are The neoplasms arising from the paraganglia—namely
composed of small, round, and undifferentiated cells, pheochromocytomas—and paragangliomas arising from
Spectrum Cytopathologic Features of Medullary Thyroid Carcinoma (See Figs. 10.28 to 10.33)
Fig. 10.28. FNA of a medullary thyroid carcinoma showing diag- Fig. 10.29. FNA of a medullary thyroid carcinoma. A dispersed
nostic features such as dispersed cell pattern, pleomorphic shapes, pattern of pleomorphic plasmacytoid cells with occasional giant
bi- and multinucleation, eccentric nuclei, cytoplasmic processes and forms.
nuclei with salt & pepper chromatin.
Fig. 10.30. FNA of a medullary thyroid carcinoma. Depicting plas-

macytoid cells with occasional giant forms.
A B
Figs. 10.31A and B. FNA of a medullary thyroid carcinoma showing a spindle cell pattern that overlap with soft tissue
tumors. The nuclei, however, retain the typical salt & pepper chromatin.
the adrenal medulla and sympathetic/parasympathetic

paraganglia present a broad morphologic spectrum (Figs. PARATHYROID GLANDS AND
10.34 to 10.41). PITUITARY GLAND
Cytohistologically, they may show various growth
patterns including solid, nesting (Zellballen), and trabe- The cytopathology of parathyroid and pituitary neoplasms
cular. These neoplasms can be strikingly monomorphic to (Figs. 10.49 and 10.50) are described in Chapters 13 and
extremely pleomorphic. The neoplastic cells range from 23 respectively.
small to large with frequent giant to monstrous forms.
Their shape varies from round, oval, plasmacytoid, cuboi-
dal, polyhedral, to spindle forms. The nuclei are round, ANCILLARY DIAGNOSTIC TESTS
oval, oblong and lobulated to spindle forms and contain
coarsely granular, deep-staining, evenly dispersed chro-
AUTOFLUORESCENCE
matin, which is referred to as the salt & pepper type—a
pattern almost synonymous with neuroendocrine tumors. Some neuroendocrine cells exhibit a characteristic yellow–
Their cytoplasm is variable from scant to abundant, clear, green fluorescence after fixation in formaldehyde and
pale to dense, or granular. Cytoplasmic processes are fre- other aldehyde fixatives. In some instances, the cells may
quently present from short tailing to a long one and tend become fluorescent only after the administration of L-dihy-
to be unipolar. droxyphenylalanine (DOPA) or 5-hydroxytryptophan.
Fig. 10.32. FNA of a medullary thyroid carcinoma with a small cell Fig. 10.33. FNA of a medullary thyroid carcinoma with a dispersed,
pattern resembling a small cell carcinoma. uniform small cell pattern, resembling malignant lymphoma.
Neuroendocrine Tumors, Neural Type Histologic and Cytologic Features of Pheochromocytoma/Paraganglioma

(See Figs. 10.34 to 10.50)
A B
Figs. 10.34A and B. Histologic sections of pheochromocytoma. A: Large polygonal cells (H&E). B: Spindle cells (H&E).
Fig. 10.35. FNA of a pheochromocytoma, showing a pleomorphic Fig. 10.36. Cytologic preparation of a pheochromocytoma show-
cell pattern very similar to that of medullary thyroid carcinoma. ing small to medium-sized cells, poorly defined cell borders with
nuclei containing finely granular chromatin. Note the occasional
large cell. The background has fibrillar appearance.
Fig. 10.37. Cytologic preparation of a pheochromocytoma demon- Fig. 10.38. Cytologic preparation of a pheochromocytoma. A
strating a pleomorphic pattern with predominant spindle cells. Note markedly pleomorphic cell pattern with numerous giant to mon-
the unipolar cytoplasmic processes. strous forms.
Fig. 10.39. FNA of a carotid body tumor or paraganglioma show- Fig. 10.40. FNA of a paraganglioma, peripancreatic region present-
ing an epithelioid cell pattern. ing a small cell pattern morphologically similar to low-grade neu-
roendocrine carcinoma.
A B
Figs. 10.41A and B. A: Crush smear of a paraganglioma of the cauda equina region showing a dispersed population
of small uniform cells and a giant multinucleated form. B: FNA of a recurrent paraganglioma exhibiting an epithe-
lioid pattern, morphologically similar to an epithelial malignancy.
Fig. 10.42. FNA of a mediastinal mass in a child. Small round cells Fig. 10.43. Esthesioneuroblastoma. Undifferentiated carcinoma
with poorly defined cell borders, scant cytoplasm, forming rosettes cells resembling high-grade neuroendocrine carcinoma (small cell
with the background of neuropile—a pattern characteristic of neu- carcinoma).
roblastomas.
Fig. 10.44. FNA of a primitive neuroectodermal tumor (PNET). Fig. 10.45. FNA of a primitive neuroectodermal tumor (PNET).
Syncytial tissue fragments of small, undifferentiated cells with indis- Syncytial tissue fragments of small, undifferentiated cells with indis-
tinct cytoplasm, high N/C ratios, and nuclear molding. tinct cytoplasm, high N/C ratios, and nuclear molding and rosette
formations.
Fig. 10.46. FNA of an adrenal mass in an older individual, proven Fig. 10.47. Medulloblastoma cells in cerebrospinal fluid. The cells
to be PNET with a cytologic pattern resembling a small cell carci- are small, undifferentiated with poorly defined cell borders and high
noma. N/C ratios.
Fig. 10.48. Crush preparation of a central neurocytoma with small Fig. 10.49. Pituitary adenoma. Crush smear. Dispersed pattern of
round uniform cells embedded in neuropile. uniform round cells.
Fig. 10.50. FNA of a parathyroid adenoma. These cells in syncytial

tissue fragments are small with scant cytoplasm and high N/C ra-
tios. These cells are very uniform.
Formaldehyde forms highly fluorescent tetrahydroisoquin- the majority of primary neuroendocrine carcinomas of
oline condensation products with catecholamines and beta the skin (Merkel cell carcinoma) but only in 10% or less
carboline derivatives with tryptamines such as serotonin. of small cell carcinomas.
The neural type neuroendocrine tumors are gener-
HISTOCHEMISTRY ally nonreactive to cytokeratins. Focal reactivity may be
seen in some paragangliomas arising in cauda equina and
The common tests include silver impregnation tests for roughly 20% of primitive neuroectodermal tumors.
argentaffin cells (Masson–Fontana method) and argyrophil
cells (Grimelius).The former cells contain intracellular Enzymes
substances that reduce the silver, while the argyrophil cells
require the addition of chemicals to reduce the silver. Aromatic/amino acid decarboxylase is widely distributed
in both neuroendocrine cells and their corresponding
ELECTRON MICROSCOPY tumors. Immunolocalization studies now permit the iden-
tification of catecholamine synthesizing abilities.
The most characteristic feature of neuroendocrine cells Neuron-specific enolase (NSE) is present in both neu-
at the ultrastructural level is the presence of membrane- rons and neuroendocrine cells. It is one of the most widely
bound dense core secretory granules, ranging in size from used markers as a screening method for neuroendocrine
50 to 450 nanometers in diameter. The distribution of differentiation.
these granules varies. Some may be dispersed throughout
the cytoplasm, while some may be concentrated beneath Chromogranin, Secretogranins, and Other
the plasma membrane or present in the cell processes. Secretory Granule Proteins
Some secretory granules have distinctive ultrastructural
fi ndings as noted in pancreatic islet cells. Other features These proteins represent the major constituent of neuro-
shared by epithelial type neuroendocrine cells include secretory granules. Three major chromogranin proteins
the high content of free ribosomes, low levels of rough are identified: namely, chromogranin A, chromogranin B
endoplasmic reticulum, high levels of smooth endoplas- (Secretogranin I), and chromogranin C (Secretogranin II).
mic reticulum in the form of vesicles, and prominent
microtubules. Synaptophysin
This calcium-binding glycoprotein is the most abundant
IMMUNOCHEMISTRY integral membrane protein constituent of neuronal syn-
The neuroendocrine phenotype encompasses a wide array aptic vesicles and is abundantly expressed in a variety of
of markers including those present in cytosol, cytoskele- neuroendocrine cells and their corresponding tumors.
ton, secretory granule membranes of secretory organelles,
and plasma membranes. While some markers are present Thyroid Transcription Factor 1 (TTF-1)
in all neuroendocrine cells, others are restricted in their This is a tissue specific transcription factor that is almost
distribution to specific cell types. exclusively expressed by normal thyroid and lung cells
and by their tumors. TTF-1 is present in all lung tumors
Cytosolic Markers including small cell carcinomas. TTF-1 is also expressed
in extrapulmonary small cell malignancies.
Neuron specifi c enolase is present in both neurons and
neuroendocrine cells. Another cytosolic marker includes
protein gene product 9.5(PGP9.5) which is often negative Peptide Hormones and Amines
when NSE is positive and may be strongly positive when The characteristic hormonal products of different types
NSE is negative. of neuroendocrine cells can be identified effectively using
polyclonal or monoclonal antibodies. The same peptide
Intermediate Filaments may be present in many different types of neuroendocrine
cells. For example, somatostatin may be present in certain
With the exception of neurons and chromaffin cells,
hypothalamic and cortical neurons, pancreatic D-cells,
which contain neurofilament protein, all other cells of the
gastrointestinal D-cells, bronchopulmonary neuroendo-
neuroendocrine system contain cytokeratins. Neuroendo-
crine cells, and so on.
crine tumors of the epithelial type are typically positive
with broad-spectrum cytokeratin (CK) antibodies. Both
Neural Cell Adhesion Molecule (NCAM or CD56)
CAM 5.2 (CK8 and CK18) and MNF116 (CK5, CK6,
CK8, CK17, and CK19) often demonstrate cytokeratin The neural cell adhesion molecules (NCAMs) include a
immunoreactivity in the form of a dot-like pattern of family of glycoproteins that have key roles in cell binding,
staining, corresponding to the perinuclear accumulation migration, differentiation, and proliferation. NCAMs are
of intermediate fi laments. CK20 reactivity is present in distributed in most neuroendocrine cells and neuroendo-
crine tumors. The CD56 is particularly useful in the diag- tumor, age, and so on. However, current morphologic
nosis of small cell carcinoma. subtypes and prognostic indicators alone are not suf-
fi cient to account for the diverse clinical outcomes. As
CD57 such, molecular genetic testing is essential for better clini-
The monoclonal antibody CD57 reacts with natural killer cal stratification. The amplifi cation of MYCN is present
lymphocytes, myelin-associated glycoproteins, NCAMs, in approximately 25% of neuroblastomas, which is a
and a granule matrix constituent of chromaffin cells. predictive marker for an aggressive clinical course, and the
Antibodies to CD57 react with varying proportions of testing for amplification is part of the current standard of
neural tumors including Schwannomas, neurofibromas, care. The detection of amplification can be accomplished
and granular cell tumors. Among the neuroendocrine cytogenetically as extrachromosomal, double-minute, and
tumors, CD57 is present in 100% of pheochromocytomas, homogenously staining regions. Southern blot (SB) analy-
85% of extra-adrenal paragangliomas, 85% of carcinoids sis is another way to detect amplification. However, both
of diverse origin, and 50% of small cell carcinomas. cytogenetics and SB require fresh tissue, which may not
always be available in the clinical setting. In this scenario,
CD99 a cytology cell block or even fixed smears can be used for
in situ hybridization using an MYCN probe (chromoge-
CD99 is also known as MIC-2 or p30/32 protein. This
nic or fl uorescent in situ hybridization). This technique
determinant is present in all primitive neuroectodermal
provides a unique advantage over others in that the mor-
tumors/Ewing’s sarcomas. It is also seen in certain rhab-
phology of the tumor cells can be assessed concurrently
domyosarcomas and lymphoblastic lymphomas. Para-
during the counting of the FISH/CISH signal.
gangliomas and neuroblastomas react negatively.
MOLECULAR BIOLOGY Ewing’s Sarcoma/PNET

A wide variety of molecular technologies have been used Another large and important neuroendocrine tumor
in normal and neoplastic neuroendocrine disorders in the group is Ewing’s sarcoma/PNET involving any sites (soft
research setting to understand the pathogenesis of differ- tissues, bone, solid organs, etc.). The molecular signa-
ent neuroendocrine tumors. However, the morphology ture for this tumor is the presence of a set of transloca-
and immunoprofile of neuroendocrine tumors are cur- tions including the balanced translocation that forms a
rently quite characteristic for diagnosis, and the role of the chimeric gene involving the EWS gene at 22q12, which
molecular genetic testing for diagnosis is limited. A few of is fused with a member of the ETS family of transcrip-
the techniques include in situ hybridization (e.g., to detect tion factors. The most common translocation present in
MYCN amplification in neuroblastoma), reverse tran- over 90% of the tumors is t(11;22)(q24;q12), resulting
scriptase polymerase chain reaction (RT-PCR) for Ewing’s in the EWS-Fli1 fusion gene. Approximately 5% of the
sarcoma/peripheral neuroectodermal tumor (PNET), or tumors show EWS-ERG fusion [t(21;22)(q22;q12)].
Germline mutation detection via different techniques such Other rare fusion transcripts include partnering EWS
as direct sequencing on Germline DNA specimens (e.g., in with other ETS family members—ETC1, E1AF, FEV,
cases of multiple endocrine neoplasia [MEN syndromes]). and ZSG—each accounting for less than 1% each. The
Since the proper therapy is directed by the right classifica- translocation fusions can be detected by using a break-
tion, molecular testing is becoming an integral part of not apart FISH probe flanking the break-point region in the
only diagnoses but also of targeted therapies. EWS gene since this is the common partnering gene. To
Currently, within the family of neuroendocrine tu- detect the exact chimeric gene structure, RT-PCR using
mors, two distinct tumors are routinely tested for molecu- specific primer sets can be done on RNA extracted from
lar markers in the clinical setting. the cytologic material.
Germline mutation analysis for a different MEN syn-
Neuroblastoma
drome is performed on DNA extracted from peripheral
The clinical outcome of neuroblastoma is traditionally blood or buccal cells. Further details about this testing are
categorized using different pathologic subtypes of the beyond the scope of this book.
SUGGESTED READINGS
DeLellis RA. The neuroendocrine system and its tumors. An over- DeLellis RA, Tischler AS. The dispersed neuroendocrine cell sys-
view. Am J Clin Pathol 2001;115(suppl 1):S5–S16. tem. In: Kovacs K, Asa SL, eds. Functional Endocrine Pathol-
DeLellis RA, Dayal Y. Neuroendocrine system. In: Sternberg SS, ogy. 2nd ed. Boston: Blackwell Sc. Malden, 1998:529–549.
ed. Histology for Pathologists. 2nd ed. Philadelphia: Lippincott- Ellison DA, Parham DM. Tumors of the autonomic nervous sys-
Raven, 1997:1133–1152. tem. Am J Clin Pathol 2001;115(suppl 1):S45–S55.
Kloppel G. Tumor biology and histopathology of neuroendocrine Lloyd RV, Douglas BR, Young WF. Diffuse neuroendocrine system.
tumors. Best Pract Res Clin Endocrinol Metab 2007;21:15–31. In: Endocrine Diseases. Atlas of Nontumor Pathology. Washing-
Lack E. Tumors of the Adrenal Gland and Extra-Adrenal Paragan- ton, DC: AFIP, 2002:259–308.
glioma. Washington DC: Armed Forces Institute of Pathology, Tischler AS. Paraganglia. In: Mills SE, ed. Histology for Pathologists.
1997. 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2007.
Langley K. The neuroendocrine concept today. Ann NY Acad Sci Wick MR. Immunohistochemistry of neuroendocrine and neuroec-
1994;733:1–17. todermal tumors. Seminars Diagn Pathol 2000;17:194–203.
Lloyd RV. Introduction to molecular endocrine pathology. Endocr Wick MR. Neuroendocrine neoplasia. Current concepts. Am J Clin
Pathol 1993;4:64–72. Pathol 2000;113:331–335.
APPENDIX
GLOSSARY
APUD: Amine Precursor Uptake and Decarboxylation. collection of neurons in the brain or spinal cord (e.g.,
basal ganglia).
APUDOMA: A term applied to tumors of the neuroen-
docrine cells. Homer-Wright Rosette: Tumor cells arranged around a
central core of neurofibrillary material.
Argentaffin: The ability of cells to reduce silver.
MEN Syndrome: Multiple endocrine neoplasia syndrome.
Argyrophil: Capable of binding silver salts, which may
subsequently be reduced by light or by a reducing agent Neural Crest: Formed by cells from the neural plate in
to precipitate the silver that stains black. early embryonic life before the fusion of the plate to form
the neural tube. The neural plate is an ectodermal deriva-
Autofluorescence: Exhibit fl uorescence when fixed in tive. The neural crest is the source of neurons and satellite
formaldehyde. cells in the autonomic and sensory ganglia.
C-cells: Neuroendocrine cells in the thyroid that are also Neuroectoderm: The portion of the ectoderm in the early
referred to as calcitonin-producing cells or clear cells. embryo that gives rise to the central nervous system.
Chemoreceptors: Receptors adopted for excitation by Nonchromaffin: Cells of the paraganglia that do not dem-
chemical substances (e.g., olfactory or gustatory recep- onstrate chromaffin reaction.
tors or a sense organ) such as a carotid body or aor-
tic body, which is sensitive to chemical changes in the Organs of Zuckerkandl: Pair of paraganglia in the lower
bloodstream—particularly to reduced oxygen content— abdomen along the bifurcation of the aorta.
and reflexively increases both respiration and blood pres- Paracrine: Secretes the products locally to influence the
sure. Chemoreception is the function of paraganglia. activities of adjacent epithelial cells.
Chromaffin: An affi nity for chromate salts. The tissues Paraganglia: A collection of chromaffin cells (neuroendo-
develop brown discoloration upon the addition of chro- crine) derived from neural ectoderm, occurring outside
mic salts. Also referred to as chromaffin reaction. the adrenal medulla.
Cytosol: The liquid medium of the cytoplasm (i.e., cyto- Paraganglioma: Neoplasms arising from paraganglia.
plasm minus organelles and nonmembranous insoluble
components). PEN: Pancreatic neuroendocrine neoplasms.
Enterochromaffin: Neuroendocrine cells in the small PET: Pancreatic neuroendocrine tumors.
intestinal mucosa with an affinity for chromate salts.
Pheochromocyte: Cells of the adrenal medulla.
Endocrine: The secretion of products through the base- Pheochromocytoma: Tumor of the adrenal medulla.
ment membranes into adjacent capillaries for interaction
with target tissues at distant sites. PNET: Primitive neuroendocrine tumor.
Ependymal Rosette: Cells around a central tubule. PPNET: Primitive peripheral neuroectodermal tumor.
Ganglion: A collection of neurons outside the cen- Sustentacular Cells: Supporting cells of the paraganglia
tral nervous system; occasionally, the term applied to a of glial origin.
11 MALIGNANT MELANOMA
EXFOLIATIVE AND ASPIRATION HISTOCYTOLOGIC FEATURES

CYTOPATHOLOGY
Histologically and cytologically metastatic malignant mela-
Malignant melanoma is a primary cutaneous malig- nomas present an extremely broad spectrum of morphologic
nancy but is also known to occur in various other loca- features that overlap with almost every malignant neoplasm
tions such as the eye, gastrointestinal tract, and parana- occurring in the human body. Metastatic malignant mela-
sal sinuses. Malignant melanoma accounts for 3% of all nomas present marked variation in growth patterns, cell
malignancies. The incidence of malignant melanomas is composition, and morphology with or without the presence
on the rise over the last several years. They occur over of melanin pigment. This diverse morphology is reflected
a broad age range from young adults and middle aged in the varied cytologic specimens that are utilized for the
to elder individuals and rarely in children and adoles- detection of melanoma cells, representing exfoliative and
cents. The clinical behavior is generally very aggressive aspiration cytology. The former includes body cavity fluids,
with high morbidity and mortality. Malignant melano- cerebrospinal fluid, urine, endoscopic brushings of gastro-
mas have a strong tendency to metastasize widely to intestinal or endobronchial lesions, scrapings of cutaneous
almost every possible site or organ in the body. Metas- lesions, vitreous fluid, and washings of ocular chambers.
tasis can occur several years after an initial diagnosis. At In cytologic specimens, the metastatic melanoma
times, a history of primary malignant melanoma is not cells are usually present as discrete cells, in groups/aggre-
documented. gates, syncytial tissue fragments, or in fascicles. They can
Primary cutaneous melanomas present four basic be monomorphic or exceedingly pleomorphic. The cells
histologic patterns with several morphologic variants can be small, moderate to large-sized with frequent giant,
and are basically composed of two cell types: round to bizarre forms. Varied shapes presented by melanoma cells
polygonal epithelioid and spindle type. Epithelioid mela- include round, plasmacytoid, cuboidal, polygonal, and spin-
noma cells are large, rounded, with abundant cytoplasm, dle shape among many. Their nuclei may be small to large
prominent vesicular, pleomorphic nuclei, and conspicu- to giant forms, single or multiple, round, uniform in shape
ous eosinophilic nucleoli. Melanin pigment, when pres- to irregular forms with lobulations. The nuclear chromatin
ent, appears as brownish-black, fi ne to coarsely granular can be finely granular, evenly dispersed to coarsely granu-
material within the cytoplasm. The spindle cell variant is lar or compact. Excessive parachromatin clearing is fre-
characterized by cells with elongated, narrow, tapering, quently observed. Malignant melanoma cells are known for
cytoplasmic processes. the presence of unusually large cherry–red macronucleoli;
The diagnosis of primary malignant melanoma is al- however, nucleoli may exhibit considerable pleomorphism
most always established by histopathologic examinations in size, shape, and numbers. Another frequent nuclear fea-
of the cutaneous lesions; cytopathology plays no part in ture includes the presence of single or multiple intranuclear
the initial diagnosis, but it is useful in establishing or con- inclusions. Regular and/or abnormal mitoses are common.
fi rming the diagnosis of malignant melanoma at a meta- Malignant melanoma cells demonstrate variable cytoplasm,
static site. scant to abundant, pale to dense, or vacuolated. Melanin
Malignant melanomas have a great propensity to pigment, when present, may be in the form of dusty light
metastasize widely to every possible site or organ in the brown pigmentation or as brown–black, fine to coarse
body. They usually first involve the local lymph nodes and granules that can totally obscure the cells. Melanin pigment
organs such as the lungs, the skin, the bones, the brain, can also be seen extracellularly due to the disruption of the
and the liver. Other sites that are frequently involved in- cell membranes and the release of the pigment. Excessive
clude the gastrointestinal tract, the prostate, the salivary melanin pigment may render the tissue or the body cavity
glands, the adrenal glands, and soft tissues. fluid black. The presence of melanin pigment clinches the
370
Chapter 11: Malignant Melanoma 371
diagnosis. Although 2% of primary malignant melanomas

are amelanotic, 30 to 60% of metastatic malignant melano-
mas are reported to be amelanotic. The cytologic features of
metastatic malignant melanomas seen at various sites and in
various types of cytologic specimens are listed in Table 11.1
and illustrated in Figures 11.1 to 11.29.

MALIGNANT MELANOMA
Cellularity Variable, generally high
Presentation Cells exfoliate singly in fluids; discohesive

or dispersed pattern frequent; cells isolated Fig. 11.1. FNA biopsy of malignant melanoma showing an epithe-
or in loosely cohesive groups; tissue lioid pattern. The melanoma cells are large, round to polygonal with
nuclei containing prominent macronucleoli. Note the melanin pig-
fragments in brushings or aspirates; fluid
ment in the cytoplasm (arrows).
or tissue may be discolored brown–black
due to melanin pigment
Cells Marked variation in size and shape,

within a tumor or from tumor to tumor;
small, large to giant forms; round, oval,
triangular, plasmacytoid, polygonal,
spindle-shaped, caudate forms; cell
borders well-defined; N/C ratios variable
Nucleus Variable in size; central to eccentric; bi-

multinucleated; round to oval, irregular,
multilobulated to multinucleated with
bizarre forms; nuclear membrane smooth
to irregular; chromatin fine to coarsely
granular, irregular clumping with
excessive parachromatin clearing; multiple
micronucleoli or single to multiple, Fig. 11.2. FNA biopsy of a skin nodule showing malignant melano-
small to large irregular cherry-red ma, spindle cell type. The melanoma cells are very large, with cyto-
macronucleoli; intranuclear cytoplasmic plasmic processes. Large cherry-red macronucleoli are conspicuous.
inclusions; mitotic figures ⫹/⫺ Melanin pigment is abundant.
Cytoplasm Scant to abundant, clear, pale to

dense, with or without brownish dusty
pigmentation, finely granular brownish–
black pigment or coarse, deep brownish–
black granules obscuring the cell details;
cytoplasmic tailing of round to triangular
forms; cytoplasmic vacuoles rare; large
vacuoles in balloon cell variant, bipolar
cytoplasmic processes in spindle cells
Background Extracellular melanin pigment ⫹/⫺;

necrosis, hemorrhage ⫹/⫺; myxoid stroma
in myxoid variant (rare)
Immunoprofile Positive reactivity to S100 protein (only on

formalin fixed specimens) and HMB-45,
Melin-A/MART-1, Tyrosinase, vimentin; Fig. 11.3. FNA biopsy of metastatic malignant melanoma. The
negative reactivity to cytokeratin, smooth cellular aspirate shows discrete, medium to large-sized pleomor-
muscle actin and desmin phic cells with high N/C ratios. Some exhibit unipolar cytoplasmic
processes. Note intranuclear cytoplasmic inclusions (arrows) and
prominent macronucleoli. Dusty melanin pigment is seen in some of
Ultrastructure Melanosomes and premelanosomes the cells (arrowheads).
Fig. 11.4. FNA biopsy of thyroid nodule from a young adult with Fig. 11.5. FNA biopsy of liver nodule. The patient had an ocular
a history of malignant melanoma. The aspirate shows pleomorphic melanoma. The malignant cells are large, polygonal with abundant
malignant cells. No melanin pigment is identified. In the absence of dense cytoplasm and clearly malignant nuclei. Note prominent in-
clinical history, an anaplastic carcinoma must be ruled out. Age of tranuclear inclusions (arrows). The differential diagnosis includes
the patient in this case does not favor the diagnosis of anaplastic a primary hepatocellular carcinoma. Immunostains are required to
carcinoma. Immunostains are required for diagnostic confirmation. confirm the diagnosis of malignant melanoma.
Fig. 11.6. FNA of an axillary lymph node with metastatic malig- Fig. 11.7. FNA of a parotid mass. The patient had a history of ma-
nant melanoma, showing bizarre malignant cells with prominent lignant melanoma. The cellular aspirate shows a large population of
intranuclear inclusions. No history of malignant melanoma was large malignant cells, with poorly defined cytoplasm, insignificant
available at the time of biopsy and a diagnosis of soft tissue sarcoma cytoplasm and large nuclei with excessively cleared parachromatin.
(malignant fibrous histiocytoma) was made. Nucleoli are prominent. No melanin pigment is present. This amel-
anotic melanoma cannot be differentiated from a poorly differenti-
ated carcinoma without immunostains.
Fig. 11.8. FNA biopsy of an axillary lymph node involved by a met-

astatic malignant melanoma, exhibiting a pleomorphic cell pattern.
Fig. 11.9. FNA of metastatic malignant melanoma exhibiting a Fig. 11.10. FNA of metastatic malignant melanoma to the parotid
pleomorphic pattern with round and spindle cells. gland. Note the cells are mostly amelanotic with only a suggestion
of melanin pigment (arrows). Some malignant cells exhibit cyto-
plasmic tailing. The multinucleated giant cell resembles Touton type
giant cell seen in malignant fibrous histiocytoma.
Fig. 11.11. FNA biopsy of a neck mass with no known history of ma- Fig. 11.12. FNA of a malignant melanoma consisting of small
lignant melanoma. The pleomorphic cell pattern consisting of cuboi- round cells with scant cytoplasm. This pattern presents differential
dal, round, oval spindle cells with bi- and multinucleation raised the diagnoses of neuroendocrine carcinoma and malignant lymphoma.
possibility of a neuroendocrine tumor. The presence of macronucleoli
is not in keeping with neuroendocrine tumors. Immunostain with
HMB-45 was strongly positive confirming malignant melanoma.
Fig. 11.13. FNA of another example of a metastatic malignant

melanoma showing very small discrete cells with poorly defined
cell borders and scant cytoplasm. Note the cytoplasmic tailing and
macronucleoli. The differential diagnoses include plasmacytoma or
malignant lymphoma.
A B
Figs. 11.14A and B. FNA biopsy of a large parotid mass. The cellular aspirate with exceedingly pleomorphic malig-
nant cells with spindle and giant forms entertained the differential diagnoses of soft tissue sarcoma and sarcomatoid
carcinoma and malignant melanoma. Immunostains confirmed melanoma. It was later found out that the patient had
malignant melanoma removed in the remote past.
A B
Figs. 11.15A and B. FNA biopsy of malignant melanoma metastatic to a lymph node showing a mixed round and
spindle cell pattern. Note the gigantic nucleoli. Melanin pigment is not present. A: Papanicolaou stain. B: Romanowsky
stain.
A B
Figs. 11.16A and B. FNA biopsy of a cervical lymph node. The patient had a documented history malignant melano-
ma. A: The aspirate is overwhelmingly cellular consisting of closely packed spindle cells (medium power). B: Higher
magnification showing discrete and loosely cohesive spindle cells with delicate cytoplasmic processes. Their nuclei are
oval to oblong with occasional one containing intranuclear inclusion (arrow).
Fig. 11.17. Gastric brushings showing a syncytial tissue fragment Fig. 11.18. FNA biopsy of a neck mass showing malignant melano-
of malignant cells with scant cytoplasm. Without a history of mela- ma with a spindle cell pattern. This cytologic pattern offers several
noma, these cells may be interpreted as adenocarcinoma. differential diagnostic entities such as soft tissue sarcomas, sarco-
matoid carcinomas, and neuroendocrine carcinoma.
A B
Figs. 11.19A and B. FNA of a retroperitoneal mass, showing a pleomorphic spindle cell pattern. Extensive ancillary
techniques confirmed this lesion as dendritic cell sarcoma. Malignant melanoma was considered but was not con-
firmed by immunostains.
Fig. 11.20. FNA of lung mass showing a very pleomorphic spindle- Fig. 11.21. Pleural effusion in a patient with a documented his-
shaped malignant neoplasm proven to be sarcomatoid carcinoma. tory of malignant melanoma. Note the exfoliated cells are discrete,
This pattern may be seen in spindle cell malignant melanoma. round to polygonal, and have malignant nuclei. No melanin pig-
ment is present. Without a history of malignant melanoma, the dif-
ferential diagnoses include poorly differentiated adeno or squamous
carcinoma and malignant mesothelioma.
A B
Figs. 11.22A and B. A: Pleural effusion with metastatic malignant melanoma. B: Poorly differentiated adenocarci-
noma cells. Note the resemblance of adenocarcinoma cells to melanoma cells.
Fig. 11.23. FNA biopsy of a vaginal nodule. The malignant cell Fig. 11.24. Discrete small malignant melanoma cells in cerebrospi-
contains very coarse granules of melanin pigment in the cytoplasm. nal fluid.
Fig. 11.25. FNA of metastatic malignant melanoma with a small Fig. 11.26. FNA of neck mass with discrete small round cell pat-
cell pattern reminiscent of a neuroendocrine carcinoma (carcinoid tern. The scant cytoplasm shows no melanin pigment. The differen-
tumor) or a malignant lymphoma. tial diagnoses include malignant lymphoma and a neuroendocrine
carcinoma. The immunostains confirmed the diagnosis of malignant
melanoma.
Fig. 11.27. FNA biopsy of a neck mass showing a syncytial tissue Fig. 11.28. FNA of a retro-orbital mass showing malignant mela-
fragment of malignant cells. Without ancillary tests, this malignant noma with strong positive reactivity to HMB-45.
melanoma may be interpreted as adenocarcinoma.
arise from the fact that malignant melanomas can mimic

almost every neoplasm in the body. The differential diag-
noses are site-specific, and depend on the type of specimen
(exfoliative or aspiration) and on cytomorphology. It must
be remembered that there are no specific cytologic fea-
tures for malignant melanomas except for the presence of
melanin pigment. For example, a very pleomorphic malig-
nant neoplasm with bizarre giant tumor cells in the central
nervous system must be differentiated from glioblastoma
multiforme, while a similar morphology in soft tissue
lesions may call for the diagnosis of a high-grade sarcoma.
Likewise, a pleomorphic pattern in adrenal gland lesions
will require differentiation from pheochromocytoma/
paraganglioma or an adrenal cortical carcinoma. A large
Fig. 11.29. FNA biopsy of a neck mass. The markedly cellular spec- round cell pattern with malignant cells containing abun-
imen consisted of malignant cells with scant cytoplasm that offered dant dense cytoplasm in the body cavity fluids must be dif-
no clues as to the source. Malignant melanoma was certainly a differentiated from malignant mesothelioma. The diagnostic
ferential diagnostic possibility; however, the immunostains for mel-
anoma were negative, so were the epithelial markers. An ultrastruc-
possibilities with a small round cell pattern with discrete
tural examination showed features in favor of adenocarcinoma. cells should include neuroendocrine tumors and malig-
nant lymphoma. Spontaneously exfoliated melanoma
cells always occur singly. However, in aspiration biopsies
IMMUNOPROFILE and in brushings/washings, melanoma cells may be pre-
sented in syncytial tissue fragments. Thus, in endoscopic
Malignant melanoma cells are immunoreactive to the fol-
brushings, the tissue fragments of malignant melanoma
lowing antibodies: S100 protein, HMB-45, and Melan-A
cells require differentiation from epithelial neoplasms. A
(MART-1). The S100 protein antibody is not effective on
spindle cell pattern presents a number of diagnostic possi-
alcohol fixed cells.
bilities. Table 11.2 lists the differential diagnoses of malig-
nant melanoma based on the cell morphology.
ULTRASTRUCTURE Extensive necrosis and hemorrhage that mask the
nuclear details or alteration of cytomorphology due to
Ultrastructurally, melanoma cells demonstrate premel- degeneration can result in a false negative diagnosis. The
anosomes and melanosomes. same holds true for inadequate samples or poor cyto-
preparations. Malignant melanomas with desmoplasia
may yield a poorly cellular sample in aspiration biopsies
DIAGNOSTIC DIFFICULTIES AND
and also may not exfoliate the diagnostic cells. A bland
DIFFERENTIAL DIAGNOSES
nuclear pattern in thin spindle cells with tapering cyto-
The diagnostic problems related to the cytologic diagno- plasmic processes in nonpigmented variants may be con-
sis of metastatic malignant melanoma are multifold and fused with cells of mesenchymal derivative, and therefore,
TABLE 11.2 DIFFERENTIAL DIAGNOSES OF MALIGNANT MELANOMA
Malignant Melanoma
Morphologic Features Diagnostic Entities Mistaken For See Fig(s).
Small round cells with dissociated Reactive mesothelial cells (in fluid) 6.75 7.165
pattern Malignant lymphoma 12.20
Multiple myeloma 11.13
Neuroendocrine tumors
Poorly differentiated carcinoma (adenocarcinoma or
squamous cell carcinoma), with a
single cell pattern
Large round/polygonal cells Malignant lymphoma, anaplastic large cell type 6.61
(epithelioid pattern) Hodgkin lymphoma 8.34A
to
8.34C
12.23
Poorly differentiated adenocarcinoma 14.16, 14.17, and
Poorly differentiated squamous carcinoma 14.29A and B
Malignant mesothelioma (in pleural fluid)
Pleomorphic cells Soft tissue tumors especially malignant fibrous 1.4B, 18.22A, 13.93E
histiocytoma 21.20, 21.26
Poorly differentiated carcinomas 23.23
Anaplastic carcinoma, (e.g., thyroid) 24.60
Adrenal cortical carcinoma
Pheochromocytoma/paraganglioma
Hepatocellular carcinoma
Glioblastoma multiforme
Spindle-shaped cells Soft tissue sarcomas 1.4B

Sarcomatoid carcinomas 14.25
Neuroendocrine tumors 24.41
Reactive fibroblasts from granulation tissue
Dendritic and histiocytic tumors
Signet-ring cells Adenocarcinoma
Balloon cell variant Adenocarcinoma
Myxoid stroma Soft tissue tumors
Papillary architecture Papillary carcinomas
misdiagnosed as a variety of benign connective tissue While interpreting a cytologic specimen for the pos-
neoplasms. On the other hand, fi broblasts in inflamma- sibilities of malignant melanoma, consideration must be
tory lesions or granulation tissue may be misinterpreted given to the following:
as malignant melanoma particularly in individuals with a
history of malignant melanoma. Melanin pigment strong- ● Malignant melanomas can metastasize anywhere in
ly resembles other commonly encountered pigments such the body and must always be considered in the differ-
as hemosiderin, anthracotic pigment, lipofuscin, and bile. ential diagnosis, particularly when the primary site is
Aspiration biopsies of lymph nodes with dermatopathic unknown.
lymphadenitis may be overcalled. Similarly, melanin pig- ● Malignant melanomas may metastasize several years
ment phagocytized by macrophages in the body cavity following the excision of the primary tumor, and a
fluids is a source for misinterpretation. Immunostains are second source of primary neoplasm needs to be ruled
required to confirm a diagnosis of malignant melanoma. out.
● Exfoliated malignant melanoma cells may present differ- ● Anthracotic pigment in respiratory specimens and lipo-
ent cytomorphology than the aspirated or abraded cells. fuscin in hepatocytes are potential diagnostic pitfalls
● Amelanotic tumors often need ancillary tests to con- and must be differentiated from the melanin pigment.
firm the diagnosis. ● Malignant melanomas present a wide range of mor-
● Antibody to S100 protein does not react with cells phologic patterns that mimic a variety of other
fixed in alcohol. neoplasms.
● Melanin pigment is often phagocytized by mac- ● Malignant melanomas may present unusual cytohis-
rophages. These melanophages must be differentiated tologic patterns (e.g., signet-ring type, with myxoid
from malignant melanoma cells (e.g., lymph nodes and stroma, balloon cell variant, papillary pattern, and
serous effusions). sometimes associated with psammoma bodies).
SUGGESTED READINGS
Bavi P, Sheer T, Gujral S. Malignant melanoma of mediastinum Murali R, Doubrovsky A, Watson GF, et al. Diagnosis of metastatic
misdiagnosed as a spindle cell thymoma in a fine needle aspi- melanoma by fine needle biopsy. Analysis of 2,304 cases. Am J
rate. Acta Cytol 2005;49:424–426. Clin Pathol 2007;127:385–397.
Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia: Nakhleh RE, Wick MR, Rocamora A, Swanson PE, Dehner LP.
Churchill Livingstone, 2006. Morphologic diversity in malignant melanomas. Am J Clin
de Almeida LS, Requena L, Rutten A, et al. Desmoplastic malig- Pathol 1990;93:731–740.
nant melanoma: A clinicopathologic analysis of 113 cases. Am Perry DM, Giore M, Seigler HF, Johnston WW. Fine needle aspira-
J Dermatopathol 2008;30:207–215. tion biopsy of metastatic melanoma. A morphologic analysis of
de Vries E, Elder DE, Bray F, et al. Melanocytic tumors. In: Lebolt 174 cases. Acta Cytol 1986;30:385–396.
PE, Burg G, Weedon D, Sarasin A, eds. Pathology and Genetics. Plao Y, Guo M, Gong Y. Diagnostic challenges of metastatic spin-
Skin Tumors. WHO Classification of Tumors. Lyon, France: dle cell melanoma on fine-needle aspiration specimens. Cancer
IARC Press, 2006. (Cancer Cytopathology) 2008;11:94–101.
Doubrovsky A, Scolyer RA, Murali R, et al. Diagnostic accuracy of
fine needle biopsy for metastatic melanoma and its implications
for patient management. Ann Surg Oncol 2008;15:323–332.
12 HEAD AND NECK
(MISCELLANEOUS)
change in the lymph nodes (e-Figs. 12.4 and 12.5). Myco-

EXFOLIATIVE AND ASPIRATION bacterial infection is also seen in patients with AIDS.
CYTOPATHOLOGY Midline cysts most frequently include dermoid cysts,
thyroglossal duct cysts (see Chapter 15), and sometimes
Head and neck masses encompass a broad range of lesions thyroid isthmic cysts. Thyroglossal duct cyst aspirates
involving several anatomic sites and originating in differ- present morphologic features similar to that of branchial
ent tissues and organs. They may be congenital, inflam- cleft cyst aspirates, and in addition, sometimes contains
matory, or neoplastic (Table 12.1). They may be cystic thyroid follicular cells (e-Fig. 12.6). Rarely, carcinomas
or solid. Most are palpable and easily accessible to FNA arise from thyroglossal duct cysts, with the papillary type
biopsy procedures. Scrape smears are occasionally pre- being the most frequent; when present, a cytologic diag-
pared from cutaneous lesions. Thyroid nodules, enlarged nosis of malignancy is easily made (see Chapter 13).
cervical lymph nodes, and salivary gland lesions are rou- Epidermal inclusion cysts contain abundant lamel-
tinely evaluated utilizing fi ne needle biopsy and are dis- lated keratin with mature nucleated and anucleated
cussed separately in Chapters 13, 14, and 15, respectively. squamous cells, and sometimes a foreign-body reaction
This chapter will focus on lesions that are either less fre- to keratin with the presence of multinucleated foreign-
quently encountered or not described in other chapters. body type giant cells that may contain keratin. (e-Fig.
12.3). Branchial cleft cysts occur predominantly in pa-
tients younger than 30 years of age. Generally smaller
than 5 centimeters, they are lined by stratified squamous
CYSTIC LESIONS OF THE NECK
and, occasionally, columnar epithelium. The subepithelial
area consists of lymphoid tissue with germinal centers. A
The head and neck area hosts several different types of cysts, branchial cleft cyst may get infected, resulting in a denu-
both congenital and acquired. Identification depends on dation of epithelium and replacement by granulation tis-
their anatomic location as well as cytomorphologic features. sue. The cyst contents are clear to turbid with varying cel-
Cysts arising in salivary glands are discussed in Chapter 15. lularity represented by nucleated and anucleated benign
Congenital cysts in the head and neck area include squamous cells with or without keratinization. Nuclear
cystic hygroma (seen in the pediatric age group), branchi- atypia, perhaps due to an infl ammatory response, may
al cleft cysts, thyroglossal duct cysts, and dermoid cysts. cause a potential diagnostic problem (e-Fig. 12.2; also re-
Cystic hygromas are generally discovered before fer to Chapter 15). The background can be clean or show
3 years of age and present as tense, soft, fluctuant, non- infl ammatory cells, lymphoid cells, cellular debris, kera-
tender masses that do not regress spontaneously. The tin, and multinucleated foreign-body type giant cells.
frequent site is the head and the neck. The cyst may be Metastatic well-differentiated squamous carcinoma
unilocular or multilocular, fi lled with clear straw col- is often cystic, yielding a cheesy aspirate similar to an
ored fl uid, and lined by fl attened endothelial cells (e-Fig. epidermal inclusion cyst or a caseating granuloma. The
12.1A). The aspirates are generally acellular or contain a malignant squamous cells are so well-differentiated that
few lymphocytes (e-Fig. 12.1B). Cysts in the lateral neck distinguishing them from benign (epidermal inclusion)
include branchial cleft cysts (e-Fig. 12.2), epidermal in- cysts may offer difficulties (Table 12.2; Fig. 12.1).
clusion cysts (e-Fig. 12.3), cystic lymph nodes with met- Lymph node metastases from papillary thyroid car-
astatic disease, with the most frequent being metastatic cinomas are frequently cystic. Their aspirates range from
squamous carcinomas (Figs. 12.1A and B) and papillary clear or turbid to hemorrhagic. Diagnosis can be made
thyroid carcinoma (Figs. 12.2A and B). Thyroid and only when the epithelial cells present the minimum criteria
parathyroid cysts also enter the differential diagnosis (see for the cytologic diagnosis of papillary thyroid carcinoma
Chapter 13). In countries where tuberculosis is endemic, (see Chapter 13) (Fig. 12.2). Papillary carcinoma, with or
caseating necrosis often leads to enlargement and cystic without psammoma bodies, may also originate from the
380
Chapter 12: Head and Neck (Miscellaneous) 381
TABLE 12.1 COMMON HEAD AND NECK lung, the ovary, the endometrium, and the kidney. Clini-
LESIONS ACCESSIBLE TO FINE NEEDLE BIOPSY cal data and immunocytochemical stains are necessary to
determine the source.
Lymph nodes
Cysts (congenital and acquired)

CUTANEOUS LESIONS
Salivary gland lesions
Thyroid/parathyroid
INFECTIONS
Infectious lesions may involve cervical lymph nodes pri-
Soft tissue lesions marily or secondarily from the skin lesions or oral lesions
via lymphatics. AIDS-associated infectious lesions have
Jaw bones increased in incidence in the last three decades. Actino-
mycotic abscesses may be encountered, particularly with
Neuroendocrine tumors
dental manipulations (e-Fig. 12.7).
Nasopharynx; Paranasal sinuses
CUTANEOUS NEOPLASMS
Parapharyngeal space lesions
Neoplasms originating from skin and adnexal structures
Orbit and periorbital lesions constitute a broad group of morphologically diverse
tumors. Fine needle biopsy is not a procedure of choice
Oropharyngeal lesions in the diagnosis of cutaneous neoplasms. However, it is
used often enough to rule out a cutaneous metastasis in
Cutaneous lesions a patient with a known malignancy or to identify a deep-
seated palpable lesion that turns out to be a cutaneous
TABLE 12.2 DIFFERENTIAL DIAGNOSES OF NECK CYSTS WITH SQUAMOUS CELLS
Epidermal Inclusion Cyst Branchial Cleft Cyst Cystic Squamous Carcinoma

Age Any age Younger age group Older age group
History of Squamous Not applicable Not applicable ⫹/⫺

Carcinoma
Gross Appearance of Thick, cheesy Clear to turbid Thick, cheesy

the Aspirate
Cellularity Variable Variable Variable
Presentation Cells mostly discrete Cells mostly discrete, in groups Cells mostly discrete, in groups or
or in small tissue fragments in syncytial tissue fragments
Cells Mature squamous cells; Benign mature squamous cells; Malignant squamous cells;
nucleated and anucleated pleomorphic in size; anucleated markedly pleomorphic in size and
forms; N/C ratios low; forms frequent; keratinization shape; nuclei large, pyknotic and/
pyknotic nuclei; Cytoplasm ⫹/⫺; small pyknotic nuclei or with finely granular chromatin,
clear to keratinized or with granular chromatin; parachromatin clearing and
nucleoli generally absent; nuclear micro/macronucleoli; cytoplasm
enlargement and nucleoli present clear to excessively keratinized
with inflammation
Background Abundant lamellated keratin; Lamellated keratin ⫹/⫺; Keratin pearls; lamellated keratin;
foreign-body giant cell lymphoid cells ⫹/⫺; foreign-body keratin debris; anucleated cells
reaction ⫹/⫺ giant cell reaction ⫹/⫺ with pleomorphic shapes; may be
excessively keratinized; foreign-
body giant cell reaction ⫹/⫺
A B
Figs. 12.1A and B. Metastatic squamous carcinoma. A: FNA of a cystic cervical mass showing pleomorphic large
mature squamous cells with anucleated forms. Note the spindle form. The malignant cells are very well-differentiated.
B: Another field from the same case showing extensive keratin debris.
A B
Figs. 12.2A and B. FNA of cystic lymph node in the neck showing pleomorphic, medium-sized round cells, mostly
discrete, and in small tissue fragments. A: Note the pale chromatin, intranuclear inclusion, favoring metastatic
papillary thyroid carcinoma. B: The aspirate also showed psammoma bodies.
neoplasm. Every now and then, cytopathologists will come branching and producing animated forms (Figs. 12.3 and
across such specimens that become diagnostic challenges. 12.4). The component cells are closely packed, demon-
Although primary cutaneous neoplasms or metastatic strating smooth external contours and peripheral palisad-
lesions can be encountered anywhere in the body, they ing of nuclei. Isolated cells are infrequent. The neoplas-
are more frequently biopsied from head and neck areas; tic cells are small with scant insignifi cant cytoplasm and
hence, they are discussed in this chapter. Also, primary round, oval, to slightly oblong nuclei containing compact
cutaneous neoplasms comprise an impressive list of tu- chromatin (and referred to as basaloid cells) (Fig. 12.4).
mors. However, only a few of them will be described in Nucleoli as well as mitoses are infrequent. There is an
this section. Readers may refer to the literature for a de- overall appearance of uniformity. The background is clean.
tailed review. The differential diagnosis includes basaloid squamous
carcinoma. The presence of clumped chromatin, with
parachromatin clearing, nucleoli, mitoses, and necrosis
BASAL CELL CARCINOMA
favor squamous carcinoma (Fig. 12.5). A cribriform pat-
Basal cell carcinomas are common cutaneous neoplasms tern with acellular material may be mistaken for adenoid
occurring in sun-exposed areas, specifi cally the head and cystic carcinoma. Basal cell adenocarcinoma arising in the
neck, and are only infrequently subjected to a fine needle skin over the parotid gland must be differentiated from
biopsy procedure. The aspirate is usually very cellular basal cell adenoma and adenocarcinoma (see Chapter 15,
with syncytial tissue fragments of varying sizes, showing Salivary Glands).
Fig. 12.3. FNA of a cutaneous nodule, consisting of a large syn- Fig. 12.4. FNA of a cutaneous nodule showing a syncytial tissue
cytial tissue fragment of basaloid cells, consistent with basal cell fragment of elongated cells with oblong nuclei. In the right location,
carcinoma. this pattern is consistent with basal cell carcinoma.
Fig. 12.5. FNA of a cutaneous nodule demonstrating sparse cel- Fig. 12.6. FNA of a cutaneous malignant melanoma, depicting a fas-
lularity, consisting of malignant squamous cells. cicle of spindle-shaped cells with pleomorphic oblong, spindle-shaped,
and round nuclei. Melanin pigment is not present in this field.
SQUAMOUS CARCINOMA PILOMATRIXOMA

Squamous carcinoma of the skin can occur as an ulcer Pilomatrixoma, also known as calcifying epithelioma of
with raised and indurated edges or as a nodule. The for- Malherbe, is a benign skin tumor of hair cortical cells
mer may be scraped for cytologic examination (Fig. 12.5). frequently occurring in the head and neck and upper
Differential diagnosis includes herpetic ulcers (e-Fig. extremities as a solitary dermal or subcutaneous nodule.
12.8). Squamous carcinomas presenting as nodules may Histologically, pilomatrixoma consists of a sharply cir-
be biopsied by fine needle aspiration. Cytologic presenta- cumscribed, encapsulated nodule with irregular islands
tion is the same as that described for squamous carcino- of basaloid cells merging into shadow or ghost cells. The
mas elsewhere. latter show a central pale area—the site of a lost nucleus.
Multinucleated foreign-body giant cells and calcific debris
are also seen.
MALIGNANT MELANOMA
The cytologic pattern of pilomatrixoma (Table 12.3;
Primary cutaneous malignant melanomas are best diag- Figs. 12.7A to E) is characterized by the presence of ghost
nosed and graded by histopathologic examination follow- cells and basaloid cells and squamous cells. The ghost
ing an excisional biopsy. Fine needle biopsy is performed cells are anucleated cells, about the size of metaplastic
for unsuspected, unusual nodules or recurrent skin lesions squamous cells with distinct cell borders. In the aspirate
(Fig. 12.6). smears, the cells appear isolated or in aggregates. Their
TABLE 12.3 CYTOLOGIC FEATURES OF PILOMATRIXOMA
Cellularity Variable
Presentation Polymorphic cell population with cells isolated, in aggregates

and syncytial type tissue fragments, with cellular and calcific
debris
Cells Polymorphic cell types; tissue fragments of basaloid cells with

poorly-defined cell borders, oval to elongated hyperchromatic
nuclei, scant cytoplasm; aggregates of large, round cells with
well-defined cell borders, central pale area representing site of
lost nucleus (ghost or shadow cells); squamous cells, with or
without nuclear atypia and keratinization
Background Multinucleated foreign-body type giant cells; granuloma

formations; stromal tissue fragments; keratin; calcific and
cellular debris; inflammatory cells, naked basal cell nuclei
Differential Diagnoses With predominant basaloid cell population:

Basal cell carcinoma
Metastatic small cell carcinoma
Merkel cell carcinoma
Salivary gland neoplasms
Adenoid cystic carcinoma
Pleomorphic adenoma
With squamous cells and keratin pearls:
Epidermal inclusion cyst
Squamous carcinoma
A B
Figs. 12.7A to B. FNA of a pilomatrixoma. A: Cellular debris obscuring the basaloid ans squamous cells. B: An
aggregate of squamous cells. Note the “ghost cells” in the background. (continued)
C D
Figs. 12.7C to E. (continued) C: A tissue fragment of benign squamous

cells. D, E: Tissue fragments of basaloid cells. All the features together
E support the diagnosis of pilomatrixoma.
cytoplasm stains yellow–brown with a well-defined clear of epithelial and myoepithelial cells and loose myxoid
area or a pale shadow occupying the site of the nucleus. stroma. The cytologic presentation (Figs. 12.8A and B) is
The basaloid cells may be isolated or in tissue fragments identical to that of pleomorphic adenoma of the salivary
with scant, indiscernible cytoplasm and appear as naked gland (see Chapter 15).
nuclei. Squamous cells with or without keratinization are
occasionally present. The background may show calcific
MERKEL CELL CARCINOMA
debris, infl ammatory cells, and foreign-body type multi-
nucleated giant cells. Merkel cell carcinoma is a rare and aggressive primary
Although the cytologic pattern is characteristic, di- neuroendocrine carcinoma of the skin arising from the
agnostic diffi culties may arise with a large population specialized epithelial cells known as Merkel cells. Without
of basaloid cells or with the presence of keratinized the special stains, Merkel cells cannot be distinguished
squamous cells. The diagnostic accuracy of pilomatrixo- from the surrounding cells in routine H&E preparations
ma is low with aspirates being misinterpreted as several of the skin. Merkel cell tumors occur usually in elderly
different types of neoplasms based on cell composition white patients, primarily involving the sun-exposed areas.
(Table 12.3). The incidence is reported to be 0.34/100,000 in men
as compared to 0.17/100,000 in women. The majority
of the patients are older than 65 years. Nearly half the
CHONDROID SYRINGOMA
cases (46%) are reported to involve the head and neck
Chondroid syringomas (syn–mixed tumor, pleomor- followed by upper extremities (21%), lower extremities
phic adenoma) are intradermal or subcutaneous nodules (14%), and trunk (7%) with the remaining 7% involving
occurring more frequently in the head and neck. Firm in miscellaneous sites.
consistency, they range in size from 0.5 to 3 centimeters Clinically, Merkel cell tumor presents as a rapidly
and are mobile, free from the overlying skin. growing, solitary, purple dome-shaped papule or plaque
Histologically, the neoplasm is encapsulated, com- on sun-exposed skin, frequently localized in the head
posed of a biphasic pattern with variable proportions and neck region. Merkel cell carcinomas are aggressive
A B
Figs. 12.8A and B. FNA of a subcutaneous nodule, proven to be a mixed tumor or chondroid syringoma. A: Medium
power view depicting a cellular aspirate showing an admixture of epithelial cells and myxoid matrix material.
B: Higher magnification showing predominantly, round to plasmacytoid myoepithelial cells.
tumors with a propensity for local recurrences and re- seen clustering around the blood vessels. The cell borders
gional lymph node metastases. are poorly defined, and the cytoplasm is indiscernible to
scant. The nuclei are round to oval with high N/C ratios.
Gross and Microscopic Features Their chromatin is granular and nuclear molding and
stretch artifacts may be noted. The nuclear membranes
Grossly, the Merkel cell carcinomas are confi ned to the
are smooth to irregular and, occasionally, highly convo-
dermis and subcutis and vary in size, ranging from 0.3 to
luted. Mitoses are frequent and individual cell necrosis
6 centimeters with an average of 2 to 3 centimeters. They
may be noted. Merkel cell carcinoma cells have scant
appear as gray–white masses.
cytoplasm, but occasionally, it appears pale-pink, homo-
Histologically, Merkel cell carcinomas present two
geneous, and relatively dense with well-circumscribed
basic growth patterns: namely trabecular—consisting of
round to oval buttons of cytoplasm in perinuclear loca-
cords of tumor cells two to three cells thick or wider—
tions. These buttons are described as either attached to
and a diffuse, sheet-like growth pattern that more closely
the nucleus, lying in the indentation of the nucleus, or
resembles a malignant lymphoma.
detached and lying free outside the nucleus. Ultrastruc-
The neoplastic cells are round, small with a scant rim
turally, these correspond to the distinct buttons of inter-
of amphophilic cytoplasm. Occasionally, spindle forms
mediate filaments.
are present. The nuclei are round, hyperchromatic with
finely granular chromatin and inconspicuous nucleoli and
Ultrastructure
high N/C ratios. Mitotic activity is usually very brisk.
Lymphoplasmacytic infi ltrate is often seen surrounding Ultrastructurally, Merkel cell carcinoma cells invariably
the tumor and also within the tumor. Pagetoid growth demonstrate membrane-bound dense-core secretory gran-
of the tumor cells has been described. The stroma of the ules, 80 to 300 nanometers in diameter. In many cases, the
tumor is richly vascularized. Areas of coagulative necrosis granules demonstrate a clear zone surrounding the dense
may produce geographic patterns and crush artifacts are core granules. Another important feature is the presence
seen in approximately 50% of the cases. Invasion of the of perinuclear or juxtanuclear whorls of intermediate fil-
dermal lymphatics and vessels as well as the incrustation aments—an important feature that differentiates Merkel
of the vessel with DNA (Azzopardi phenomenon) repre- cell carcinoma from other neuroendocrine tumors.
sents other features of these tumors. Amyloid deposits
have been described. Immunoprofile
Merkel cell carcinoma cells react positively to several
neuroendocrine markers such as chromogranin, synapto-
The aspirates are usually very cellular, consisting of a large physin, and neuron-specific enolase. The cells are positive
population of monomorphic small, round to cuboidal to low molecular weight keratin, CK20, and negative to
cells, present as discrete, in loosely cohesive groups or in high molecular weight keratin and TTF-1. The positive
syncytial tissue fragments without any architectural pat- reactivity to CK20 and the negative reactivity to TTF-1
terns (Table 12.4; Figs. 12.9A to C). Occasionally, pseu- are important features that differentiate small cell carci-
dorosettes may be present. The neoplastic cells are also nomas from Merkel cell carcinoma.
TABLE 12.4 CYTOPATHOLOGIC FEATURES OF MERKEL CELL (NEUROENDOCRINE) CARCINOMA
Cellularity Highly Cellular
Presentation Dissociated pattern common, cells mostly isolated; also in groups and in syncytial tissue fragments
Cells Monomorphic, small, round, 10–16 ␮m in largest dimension; poorly defined cell borders; high N/C
ratios
Nucleus Round to oval; smooth nuclear membrane; convoluted shapes have been described; salt & pepper
chromatin; nucleolus ⫹/⫺; mitoses frequent; no nuclear molding; karyorrhexis ⫹/⫺; stretch
artifacts
Cytoplasm Indiscernible to scant
Background Necrosis ⫹/⫺; stripped nuclei
Immunoprofile Positive reactivity to neuroendocrine markers, neurofilaments, low molecular weight cytokeratin,
CK20; negative reactivity to CK7, TTF-1, S100 protein, high molecular weight keratin, and
leukocyte common antigen (LCA)
Ultrastructure Electron dense, membrane bound secretory granules; paranuclear whorls or buttons of
intermediate filaments
Differential Diagnoses Other neuroendocrine carcinomas

Malignant lymphoma/leukemia
Malignant melanoma
Poorly differentiated adnexal tumors
Metastatic poorly differentiated adeno/squamous carcinomas
A B
Figs. 12.9A to C. A: FNA of a submandibular mass proven to be a

Merkel cell carcinoma consisting of discrete small round cells with
scant to indiscernible cytoplasm, round to elongated nuclei with
coarsely granular to compact chromatin. Note the nuclear mold-
ing. B: Same aspirate stained by Romanowsky method. C: Different
example of Merkel cell carcinoma presenting a typical morphology
C of a small cell neuroendocrine carcinoma.
387
Diagnostic Difficulties and Differential Diagnoses CUTANEOUS METASTATIC MALIGNANCY

The differential diagnoses of Merkel cell carcinoma Cutaneous metastases from internal malignancies (Figs.
(Table 12.4) includes lesions composed of small cells (e.g., 12.16 and 12.17) are rare, the reported incidence ranging
other neuroendocrine carcinomas, malignant lymphoma/ from 0.7 to 4.4% in patients dying from cancer. The pres-
leukemia, poorly differentiated adenocarcinomas, basaloid ence of cutaneous metastasis indicates an advanced disease;
squamous carcinomas, and malignant melanoma) (Figs. occasionally, it can be the first manifestation. The abdominal
12.10 to 12.15). Ancillary tests are required for accurate wall, chest wall, and scalp are reported to be more frequent
typing of the neoplasm. Please refer to Chapter 15 and sites. Anecdotal cases of cutaneous metastasis as the initial
Tables 15.38 and 15.39 for the differential diagnostic fea- manifestation of malignancy elsewhere in the body have
tures of small cell lesions in the head and neck area includ- been reported. With a known primary site, identification of
ing the salivary glands. a metastatic lesion generally does not pose a problem.
Fig. 12.10. FNA of a small cell carcinoma metastatic to the cervical Fig. 12.11. Metastatic poorly differentiated squamous carcinoma of
lymph node. Note the identical presentation of metastatic small cell the ear lobe to the cervical lymph node, easily mistaken for a small
carcinoma of the lung is identical to that of Merkel cell carcinoma. cell or Merkel cell carcinoma. The aspirate was initially interpreted
The differentiation between the two can be proven with CK20 posi- as such. However, the neuroendocrine markers were negative.
tivity to Merkel cell carcinoma cells.
Fig. 12.12. FNA of a metastatic poorly differentiated squamous Fig. 12.13. FNA of a cervical lymph node involved by a malignant
carcinoma to the cervical lymph node in a patient with the history lymphoma. The discrete large lymphoma cells of a large B-cell lym-
of lung cancer. Note the morphologic pattern can be misinterpreted phoma should always be considered in the differential diagnosis of
as a neuroendocrine carcinoma. a neuroendocrine carcinoma.
Fig. 12.14. FNA of a cervical lymph node involved by anaplastic

K-1 malignant lymphoma. These lymphoma cells are discrete and
somewhat larger than the neuroendocrine carcinoma cells. Note the
similarity to squamous carcinoma cells in Figure 12.12.
A B
Figs. 12.15A and B. A: FNA of cervical mass in a patient with a history of acute myeloid leukemia showing
granulocytic sarcoma involving the soft tissues of the neck. B: Multiple myeloma involving the soft tissues of the neck.
Without a relevant clinical history, these two diagnostic entities overlap morphologically with small cell carcinomas.
Fig. 12.16. FNA of a metastatic poorly differentiated squamous Fig. 12.17. FNA of metastatic adenocarcinoma of the lung to the
carcinoma of the lung to the skin. skin.
CERVICAL (EXTRA-ADRENAL) may be present along with multinucleated cells. Their

PARAGANGLIOMA cytoplasm is clear, pale to granular, and dense. Their nu-
clei are variable, with small to giant forms and coarsely
Paragangliomas are rare neoplasms arising from neural
granular chromatin. Interdigitation of cell processes is
crest-derived paraganglionic tissue, which is widely dis-
rather characteristic. The cytologic features of paragan-
tributed in the body. The paraganglionic tissue belongs
gliomas are as varied as their histomorphology (Table
to the diffuse neuroendocrine system (Chapter 10) and is
12.5; Figs. 12.18A to D; also refer to Chapter 10, Figs.
present as small nests that are generally adjacent to the
10.39) and Chapter 21. Diagnostic accuracy, as reported
autonomic nerves and their ganglia.
in the literature, is low, often due to inadequate aspirates
Paragangliomas frequently occur infrequently in the
(Figs. 12.18C and D) and morphologic overlap with sev-
head and neck region. Among these, the carotid body tu-
eral other types of tumors.
mors are more common, arising at the bifurcation of the
The differential diagnoses (Table 12.6) include other
carotid artery. Other locations include the middle ears
neuroendocrine tumors (e.g., medullary thyroid carci-
and the base of the skull. Paragangliomas are vascular,
noma) (Fig. 12.19), metastatic poorly differentiated car-
may be pulsatile, and reach up to 4 to 6 centimeters in
cinomas, malignant melanoma (Fig. 12.20), malignant
size. Due to its extreme vascularity and close proximity to
lymphoma, or alveolar soft part sarcoma (see Chapter 24,
the vital structures in the neck, a clinically suspected ca-
Table 24.11).
rotid body tumor is generally not recommended for a fine
needle biopsy procedure. Unsuspected paragangliomas
may be biopsied and must be considered in the differen-
tial diagnosis of cervical masses.
SOFT TISSUE (MESENCHYMAL) LESIONS
Grossly, they are well-defined, fleshy pinkish white
to hemorrhagic and may show a cystic change. Para-
gangliomas are histologically characterized by nests and A number of diverse lesions, both benign and malignant,
alveoli of small to large, round to oval, polygonal to are encountered in the soft tissues of the neck. The malig-
spindle-shaped cells separated by a sinusoidal network, nant lesions are usually secondary tumors. Non-neoplastic
and at times, hyalinized stroma. Giant and myoid forms lesions very often include proliferating granulation tissue.
TABLE 12.5 CYTOPATHOLOGIC FEATURES OF PARAGANGLIOMA
Cellularity Variable; Scant to Cellular
Presentation Cells discrete with a dispersed pattern and/or in loosely cohesive groups and in syncytial tissue
fragments as nests, trabeculae, occasionally rosettes
Cells Size and shapes variable; monomorphic to extremely pleomorphic; small to giant forms; round,
oval, plasmacytoid, polygonal to spindle shapes, strap cells; cell borders poorly-defined; N/C
ratios variable
Nucleus Variable in size; central to eccentric; bi- to multinucleation; round to oblong; smooth nuclear
membranes; occasionally convoluted; granular chromatin; nucleoli prominent in aggressive
tumors; intranuclear inclusions ⫹/⫺; mitoses ⫹/⫺
Cytoplasm Variable, scant indiscernible to abundant; pale, dense to granular to vacuolated; cytoplasmic
processes, generally unipolar; melanin pigment ⫹/⫺
Background Bare nuclei frequent; bloody
Immunoprofile Positive reactivity to neuroendocrine markers; S100 positivity for sustentacular cells
Ultrastructure Membrane-bound neurosecretory granules
Differential Diagnoses (for Medullary thyroid carcinoma

Cervical Paraganglioma) Metastatic poorly differentiated carcinoma
Malignant melanoma
Soft tissue tumors
A B
C D
Figs. 12.18A to D. A, B: FNA of a cervical mass. The cellular aspirate consists of pleomorphic cells, some are discrete
and in loosely cohesive groups, while some are forming small tissue fragments without any architectural patterns.
The cells are medium-sized, round, plasmacytoid and short spindle-shaped with unipolar cytoplasmic processes.
The nuclei are round with coarsely granular chromatin. The N/C ratios are high and the cytoplasm is variable. The
differential diagnoses of this cellular presentation include paraganglioma, medullary thyroid carcinoma, and malig-
nant melanoma. C, D: Aspirates of cervical paragangliomas that were poorly cellular and consisted of small, round
lymphocyte-like cells. These two inadequate aspirates were interpreted as nondiagnostic. Surgical excision of both
confirmed paraganglioma.
Many are unusual and uncommon (e.g., extramedullary mass lesions involving this anatomic site. The biopsy may
hematopoiesis). Malignant lesions affecting the soft tissues be performed under the guidance of computed tomogra-
are usually secondary tumors. Soft tissue or mesenchymal phy or ultrasound.
tumors are frequent in the head and neck area. Their cyto- Orbital lesions subjected to FNA biopsy procedure
logic presentations are described in Chapter 24. include; 1) ocular lesions both non-neoplastic and neo-
plastic; 2) optic nerve neoplasms; 3) soft tissue tumors; 4)
lymphoid lesions; 5) metastatic tumors; and 6) lachrymal
gland lesions. Periorbital lesions include those involving
ORBIT AND PERIORBITAL LESIONS
the eyelids, inner and outer canthus, and eyebrow. Ocular
lesions can also be diagnosed by examining the vitreous
Orbital contents include the eyeball, periocular skeletal fluid. Diagnostic vitrectomy has been successfully used in
muscles, a pad of adipose tissue, and delicate fibrovas- the diagnosis of various pathologic processes involving
cular stroma. Non-neoplastic and neoplastic lesions aris- the eye. Cytologic features in vitreous fluid in cases of
ing from these structures span a wide spectrum. How- glaucoma, inflammatory lesions, infectious processes, and
ever, orbital lesions are not commonly encountered in the ocular tumors have been described.
usual setting of cytopathology practice. Fine needle aspi- The orbital neoplasms can be grouped into two broad
ration biopsy, although proven to be a popular diagnostic categories: 1) those occurring in pediatric age groups and
technique, has been used infrequently in the evaluation of 2) those occurring in adults.
TABLE 12.6 DIFFERENTIAL DIAGNOSES OF PARAGANGLIOMA IN THE NECK

Paraganglioma Dispersed cell pattern; neoplastic cells very pleomorphic in size and shape; nuclei variable 12.18
in size, round, oval, spindle-shaped; nuclear membrane irregularity, unusual; coarsely 10.39
granular chromatin, nucleoli may be prominent, intranuclear cytoplasmic inclusions;
mitoses ⫹/⫺; variable cytoplasm with unipolar cytoplasmic processes; neuroendocrine
markers ⫹; calcitonin ⫺; S100 protein positive reactivity with sustentacular cells
Medullary thyroid Predominantly dispersed cell pattern; syncytial tissue fragments unusual; neoplastic cells 12.19
carcinoma pleomorphic in size and shape; nuclei round, oval to spindle-shaped; nuclear membrane
irregularity, unusual; coarsely granular chromatin; inconspicuous nucleoli; intranuclear
cytoplasmic inclusions; mitoses unusual; cytoplasm variable with unipolar cytoplasmic
processes; calcitonin ⫹
Metastatic poorly Malignant cells isolated; in loosely cohesive groups or in syncytial tissue fragments; cells 14.27
differentiated pleomorphic in shape and size; nuclei round, oval, spindle-shaped; nuclear membrane
carcinoma irregularity frequent; fine to coarsely granular chromatin; micro/macronucleoli prominent;
intranuclear cytoplasmic inclusions; mitoses ⫹/⫺; cytoplasm variable in quality and
quantity
Malignant Predominantly dispersed cell pattern; malignant cells very pleomorphic in size and shape; 12.20
melanoma nuclei round to oval or spindle-shaped; nuclear membrane irregularities unusual; fine to
coarsely granular chromatin; prominent nucleoli; intranuclear cytoplasmic inclusions;
mitoses ⫹/⫺; cytoplasm variable; melanin pigment ⫹/⫺; unipolar cytoplasmic tailing;
HMB-45 ⫹; Melan-A ⫹
Malignant Usually cellular aspirate with a dispersed pattern; cells discrete with rare tissue fragment. 19.43
lymphoma Small to medium-sized; poorly-defined cell borders; high N/C ratios, nuclei round; nuclear
membrane irregularities ⫹/⫺; parachromatin clearing; nucleoli single large one to multiple
small ones; mitoses ⫹; no nuclear molding; karyorrhexis; stretch artifacts ⫹/⫺
Fig. 12.19. FNA of a cervical lymph node with metastatic medul- Fig. 12.20. FNA of a cervical mass depicting a population of dis-
lary thyroid carcinoma. Without a history of thyroid carcinoma, crete round to polygonal pleomorphic cells. Differential diagnoses
this aspirate consisting of uniform small cell will be difficult to in- of metastatic melanoma and paraganglioma were considered. The
terpret without immunostains. S100 protein and HMB-45 stains were positive. There was a history
of malignant melanoma in remote which was not available at the
time of biopsy, past malignant melanoma.
Fig. 12.21. Vitreous fluid in an infant showing small round cells Fig. 12.22. FNA of an embryonal rhabdomyosarcoma in a young-
consistent with retinoblastoma. ster, with metastasis to the orbit.
Rhabdomyosarcoma
One-fourth of head and neck sarcomas in the pediatric age
group originate from the orbit. Embryonal rhabdomyo-
sarcoma (Fig. 12.22) is the most frequent histologic type
(see Chapter 25 for cytologic features).
Metastasis Orbital Malignancies in Childhood

Metastasis may occur in orbital areas from neuroblastoma,
Ewing’s sarcoma, and Wilms’ tumor. Leukemic infiltrate
and malignant lymphoma often involve the orbit as well.
Fig. 12.23. FNA of an ocular lesion showing a large population of ORBITAL LESIONS IN ADULTS
pleomorphic round and spindle-shaped cells, which stained positive
for HMB-45 consistent with the clinical impression of malignant In adults, orbital lesions span a wide spectrum ranging
melanoma. from inflammatory and infectious lesions to several types
of benign and malignant neoplasms. The infectious lesions
of importance are mycotic infections. Inflammatory
pseudotumors may form mass lesions, showing a mixed
ORBITAL NEOPLASMS IN CHILDHOOD
inflammatory cell population on aspiration biopsy.
A detailed discussion on all orbital neoplasms in
Retinoblastoma
adults is beyond the scope of this atlas. The most com-
Retinoblastoma—a malignant neoplasm derived from the mon primary ocular malignant neoplasm of the globe in
embryonic neural retina—is the most common intraoc- adults is malignant melanoma arising from the choroid
ular tumor of childhood. It may be sporadic or heredi- and ciliary body. It can be diagnosed accurately from its
tary, being transmitted as an autosomal dominant trait. characteristic cytologic features (Fig. 12.23).
Hereditary forms are almost always bilateral. Grossly, the Optic nerve neoplasms include Schwannoma, menin-
tumor presents as a soft polypoid mass projecting into gioma (Figs. 12.24 and 12.25), and glioma (Fig. 12.26).
the vitreous fl uid. Cytohistologically (Fig. 12.21), the All may be recognized correctly from cytologic samples.
tumor shows closely packed small, round cells with scant Metastases to the orbit can originate from several di-
cytoplasm, hyperchromatic molded nuclei, often forming vergent sources, with the most frequent being the breast
rosettes. Differentiated cells acquire eosinophilic cyto- in women (Fig. 12.27) and the lung in men (Fig. 12.28).
plasm. The differential diagnoses include all of the small, Other sites include the prostate (Fig. 12.29), the kidney, the
round cell tumors of childhood. Its differentiation from thyroid, malignant melanoma, and malignant lymphoma.
neuroblastoma, which often involves the orbit, may be Lymphoid lesions of the orbit are frequent, constitut-
extremely difficult. ing 10 to 15% of orbital lesions, and range from benign
A B
Figs. 12.24A and B. A: FNA of a retro-orbital mass showing a cellular aspirate consisting of oval epithelioid cells
with bland nuclei. B: A different field from the same case showing a paucicellular area with short spindle cells. The
patient had a history of meningioma.
Fig. 12.25. FNA of a retro-orbital mass showing spindle-shaped

cells with bland uniform nuclei in a fibrillar background, consistent
with an astrocytoma.
A B
Figs. 12.26A and B. FNA of a recurrent astrocytoma involving the retro-orbital area. Note the bland spindle-shaped
astrocytes with long processes.
lymphoid proliferations to indeterminate lesions to ma- cells. While the malignant lymphomas show an immature
lignant lymphomas. The benign lymphoid proliferations lymphoid population (Figs. 12.30 and 12.31) and are im-
are further classifi ed as infl ammatory pseudotumor and munologically monoclonal.
reactive hyperplasia. The pseudotumor cytohistologically Malignant lymphomas arising from mucosa-associated
shows a polymorphic cell population of inflammatory lymphoid tissue (MALT) are the most common type of
A B
Figs. 12.27A and B. FNA of a retro-orbital mass with adenocarci- Fig. 12.28. FNA of poorly differentiated squamous carcinoma of
noma consistent with metastatic breast carcinoma. the lung metastatic to retro-orbital region (Romanowsky).
Fig. 12.29. FNA of a retro-orbital mass in a patient with a history Fig. 12.30. Vitreous fluid showing a dispersed population of im-
of poorly differentiated prostate adenocarcinoma. These malignant mature and monomorphic lymphoid cells consistent with malignant
cells reacted positively with prostatic specific antigen. lymphoma.
malignant lymphomas occurring in the orbit and orbital

adnexa. They are almost always B-cell type and occur in
older age group individuals. They involve orbital soft tis-
sues and the adnexa.
Indeterminate lesions cannot be categorized cytohis-
tologically as benign or malignant without the use of an-
cillary testing such as flow cytometry.
LACHRYMAL GLAND LESIONS
Lesions of the lachrymal gland that are studied cytologi-

Fig. 12.31. FNA of a retro-orbital mass consisting of small mono-
cally include infl ammatory pseudotumors, pleomorphic
morphic lymphoid cells. The diagnosis of malignant lymphoma was adenomas or mixed tumors, adenoid cystic carcinomas,
confirmed by a biopsy. and primary lymphomas.
Anteriorly, its wall is continuous with the nasal cavity,

EYELIDS, INNER AND OUTER and inferiorly, it continues with the oropharynx.
CANTHUS, AND EYEBROWS
NASOPHARYNGEAL CARCINOMA
Cytologic features of palpable lesions of the periorbital
area that have been reported in the literature include cha- Nasopharyngeal carcinomas occur primarily in Asian
lazion, inflammatory pseudotumors, basal and squamous males and are relatively rare in Caucasians. The primary
carcinomas, malignant melanoma, neuroendocrine lesion in the nasopharynx is often unnoticed as patients
tumors, and sebaceous carcinoma. may be asymptomatic. The patients often present with cer-
Sebaceous carcinomas, although rare, arise more fre- vical lymph node metastasis. A close association between
quently in the ocular adnexa than elsewhere in the body. nasopharyngeal carcinoma and the Epstein-Barr virus has
They originate from the meibomian glands located in the been established. The tumor has a bimodal age distribu-
eyelid, caruncles, eyebrows, and those associated with tion with peaks in the second and sixth decades.
the hair follicles. They are often misdiagnosed clinically Histologically, three subtypes for nasopharyngeal car-
as well as histologically as squamous or basal cell carci- cinomas have been described: namely, squamous carci-
noma. Sebaceous carcinomas are aggressive and spread noma with keratinization, without keratinization, and the
locally and to distant sites. Cytohistologically, they are undifferentiated type. The undifferentiated type, also called
composed of large, round to polygonal cells with lipid lymphoepithelioma, consists of syncytia and discrete large
rich to dense cytoplasm and central large round to oval round cells with scant cytoplasm, large nuclei with finely
nuclei with prominent nucleoli (Fig. 12.32). granular chromatin, prominent nucleoli, and scant cyto-
plasm in a background of lymphoid cells (Figs. 12.33A to
C). The differential diagnoses include malignant lymphoma,
Hodgkin and non-Hodgkin type, metastatic germ cell tu-
NASOPHARYNX, SINONASAL TRACT mors, and metastatic poorly differentiated carcinoma. Ex-
(NASAL CAVITIES AND PARANASAL tramedullary hematopoiesis (Fig. 12.33D) in the soft tissues
SINUSES) of the neck may be a potential diagnostic pitfall because of
the multilobated megakaryocytes that might be mistaken
Neoplastic lesions of the nasopharynx and sinonasal for malignant cells. The squamous type nasopharyngeal
tract (nasal cavity and paranasal sinuses) are extremely carcinomas are generally a poorly differentiated type.
uncommon. They are very rarely evaluated by fine needle
biopsy; thus, they are infrequently encountered in routine
SINONASAL TRACT AND PARANASAL
cytopathology practice.
SINUSES (MAXILLARY, ETHMOID,
FRONTAL, AND SPHENOIDAL)
NASOPHARYNX
Primary malignant neoplasms at this anatomic site include
The nasopharynx is the portion of the pharynx that sinonasal undifferentiated carcinoma (SNUC), esthesion-
lies behind the nasal cavity and above the soft palate. euroblastoma (olfactory neuroblastoma), squamous car-
cinoma, and malignant melanoma.
SINONASAL UNDIFFERENTIATED
CARCINOMA (SNUC)
SNUC is an uncommon, highly aggressive, and clinico-
pathologically distinctive carcinoma of unknown histogen-
esis. The tumor is hypercellular with various growth pat-
terns such as solid, trabecular, sheet-like diffuse, ribbons,
lobular, nesting, or organoid. The tumor is composed of
small to medium-sized, round, oval to pleomorphic cells
containing round, large nuclei with fine to coarsely gran-
ular chromatin and both micro or macronucleoli. Their
cytoplasm is variable. Mitotic activity is very brisk and
tumor necrosis is frequent. No lymphocytes are present in
the background unlike nasopharyngeal carcinomas.
Fig. 12.32. FNA of a sebaceous carcinoma. Note the malignant cells
Cytologic features include small to medium-sized, round
are large, with well-defined cell borders, abundant dense cytoplasm, cells with poorly defined cell borders, scant to insignificant
and pleomorphic nuclei. cytoplasm, round nuclei with high N/C ratios. The nuclear
A B
C D
Figs. 12.33A to D. Nasopharyngeal carcinoma (lymphoepithelioma) A, B: FNA of a nasopharyngeal mass showing
large undifferentiated malignant cells in the background of lymphoid cells. C: A different example of nasopharyngeal
carcinoma showing undifferentiated malignant cells with sparse lymphocytes in the background. D: FNA of a soft
tissue mass consistent with extramedullary hematopoiesis. The megakaryocytes may be misinterpreted as cells of
lymphoepithelioma.
chromatin can be coarsely granular, deep-staining, resem- 69 years. Grossly, esthesioneuroblastomas occur as uni-
bling small cell neuroendocrine carcinoma. The chromatin lateral polypoid gray to gray–red nodules involving the
can also be finely granular with micro and macronucleoli. nasal vault or as a diffuse involvement.
Mitoses may be frequent (Figs. 12.34A to C). Histologically and cytologically, the tumors present a
The neoplasm is reactive to epithelial markers such pattern very similar to neuroblastoma, being composed of
as pankeratins and negative for CK4, CK5/6, and CK14. small, round primitive cells with a rosette formation and the
Their reactivity to neuroendocrine markers such as chro- presence of neuropil (Fig. 12.35). Ganglionic differentiation
mogranin and synaptophysin is variable. Ultrastructur- is not noted and the patients with esthesioneuroblastoma
ally, dense core secretory granules are occasionally seen. do not have elevated urinary levels of vanillylmandelic acid
The differential diagnoses of SNUC include olfactory and homovanillic acid. These tumors are locally invasive
neuroblastoma, small cell (neuroendocrine) carcinoma, and metastasize to cervical lymph nodes, lungs, and long
squamous carcinoma, malignant melanoma, malignant bones. The tumor cells express neuroendocrine markers
lymphoma, and rhabdomyosarcoma. and ultrastructurally demonstrate electron dense neurose-
cretory granules, neurofilaments, and neurotubules.
Esthesioneuroblastoma (Olfactory Neuroblastoma)
Esthesioneuroblastoma is a rare malignant neoplasm aris-
METASTATIC MALIGNANCY TO
ing from neuroectodermal cells present within olfactory
PARANASAL SINUSES
epithelium and is confined to the superior nasal turbinate,
cribriform plate, and upper one-third of the nasal septum. Among the malignant neoplasms that metastasize to
These tumors can occur at any age but show two peaks— the paranasal sinuses, renal cell carcinoma tops the list,
one between 11 to 20 years and the other between 60 to followed by the breast, the lung, malignant lymphoma,
A B
Fig. 12.34A to C. Sinonasal undifferentiated carcinoma A: FNA

showing undifferentiated small round cells with high N/C ratios and
indiscernible cytoplasm. There is no nuclear molding. B, C: Sinonasal
undifferentiated carcinoma metastatic to the brain. The malignant
cells are medium-sized with scant cytoplasm, large nuclei with gran-
C ular chromatin and prominent nucleoli.
Fig. 12.35. FNA of an olfactory neuroblastoma. The aspirate is

paucicellular, showing loosely cohesive small round cells with poor-
ly defined cell borders, indiscernible cytoplasm, and high N/C ratios.
There is no nuclear molding. Without immunostains, the diagnosis
cannot be confirmed.
malignant melanoma, and salivary gland carcinomas superior constrictor muscle of the pharynx medially, and
(Figs. 12.36 to 12.38). the mandibular ramus laterally.
Parapharyngeal space can harbor several different
types of tumors, although of rare occurrence. The com-
PARAPHARYNGEAL SPACE
monest among these neoplasms are salivary gland tu-
Parapharyngeal space is anatomically well-defined space mors, paragangliomas, malignant lymphomas, soft tissue
of loose connective tissue, deep to the tonsils and lateral tumors such as neurofi broma or Schwannoma, giant cell
to pharynx. Boundaries include the base of the skull supe- tumors (Fig. 12.39), lymphoepitheliomas, and squamous
riorly, fascial attachments to the hyoid bone inferiorly, the carcinomas.
Fig. 12.36. FNA of a frontal sinus tumor showing a metastatic Fig. 12.37. FNA of a metastatic adenocarcinoma to the ethmoid
poorly differentiated lung carcinoma. sinus.
Fig. 12.38. FNA of a mass involving the maxillary sinus. The pa-
tient has a history of adenoid cystic carcinoma of the parotid gland.
The syncytial tissue fragment composed of small cells presenting a
trabecular pattern is so characteristic of adenoid cystic carcinoma.
A B
Figs. 12.39A and B. A: FNA of a large mass in the parapharyngeal space. The multinucleated osteoclast-type giant
cells in the background of mononuclear cells are very characteristic of giant cell tumor (Romanowsky). B: The
cell block confirming the cytologic diagnosis (H&E).
A B
Figs. 12.40A and B. FNA of an ameloblastoma of the mandible. A: The cellular aspirate showing a syncytial tissue
fragment of closely packed basaloid cells. B: A different field showing aggregates of basaloid cells in a loose stroma.
The tumor is benign, more frequent in women, and occurs

MANDIBLE/MAXILLA
in patients over the age of 40 years. Histologically, amelo-
blastoma consists of odontogenic epithelium forming a
Lesions of the mandible and maxilla are rarely encoun- follicular or plexiform pattern and lining cystic structures
tered in routine cytopathology practice. These include with intervening fi brous tissue stroma. The smears show
ameloblastoma, central giant-cell granuloma, and meta- sheets and aggregates of basaloid cells with palisading of
static lesions. peripheral nuclei. The basaloid cells have scant cytoplasm
Ameloblastoma occurs predominantly in the man- and monomorphic pattern. Mitosis and necrosis are not
dible. When located in the maxilla, the tumor may extend present (Figs. 12.40A and B). Squamous differentiation
into the maxillary sinus, orbit, or the base of the skull. may be present.
SUGGESTED READINGS
Asim E, Wenig BM. Sinonasal undifferentiated carcinoma: Clinical Plaza JA, Suster S. The Toker tumor. Spectrum of morphologic
and pathologic features and a discussion on classification, cel- features in primary neuroendocrine carcinomas of the skin
lular differentiation, and differential diagnosis. Adv Anat Pathol (Merkel cell carcinoma). Ann Diagn Pathol 2006;10:376–385.
2005;12:134–143. Sanchez CS, Bascunana AG, Pastor Quirante FA, et al. Mimics
Dey P, Jogan S, Amir T, et al. Fine needle aspiration cytology of of pilomatrixoma in fine needle aspirates. Diagn Cytopathol
Merkel cell carcinoma. Diagn Cytopathol 2004;31:364–365. 1996;14:75–83.
Ferry JA, Fung CY, Zukerberg L, et al. Lymphoma of the Tani E, Seregard S, Rupp G, et al. Fine needle aspiration cytology
ocular adnexa: A study of 353 cases. Am J Surg Pathol and immunochemistry of orbital masses. Diagn Cytopathol
2007;31:170–184. 2006;34:1–5.
Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck. Wenig BM. Atlas of Head and Neck. 2nd ed. Philadelphia:
2nd ed. Philadelphia: W.B. Saunders, 2001. W.B. Saunders, 2008.
13 THYROID AND PARATHYROID
Thyroid nodules are a common occurrence, with the reported B. Benign thyroid neoplasms versus malignant neoplasm
incidence being 4 per 100 population by palpation and (e.g., follicular adenoma vs. follicular carcinoma, pap-
from 30 to 60% in autopsy series. In recent years, with the illary, or medullary carcinoma; Hürthle cell adenoma
increasing use of ultrasonography and PET scans, more thy- vs. Hürthle cell carcinoma).
roid nodules are being discovered as incidental findings, tak- C. Typing the malignant neoplasm (e.g., papillary carci-
ing the estimated figure to a staggering 50 to 60%. Many noma vs. follicular carcinoma, medullary carcinoma
nodules are multiple, small, and asymptomatic and are sub- vs. Hürthle cell carcinoma, anaplastic, papillary, or
jected to fine needle biopsy procedures under ultrasound follicular carcinomas).
guidance. The steady rise in the number of thyroid nodules D. Primary thyroid cancer versus metastatic malignancy
being biopsied compounded the issues that had already to the thyroid.
plagued the cytopathologists’/endocrinologists’/surgeons’
The first two categories may have significant therapeutic
community. Widespread inconsistencies in adequacy assess-
implications due to the possibility of unwarranted surgical
ments, reporting system, and terminologies had led to man-
procedures. Many of the potential errors can be avoided by
agement problems. A consensus conference sponsored by the
ensuring an adequate specimen and following strict diagnos-
National Cancer Institute in 2007 recommended guidelines
tic criteria for the adequacy. The importance of an adequate
for reporting thyroid fine needle biopsy interpretations. The
specimen cannot be overemphasized. In our own experience,
new guidelines for specimen adequacy and the criteria for
the majority of diagnostic errors occurred during the learn-
various thyroid lesions and for reporting the interpretations
ing phase as a result of interpretation based on suboptimal
will be discussed in the section on the Reporting System.
or poorly cellular samples and inexperience. These were sig-
Over the last three decades, thyroid fine needle biopsy
nificantly reduced during the subsequent years.
has developed into an accurate and cost-effective diagnos-
tic test. Without fine needle biopsy, the distinction between
benign and malignant lesions is not possible, either clini-
cally on radionuclide imaging or on ultrasonography. By FACTORS THAT INFLUENCE THE
using the well-documented cytologic criteria, most diagnos- CYTOPATHOLOGIC INTERPRETATION
tic entities can be readily identified from cytologic samples. OF THYROID ASPIRATES
However, diagnostic dilemmas are encountered because of
1. Overlapping cytologic features between nonneoplastic I. CYTOPREPARATIONS AND
and neoplastic diseases; STAINING METHODS
2. Overlapping features between various thyroid
neoplasms; Cytopreparations
3. Coexistence of nonneoplastic and neoplastic disease
Direct smears allow better assessment of cellularity and
processes;
visualization of architectural confi gurations of the tissue
4. Poor cellularity of the aspirated sample and suboptimal
fragments. These features are altered to some extent when
cytopreparation;
the samples are collected in a liquid medium. The cur-
5. Degenerative changes masking or mimicking malig-
rently popular liquid-based technology is another exam-
nancy; and
ple where the cytomorphology is modified significantly.
6. Limited experience.
The differential diagnostic problems in aspiration Staining
cytopathology of thyroid diseases can be grouped into
The use of FNA biopsy of the thyroid lesions was popular-
four broad categories:
ized in Scandinavian countries where only Romanowsky
A. Nonneoplastic versus neoplastic diseases (e.g., nodular stain was used on air-dried material. Physicians who advo-
goiter or chronic lymphocytic thyroiditis interpreted cated the test were clinicians and not the pathologists or
as malignant neoplasms). cytopathologists. Thus, Romanowsky became the norm
401
for FNA biopsies. However, this method of fixation and tions, colloid stains deep magenta. In spray fixed Papani-
staining has certain shortcomings such as poor nuclear colaou stained preparations, it appears as a thin cyano-
details. An important and oft-ignored fact is that the cyto- philic film against the white background of the slide and is
logic criteria based on one method of fi xation and stain- orange when mixed with blood. With inspissation, colloid
ing does not apply to the other methods. appears dense and presents cracks or washes off when
immersed in 95% alcohol for fixation. Colloid stains pink
in alcohol-fi xed specimens whether stained by Papanico-
II. HISTORICAL BIAS AGAINST ANY ATTEMPT
laou or Hematoxylin and Eosin.
TO CYTOLOGICALLY DIFFERENTIATE
FOLLICULAR AND HÜRTHLE CELL LESIONS/
NEOPLASMS AND EXISTING INCONSISTENCIES IMMUNOPROFILE
IN INTERPRETATIVE CRITERIA
Follicular cells are reactive to low-molecular weight keratin
Historically, the criteria for the histologic diagnosis of fol- and thyroglobulin.
licular carcinomas have been debated and are still being
debated, leading to considerable interobserver variations.
The same debate continues with Hürthle cell lesions includ-
ing neoplasms, from terminology—whether to include them
CYTOPATHOLOGY OF THYROID LESIONS
as follicular lesions or to consider them as a separate entity.
This debate has continued to cause interpretative problems NODULAR GOITER
in cytopathology as well. Marked inconsistencies in inter-
pretations and diagnostic terminologies have resulted in Nodular goiter (synonyms: adenomatous goiter, colloid
disparities in the management strategies. It is hoped that goiter, nontoxic nodular goiter, and multinodular goiter) is
the criteria, guidelines, reporting system, and recommenda- an enlargement of the thyroid gland caused by intermittent
tions made by The Bethesda System (TBS) for Thyroid Fine or persistent hyperplasia in response to thyroid-stimulating
Needle Biopsies will lead to uniformity in interpretations hormone or thyroid-growth immunoglobulin. The compen-
and the management of thyroid nodules. satory rise in serum thyroid stimulating hormone (TSH) may
be caused by hypothyroxinemia related to iodine deficiency,
environmental goitrogens, or unknown factors. Nodular
goiter is the most common benign condition mistaken for a
NORMAL HISTOLOGY AND CYTOLOGY thyroid tumor and the most frequently biopsied.
OF THE THYROID Initially, as the thyroid gland undergoes cycles of
hyperplasia and involution/hyperinvolution, the gland is
diffusely enlarged, and all the lobules are involved. As the
The normal thyroid gland is located in front of the neck,
cycles continue, they eventually lead to nodule formations.
straddling the trachea. It consists of two lobes joined by
Since, the lobules do not respond in a uniform manner, the
an isthmus and weighs approximately 15 grams. Each lobe
nodules vary in size. Some nodules are appreciated only
consists of multiple lobules and each lobule, in turn, is com-
microscopically, while others are large enough to cause
posed of several follicles, which represent units of thyroid
clinical enlargement and even cause pressure symptoms.
parenchyma. An individual follicle is a three-dimensional
One or more nodules may become dominant. These nod-
structure formed by a closed sac, filled with colloid, and
ules often undergo degeneration, hemorrhage, and necro-
lined by cuboidal epithelial cells that rest on a basement
sis followed by granulation tissue leading to fibrosis and
membrane. The intervening stroma is delicate and vascular.
calcification. Cyst formation is very frequent.
In cytologic preparations, the normal thyroid follicle
The nodules are usually cold on radionuclide imaging
may be seen either in a cross-section or en face or in its
and cannot be differentiated from a neoplasm.
entirety as a three-dimensional structure. The follicle com-
prises cuboidal cells with regularly spaced small nuclei, 7
Radiologic Features
to 9 nanometers in diameter and containing appreciable
pale cytoplasm, arranged around a lumen with or without The ultrasound fi ndings of nodular goiter are variable.
colloid. The cell borders may or may not be well-defined. Small (less than 1 cm), solitary or multiple, fluid-filled
Seen en face, the follicles exhibit a honeycomb arrange- nodules are often caused by thyroid nodular hyperplasia.
ment. A follicle in its entirety will show a honeycomb The cystic spaces either represent colloid-filled cysts or
arrangement and uniform nuclei when viewed in different fluid from degeneration and necrosis. A comet tail artifact
planes of focus. The nuclear chromatin is finely granular may be visualized in colloid cysts—a fi nding reported to
and evenly dispersed or compact. have a sensitivity and specificity of 100% in predicting the
Colloid has different staining qualities depending on benign nature. Multiple cystic spaces separated by septa-
the method of fixation and the type of stain used (see Figs. tions in a honeycomb pattern strongly indicate benign
13.4A to C). In air-dried Romanowsky stained prepara- nonneoplastic nodules.
Chapter 13: Thyroid and Parathyroid 403
Gross and Histologic Features accumulation of histiocytes with or without hemosiderin.

Nuclear atypia may be pronounced. Squamous metaplasia
The thyroid with nodular goiter is variably enlarged. It may is occasionally present. With cystic changes, the follicles get
be massive, bulky with asymmetric lobes, and multiple nod- dilated; the follicular lining epithelium forms papillary-like
ules that vary greatly in size, and some may be fluid-filled projections that are directed toward the center within the
cysts. The cut surface demonstrates a variegated pattern. cystic cavity. With recent hemorrhage, granulation tissue
The nodules may be uniform, solid and fleshy, hemorrhagic, may be present. Fibrosis eventually develops. It can be focal
or cystic. Fibrotic areas and calcification are often noted. or extensive with broad bands of collagenized tissue. Cal-
These changes are more frequent with the larger nodules. cification may also be present. Occasionally, psammoma
The microscopic pathology varies widely, dominated by bodies are identified in nodular goiters.
nonencapsulated, small to large distinct nodules exhibiting
changes ranging from hyperplasia, involution to hyperinvo-
lution. The hyperplastic nodules consist of closely packed
small to medium-sized follicles without colloid and are The spectrum of histologic features described above are
lined by tall columnar epithelium, sometimes with papillary amply represented in aspirated samples (Table 13.1; Figs.
changes. The follicular cell nuclei have a vesicular chromatin 13.1 to 13.9). They refl ect the various stages of the dis-
pattern and sometimes appear ground-glass-like, similar to ease process, namely, hyperplasia, involution/hyperinvo-
that seen in papillary carcinoma. Involution is characterized lution, as well as several of the secondary changes such as
by variably distended follicles with the accumulation of col- Hürthle cell metaplasia, recent or old hemorrhage, and its
loid and low cuboidal epithelium. With hyperinvolution, the sequelae (e.g., degeneration, necrosis, granulation tissue,
follicles are overdistended with colloid, resulting in a flat- fibrosis, and calcification).
tening of the lining epithelium containing pyknotic nuclei. Fine-needle aspirates generally show an admixture
Hürthle cell metaplasia of follicular cells is very common in of colloid and benign follicular cells in varying propor-
nodular goiter. It can be focal or generalized and may form tions. The colloid is abundant in hyperinvoluted goiters
large nodules. Retrogressive changes in nodular goiter occur (Fig. 13.4A) while scant or absent from the hyperplastic
frequently, characterized by recent and/or old, hemorrhage, areas (Fig. 13.5A). These two patterns represent two ends
degeneration of the follicular cells, cyst(s) formation, and of the spectrum of cytopathologic features of nodular
TABLE 13.1 CYTOPATHOLOGIC FEATURES OF NODULAR GOITER
Presentation Admixture of colloid and follicular epithelial cells in varying proportions; cells isolated, in loosely
cohesive groups and in tissue fragments
Architectural Patterns Regular follicles with evenly spaced nuclei, monolayered sheets with honeycomb arrangement;
of the Tissue Fragments papillary-like pattern in hyperplastic goiters with component cells in a honeycomb arrangement
Follicular Cells Small, cuboidal to round with well to poorly defined cell borders; degenerating or reactive/regenerating
follicular cells with enlargement and spindle shapes
Nucleus Round to oval, 7–9 ␮m in diameter; smooth nuclear membrane; uniformly distributed finely granular
to compact chromatin; pyknotic nuclei in hyperinvoluted goiters; nucleoli inconsistent but may be
present in hyperplastic goiters
Cytoplasm Scant to moderate, pale
Hürthle Cell ⫹/⫺; isolated and sheets of Hürthle cells with well-defined cell borders, size variable, larger than
Metaplasia the normal follicular cells; moderate to abundant granular cytoplasm; transition forms from normal
follicular cells to Hürthle cells within a tissue fragment; nucleus similar to or larger than the normal
follicular cells; lack prominent macronucleoli
Colloid Pale, thin film to thick, inspissated blobs with or without cracks (fissures); cyanophilic to eosinophilic
in Papanicolaou stained preparations, lavender to purple with Romanowsky stain
Psammoma Bodies Rarely present; naked or incorporated in a tissue fragment of benign follicular cells
Secondary Changes Histiocytes with or without hemosiderin; multinucleated foreign-body-type giant cells; stromal cells, mostly
in tissue fragments but isolated spindle cells may be present; calcific debris; squamous metaplasia ⫹/⫺
Fig. 13.1. FNA nodular goiter. The follicular epithelial cells are
small, with uniform round nuclei, containing compact chromatin.
Follicular pattern can easily be appreciated. Scant colloid is present
in the background.
A B
C D
Figs. 13.2A to D. FNA nodular goiter. A, B: Monolayered tissue fragment of follicular cells with honeycomb ar-
rangement. The nuclei are uniform and regularly spaced. Also note a follicular pattern with colloid within the lumens.
C: Benign follicular cells forming a honey-comb sheet, from nodular goiter (Diff-Quik). (Courtesy of Dr. Mariza de
Peralta-Venturina, Cedar-Sinai Hospital, Los Angeles, California.) D: Benign follicular cells forming a honey-comb
sheet, from nodular goiter (ThinPrep). (Courtesy of Dr. Claire W. Michael, University Of Michigan Health System,
Ann Arbor, Michigan.)
goiter with most cases exhibiting a pattern somewhere in to D). The follicles are generally small, showing a central
between, with or without secondary changes. lumen bordered by cuboidal cells with regularly spaced,
The benign follicular cells in aspirates from nodular small, uniform nuclei. Colloid may be present within their
goiters are seen either isolated, in aggregates, or in tissue lumina. Occasionally, a follicle is seen in its entirety (Fig.
fragments, either as a monolayered sheet with a honeycomb 13.3) in a three-dimensional form. The entire follicle exhib-
arrangement or with a follicular pattern (Figs. 13.1, 13.2A its a honeycomb arrangement in different planes of focus.
Fig. 13.3. Nodular goiter. Two follicles seen in their entirety and
presenting a three-dimensional pattern. Note the uniform, small
nuclei with compact chromatin and well-defined cell borders. The
honeycomb pattern is seen indifferent planes of focus.
A B
Figs. 13.4A to C. FNA of nodular goiter. A: Note abundant colloid

staining pale to dense, eosinophilic with Papanicolaou stain. Col-
loid also stains cyanophilic with Papanicolaou. B: Colloid staining
metachromatically purple-violet with Romanowsky stains. C: Col-
loid stains wispy, veil-like in liquid-based preparations (ThinPrep).
(Courtesy of Dr. Claire W. Michael, University Of Michigan Health
C System, Ann Arbor, Michigan.)
The tissue fragments without a follicular pattern appear not seen but may be present in hyperplastic follicular cells
as monolayered sheets. The component cells have well- or with reparative/regenerative changes. Small, pyknotic,
defined cytoplasmic borders and contain regularly spaced, dense-staining nuclei are characteristic of hyperinvoluted
uniform nuclei that maintain their polarity (Figs. 13.2A goiters, where the follicular cells are seen singly or in small
to C). There is a small amount of clear to pale cytoplasm. groups, floating in large lakes of colloid (Fig. 13.4A). Their
Very large tissue fragments of benign follicular epithe- scanty, pale cytoplasm fades away against the background
lium with a honeycomb arrangement and uniform nuclei of the colloid, and their pyknotic nuclei appear bare and
are referred to by some as macrofollicles. The follicular are difficult to distinguish from lymphocytes. The aspi-
cell nuclei are round, with diameters ranging from 7 to rates of hyperplastic goiters show abundant cellular mate-
9 nanometers. The nuclear chromatin is finely granular and rial (Fig. 13.5A) consisting of tissue fragments of benign
uniformly distributed or compact. Nucleoli are generally follicular cells with and without a follicular pattern.
A B
Figs. 13.5A and B. FNA of nodular goiter. A: Low power of a cellular aspirate with several tissue fragments of fol-
licular epithelium. The monolayered architecture can be appreciated even at this low power. B: Higher magnification
showing a monolayered sheet of follicular epithelium with well-defined cell borders and centrally located, uniform,
small nuclei. The honeycomb pattern is well-demonstrated. No colloid is present in the background.
A B
Figs. 13.6A and B. FNA nodular goiter. A: Macrophages, some containing hemosiderin pigment, indicating old hem-
orrhage. Benign follicular cells are present in the background. B: Histiocytes and benign follicular cells. (Courtesy of
Dr. Mariza de Peralta-Venturina, Cedar-Sinai Hospital, Los Angeles, California.)
Fig. 13.7. Hürthle cell metaplasia in nodular goiter. This large tis- Fig. 13.8. FNA of a nodular goiter showing fragments of benign
sue fragment of follicular cells is composed of benign follicular cells follicular cells with mild nuclear atypia and spindle showing cyto-
that are pleomorphic in size, demonstrating transition forms from plasmic processes and slightly enlarged nuclei.
regular follicular cells to Hürthle cells. The latter are large with
abundant granular cytoplasm. Their nuclei have compact chromatin
and lack macronucleoli.
nuclei remain normal-sized to slightly enlarged and may

contain prominent nucleoli. These cells with prominent
nucleoli often cause concern and may be misinterpreted
as neoplastic. The degenerating follicular cells, because of
expanded granular cytoplasm containing hemosiderin,
strongly resemble macrophages. The only differentiating
feature is that the follicular cells occur in tissue fragments
unlike macrophages, which occur singly. The aspirates of
nodular goiter that has undergone degenerative changes
may contain isolated groups or tissue fragments of cells with
varying degrees of nuclear atypia. The follicular cells with
regressive changes may assume a spindle shape (Figs. 13.8;
see section on spindle cells; Figs. 13.93A to C, 13.94, and
13.98A) or undergo squamous metaplasia (Fig. 13.9). With
Fig. 13.9. Squamous metaplasia. The mature squamous cells are the cystic change, the fine needle biopsy will often yield fluid
concentrically arranged forming a pearl. contents of variable consistence. Their cytologic prepara-
tions show large numbers of histiocytes or macrophages.
The cellularity can be overwhelming. The colloid is usually Histiocytic aggregates occasionally may be mistaken for
scant or absent, and the aspirates are often interpreted as cells of papillary carcinoma. The cytoplasm of the mac-
follicular lesions or neoplasms. The papillary hyperplasia rophages contains large, coarse, greenish–brown granules
yields papillary-like tissue fragments of follicular epithe- of hemosiderin pigment, indicating an old hemorrhage in
lium with a branching pattern and smooth external con- the nodule. The cyst contents, when examined unfixed and
tours (see Figs. 13.73 to 13.77). However, their component fresh, often show cholesterol and oxalate crystals (see Fig.
cells show well-defined borders arranged in a honeycomb 13.138A) and calcific debris. Accompanying the histiocytes,
pattern—a feature that greatly helps distinguish hyperpla- are multinucleated histiocytic foreign-body type giant cells.
sia from papillary carcinoma. They also lack the nuclear The presence of such cells has no diagnostic significance.
features of papillary carcinoma. Because of the old hemorrhage, granulation tissue,
Hürthle cell metaplasia of follicular cells is a common and fi brosis, the aspirates of nodular goiter may also
occurrence in nodular goiters. The metaplastic Hürthle show stromal cells, either isolated or in tissue fragments.
cells are usually present in tissue fragments and less often Isolated stromal cells have large, elongated to spindle-
as discrete or in loosely cohesive groups (Fig. 13.7; also see shaped nuclei with nucleoli. Their uniform size and bland
Figs. 13.41A to C). They vary in size and shape, ranging chromatin suggest their benign nature.
from medium-sized to large, cuboidal, oval to polygonal, Rarely, aspirates of nodular goiter show psammoma
and contain abundant granular or sometimes dense cyto- bodies, which may be naked or incorporated in tissue frag-
plasm and slightly eccentric nuclei. Their cell borders are ments of benign follicular cells (see Figs. 13.88A and D).
usually well-defined. The nuclei of the metaplastic Hürthle Their presence is a potential diagnostic pitfall. The differ-
cells tend to be pleomorphic in size with frequent giant entiation between psammoma bodies seen in nodular goi-
forms. Their chromatin pattern is variable from granular ter and those seen in papillary carcinomas are described
to pyknotic, structureless, and deep-staining. The presence in the section on papillary carcinoma (see Table 13.22).
of nucleoli is not common. Transition forms from regu-
lar small follicular cells to Hürthle cells are often noted,
Diagnostic Accuracy and Potential
serving as a feature in favor of metaplasia rather than the
Diagnostic Errors
neoplasm. A cellular aspirate from nodular goiter with a
predominance of metaplastic Hürthle cells represents a The usual cytologic pattern of nodular goiter (Table 13.1)
potential diagnostic pitfall and may be misinterpreted as thus consists of benign follicular cells and colloid in vari-
Hürthle cell neoplasm. The differentiating features are dis- able proportions. Hürthle cell metaplasia and histiocytes
cussed in the section on Hürthle cell neoplasms. with or without hemosiderin, multinucleated giant cells,
Hemorrhage and degeneration in a nodular goiter are and calcific debris represent secondary changes. All of these
common events initiating the regressive changes in the fol- features may not be present in aspirates of every nodular
licular cells. These events eventually lead to cyst formations, goiter, and it is not necessary to fulfill all the criteria listed in
fibrosis, and calcifications. The aspiration biopsy may yield Table 13.1 to make a cytologic diagnosis of nodular goiter.
variable amounts of clear to bloody fluid of varying con- The presence of colloid and/or histiocytes should not be
sistence. The cytologic specimens demonstrate degenerat- a requirement for the diagnosis of nodular goiter. Colloid
ing follicular cells, which appear enlarged with abundant reflects the functional activity of the follicular cells and does
granular, foamy, or vacuolated cytoplasm and sometimes not indicate whether the follicular cells are neoplastic or
with phagocytized hemosiderin pigment (Fig. 13.6A). Their nonneoplastic. Likewise, histiocytes represent a degenerative
presents different morphology than the adenoma itself.

FOLLICULAR NEOPLASIA The capsule is of varying thickness.
Follicular adenomas present an array of morphologic
TBS has grouped all aspirates composed of follicular cells patterns based on their architecture (growth pattern),
into one category “suspicious for follicular neoplasm” cell morphology or types, and functional differentiation
to include lesions such as hyperplastic goiters, follicular (amount of colloid), with the common denominator being
adenomas, follicular carcinomas, and a follicular variant total encapsulation and benign behavior. Recognition of
of papillary carcinomas with recommendations for lobec- any morphologic variant carries no clinical significance.
tomy for confirmation. Follicular adenomas are classified into conventional types
The following text is in variance with the new and several morphologic variants, with the former being
Bethesda System. The author has attempted to cytologi- more common (Table 13.3).
cally provide probabilities on whether a given follicular The conventional type of follicular adenomas present
lesion is nonneoplastic or neoplastic, and if neoplastic, four basic histomorphologic patterns: colloid or macro-
whether it is benign or malignant. The text that follows follicular, simple or normofollicular, fetal or microfollicu-
explains the criteria used. lar, and embryonal or trabecular (e-Figs. 13.1 to 13.4). In
a given adenoma, the pattern remains generally uniform,
although a combination of one or two morphologic pat-
FOLLICULAR ADENOMAS terns may be encountered, particularly when the lesion is
Follicular adenomas are encapsulated, follicular cell- large. This factor must be taken into account when per-
derived benign neoplasms of the thyroid demonstrating a forming an aspiration biopsy of a large nodule so that sev-
follicular growth pattern. They occur more commonly in eral areas can be sampled. The cytologic features of con-
women over a wide age range but are frequent in the fifth ventional follicular adenomas are listed in Table 13.4.
to sixth decades. After nodular goiter, follicular adenomas
are the most common cause of nonfunctioning thyroid Colloid Adenoma
nodules. The true incidence of follicular adenomas may Colloid adenoma (also referred to as a colloid nodule by
not be known for two reasons: 1) many hyperplastic nod- some) represents the most differentiated follicular adenoma
ules may be interpreted as adenomas and 2) oncocytic or (macrofollicular adenoma) with overdistended varying-
Hürthle cell tumors are often considered as morphologic sized but large follicles containing abundant colloid (e-Fig.
variants of follicular neoplasms. Adenomas are common 13.1). The lining epithelium is flattened with pyknotic
in iodine-deficient areas. Clinically, they present as a pain-
less neck mass of varying duration. Smaller lesions are
often detected as incidental findings. Adenomas are most
TABLE 13.3 MORPHOLOGIC VARIANTS OF
often solitary, but multiple adenomas in the same lobe FOLLICULAR ADENOMAS
or both lobes are not uncommon. Frequently of great
size, they may undergo degenerative changes, hemor- Conventional
rhage, necrosis, and infarction. Acute hemorrhage is usu-
ally associated with painful, rapid enlargement. In larger Macrofollicular (Colloid)
adenomas, the central areas tend to be edematous and
with scarring. Normofollicular (Simple)
Radiologic Features—Thyroid imaging with radionu-
clide shows a hypofunctioning area or a “cold nodule.” Microfollicular (Fetal)
On ultrasound, follicular adenomas appear as solitary
hypoechoic areas. Trabecular (Embryonal)
Gross and Microscopic Features—Grossly, follicular
adenomas are sharply circumscribed, discrete, solitary, Oncocytic (Hürthle cell) adenomaa
expansile lesions. Follicular adenomas vary greatly in size.
Areas of degeneration and hemorrhage are often present, Hyalinizing trabecular
particularly in larger lesions. Cystic change is reported
in roughly 30% of follicular adenomas. Solid neoplasms Adenoma with clear cell change
show a fleshy, bulging cut surface, while the colloid-rich
adenomas show minute cysts filled with glistening amber- Adenoma with papillary hyperplasia
colored colloid.
Atypical adenoma
Microscopically, follicular adenoma is encapsulated—
a feature that differentiates it from a nonneoplastic nod-
Miscellaneous
ule of adenomatous or a nodular goiter. The thyroid
parenchyma adjacent to the capsule is compressed and a
Oncocytic or Hürthle cell adenomas are described separately in Chapter 8.
presents different morphology than the adenoma itself.

FOLLICULAR NEOPLASIA The capsule is of varying thickness.
Follicular adenomas present an array of morphologic
TBS has grouped all aspirates composed of follicular cells patterns based on their architecture (growth pattern),
into one category “suspicious for follicular neoplasm” cell morphology or types, and functional differentiation
to include lesions such as hyperplastic goiters, follicular (amount of colloid), with the common denominator being
adenomas, follicular carcinomas, and a follicular variant total encapsulation and benign behavior. Recognition of
of papillary carcinomas with recommendations for lobec- any morphologic variant carries no clinical significance.
tomy for confirmation. Follicular adenomas are classified into conventional types
The following text is in variance with the new and several morphologic variants, with the former being
Bethesda System. The author has attempted to cytologi- more common (Table 13.3).
cally provide probabilities on whether a given follicular The conventional type of follicular adenomas present
lesion is nonneoplastic or neoplastic, and if neoplastic, four basic histomorphologic patterns: colloid or macro-
whether it is benign or malignant. The text that follows follicular, simple or normofollicular, fetal or microfollicu-
explains the criteria used. lar, and embryonal or trabecular (e-Figs. 13.1 to 13.4). In
a given adenoma, the pattern remains generally uniform,
although a combination of one or two morphologic pat-
FOLLICULAR ADENOMAS terns may be encountered, particularly when the lesion is
Follicular adenomas are encapsulated, follicular cell- large. This factor must be taken into account when per-
derived benign neoplasms of the thyroid demonstrating a forming an aspiration biopsy of a large nodule so that sev-
follicular growth pattern. They occur more commonly in eral areas can be sampled. The cytologic features of con-
women over a wide age range but are frequent in the fifth ventional follicular adenomas are listed in Table 13.4.
to sixth decades. After nodular goiter, follicular adenomas
are the most common cause of nonfunctioning thyroid Colloid Adenoma
nodules. The true incidence of follicular adenomas may Colloid adenoma (also referred to as a colloid nodule by
not be known for two reasons: 1) many hyperplastic nod- some) represents the most differentiated follicular adenoma
ules may be interpreted as adenomas and 2) oncocytic or (macrofollicular adenoma) with overdistended varying-
Hürthle cell tumors are often considered as morphologic sized but large follicles containing abundant colloid (e-Fig.
variants of follicular neoplasms. Adenomas are common 13.1). The lining epithelium is flattened with pyknotic
in iodine-deficient areas. Clinically, they present as a pain-
less neck mass of varying duration. Smaller lesions are
often detected as incidental findings. Adenomas are most
TABLE 13.3 MORPHOLOGIC VARIANTS OF
often solitary, but multiple adenomas in the same lobe FOLLICULAR ADENOMAS
or both lobes are not uncommon. Frequently of great
size, they may undergo degenerative changes, hemor- Conventional
rhage, necrosis, and infarction. Acute hemorrhage is usu-
ally associated with painful, rapid enlargement. In larger Macrofollicular (Colloid)
adenomas, the central areas tend to be edematous and
with scarring. Normofollicular (Simple)
Radiologic Features—Thyroid imaging with radionu-
clide shows a hypofunctioning area or a “cold nodule.” Microfollicular (Fetal)
On ultrasound, follicular adenomas appear as solitary
hypoechoic areas. Trabecular (Embryonal)
Gross and Microscopic Features—Grossly, follicular
adenomas are sharply circumscribed, discrete, solitary, Oncocytic (Hürthle cell) adenomaa
expansile lesions. Follicular adenomas vary greatly in size.
Areas of degeneration and hemorrhage are often present, Hyalinizing trabecular
particularly in larger lesions. Cystic change is reported
in roughly 30% of follicular adenomas. Solid neoplasms Adenoma with clear cell change
show a fleshy, bulging cut surface, while the colloid-rich
adenomas show minute cysts filled with glistening amber- Adenoma with papillary hyperplasia
colored colloid.
Atypical adenoma
Microscopically, follicular adenoma is encapsulated—
a feature that differentiates it from a nonneoplastic nod-
Miscellaneous
ule of adenomatous or a nodular goiter. The thyroid
parenchyma adjacent to the capsule is compressed and a
Oncocytic or Hürthle cell adenomas are described separately in Chapter 8.
TABLE 13.4 CYTOPATHOLOGIC FEATURES OF CONVENTIONAL FOLLICULAR ADENOMA
Macrofollicular Type, Normofollicular or Simple Type Microfollicular/Trabecular Types

Follicular Adenoma Follicular Adenoma (Cellular Follicular Adenoma)
Histology Encapsulated; colloid filled Encapsulated; resembles normal thyroid Encapsulated; microfollicular and/
varying-sized but large parenchyma, consisting of normal- or trabecular growth patterns,
follicles, distended with sized follicles containing colloid; lining colloid scant
colloid, lining follicular epithelium low cuboidal with basally
epithelium flattened with located uniform round nuclei; often
pyknotic nuclei present a combination of various growth
patterns
Cytopathologic Abundant colloid; may Depends on morphology of the biopsied Cellularity variable but generally
Features be inspissated with area. Usually presents a combination of high, syncytial tissue fragments
fissures and cracks; patterns 1 and 2. with or without follicular pattern,
sparse epithelial cells with 1. Pattern resembling nodular goiter. slender to broad trabecular with
pyknotic nuclei; frequently Varying proportion of colloid and or without interdigitation, nuclei
appear as stripped nuclei benign follicular cells forming regular enlarged; nuclei enlarged, round,
and resemble lymphocytes follicles or honeycomb sheets; uniform smooth nuclear membranes;
or minimally enlarged, round nuclei granular chromatin; nucleoli
with granular chromatin; nucleoli absent, mitoses absent colloid in
absent. the background negligible; may be
2. Pattern resembling a cellular follicular present in follicular lumen
adenoma.
Syncytial tissue fragments of follicular
cells with or without a follicular
pattern; uniform, minimally enlarged,
round nuclei with granular chromatin;
nucleoli absent.
3. A combination of patterns 1 and 2.
Differential Nodular goiter; Nodular goiter ● Hyperplastic goiter

Diagnoses macrofollicular variant of ● Minimally invasive follicular
papillary carcinoma carcinoma
● Chronic lymphocytic thyroiditis
● Follicular variant of papillary
carcinoma
● Medullary carcinoma
● Parathyroid hyperplasia/
adenoma
nuclei. This adenoma virtually replicates the pattern of of papillary carcinoma; the distinguishing feature is the
hyperinvoluted goiter, except for the encapsulation. typical nuclear morphology of papillary carcinoma.
Cytopathologic Features. Aspirates of colloid or macro-
Simple Adenoma
follicular adenomas exhibit abundant colloid and have a
sparse cellular component with tissue fragments of fol- Simple adenoma (normofollicular) histologically consists
licular epithelium forming small follicles or a honeycomb of well-developed follicles of approximately normal size
pattern. Nuclei are small, and the chromatin is compact (e-Fig. 13.2). The lining epithelium is low cuboidal with
and deep-staining (Table 13.4; Fig. 13.10). The presence of either normal-sized or slightly enlarged nuclei. The amount
abundant colloid and absent or sparse cellular component of colloid within the follicles varies. Cellular areas consist-
may render the aspirate inadequate or nondiagnostic. ing of less well-developed follicles may be present along
The cytologic pattern of colloid adenomas is indistin- with more well-developed follicles containing significant
guishable from that of hyperinvoluted goiters. The only amounts of colloid, particularly in very large adenomas.
malignant neoplasm that strongly resembles a colloid
adenoma or a hyperinvoluted goiter, both macroscopi- Cytopathologic Features. The cytopathologic pattern of
cally and microscopically, is the macrofollicular variant simple adenoma depends on the histologic differentiation
Fig. 13.10. FNA macrofollicular adenoma. The aspirate contains

abundant colloid and sparse follicular cells. This pattern is inter-
preted as nodular goiter and cannot be differentiated from a macro-
follicular adenoma which remains a histologic diagnosis.
A B
Figs. 13.11A and B. Simple adenoma. A: The aspirate consists of a few tissue fragments of follicular epithelium
presenting a follicular pattern (medium power). B: Higher magnification showing enlarged follicular cell nuclei
with granular chromatin. The follicular cells contain modest cytoplasm. The surgical excision confirmed a follicular
adenoma consisting of normal-sized follicles. This type of follicular adenoma may present a cytologic pattern
of nodular goiter or a mixed pattern with syncytial tissue fragments and honeycomb sheets.
Microfollicular/Trabecular Adenoma
of the areas sampled (Table 13.4). When the adenoma
(Cellular Follicular Adenoma)
resembles a normal gland, the aspirates present cytologic
features of a nodular goiter (i.e. an admixture of colloid Microfollicular adenoma (or fetal adenoma), as the
and benign follicular epithelium with honeycomb sheets name implies, is composed of poorly developed or mal-
and regular follicles) and are often interpreted as such. The developed follicles with little or no colloid, denoting poor
differentiation between the nodular goiter and a simple architectural as well as functional differentiation (e-Fig.
follicular adenoma is often impossible, with the final diag- 13.3). The lining epithelium is cuboidal with nuclei that
nosis depending on the demonstration of encapsulation. may be variably increased in size. Trabecular adenoma (or
A varied morphologic pattern consisting of micro/ embryonal adenoma) displays a trabecular growth pat-
macrofollicular areas will yield a combination of cytologic tern with anastomosing ribbons or trabeculae of follicu-
patterns; sampling of cellular areas exhibit syncytial tissue lar epithelium (e-Fig. 13.4). There is neither a follicular
fragments with and without follicular pattern similar to growth pattern nor the presence of colloid.
that seen in cellular follicular adenomas (microfollicular/ Because microfollicular and trabecular adenomas are
trabecular). The cytologic diagnosis depends on the area cellular neoplasms, they will henceforward be referred to
sampled. A combination of cytologic features of nodular as “cellular follicular adenomas.”
goiter and cellular follicular adenoma strongly supports the
diagnosis of a follicular adenoma with mixed morphology. Cytopathologic Features. Unlike macrofollicular and
Such a varied pattern is frequently seen in a large adenoma simple adenomas, aspirates of cellular follicular ade-
demonstrating more than one pattern (Fig. 13.11). nomas (Figs. 13.12 to 13.16) show a distinctly different
cytopathologic pattern (Table 13.3). The aspirate is usu- small nuclei, while those from cellular adenomas dem-
ally very cellular and consists of syncytial-type tissue frag- onstrate crowded, overlapped, and enlarged nuclei with
ments of follicular epithelium, with or without a follicular altered polarity. It is important to recognize this feature,
pattern. A follicular pattern is more commonly seen in a otherwise aspirates consisting of microfollicles will be
microfollicular adenoma, whereas in the trabecular type, interpreted as follicular neoplasms/adenomas.
syncytial-type tissue fragments with broad trabeculae pre- The nuclear size in cellular follicular adenomas
dominate. Discrete, varying-sized follicles are often pres- remains uniform in a given case but is variably increased
ent. The presence and the significance of microfollicles in in size from tumor to tumor. The nuclei are crowded and
thyroid aspirates has been over-emphasized and consid- overlapped. The cell borders are indistinct. The nuclear
ered to be diagnostic of follicular neoplasms. It should be chromatin is granular and rather coarse but evenly dis-
noted that the microfollicles are also seen in aspirates of tributed. Nucleoli are infrequent, and the cytoplasm is
nodular goiters. The differentiating feature is the nuclear variable but scanty and colorless to pale. Nuclear pleo-
size and arrangement and not the size of the follicle per se. morphism and the presence of nucleoli should raise the
The microfollicles from goiter show regularly arranged suspicion of follicular carcinoma.
A B
Figs. 13.12A and B. Cellular follicular adenoma. A: The aspirate is very cellular consisting of several tissue fragments
as well as discrete and loosely cohesive groups of follicular cells (low power). B: Higher magnification shows
syncytial tissue fragments with follicular pattern. Their nuclei are enlarged, crowded, and overlapped, with granular
chromatin. Nucleoli are not present. The background is clean and lacks colloid.
A B
Figs. 13.13A and B. FNA, Cellular follicular adenoma. A: Cellular aspirate consisting of follicular epithelium with
and without a follicular pattern. Their nuclei are enlarged in size, crowded, and overlapped. Their chromatin is
granular and nucleoli are absent. The background is clean. B: Another example of a cellular follicular adenoma,
consisting of syncytial tissue fragments of follicular cells with a trabecular pattern. Their nuclei are enlarged with
granular chromatin and occasional nucleoli. The latter raises the possibility of carcinoma. The background is devoid
of colloid.
A B
Figs. 13.14A and B. FNA cellular follicular adenoma. A: The aspirate is extremely cellular consisting of several
closely packed syncytial tissue fragments of follicular epithelium, low power. B: Higher magnification showing
syncytial architecture with and without a follicular pattern. Their nuclei are enlarged, crowded with coarsely
granular chromatin. No colloid is present in the background.
Fig. 13.15. FNA cellular follicular adenoma. This cellular aspirate

consists of syncytial tissue fragments of follicular epithelium with
a trabecular and a follicular pattern. Their nuclei are moderately
enlarged with coarsely granular chromatin. Nucleoli are not appre-
ciated. Colloid globules are present within the follicles.
A B
Figs. 13.16A to B. A: FNA of a cellular follicular adenoma. Large syncytial tissue fragment of follicular cells. The fol-
licular architecture is not evident. The nuclei are moderately but uniformly enlarged in size, crowded and overlapped.
No nucleoli are appreciated. The background is clean, devoid of colloid. Thyroidectomy revealed a cellular follicular
adenoma (Diff-Quik). (Courtesy of Mithra Baliga, M.D., University of Mississippi, Jackson, Mississippi.) B: Low
power view of a cellular aspirate containing numerous variably sized clusters of follicular cells, scattered microfol-
licles, and a few single cells. (continued)
Figs. 13.16C. (continued) C: Syncytium of follicular cells showing

irregularly spaced cells with no distinct cell borders. Their nuclei
are relatively larger and hyperchromatic (ThinPrep). (Courtesy of
Dr. Claire W. Michael, University Of Michigan Health System, Ann
C Arbor Michigan.)
Fig. 13.17. Histologic section of hyalinizing trabecular adenoma.

The trabecular pattern is formed by elongated cells aligned perpen-
dicular to the capillaries. The cells have abundant eosinophilic cy-
toplasm (H&E).
The background is usually clean, and the colloid is are medium-sized, oval, polygonal to spindle-shaped,
rarely present but may be seen within the lumina of the either arranged in solid masses or as trabeculae separated
follicles. by dense hyaline stroma. The trabeculae are straight or
The cellular follicular adenomas overlap with well- sinuous and two to three layers thick. The neoplastic cells
differentiated follicular carcinomas both cytologically and adjacent to the stroma are often mummified, and those
histologically, and the distinction between the two is dif- within the trabeculae form a pseudofollicular pattern,
ficult. Additionally, the aspirates of cellular follicular ade- with or without colloid. Another characteristic pattern
nomas present morphologic similarities with parathyroid consists of elongated neoplastic cells aligning with their
adenomas and medullary thyroid carcinomas. The differ- bases inserted vertically into the capillaries of the delicate
entiating features are discussed in respective chapters. fibrovascular stroma. The tumor cells contain variable
pale to granular cytoplasm with perinuclear clearing.
Morphologic Variants of Follicular Adenomas
Their nuclei are round and mildly enlarged with granu-
Hyalinizing Trabecular Adenoma. Hyalinizing trabecular chromatin, micronucleoli, frequent inclusions, and
lar adenoma, also referred to as “paraganglioma-like ade- grooves. The nuclear/cytoplasmic ratio is low. The stroma
noma of thyroid” (PLAT) is a distinctive but uncommon is variable, often increased, and with dense hyaline resem-
subtype of follicular adenomas with a female preponder- bling amyloid. The stains for amyloid are negative.
ance. These tumors generally behave in a benign fashion. Immunoprofile—Hyalinizing trabecular adenoma
Recurrence or metastasis is infrequent. reacts positively to thyroglobulin, TTF-1, cytokeratin,
Gross and Microscopic Features—Grossly, the and vimentin and reacts negatively to HBME-1, calci-
tumors are discrete, circumscribed, and solid; they are tan tonin, S100 protein, and neurofilament. Neuroendocrine
to gray–pink in color, with a granular texture. differentiation has been reported.
Histologically, the hyalinizing trabecular adenomas Cytopathologic Features—The aspirates of hyaliniz-
are characterized by encapsulation and an alveolar or tra- ing trabecular adenomas tend to be cellular, consisting of
becular growth pattern (Fig. 13.17). The neoplastic cells oval to spindle-shaped cells, isolated, in loosely cohesive
groups, or in syncytial tissue fragments without any fol- cells with long cytoplasmic processes may be present. The
licular or papillary architectural pattern (Table 13.5; Figs. nuclei are round, oval to elliptical, and mildly pleomorphic
13.18 to 13.20). At times, the neoplastic cells in syncytial in size, have a smooth border, and contain finely granular,
tissue fragments radiate from a central hyaline, acellular evenly distributed chromatin with micronucleoli. Intra-
area (Figs. 13.18C and 13.19). The cytoplasm of the neo- nuclear inclusions and nuclear grooving are frequent. The
plastic cells is pale to dense and variable, sometimes fila- background may contain amorphous hyaline material
mentous, and not well-visualized. Bipolar and triangular similar to amyloid, staining pink to gray–blue.
TABLE 13.5 CYTOPATHOLOGIC FEATURES OF HYALINIZING TRABECULAR ADENOMA
Presentation Cells, discrete, in groups or in syncytial tissue fragments
Architecture of the Syncytial without follicular pattern; papillary-like with branching trabeculae; central cores of acellular
Tissue Fragments hyaline material ⫹/⫺
Cells Variably increased in size; round, oval, polygonal to elongated; poorly defined cell borders; N/C ratios low
Nucleus Increased variably; often eccentric; round, oval to elongated, smooth nuclear membranes, finely granular
chromatin; micronucleoli present, intranuclear inclusions very frequent; grooves ⫹
Cytoplasm Abundant, pale, fibrillar to finely granular; long, tapered cytoplasmic processes ⫹/⫺; yellow cytoplasmic
bodies ⫹/⫺; perinuclear halo ⫹/⫺
Psammoma Bodies ⫹/⫺
Background Hyaline material, staining metachromatically purplish-red with Romanowsky stain; colloid absent
Immunoprofile Positive reactivity to: thyroglobulin, TTF-1, cytokeratin and vimentin; distinctive cell membrane staining
pattern with MIB1, Nonreactive to: calcitonin and neuroendocrine markers
Differential Conventional follicular adenoma

Diagnoses Papillary thyroid carcinoma
Medullary thyroid carcinoma
A B
Figs. 13.18A to B. FNA of hyalinizing trabecular adenoma. A: The follicular cells are in syncytial tissue fragments,
forming trabeculae. Note the abundant granular cytoplasm, round to oval nuclei with powdery to finely granular
chromatin, grooves, and pseudoinclusions. B: Different field from the same case showing medium-sized to large,
round cells with a trabecular pattern. Their nuclei are enlarged, pleomorphic and contain pseudoinclusions. The
aspirate may be interpreted as papillary carcinoma. (continued)
Figs. 13.18C. (continued) C: FNA of a different case of hyalinizing

trabecular adenoma, depicting loosely cohesive, enlarged follicular
cells with enlarge pleomorphic nuclei, containing finely granular
chromatin and intranuclear inclusions. Note the stromal hyaline
C material (arrow).
Fig. 13.19. FNA of a hyalinizing trabecular adenoma. This image

shows intercellular hyaline material (arrows). The nuclei have pow-
dery chromatin, and inclusions. (Courtesy of Dr. Mariza de Peralta-
Venturina, Cedar-Sinai Hospital, Los Angeles, California.)
A B
Figs. 13.20A and B. FNA of an atypical adenoma. A cellular aspirate showing syncytial tissue fragments, with and
without a follicular pattern. The cells are large, pleomorphic in size, with appreciable cytoplasm. Their nuclei are
large, round, with granular chromatin, parachromatin clearing and contain nucleoli. The pattern is consistent with
follicular carcinoma. Thyroidectomy revealed an encapsulated follicular adenoma with questionable invasion and
was interpreted as atypical adenoma versus follicular carcinoma.
The cytologic recognition of hyalinizing trabecular Follicular Adenoma with Clear Cell Change. Folli-
adenomas is difficult because of the morphologic overlap cular adenoma with a clear cell change is of uncom-
with papillary and medullary carcinomas. Although very mon occurrence. Its demographics, clinical presenta-
rare, primary paraganglioma of the thyroid may be con- tion, and behavior are similar to the conventional type
sidered in the differential diagnosis. adenomas.
Histologically, follicular adenoma with clear cell TABLE 13.6 DIFFERENTIAL DIAGNOSES
change shows an encapsulated tumor with a follicular OF FOLLICULAR ADENOMAS
or solid growth pattern formed by benign follicular cells
containing abundant clear empty-looking cytoplasm. The Macrofollicular ● Nodular goiter
nuclei are small and uniform. Adenoma ● Macrofollicular variant of papillary
Cytologically, the clear cell pattern is difficult to carcinoma
recognize when the cytoplasmic borders are indistinct
Simple or ● Nodular goiter
or disrupted, and the bare nuclei scattered in the back-
Normofollicular
ground resemble lymphocytes. The clear cytoplasm is Adenoma
difficult to appreciate in cytologic preparations. The dif-
ferential diagnosis includes intrathyroidal parathyroid Microfollicular ● Hyperplastic goiter (cellular
adenoma. and Trabecular adenomatoid nodule)
Adenoma ● Follicular nodule from Hashimoto’s
Follicular Adenoma with Papillary Hyperplasia. Follicu- thyroiditis
lar adenomas with papillary hyperplasia or a papillary ● Well-differentiated follicular
change are characterized by degenerative changes with carcinoma
cyst formation and a papillary change in the lining of fol- ● Follicular variant of papillary
licular cells. The papillae are edematous, directed toward carcinoma
● Medullary carcinoma
the center of the cyst, and lined by benign follicular epi-
● Parathyroid adenoma
thelium containing basally located nuclei with compact
chromatin. They lack the typical nuclear morphology Hyalinizing ● Papillary carcinoma
of papillary carcinoma. They also lack the fibrovascular Trabecular ● Medullary carcinoma
cores that are typical of papillary carcinomas. Adenoma
Cytologically, follicular adenomas with papillary
hyperplasia may be misinterpreted as papillary carci- Follicular ● Papillary carcinoma
noma. The aspirates are usually cellular, consisting of syn- Adenoma with ● Nodular goiter
cytial tissue fragments of follicular cells with a papillary- Papillary Change
like pattern. The typical nuclear features of conventional
papillary carcinoma are lacking. The diagnostic prob- Follicular ● Metastatic renal cell carcinoma
lems are discussed in detail in the section on papillary Adenoma with ● Parathyroid adenoma
carcinoma. Clear Cell Change
Atypical Adenoma ● Cellular follicular adenoma

Atypical Follicular Adenoma. The term “atypical ade-
(microfollicular/trabecular)
noma” is applied to those follicular adenomas that ● Follicular carcinoma
are histologically characterized by 1) hypercellularity;
2) closely packed follicles often lacking lumina; 3) back-
to-back arranged trabeculae; 4) solid areas; 5) areas with
spindle-shaped cells; 6) mitotic figures; 7) complete encap-
sulation and lack of invasive features; and 8) a favorable
FOLLICULAR CARCINOMA
outcome.
Cytopathologic Features—The aspirates of atypical Follicular carcinomas are reported to represent 13
adenomas demonstrate marked cellularity, consisting of to 17% of thyroid carcinomas but vary depending on
syncytial tissue fragments of follicular epithelium (Figs. whether or not Hürthle cell carcinoma was included in
13.20A and B) with or without a follicular and trabe- the group. Follicular carcinomas are several times more
cular pattern with marked crowding and overlapping of common in women than in men, but the age distribu-
enlarged, pleomorphic nuclei containing nucleoli. This tion differs from that of papillary carcinoma, being more
cytologic pattern is similar to that seen in follicular car- frequent in the middle and older age groups. A high
cinomas (see Table 13.7). These aspirates may be inter- incidence is reported in geographic areas with endemic
preted as follicular carcinomas, but histologically, the thy- goiters. Follicular carcinomas can be distinguished from
roid nodules are diagnosed as atypical adenomas due to papillary carcinomas in several ways. They are solitary
a lack of invasion. Atypical adenoma is thus a histologic lesions and rarely metastasize to cervical lymph nodes,
diagnosis and never made from cytologic samples. and they spread via the bloodstream to distant organs
The other variants listed in Table 13.3 are of uncom- such as the lungs, the bones, the brain, and the liver. The
mon occurrence and will not be further discussed. The prognosis is generally good, depending on the invasive
differential diagnoses of various types of follicular ade- characteristics of the tumor but is less favorable than for
nomas are listed in Table 13.6. papillary carcinoma.
Gross and Microscopic Features Cytopathologic Features of Well-Differentiated

Follicular Carcinomas
Like adenomas, follicular carcinomas are, grossly, well-
circumscribed and sharply demarcated from adjacent The cytopathologic features of follicular carcinomas
parenchyma. Poorly differentiated carcinomas are usually are usually not described separately from follicular ade-
very large, bulky, and may replace the entire lobe. The cut nomas (TBS), although there are certain features that
section shows a bulging surface, fleshy areas, hemorrhage, suggest there are strong possibilities that are appreciated
and necrosis with or without calcification. only in wet-fixed, Papanicolaou-stained preparations.
The microscopic pattern is as varied as that of the The aspirates of follicular carcinomas tend to be gen-
adenomas, ranging from well-developed follicles to trabe- erally very cellular, composed of varying-sized syncytial
cular or alveolar growth patterns to large solid sheets of tissue fragments of follicular epithelium, with or without
tumor cells with no evidence of follicular cell differentia- a follicular pattern. Nuclei are very crowded and over-
tion. Different growth patterns may be seen in the same lapped, and their density within a given tissue fragment
tumor. The follicular cells have larger nuclei with coarsely is much greater than that seen in follicular adenomas
granular chromatin, often separated by clear parachro- (Figs. 13.21A to E and 13.22). The architecture of the
matin. Nucleoli are frequent. Mitosis may be seen, par- follicles can be strikingly irregular (Fig. 13.21B). The
ticularly in poorly differentiated carcinomas. nuclei are considerably increased in size, round to oval,
The classifi cation of follicular carcinomas may be and either uniform or pleomorphic. The nuclear size is
based on differentiation (e.g., well-differentiated or an important parameter and can be judged against an
poorly differentiated) or on the extent of invasion, such intact red blood cell in the background (a feature not
as capsular or blood vessel invasion or wide invasion of appreciated if fixed in a liquid medium or in air-dried
the surrounding parenchyma, regardless of the cytomor- Romanowsky-stained preparations). The nuclear chro-
phology. Usually well-differentiated carcinomas tend to matin is coarsely granular with parachromatin clearing.
be minimally invasive, and the poorly differentiated car- Micro- and/or macronucleoli are almost always present,
cinomas tend to be widely invasive. and intranuclear inclusions are almost never seen. Col-
A histologic diagnosis of follicular carcinoma is loid is very rarely seen in the background, but it may be
based on the presence of invasive characteristics such as present within the follicular lumens. The background is
capsular or vascular invasion or an invasion of the paren- usually clean.
chyma outside the capsule and the extent of it. Although The cytopathologic features of well-differentiated
everyone agrees that the demonstration of invasive fea- follicular carcinomas overlap with those of follicular ade-
tures (e-Figs. 13.5 and 13.6) is absolutely essential for the nomas, proliferating follicular nodules from Hashimoto’s
diagnosis of follicular carcinoma, considerable confusion, thyroiditis and a follicular variant of papillary carcinoma
controversy, and debate exist over what constitutes a cap- (see the section on differential diagnoses of follicular pat-
sular or vascular invasion and how much invasion is sig- terned lesions) (Table 13.7; see Figs. 13.27 to 13.31).
nificant. Thus, the interpretation becomes subjective, and They also share morphologic overlap with medullary car-
the diagnosis of follicular neoplasms varies greatly. cinoma and parathyroid adenoma.
Wide invasion of the parenchyma is an acceptable
criterion of invasion for all pathologists when the tumor Cytopathologic Features of Poorly Differentiated
invades the capsule and extends into the adjoining paren- Follicular Carcinomas
chyma widely. The tumor may form pushing nodules
The aspirates of poorly differentiated follicular carcino-
and incite fibrosis and should not be considered as sepa-
mas should pose no diagnostic problems. Their cellular
rate nodules. Widely invasive tumors tend to be poorly
aspirates consist of large syncytial tissue fragments of
differentiated.
malignant cells along with loosely cohesive cells (Table
13.7; Figs. 13.23 to 13.26).
The tissue fragments may exhibit a follicular or tra-
The aspirates of follicular carcinomas present a spectrum becular pattern or present large islands with no architec-
of cytologic features (Table 13.7). At one end of the spec- tural pattern. The malignant cells tend to be larger than
trum, the cytologic pattern closely resembles that of cellu- those seen in well-differentiated carcinomas, pleomorphic
lar follicular adenomas. The other end of the spectrum rep- in size with variable pale to dense cytoplasm, large round
resents poorly differentiated follicular carcinomas where nuclei with intensely stained, coarsely granular chro-
the neoplastic cells are clearly malignant. The cytologic matin, and parachromatin clearing. Nucleoli are easily
recognition of well-differentiated or low-grade follicular identified. Colloid is generally not conspicuous. The back-
carcinomas offers considerable difficulties because of the ground may show necrosis. The morphologic variants of
overlapping features with cellular adenomas and are gen- follicular carcinomas include carcinomas with clear cell
erally not attempted or recommended (TBS). The poorly change, mucinous features, and rhabdoid features. These
differentiated follicular carcinomas are readily identified. are extremely uncommon.
TABLE 13.7 CYTOPATHOLOGIC FEATURES OF FOLLICULAR CARCINOMAS
Well-Differentiated Follicular Carcinoma Poorly Differentiated Follicular Carcinoma

Cellularity Variable; usually high Variable; usually high
Presentation Cells mostly in syncytial tissue fragments or Cells mostly in syncytial tissue fragments or in
in loosely cohesive groups; scant or absent loosely cohesive groups; scant or absent colloid
colloid
Architecture of the Tissue With or without follicular pattern; follicles Syncytial without a follicular pattern; follicular
Fragments may be discrete, irregular, vary in size and pattern infrequent; trabeculae with or without
may contain small amount of colloid; branching and anastomosing; marked crowding and
trabeculae with or without branching overlapping of nuclei
and anastomosing; marked crowding and
overlapping of nuclei
Cells Poorly defined cell borders; N/C ratios high Enlarged, pleomorphic in size; poorly defined cell
borders; N/C ratios high
Nucleus Round, mild to moderate increase in size, Round, moderate to marked increase in size,
smooth nuclear membranes; coarsely considerably pleomorphic, smooth nuclear
granular chromatin; nucleoli ⫹, membranes; coarsely granular chromatin; nucleoli ⫹,
parachromatin clearing; grooves or parachromatin clearing; grooves or inclusions absenta
inclusions absent
Cytoplasm Usually scant; pale but may be dense Usually scant; pale but may be dense
Colloid Absent or scant Absent or scant
Background Usually clean Usually clean; may show necrosis
Differential Diagnoses Hyperplastic goiter Hürthle cell carcinoma

Follicular nodule in Hashimoto’s thyroiditis Medullary carcinoma
Follicular adenoma Anaplastic carcinoma
Follicular variant of papillary carcinoma Squamous carcinoma
Medullary carcinoma Metastatic carcinoma
Parathyroid adenoma
Note that the cells from poorly differentiated ‘insular’ carcinoma are small with nuclear size up to 10 ␮m.
a
A B
Figs. 13.21A to B. FNA of well-differentiated follicular carcinomas; spectrum of cytologic presentation. A: Syncytial
tissue fragments of follicular cells with a follicular pattern. The nuclei are large, round and vary in size. The chroma-
tin is granular with micronucleoli, a feature that favors invasive characteristics. Thyroidectomy confirmed the diagno-
sis of follicular carcinoma. B: Cellular aspirate consisting syncytial tissue of follicular cells forming irregular follicles.
Their nuclei are considerably enlarged in size and hyperchromatic, containing nucleoli. (continued)
C D
Figs. 13.21C to E. (continued) C: Syncytial architecture, extreme

crowding, and overlapping of enlarged nuclei, coarsely granular
chromatin with parachromatin clearing and nucleoli are diagnostic
of follicular carcinoma. Such extreme crowding of nuclei is gener-
ally not seen in adenomas. Note the discrete follicles in the back-
ground. They are irregular with extreme crowding of nuclei. D: A
syncytial tissue fragment of follicular cells without any architec-
tural pattern. Their nuclei are considerably enlarged and pleomor-
phic with coarsely granular chromatin, some containing nucleoli.
E: FNA showing syncytial tissue fragments of follicular cells with
a follicular and a trabecular pattern. The nuclei contain granular
chromatin with parachromatin clearing and prominent nucleoli.
E The thyroidectomy showed a widely invasive follicular carcinoma.
A B
Figs. 13.22A and B. FNA of a follicular carcinoma (Diff-Quik). A: Nuclear morphology is not as clear in
Romanowsky-stained preparations as in Papanicolaou stain. B: Follicular carcinoma in liquid-based preparation.
ThinPrep. (Courtesy of Dr. Claire W. Michael, University Of Michigan Health System, Ann Arbor, Michigan.)
Immunoprofile
follicular cells also react to TTF-1 and to low-molecular
The cells of follicular neoplasms, including follicular ade- weight keratin but not to the high-molecular weight keratin.
nomas and their morphologic variants as well as follicular Vimentin is coexpressed with keratin, and the cells show
carcinomas, demonstrate positive reactivity to thyroglobu- negative reactivity to carcinoembryonic antigen (CEA) and
lin, with the intensity depending on the differentiation. A calcitonin. Follicular carcinomas consistently react nega-
positive reaction is also noted in the colloid. The neoplastic tively to CK19, galectin-3, and RAT-oncogen.
Fig. 13.23. FNA follicular carcinoma. This syncytial tissue frag-

ment of follicular cells show marked crowding and overlapping
of enlarged nuclei with coarsely granular chromatin and contains
nucleoli. The cytologic diagnosis of follicular carcinoma was con-
firmed on thyroidectomy.
A B
Figs. 13.24A and B. FNA follicular carcinoma A: Cellular aspirate consisting of several syncytial tissue fragments
with and without a follicular pattern, showing markedly enlarged pleomorphic nuclei. B: A different field depicting
clearly malignant cells forming syncytia with a follicular pattern. Thyroidectomy confirmed a follicular carcinoma,
which was widely infiltrating the adjacent parenchyma.
Fig. 13.25. FNA of a poorly differentiated follicular carcinoma

demonstrating syncytial tissue fragments of follicular cells without
any architectural pattern. The malignant cell nuclei are pleomor-
phic, hyperchromatic and contain nucleoli.
of poor cytohistologic correlations. Aspirates that are cel-

DIAGNOSTIC ACCURACY
lular, consisting only of follicular cells are interpreted as
Traditionally, the cytopathology/pathology community “follicular lesions” or “follicular patterned lesions.” This
has resisted differentiating follicular lesions into nonneo- has been an acceptable diagnostic interpretation for most
plastic and neoplastic and benign from malignant because endocrinologists and surgeons. With such a noncommittal
A B
Figs. 13.26A and B. Poorly differentiated follicular carcinoma. FNA showing syncytial tissue fragments of clearly
malignant follicular cells. Follicular pattern is evident. The nuclei contain granular chromatin with parachromatin
clearing and prominent nucleoli. The malignant cells contain appreciable cytoplasm. The thyroidectomy showed a
widely invasive follicular carcinoma.
diagnosis, the diagnostic accuracy and the cytohistocorre- 2. The architectural patterns of the tissue fragments of folli-
lations do not count. cular epithelium differ in nonneoplastic follicular lesions
from follicular neoplasms. The former display monolay-
ered sheets with a honeycomb arrangement and regular
Differential Diagnoses of Follicular Lesions
follicles. The tissue fragments in neoplastic lesions are
The follicular cell-derived lesions of the thyroid present- characterized by syncytial architecture. If the architec-
ing a follicular growth pattern are referred to as follicu- tural pattern of the tissue fragments is disregarded and
lar lesions or follicular-patterned lesions and include the emphasis is placed on cellularity alone, differentiation
following: of follicular lesions is not possible. Hypercellularity of
the aspirate does not equate with neoplasia.
A. Nonneoplastic entities:
Nodular goiters 3. Follicular cell nuclei gradually increase in size from
Proliferating follicular nodules from chronic lympho- nodular goiter to follicular adenomas to follicular car-
cytic (Hashimoto’s) thyroiditis cinomas. The difference of nuclear size between goiters
B. Neoplasms: and follicular carcinomas is considerable and can easily
Follicular adenomas be appreciated. There is certainly an overlap between
Follicular carcinomas, well-differentiated some cases of follicular adenomas and low-grade or
Follicular variant of papillary carcinomas well-differentiated carcinomas where the nuclear size
approximates. The cytologic distinction in such cases
All the above-mentioned follicular lesions share several
is not possible.
morphologic features, both cytologically and histologically.
4. The compact chromatin pattern of the follicular cell
The common cytologic feature shared by the aspirates
nuclei in nodular goiter changes to granular in cellular
of the above-referenced follicular lesions is hypercellular-
adenomas and to coarsely granular with the presence
ity with a large population of follicular cells in a clean
of nucleoli and parachromatin clearing in follicular
background containing little or no colloid. However, cer-
carcinomas. The presence of nuclear pleomorphism
tain cytologic parameters are noticeable. These are repre-
with oval, oblong nuclear shapes, powdery chroma-
sented by alterations in the architectural patterns of the
tin, micronucleoli, grooves, and nuclear inclusions
tissue fragments of follicular epithelium and their nuclear
favor the follicular variant of papillary carcinoma. The
morphology.
nuclei in follicular adenomas and the low-grade fol-
The following observations are useful:
licular carcinomas tend to be uniformly enlarged in a
1. The amount of colloid decreases from involuted to given case.
hyperplastic goiter to cellular follicular adenoma and 5. The aspirates of poorly differentiated follicular carci-
follicular carcinoma. Consequently, the cellularity in nomas demonstrate clearly malignant features; they
the aspirated material is more noticeable. It is impor- are not diagnostic problems.
tant to realize that the absence of colloid does not rule 6. Nodular proliferations of follicular epithelium in
out a diagnosis of nodular or hyperplastic goiter. The Hashimoto’s thyroiditis will yield cellular samples
mere absence of colloid is not a criterion in favor of exhibiting morphology very similar to that displayed by
neoplasm. cellular follicular adenomas or follicular carcinomas.
The presence of lymphocytes in the background or HÜRTHLE CELL NEOPLASMS

permeating the follicular cell tissue fragments sup-
ports the diagnosis of Hashimoto’s thyroiditis. If the Hürthle cell neoplasms have generated considerable inter-
lymphoid cells are sparse, overlooked, or even absent, est over the last several decades and still do. To begin
it is not possible to recognize the nature of the lesion with, Hürthle cell neoplasms are considered by many
as Hashimoto’s thyroiditis and will be interpreted as pathologists to be morphologic variants of follicular
a follicular neoplasm. This constitutes an important neoplasms; hence, they are classifi ed and referred to as
diagnostic pitfall causing a false-positive diagnosis. “follicular adenoma, oxyphil cell type” and “follicular
The differentiation of follicular nodules from follicu- cell carcinoma, oxyphil cell type. Proponents of this view
lar neoplasms in the background of Hashimoto’s thy- believe that there is no justifi cation for isolating Hürthle
roiditis does not pose a problem in surgical pathol- cell adenomas or carcinomas because their morphologic
ogy, where the entire lobe or a gland is available for pattern and behavior parallels that of follicular adenoma
examination. or carcinoma, respectively. It is felt that the oncocytic
change is an inconsequential event that has no effect on
If the above-mentioned features are used as guide- the natural history. In sharp variance with this viewpoint
lines, the majority of the benign nonneoplastic diseases is the opinion of some that the Hürthle cell neoplasms
can be separated from neoplastic lesions. These features are aggressive with unpredictable biologic behavior, a
are best seen in wet-fi xed Papanicolaou-stained prepara- frequent recurrence rate, distant metastasis, and a high
tions. The differentiating features of various cellular fol- incidence of fatal outcomes.
licular lesions are listed in Table 13.8 and illustrated in The above-mentioned controversy extends to the
Figures 13.27 to 13.31. cytologic interpretation as well, and the reasons are
Lately, the follicular variant of papillary carcinoma the same as that for follicular lesions. The histologic
has generated considerable interest. There seems to be a criteria for the diagnosis of Hürthle cell carcinomas
wide variance in the cytologic recognition of the follicu- parallel those of follicular carcinomas. Needless to
lar variant of papillary carcinoma. Some have reported say, these interpretations have become very subjective.
very low sensitivity. Many follicular variants of papillary Many cytopathologists, and therefore, endocrinolo-
carcinomas are interpreted cytologically as either nodu- gists/surgeons believe that the cytologic differentiation
lar goiter or follicular neoplasms. The diagnostic prob- of Hürthle cell adenomas from Hürthle cell carcino-
lems very often arise from the fact that, in some cases mas is not possible since the diagnosis of malignancy
of follicular variant of papillary carcinoma, the typical is made only from histologic examination. Along the
nuclear morphology may be limited to only a few focal same lines, it is also believed by some cytopathologists
areas. Sampling is the main reason for the lack of diag- that the nonneoplastic Hürthle cell nodules cannot be
nostic criteria. Please refer to the section on papillary differentiated from Hürthle cell neoplasms (possibly so
carcinomas. in air-dried Romanowsky stained preparations). Conse-
quently, all aspirates composed of Hürthle cell popula-
tion are lumped as Hürthle cell lesions and categorized
HÜRTHLE CELL LESIONS as indeterminate/suspicious in the reporting scheme,
thereby recommending surgical excision. The author
TBS does not separate Hürthle cell lesions into nonneo-
disagrees with this approach and strongly feels that the
plastic and neoplastic and benign from malignant. All
cytologic triage of Hürthle cell lesions into nonneoplas-
aspirates consisting of Hürthle cells are reported as “sus-
tic and neoplastic and benign from malignant is possible
pect Hürthle cell neoplasm.” The following text, however,
in most instances. These observations are also supported
differs from TBS’s recommended criteria, because this
by other investigators.
author has confidence in the attempts to triage Hürthle
cell lesions based on the criteria described below.
Hürthle cells (synonyms: oncocytes, Askanazy cells,
HÜRTHLE CELL ADENOMA
or oxyphils) are altered follicular cells. They are large
polygonal cells with abundant granular cytoplasm; (Synonyms: oncocytic adenoma, oxyphilic adenoma, and
the granularity is the result of abundant mitochondria. follicular adenoma with oncocytic features). Hürthle cell
Hürthle cells do not concentrate radioactive iodine. adenomas are benign thyroid neoplasms that are exclu-
Hürthle cells are seen in several conditions affecting sively or predominantly composed of Hürthle cells or
the thyroid such as Hashimoto’s thyroiditis, adenomatous oncocytes (over 75%). Their true incidence cannot be
goiters, post radiation, and Graves’ disease. This change assessed because they are often considered the morpho-
can be extensive, resulting in the formation of nodules logic variants of follicular adenomas. Hürthle cell ade-
that are either palpable or detected on ultrasound and, nomas are more frequent in women with a male:female
clinically, cannot be differentiated from neoplasms, often ratio of 1:8. Although Hürthle cell adenomas can occur
necessitating fine needle biopsies. at any age, they are more common between the third and
TABLE 13.8 DIFFERENTIAL DIAGNOSES OF FOLLICULAR LESIONS (FOLLICULAR PATTERNED LESIONS)

DIFFERENTIATING FEATURES
Follicular
Adenoma
Follicular Nodule Cellular Type Follicular Variant
Hyperplastic in Hashimoto’s (Microfollicular Follicular of Papillary
Nodular Goiter Thyroiditis and Trabecular) Carcinoma Carcinoma
Cellularity Usually cellular Usually cellular Usually cellular Usually cellular Usually cellular
Presentation Follicular cells Follicular cells mostly Mostly in tissue In tissue fragments, In tissue fragments;
mostly in tissue in tissue fragments; fragments sometimes in loosely & in loosely
fragments sparse to abundant cohesive groups cohesive groups
lymphoid cells
Architecture Regular small Tissue fragments Syncytial tissue Syncytial tissue Syncytial tissue
follicles with evenly with or without fragments with or fragments with or fragments with or
spaced nuclei; follicular pattern; without follicular without follicular without follicular
monolayered nuclei often crowded pattern; follicles and trabecular pattern with
with honeycomb and overlapped; irregular with pattern; follicles crowding and
pattern; permeated by mature crowding and may be markedly overlapping of
infrequently lymphocytes overlapping of irregular with intense nuclei; inspissated
papillary nuclei; trabecular crowding and colloid within
configuration but pattern ⫹/⫺ overlapping of nuclei follicular lumina;
with honeycomb follicles elongated,
arrangement of curvaceous
component nuclei
Nuclear Size Normal to slightly Considerably variation Variably enlarged Considerably Enlarged with
increased; uniform; in size but uniformly in a enlarged with variation in size
7–9 ␮m in diameter given neoplasm variation in size
Chromatin Finely granular, Fine to coarsely Fine to coarsely Fine to coarsely Dusty, powdery to
evenly distributed, granular; smooth granular; granular; finely granular
sometimes nuclear membranes smooth nuclear parachromatin
compact; membranes clearing; nuclear
smooth nuclear membranes may be
membranes irregular
Nucleolus Micronucleoli ⫹/⫺ Micronucleoli ⫹/⫺ Micronucleoli ⫹/⫺ Micronucleoli/ Micronucleoli ⫹/⫺
macronucleoli
Intranuclear Absent Rarely present Absent On rare occasions Usually present

Inclusions (a diagnostic clue)
Nuclear Rare Absent Absent Absent Present

Grooves
Cytoplasm Variable, clear to Variable, clear to pale Scant, pale Variable, generally Usually scant to
pale scant, pale to dense pale
Colloid Scant to absent Scant to absent Scant to absent, Scant to absent, Often
may be present as may be present as
droplets, within or droplets, within or
outside follicular outside follicular
lumina lumina
(continued)
Follicular
Adenoma
Follicular Nodule Cellular Type Follicular Variant
Hyperplastic in Hashimoto’s (Microfollicular Follicular of Papillary
Nodular Goiter Thyroiditis and Trabecular) Carcinoma Carcinoma
Multinucleated Absent Rarely present Absent Absent Present
Foreign-Body-
Type Giant
Cells
Helpful Cytologic changes Hürthle cell Syncytial Syncytial architecture Cytologic features
Features of nodular goiter metaplasia and architecture; considerable increase of papillary
lymphoplasmacytoid absent colloid in in nuclear size, more carcinoma on other
cells in the the background; pleomorphic, more slides
background (high nucleoli generally hyperchromatic;
antimicrosomal or absent nucleoli ⫹; absent
antithyroglobulin colloid
antibody titers)
Differential Diagnoses of Follicular Patterned Lesions (See Figs. 13.27 to 13.31)
The following sets of images demonstrate the common as well as differentiating features between various follicular lesions.
A B
C D
Figs. 13.27A to D. A: Nodular goiter. B: Follicular hyperplasia in chronic lymphocytic thyroiditis. C: Follicular
adenoma. D: Follicular carcinoma. (continued)
Figs. 13.27E. (continued) E: Follicular variant of papillary carci-
E noma.
A B
C D
Figs. 13.28A to E. A: Nodular goiter. B: Follicular hyperplasia in

chronic lymphocytic thyroiditis. C: Follicular adenoma. D: Follicu-
E lar carcinoma. E: Follicular variant of papillary carcinoma.
426
A B
C D
Figs. 13.29A to E. A: Nodular goiter. B: Follicular hyperplasia in

chronic lymphocytic thyroiditis. C: Follicular adenoma. D: Follicu-
E lar carcinoma. E: Follicular variant of papillary carcinoma.
fourth decades of life. The clinical presentation is the tumors are very vascular with frequent hemorrhage and
same as follicular adenomas. cystic changes and are known to undergo post-needle
biopsy infarction with high incidence.
Histologically, Hürthle cell adenomas are completely
encapsulated. The capsule is variably thick. The tumor is
Hürthle cell adenomas are usually solitary, discrete tumors composed entirely of large Hürthle cells with abundant,
that may reach a large size. Multiple Hürthle cell tumors granular, consistently deep eosinophilic cytoplasm. The
as well as bilaterality and association with other diseases cell borders are distinct and well-defined. Their nuclei are
have been reported. Their cut surfaces are bulging with round and uniform, containing fi nely granular chroma-
characteristic mahogany–brown coloration. Hürthle cell tin with a prominent macronucleolus. The N/C ratios are
A B
C D
Figs. 13.30A to E. Differential diagnoses of follicular lesions. Cyto-

logic features of follicular lesions (follicular-patterned). A: Nodular
goiter. B: Chronic lymphocytic thyroiditis: C: Cellular follicular ade-
noma. D: Follicular carcinoma. E: Follicular variant of papillary car-
cinoma. All four lesions demonstrate a microfollicular pattern. The
presence of microfollicles by themselves is not indicative of a follicu-
lar neoplasm unless the follicles are irregular; demonstrate crowded
E and overlapped, enlarged nuclei, and syncytial architecture.
Cytopathologic Features of Hürthle

characteristically very low. The growth patterns of Hürthle
Cell Adenoma
cell adenomas can be follicular, solid or trabecular, and
occasionally papillary. The follicles vary in size and may The aspirates of Hürthle cell adenomas are generally cel-
contain abundant colloid. Cystic change is not uncom- lular, consisting of a large population of cells characterized
mon. Psammoma bodies may be present in adenomas by a dispersed pattern as well as loosely cohesive groups
with a papillary growth pattern. Hürthle cell adenomas and tissue fragments with a monolayered architecture and
may demonstrate nuclear pleomorphism. However, the acinar pattern (Table 13.9; Figs. 13.32 and 13.33). Hürthle
chromatin in these pleomorphic nuclei is deep-staining, cell adenoma cells present a very distinctive appearance on
smudgy, and structureless—indicating degeneration—and account of their abundant, granular cytoplasm, and a strik-
the nuclei are not indicative of malignancy. ingly monomorphic cell population. Syncytial architecture
A B
C D
Figs. 13.31A to D. Cytologic features of follicular lesions (follicular-patterned). A: Hyperplastic goiter. B: Follicular
adenoma. C: Follicular carcinoma. D: Follicular variant of papillary carcinoma. The cytologic distinction of these
various lesions is difficult from this type of preparation (Diff-Quik). (Courtesy of Dr. Mariza de Peralta-Venturina,
Cedar-Sinai Hospital, Los Angeles, California.)
is not a feature of Hürthle cell adenomas. A papillary pat- and, importantly, from nonneoplastic Hürthle cell lesions.
tern may occasionally be present. The cells of Hürthle cell Rarely, psammoma bodies may be identified.
adenomas are usually very large, polygonal, round to oval, Hürthle cell neoplasms, being very vascular, usu-
with well-defined cell borders. Binucleation is frequent. ally have a bloody background. The amount of colloid
The nuclei can be central or eccentric. The cytoplasm is is variable: it can be absent, scant, or appreciable. The
abundant and granular, resulting in very low N/C ratios. presence of colloid is not a feature against the diagnosis
The staining of the cytoplasm is dependent on the fixative of Hürthle cell neoplasm. However, benign regular type
and the stains used. With spray-fixed smears and Papani- follicular cells are not present in the background. The
colaou stain, the cytoplasm stains eosinophilic, cyano- occurrence of histiocytes with or without hemosiderin
philic, or amphophilic, while with the wet-fixed with 95% indicates old hemorrhage within the tumor and does not
alcohol, the Hürthle cells stain deep eosinophilic, similar rule out a neoplasm. A combination of normal follicu-
to an H&E-stained specimen. The Hürthle cell cytoplasm lar cells and Hürthle cells does not favor a Hürthle cell
stains lavender with a Romanowsky stain (Fig. 13.33D). neoplasm.
The nuclei of the Hürthle cell adenomas are always round Being very vascular, Hürthle cell adenomas are prone
with smooth, crisp nuclear membranes containing finely to post-biopsy infarction. The importance of this lies in
granular, evenly dispersed chromatin. In a given neoplasm, the fact that infarction may compromise the final histo-
the nuclei of the Hürthle cell adenomas tend to be of the logic diagnosis; for example, if the surgical pathologist
same size and very uniform. A single cherry–red macronu- is not informed of the cytologic diagnosis, he or she may
cleolus is the hallmark of neoplastic Hürthle cells—a fea- overlook the viable tumor that is usually present as a thin
ture that often helps to differentiate Hürthle cell neoplasm rim at the periphery. Spontaneous infarction can also
from other thyroid follicular and C-cell derived neoplasms occur in Hürthle cell adenomas.
TABLE 13.9 CYTOPATHOLOGIC FEATURES OF HÜRTHLE CELL ADENOMA AND CARCINOMA
Hürthle Cell Adenoma Hürthle Cell Carcinoma

Cellularity Cellular Cellular
Presentation Cells isolated, in loosely cohesive groups or Cells isolated, in loosely cohesive groups or in syncytial
in two-dimensional sheets; follicle formation tissue fragments, usually without any architectural patterns;
infrequent; papillary tissue fragments in papillary tissue fragments present in papillary variant;
tumors with papillary architecture; dispersed dispersed cell pattern common
cell pattern common; transgressing capillaries
through the tissue fragments ⫹/⫺
Cells Large; well-defined cell borders; polygonal, Can be uniformly small to medium-sized; round, oval
round to oval; low N/C ratios to cuboidal; cytoplasmic borders well to poorly defined;
very high N/C ratios; can be very pleomorphic in poorly
differentiated carcinomas
Nucleus Central to eccentric; frequent binucleation; Central to eccentric; round, minimally pleomorphic in size;
round, uniform and monomorphic in a given usually same size as that of benign counterpart or slightly
case; thin, crisp nuclear membranes, finely enlarged; smooth nuclear membranes, finely granular
granular, uniformly dispersed chromatin; chromatin with prominent cherry-red macronucleus;
single large cherry-red macronucleolus is nuclei may present clearly malignant features with coarse
characteristic; nuclear pleomorphism and chromatin; parachromatin clearing, intranuclear inclusions
pyknosis are rare in poorly differentiated, widely invasive tumors
Cytoplasm Abundant, granular; may stain eosinophilic, Usually scant, eosinophilic amphophilic to cyanophilic;
amphophilic or cyanophilic granular to moderate in poorly differentiated carcinomas
Colloid Variable; often absent Absent
Psammoma Infrequently present May be present in papillary variant

Bodies
Background Often bloody, necrosis ⫹/⫺; features of nodular Often bloody, necrosis ⫹/⫺; features of nodular goiter not
goiter not present; lymphocytes absent; no present; lymphocytes absent; no regular type follicular cells
regular type follicular cells; degenerative
changes with evidence of old hemorrhage and
histiocytes with or without hemosiderin ⫹/⫺
Immunoprofile Immunoreactive to thyroglobulin, TTF-1; low Immunoreactive to thyroglobulin, TTF-1; low molecular
molecular weight keratin weight keratin
Ultrastructure Large numbers of mitochondria Large numbers of mitochondria
Differential Proliferative Nonneoplastic Hürthle Cell Poorly Differentiated Follicular Carcinoma

Diagnoses Nodules from Nodular Goiter Papillary Carcinoma, Tall Cell Variant and Oxyphilic Variant
Chronic Lymphocytic Thyroiditis, Medullary Carcinoma
Post Graves’ Disease Anaplastic Carcinoma
Metastatic Renal Cell Carcinoma
time of presentation is 55 years. Hürthle cell carcinomas

HÜRTHLE CELL CARCINOMA
present an aggressive clinical behavior with a high degree
(Synonyms: oncocytic carcinoma, oxyphilic carcinoma, of mortality. Hürthle cell carcinomas are locally invasive,
and follicular carcinoma with oncocytic features). Hürthle frequently recur, and unlike follicular carcinomas, metas-
cell carcinomas are predominantly or exclusively com- tasize to the cervical lymph nodes. They also metastasize
posed of Hürthle cells. They are more common in women to the distant organs such as the lungs, the bones, and the
and occur in the older age group; the mean age at the liver. Hürthle cell carcinomas generally do not take up
Hürthle Cell Lesions (See Figs. 13.32 to 13.42)
Fig. 13.32. Hürthle cell adenoma. The cellular aspirate shows large
round to polygonal cells with well-defined cell borders, discrete
and arranged in sheets. Note the abundant granular eosinophilic
cytoplasm. The nuclei are uniform, round, and central to eccentric
with finely granular chromatin. The cherry–red macronucleolus is
the hallmark of neoplastic Hürthle cells. Note the low N/C ratios.
There is no colloid in the background.
A B
C D
Figs. 13.33A to D. Hürthle cell adenoma. A: The neoplastic Hürthle cells are round to oval, pleomorphic in size,
containing amphophilic cytoplasm. Some cells are binucleated. Macronucleoli are conspicuous. The background is
clean with no colloid. B: FNA of a different case of Hürthle cell adenoma. The cellular aspirate shows large round
to polygonal cells with well-defined cell borders, occurring singly or arranged in sheets. Note the abundant granular
cytoplasm is stained cyanophilic. The nuclei are uniform, round containing macronucleoli. C: Hürthle cell adenoma
showing a predominantly discohesive and monotonous population and occasional microfollicle. The cells are en-
larged and contain abundant granular cytoplasm. The N/C ratios are low (Thin Prep). (Courtesy of Dr. Claire W.
Michael, University Of Michigan Health System, Ann Arbor, Michigan.) D: Hürthle cell adenoma (Romanowsky).
radioactive iodine. Large tumor size (⬎4 cm), extrathy- The nuclei are uniformly round and only slightly increased
roidal extension, and nodal metastasis are factors associ- in size, compared to its benign counterpart. However,
ated with an unfavorable outcome. fi nely granular chromatin and the characteristic macro-
nucleolus are present in both adenomas and carcinomas.
Gross and Histologic Features Hürthle cell carcinomas may also exhibit a very pleomor-
phic pattern (Figs. 13.38A to C). Multiple nucleoli are
Grossly, Hürthle cell carcinomas are large and bulky,
frequent along with intranuclear inclusions (Fig. 13.38A).
replacing the entire lobe with a fl eshy, brown cut sur-
The presence of intranuclear inclusions is not a consistent
face that frequently contains areas of necrosis and
or specifi c feature of Hürthle cell carcinomas. The back-
hemorrhage.
ground may be clean, necrotic, or bloody and devoid of
Histologically, Hürthle cell carcinomas may be com-
colloid. Degeneration and hemorrhage is quite common
pletely encapsulated with capsular or vascular invasion,
in Hürthle cell neoplasms. Local recurrence is frequent
or they can be widely invasive, characterized by a solid,
with Hürthle cell carcinomas.
alveolar, trabecular, or papillary growth patterns. The
malignant Hürthle cells are usually of much smaller size,
compared to their benign counterpart. The N/C ratios PAPILLARY VARIANT OF HÜRTHLE
are high and macronucleoli are very prominent. The car- CELL CARCINOMA
cinoma demonstrates an increased proliferative activity
with mitosis. Hürthle cell carcinomas also demonstrate The papillary variant of Hürthle cell carcinoma is very
a poorly differentiated pattern with large pleomorphic rare and is characterized by a papillary growth pattern.
malignant cells containing clearly malignant nuclei. The The papillary fronds are lined by cuboidal to columnar
carcinoma frequently involves the perithyroidal soft oncocytic cells. Their nuclei contain granular chroma-
tissues. tin, micronucleoli, and intranuclear inclusions. However,
The diagnosis of Hürthle cell carcinoma is entirely powdery, pale chromatin and nuclear grooves are not
based on demonstrating invasive characteristics such as seen. Psammoma bodies are frequently identified. The
capsular and vascular invasion and the invasion of the clinical behavior is considered to be similar to conven-
surrounding parenchyma similar to those described for tional papillary carcinomas while others have reported
conventional follicular carcinomas. The same diagnos- aggressive behavior.
tic criteria are applicable and the same controversies are Cytologically, the aspirates are cellular, composed of
encountered. syncytial tissue fragments of Hürthle cells with papillary
configurations. The neoplastic cells are small to medium-
Cytopathologic Features of Hürthle Cell Carcinoma sized with typical Hürthle cell morphology, variable gran-
ular cytoplasm, and nuclei containing prominent nucleoli.
The aspirates of Hürthle cell carcinomas are hypercellular Intranuclear inclusions are frequent. Psammoma bodies
and exhibit a spectrum of cytologic features (Table 13.9; are also present.
Figs. 13.34 to 13.39) that varies from small to medium- Histologically and cytologically, the papillary vari-
sized, uniform round, cuboidal, plasmacytoid cells with ant of Hürthle cell carcinoma is diffi cult to differentiate
high N/C ratios to a very pleomorphic cell pattern. In our from the oxyphilic variant, the tall cell variant, and the
experience, the latter is only infrequently encountered Warthin’s-like variant of papillary carcinomas.
while the small to medium-sized cell pattern is more com-
monly observed. The malignant cells appear discrete, in Immunoprofile
loosely cohesive groups or in syncytial tissue fragments,
and the dispersed cell pattern is more frequent. The malig- The cells of Hürthle cell or oncocytic neoplasms react
nant Hürthle cells are characterized by granular, some- positively to thyroglobulin but less intensively than their
times dense, variable, but scant cytoplasm with slightly follicular counterparts. The cells show positive reactivity
larger, round nuclei with high N/C ratios. In fact, a very to TTF-1 in 30% of cases and to low-molecular weight
cellular aspirate with a dispersed cell pattern formed by keratin but not to calcitonin. Galectin-3 is demonstrated
monomorphic small to medium-sized Hürthle cells with in 95% of Hürthle cell neoplasms and shows reactivity to
prominent cherry–red macronucleoli makes a striking pre- HBME-1 in 55% of cases. There was a specificity of 88%
sentation, even at low power (Figs. 13.34A and 13.37). when both markers were used.
The syncytial tissue fragments may show no archi-
tectural confi gurations or may demonstrate follicular or
trabecular patterns. Papillary architecture is encountered DIAGNOSTIC ACCURACY
in the papillary variant of Hürthle cell carcinoma. Many AND DIFFERENTIAL DIAGNOSES
investigators have reported transgressing blood vessels Because of their characteristic cytomorphology, high
in the tissue fragments of malignant cells, and these are diagnostic accuracy can be expected for Hürthle cell
considered to be a key feature in the cytologic diagnosis. neoplasms. However, in actual practice it is not so. The
A B
C D
Figs. 13.34A to D. Hürthle cell carcinoma A: Hürthle cell carcinoma, showing a dispersed pattern formed by small
to medium-sized uniform cells with high N/C ratios. Note the characteristic nuclear morphology with prominent ma-
cronucleoli. B: Hürthle cell carcinoma showing syncytial arrangement with crowding and overlapping of nuclei. Their
chromatin is coarsely granular and single or multiple nucleoli are conspicuous. C: Syncytial tissue fragments of plas-
macytoid Hürthle cells with high N/C ratios. Note the psammoma body. D: Hürthle cell carcinoma showing much
smaller cells, occurring singly, in loosely cohesive groups or in syncytial tissue fragments. Smaller cell size, scant but
dense cytoplasm, relatively large nucleus with high N/C ratios and prominent macronucleoli characterize malignancy
in Hürthle cell neoplasms. Also note the plasmacytoid cells, resembling medullary carcinoma cells.
A B
Figs. 13.35A and B. FNA of Hürthle cell carcinoma. The cellular aspirate shows Hürthle cells, dispersed singly,
in groups and in syncytial tissue fragments. They are small, pleomorphic with high N/C ratios. Nucleoli are
conspicuous.
A B
Figs. 13.36A and B. Hürthle cell carcinoma. A: Diff-Quik stained preparation showing a syncytial tissue fragment
of Hürthle cells. Note the prominent nucleoli. (Courtesy of Mithra Baliga, M.D., University of Mississippi, Jackson,
Mississippi.) B: The aspirate shows a predominant single cell population with uniform size. Their nuclei are enlarged
and the nucleoli are prominent (Thin Prep). (Courtesy of Dr. Claire W. Michael, University of Michigan Health
System, Ann Arbor, Michigan.)
Fig. 13.37. FNA of a Hürthle cell carcinoma. The cellular aspirate

is composed of small, round to cuboidal cells, discrete and forming
small syncytial tissue fragments. The cell borders are poorly defined.
N/C ratios are high and macronucleoli are prominent.
A B
Figs. 13.38A to B. Hürthle cell carcinoma. A: FNA of the vertebral mass showing syncytial tissue fragments
of Hürthle cells. Their cytoplasm is scant and macronucleoli are conspicuous. B: The malignant cells are large,
containing abundant cytoplasm and are arranged in syncytial fashion. However, note that their nuclei are enlarged,
very pleomorphic with prominent nucleoli different example of Hürthle cell carcinoma, showing syncytial tissue
fragments with very pleomorphic nuclei. (continued)
Figs. 13.38C. (continued) C: different example of Hürthle cell car-

cinoma, showing syncytial tissue fragments with very pleomorphic
C nuclei.
Fig. 13.39. Papillary Hürthle cell carcinoma. This syncytial tissue

fragment of Hürthle cells contains psammoma bodies.
diagnostic accuracy cannot be assessed from the avail-

Hürthle Cell Adenoma versus
able data. An important limiting factor is that most
Hürthle Cell Carcinoma
institutions include all aspirates, which is a large pop- The cytologic patterns seen in aspirates of Hürthle cell
ulation of Hürthle cells, under the term “Hürthle cell adenomas are strikingly different from those seen in car-
lesion.” This diagnostic category is also recommended cinomas in Papanicolaou-stained preparations. The fea-
by TBS. tures are also appreciated in histologic sections, if one
When a Hürthle cell lesion is not differentiated as cares to look for them. Certain parameters are important
nonneoplastic, neoplastic, benign, or malignant, the ques- in differentiating adenomas from carcinomas:
tion of concordance or discordance between cytology and
The cell size: Cells of Hürthle cell adenomas are dis-
histology does not matter or is inconsequential since sur-
tinctly larger than those in carcinomas.
gical intervention is recommended for all aspirates that
are cytologically interpreted as Hürthle cell lesions. The The nuclear size: This remains almost the same in
incidence of false-positive or false-negative diagnoses adenomas and carcinomas with minimal variations in
becomes irrelevant. carcinomas. What is more striking and very obvious
Many investigators believe that Hürthle cell carci- is that the N/C ratios are markedly increased in carci-
nomas present very aggressive behavior, and they recom- noma cells as supported by morphometry.
mend a total thyroidectomy. It makes a great deal of sense Amount of cytoplasm: The benign neoplastic Hürthle
then to provide the probabilities of neoplasia, particularly cells are characterized by abundant cytoplasm, in sharp
that of malignancy, and to identify nonneoplastic Hürthle contrast to the scant cytoplasm of the carcinoma cells.
cell lesions from the aspirates. Patients with a nonneo- The N/C ratios are low in adenomas and very high in
plastic diagnosis can be managed conservatively. carcinomas.
The common denominator for the Hürthle cell neo- Hürthle Cell Adenoma/Carcinoma versus Hürthle
plasm is the prominent macronucleolus. The variations in Cell Metaplasia in Nodular Goiter
cytologic features are illustrated in Figures 13.40A to C.
Hürthle cell metaplasia is an extremely common feature
in nodular goiters (Figs. 13.41A to C). A few scattered
Hürthle Cell Adenoma/Carcinoma versus Hürthle cells along with benign follicular cells are often
Nonneoplastic Hürthle Cell Nodules present in aspirates from nodular goiter. However, nod-
ules that are entirely composed of Hürthle cells will yield
Clinically palpable or ultrasonically detected thyroid
a large population of Hürthle cells. We have found the
nodules formed entirely of Hürthle cells occur in nodu-
cytologic features described in Table 13.10 (Figs. 13.40A
lar goiters, Hashimoto’s thyroiditis, and sometimes in
to C) to be very helpful.
post-Graves’ disease. Clinically and on imaging, these
Hürthle cells aspirated from nonneoplastic Hürthle
nodules cannot be differentiated from a neoplasm and
cell nodules tend to be cohesive and present as sheets
are subjected to aspiration biopsy. A large population of
of epithelium with a honeycomb arrangement and have
Hürthle cells in cytologic samples has caused consider-
well-defi ned cell borders and abundant cytoplasm that
able diagnostic diffi culties in separating nonneoplastic
is either dense or granular and contains centrally placed
lesions from Hürthle cell neoplasms. Cytologically, these
nuclei (Figs. 13.41A to C, 13.42). A follicular pattern is
aspirates have been interpreted as “Hürthle cell lesion” or
not uncommon. Transitional forms from regular follicu-
as “indeterminate/suspicious” and often result in surgical
lar cells to large, polygonal cells are usually present (Fig.
excision. The incidence of benign nonneoplastic Hürthle
13.41B) and serve as an important diagnostic clue. The
cell lesions in these groups is reported in the range of 17
nuclei are almost always pleomorphic in size, and gener-
to 50%. The cytologic criteria for differentiating Hürthle
ally do not show macronucleoli. The nuclear chromatin is
cell neoplasms from Hürthle cell nodules are subtle and
coarsely granular and pyknotic forms are very frequent.
recognizing them requires experience (Table 13.10).
Colloid is present in the background, but it is variable and
A B
Figs. 13.40A to C. Comparison of cytomorphology of various

Hürthle cell lesions. A: Hürthle cell adenoma. B: Hürthle cell carci-
C noma. C: Hürthle cell metaplasia.
TABLE 13.10 DIFFERENTIAL DIAGNOSES OF HÜRTHLE CELL LESIONS CYTOPATHOLOGIC FEATURES
Hürthle Cell Nodules in Hürthle Cell Nodules in

Hürthle Cell Neoplasms Nodular Goiter Hashimoto’s Thyroiditis
Cellularity Variable but generally high Variable Variable
Presentation Neoplastic cells isolated, Hürthle cells usually in varying- Hürthle cells isolated, or in
loosely cohesive, in sized tissue fragments as sheets varying-sized tissue fragments,
two-dimensional sheets, with honeycomb arrangement, syncytial architecture unusual,
follicular pattern ⫹/⫺; small follicular pattern may be present; monomorphic cell absent
to large syncytial tissue isolated cell pattern infrequent;
fragments; usually without monomorphic cell pattern absent;
any architectural patterns; varying numbers of benign
papillary pattern infrequent; follicular cells
monomorphic cell pattern
Hürthle Cells Large, polygonal or oval Very pleomorphic in size; Very pleomorphic in size,
in adenomas; round to transition forms from well-defined cell borders; low
cuboidal, small to medium- normal benign follicular cells N/C ratios
sized in carcinomas; well characteristic within a given
to poorly defined cell tissue fragments; well-defined cell
borders; N/C ratios low borders; low N/C ratios
in adenomas; high in
carcinoma
Nucleus Central to eccentric Central location; bi- Central locations; bi-

location, frequently multinucleation infrequent; multinucleation infrequent;
binucleated; round with variable in size from cell to cell variable in size from cell to
smooth nuclear membranes; with occasional giant forms; cell with occasional giant
finely granular chromatin; chromatin finely granular to forms; chromatin finely
prominent, single cherry-red smudgy; may be pyknotic; granular to smudgy; may be
nucleolus; size uniform in a micronucleoli ⫹/⫺; cherry-red pyknotic; micronucleoli ⫹/⫺;
given case macronucleolus not observed cherry-red macronucleolus
very rare
Cytoplasm Abundant, granular Variable, granular, and Variable; granular;

in adenomas; stain eosinophilic to cyanophilic eosinophilic to cyanophilic
eosinophilic, cyanophilic,
or amphophilic;
scant in carcinomas;
intracytoplasmic
lumens ⫹/⫺
Regular Type Follicular Cells Absent Present with transition forms ⫹/⫺
Lymphoplasmacytic and Absent Absent Present in variable numbers;

Germinal Center Cells may be sparse; lymphoid
tangles ⫹/⫺
Degenerative Changes; ⫹/⫺ ⫹/⫺ Absent

Histiocytes with and without
Hemosiderin
Regular Type Follicular Cells Absent Present with transition forms ⫹/⫺
Transgressing Blood Vessels ⫹/⫺; can be appreciated ⫺ ⫺

in Tissue Fragments of if the tissue fragments are
Hürthle Cells large
A B
C D
Figs. 13.41A to D. Hürthle cell metaplasia in nodular goiter. A: Large follicle formed by follicular cells with abun-
dant eosinophilic cytoplasm and deep-staining nuclei. B: sheet of Hürthle cells with a honeycomb arrangement. The
nuclei are pleomorphic in size and lack macronucleoli. The cytoplasm is abundant. C: A large sheet of metaplastic
Hürthle cells with abundant eosinophilic cytoplasm. The nuclei lack macronucleoli. D: Tissue fragments of Hürthle
cells from Hashimoto’s thyroiditis. The nuclei are enlarged, pleomorphic in size and lack macronucleoli.
can be abundant. Groups and tissue fragments of regular number of Hürthle cells with a few lymphocytes and
type follicular cells are often present in the background. plasma cells (Figs. 13.41D and 13.42) can be interpreted
Degenerative changes with histiocytes containing hemo- as a nonneoplastic Hürthle cell lesion. Experience is help-
siderin are features that favor nodular goiter. Papillary ful in recognizing such lesions. A predominant Hürthle
change in a nodular goiter with extensive Hürthle cell cell component in an aspirate suggests a diagnosis of a
metaplasia is also a potential diagnostic pitfall. neoplasm. A few stretched out lymphocytes, an admixture
of regular follicular cells with or without nuclear atypia,
and transition forms serve as a clue to the diagnosis of
Hürthle Cell Adenoma/Carcinoma versus Hürthle
Hashimoto’s thyroiditis (Table 13.10).
Cell Nodules in Hashimoto’s Thyroiditis
Hürthle cell metaplasia is considered a hallmark of
Hürthle Cell Carcinoma versus Other Neoplasms
Hashimoto’s thyroiditis. The presence of varying-sized
nodules that are composed entirely of Hürthle cells is a Several different types of neoplasms share morphologic
frequent histologic fi nding in Hashimoto’s thyroiditis. similarities with Hürthle cell adenomas and carcinomas.
These nodules may reach a significant proportion and be These include the oncocytic variant of papillary carcinoma,
palpable, presenting as a cold nodule and necessitating an medullary carcinoma, oncocytic parathyroid adenoma
FNA biopsy. They are also detected as incidental findings either in an intrathyroid location or in close proximity to
on ultrasounds performed for nonthyroid-related rea- the thyroid, and metastatic renal cell carcinoma. A poorly
sons. An aspirate of a cold nodule in the background of a differentiated Hürthle cell carcinoma also resembles cells
diffusely enlarged goiter showing many or a predominant of anaplastic carcinoma of squamoid type.
A B
Figs. 13.42A and B. Hürthle cell metaplasia in Hashimoto’s disease Tissue fragments of Hürthle cells from
Hashimoto’s thyroiditis. The nuclei are enlarged, pleomorphic in size and lack macronucleoli.
Hürthle Cell Carcinoma versus and the histologic differentiation. Mortality is very low at
Medullary Carcinoma 6.5% on long-term follow-up. A higher incidence of poorly
differentiated and sclerosing types have been reported in
Because of their small size, round to oval shape, and mon-
children exposed to radiation from the Chernobyl Studies.
omorphic pattern, Hürthle cell carcinoma cells strongly
Risk factors for developing papillary thyroid carcinoma
resemble the cells of medullary carcinoma when the lat-
include prior exposure to ionizing radiation, genetic fac-
ter presents a monomorphic pattern. Medullary carci-
tors, and nodular disease of the thyroid.
noma cells occasionally demonstrate abundant deep-
staining cytoplasm and large pyknotic nuclei—a feature
that is sometimes observed in Hürthle cell neoplasms. Radiologic Features
The differentiating features include prominent cherry– Papillary carcinomas present as cold nodules on radionu-
red macronucleoli in Hürthle cell carcinomas, which are clide imaging. On ultrasound, two patterns are described:
characteristically absent in medullary carcinoma cells. The 1) the presence of a solid hypoechoic nodule with dis-
nuclear chromatin is very coarse in medullary carcinomas crete echogenic foci and microcalcifications and 2) a solid
unlike the finely granular pattern of Hürthle cell carci- hypoechoic nodule with coarse echogenic foci.
noma cells (see Figs. 13.114 and 13.115). If the cytologic
preparations of Hürthle cell carcinoma fail to stain the
macronucleoli, differentiation between the two may be
difficult. Immunostains for thyroglobulin and calcitonin The gross appearance of papillary carcinoma varies with
are required to confirm the diagnosis. the size. Large tumors are typically fleshy, velvety, frag-
ile, and may extend to the capsule of the thyroid. Papil-
lary carcinomas are usually nonencapsulated but can be
PAPILLARY CARCINOMA
partially encapsulated. Markedly desmoplastic carcino-
Papillary carcinomas are the most common, differentiated mas may appear like a scar tissue. Cystic changes due to
malignancy of the thyroid, comprising up to 80% of all degeneration are very common. Calcification is frequent.
thyroid cancers in the United States. They occur more fre- Microscopically, papillary carcinomas are character-
quently in women, with a female:male ratio of 3:1 and are ized by a papillary growth pattern with neoplastic epi-
seen in all age groups, with a peak in the third to fourth thelium arranged on fi brovascular cores (e-Figs. 13.7A
decade of life. Papillary carcinomas are slow-growing and B). The papillary fronds may be well-developed
and follow an indolent course. They have a tendency for with a complex branching pattern, or they may be rudi-
intraglandular spread, cervical lymph node metastasis, mentary without discernible fi brovascular stalks; some
and local invasion but demonstrate fewer predilections for fronds may be broad and edematous and may contain
hematogenous spread than do follicular carcinomas. Dis- foamy histiocytes. Generally, the covering epithelium is
tant metastases are uncommon; they occur late in the dis- single-layered, although it may be multilayered, and the
ease, and relapses can occur as late as 30 years after initial nuclei are stratifi ed. The neoplastic cells can be cuboi-
treatment. The prognosis for papillary thyroid carcinoma dal, columnar, or squamoid with variable cytoplasm
is generally considered favorable; however, it depends on surrounding a central ovoid nucleus. These nuclei have
several risk factors such as the patient’s age, the exten- pale chromatin with peripheral condensation that gives
sion stage (e.g., occult, intrathyroidal, or extrathyroidal), a ground glass or watery appearance, which is typical
of papillary carcinoma (e-Figs. 13.7B and 13.8). Intra- diagnosis of papillary carcinoma cannot be based on just
nuclear inclusions and nuclear grooves are characteristic. one criterion because any feature listed in Table 13.12
Micronucleoli are almost always seen, particularly with can be seen in benign diseases. It is important, therefore,
pale watery chromatin. Mitoses are extremely rare. to be familiar with the typical cytopathologic features in
Papillary carcinomas are often mixed, with areas of order to appreciate the variations and diagnostic pitfalls.
follicular differentiation in varying proportions (e-Fig. For this reason, typical cytopathologic features are first
13.8). The follicles may be well-developed, filled with col- described individually in detail and then discussed later in
loid, or form closely packed narrow tubules. Areas of solid the chapter in terms of their significance.
growth pattern may also be present. Roughly 40 to 60% Papillary carcinomas yield very cellular aspirates. The
of papillary carcinomas have lamellated calcific spherules cellularity is often overwhelming. A typical presentation
called psammoma bodies. These are basophilic and non- at a very low magnifi cation includes a large number of
birefringent, 5 to 100 nanometers in size, and seem to tissue fragments with characteristic structural patterns
arise between epithelial cells. Naked psammoma bodies mixed with a large population of pleomorphic, isolated
may be found in thyroid tissue adjacent to or even dis- and groups of neoplastic cells (Fig. 13.43). The architec-
tant from the cancer. The colloid in papillary carcinoma is tural patterns of the tissue fragments of neoplastic fol-
dense-staining. Multinucleated giant cells are commonly licular cells, seen in aspirates of papillary carcinoma, are
seen. Several morphologic variants have been described multiple (see Figs. 13.45A to I).
in Table 13.11.
Cells of Papillary Carcinoma
Cytopathologic Features of Conventional
Cells of papillary carcinoma (Figs. 13.44A to G) are so
Papillary Carcinoma
varied that practically any shape and size may be encoun-
The cytopathologic features of papillary thyroid carci- tered. They range from cuboidal, columnar, ovoid, polygo-
nomas are numerous and complex (Table 13.12). The nal, and squamoid to spindle-shaped. Papillary carcinoma
cells may be medium-sized to large, sometimes exceeding
10 nanometers in diameter. The cell borders in single cells
TABLE 13.11 MORPHOLOGIC VARIANTS tend to be well-defined. The cytoplasm is variable, scant to
OF PAPILLARY CARCINOMA abundant, and may be pale, foamy, vacuolated, granular,
or dense. The carcinoma cells with abundant, dense cyto-
Usual or conventional plasm appear Hürthleoid. Their nuclei are generally slightly
eccentric in position and are round, oval, or ovoid; they are
Follicular
often irregular in shape and varied in size. In well-developed
papillary fronds, the nuclei appear small because they are
Macrofollicular
closely packed together. In monolayered tissue fragments,
Diffuse follicular they appear considerably larger. The nuclear membranes
are sharp and may show irregularities. The chromatin is
Tall cell so finely granular and dusty to powdery that the nuclei
appear clear, pale, or watery. Single or multiple micro- and/
Columnar cell or macronucleoli are always seen. Although not diagnostic
by itself, nuclear grooves are a consistent feature. It is seen
Oxyphil cell or oncocytic as a chromatin ridge along the long axis of the nucleus and
is probably due to the irregular infolding of the nuclear
Solid and trabecular membrane. Another characteristic feature is the presence
of intranuclear cytoplasmic inclusions—a consistent fea-
Diffuse sclerosing ture in aspirates of papillary carcinoma (Figs. 13.44B to G)
and is considered to be cytoplasmic invagination. They
Papillary carcinoma with nodular fasciitis-like stroma occur as sharply defined, clear, round inclusions that are
bordered by condensed chromatin. Intranuclear inclusions
Clear cell may be large and single and occupying the entire nucleus or
small and multiple. The multiple inclusions within a single
Encapsulated
nucleus present a soap bubble appearance. An intranuclear
inclusion should take up at least 10% of the total nuclear
Warthin’s tumor-like
surface area to distinguish it from nonspecific vacuoles,
which are often seen in air-dried preparations. Also, the
Cribriform morular
sharp border of these inclusions is a differentiating feature
Papillary microcarcinoma from the vacuoles seen in some degenerating nuclei, where
the vacuoles merge with the chromatin.
TABLE 13.12 CYTOPATHOLOGIC FEATURES OF CONVENTIONAL (USUAL TYPE)

PAPILLARY CARCINOMA
Cellularity Variable; overwhelmingly cellular to scant in tumors with desmoplasia, or with cystic change
Presentation Neoplastic cells isolated, in loosely cohesive groups or in syncytial tissue fragments with various
architectural configurations
Architecture of the Papillary, with or without complex branching, containing central fibrovascular cores; papillary-like without
Tissue Fragments visible central cores but appearing as finger-like processes; monolayered (two-dimensional, but syncytial)
with or without branching; syncytial with follicular pattern; syncytial without architectural patterns or
appear as three-dimensional balls, onion-skin pattern or swirls; nuclei variably crowded and overlapped
Cells Wide range of size and shapes; small, medium-sized to very large; round, cuboidal, short columnar,
elongated, polygonal, spindle-shaped, cell borders well to poorly defined; N/C ratios variable
Nucleus Pleomorphic in size and shape; round, oval, oblong; nuclear membranes smooth to irregular; chromatin
characteristically, pale, dusty, powdery to finely granular; multiple micro/macronucleoli; longitudinal
grooves, single or multiple intranuclear inclusions; small to large occupying the entire nucleus,
bordered by condensed chromatin; mitoses rare to absent; degeneration may mask nuclear features
Cytoplasm Variable, insignificant in conventional types to abundant in some morphologic variants; pale
Squamous Metaplasia ⫹/⫺
Psammoma Bodies Often present; naked or incorporated in syncytial tissue fragments of neoplastic cells displaying
nuclear features of papillary carcinoma; single or multiple within any given tissue fragment; concentric
lamellated to star-burst appearance; basophilic to combination of multiple colors: brown, amber, violet
to purple; sometimes refractile; naked psammoma bodies not of diagnostic importance
Multinucleated Foreign- Almost always present; variable in numbers and size, number of nuclei vary; round to oval with finely
Body-Type Giant Cells granular chromatin and micronucleoli; grooves and inclusions not present; cytoplasm abundant, dense
and not phagocytic
Background Usually clean without necrosis; evidence of recent or old hemorrhage—histiocytes with or without
hemosiderin; lymphocytic infiltrate ⫹/⫺ colloid variable; pale to dense, often stringy
Immunoprofile Reactive to thyroglobulin, TTF-1; cytokeratin 19
Papillary Carcinoma (See Figs. 13.43 to 13.49)
Fig. 13.43. FNA Papillary carcinoma. Low power of a cellular aspi-

rate showing branching papillary fronds.
A B
C D
E F
Figs. 13.44A to G. Cells of papillary carcinoma. The papillary car-

cinoma cells depicted in these images show a wide variation in size
and shape. The amount of cytoplasm is variable, ranging from scant
to abundant and from pale to dense. The nuclear characteristics
however, remain the same. All contain powdery to finely granu-
lar chromatin, nucleoli, grooves, and inclusions. A: Medium-sized
round cells. B: Small round to plasmacytoid cells. C: Small round to
short columnar cells. D: Medium to large, round to polygonal cells.
E: Large cells with pale cytoplasm. F: Large to giant forms with
abundant dense cytoplasm imparting a Hürthleoid appearance.
G G: Tall columnar to spindle shape.
442
The nuclear characteristics of papillary carcinomas The architectural confi gurations of the tissue frag-
are diagnostic. In cytologic material, the tetrad of pale, ments vary considerably, dependant on the morphology
enlarged nuclei with dusty chromatin, nucleoli, a chroma- of the carcinoma. They can be syncytial without any pat-
tin ridge or groove, and intranuclear cytoplasmic inclu- tern or present papillary, papillary-like, follicular, mono-
sions are virtually pathognomonic of papillary carcinoma layered three-dimensional tight clusters, and infrequently
(see Figs. 13.60A and B) and are considered to be the show swirls, and a cartwheel pattern (Figs. 13.45A to I).
minimal diagnostic criteria (Table 13.12). Regardless of the architectural pattern, the component
A B
C D
E F
Figs. 13.45A to F. Architectural patterns of tissue fragments in papillary carcinoma. The tissue fragments are all syncytial
but present various patterns. A: Papillary with central cores of fibrovascular tissue, covered by neoplastic cells. B: Syncy-
tial architecture without any particular pattern. C: Monolayered. Note the nuclear polarity is altered; the cell borders are
poorly defined and there is focal overlap. D: Follicular pattern with dense colloid in the follicular lumens. E: Papillary-like
with smooth external contour and peripheral palisading of nuclei. F: Syncytial arrangement with no pattern. (continued)
G H
Figs. 13.45G to I. (continued) G: Cartwheel pattern. The neoplas-

tic cells radiate from the center, with their nuclei facing the perim-
eter. H: The cells in this papillary carcinoma aspirate demonstrate
squamous metaplasia and are arranged in concentric fashion.
I: Papillary frond from papillary carcinoma (Romanowsky). (Cour-
tesy of Dr. Mariza de Peralta-Venturina, Cedar-Sinai Hospital, Los
I Angeles, California.)
Fig. 13.46. Psammoma body with concentric lamellations, incor- Fig. 13.47. Multinucleated giant cell present in the close proximity
porated in a syncytial tissue fragment consisting of malignant cells to a monolayered but syncytial tissue fragment with nuclear fea-
with nuclear features of a papillary carcinoma. tures of papillary carcinoma.
cells present typical nuclear characteristics. Other cyto- and refractile appearance. Multinucleated foreign-body
logic features include the presence of psammoma bodies type giant cells (Fig. 13.47) are frequent but are a non-
(Fig. 13.46). In Papanicolaou-stained preparations of specific fi nding. Colloid can be present in the form of
fi ne needle aspirates, the psammoma bodies not only stretched out ropy strands (Fig. 13.48) or as dense blobs
stain basophilic but also stain lavender, golden brown, or within or outside the follicular lumina. Degenerative
amphophilic. The architecture may also be different. In changes are manifested in the aspirate by the presence of
addition to concentric lamellation, they have a star-burst histiocytes with or without hemosiderin.
Fig. 13.48. Stretched strands of dense sticky colloid alongside the

monolayered tissue fragments of papillary carcinoma.
A B
Figs. 13.49A to C. FNA of papillary carcinoma. A: Cellular prepa-

ration with small cellular clusters and simple papillae. The nuclei
are densely packed within the clusters when compared to those of
nodular goiter (low power). B: Syncytial tissue fragment of pap-
illary carcinoma cells with intranuclear inclusions. C: Papillary
clusters with central psammoma bodies (ThinPrep). (Courtesy of
Dr. Claire W. Michael, University of Michigan Health System, Ann
C Arbor, Michigan.)
The cytologic features of papillary carcinoma present Other markers that have been reported include CK19,
similar morphologic alterations in liquid-based preparations CD15, HBME-1, and galectin-3 (61–66).
as compared to direct smears, as seen in Figs. 13.49A to C. Molecular analysis has shown mutations in RAS proto-
oncogenes, BRAF oncogenes, and RET/PTC gene rear-
Immunoprofile rangement in papillary carcinomas. The routine diagnostic
application of these tests has not been established as yet.
The cells of papillary carcinoma demonstrate positive
reactivity to thyroglobulin and to thyroid transcription
Morphologic Variants of Papillary Carcinoma
factor-1 (TTF-1) in a consistent fashion, except for the
columnar cell variant. The papillary carcinoma cells also Several histologic variants of papillary thyroid carcinomas
react to both low- and high-molecular weight keratins. have been described (Table 13.11). Some variants have a
better prognosis than the conventional types, while oth- follicular variant may contain desmoplastic stroma.
ers tend to behave in an aggressive fashion with a higher Psammoma bodies can be identified in the interfollicular
frequency of morbidity and mortality. Those with aggres- stroma. The metastatic foci from the follicular variant
sive behavior include the tall cell, diffuse sclerosing, and often show the typical morphology of conventional pap-
diffuse follicular variants, as well as papillary thyroid illary carcinoma.
carcinomas with dedifferentiated areas. The morphologic
variants that are sometimes associated with an unfavor- Cytopathologic Features of Follicular Variant of Papil-
able outcome include the follicular, solid, and oncocytic lary Carcinoma. The aspirates of the follicular variant
variants, as well as those arising in the background of of papillary carcinoma are usually cellular (Figs. 13.50A
autoimmune thyroiditis. and B, 13.51A and B) but may be scanty in the presence
The classification of the morphologic variants of pap- of desmoplastic stroma. The typical cytologic appearance
illary carcinomas is based on the architectural (growth) includes small to moderately enlarged follicular cells, in
patterns and cell morphology. Any variant must have loosely cohesive groups and in syncytial tissue fragments,
more than 75% of the tumor composed of a specific mor- with and without a follicular pattern. The neoplastic fol-
phologic pattern to qualify for a specific designation. The licles may be seen as discrete and may present angulated
common denominator for all the variants is the typical forms (Fig. 13.50D). Their enlarged, round to ovoid nuclei
nuclear morphology characterized by pale nuclei, nucleoli, contains pale, dusty, powdery chromatin; micronucleoli;
nuclear grooves, and intranuclear cytoplasmic inclusions, grooves; and inclusions, all of which clinch the diagno-
with the exception being the columnar cell variant. These sis of a follicular variant (Table 13.13). The cytoplasm
nuclear features allow an accurate diagnosis of papillary of the cells of this variant is scant or barely visible, and
carcinoma, both histologically and cytologically. It is very their cell borders are poorly defi ned. The aspirates often
common to see multiple growth patterns in a given papil- show monolayered (two-dimensional), syncytial tissue
lary carcinoma. The cytologic typing thus depends on the fragments, which are often misinterpreted as indicative of
area sampled and may not be representative of the major nodular goiter, particularly in Romanowsky-stained prep-
morphologic pattern. Certain diagnostic features such as arations. The colloid is usually present as dense, rounded
encapsulation, stroma (whether desmoplastic or nodular casts within the follicular lumens, as well as in the back-
fasciitis-type), and micropapillary carcinomas cannot be ground (Fig. 13.50C). Papillary or papillary-like tissue
appreciated in cytologic samples. fragments are generally not observed unless the needle
With the exception of columnar cell carcinomas, all also samples the focal papillary growth pattern, if present
the subtypes have the same characteristic nuclear features, within the tumor. Psammoma bodies and multinucleated
and a generic diagnosis of papillary thyroid carcinoma is giant cells are sometimes present. The background is usu-
easily made with a high degree of accuracy. Cytologic rec- ally clean.
ognition of morphologic subtypes may be unwarranted
and insignificant in terms of patient management. A total
thyroidectomy is routinely performed with a diagnosis of Diffi culties with Cytologic Diagnosis of Follicular Vari-
papillary thyroid carcinoma, regardless of the morpho- ant of Papillary Carcinoma. This distinctive subtype of
logic subtypes. papillary carcinoma is correctly identified both histologi-
cally and cytologically when classic features (i.e., the typi-
cal nuclear morphology of conventional papillary carci-
Follicular Variant of Papillary Carcinoma
noma) are present. However, recognition of these tumors
The follicular variant of papillary carcinomas comprise has caused many problems at multiple levels, including
up to 12% of thyroid papillary carcinomas and present a aspiration cytology, intraoperative frozen sections, and
higher incidence of cervical lymph node metastases. histologic interpretations.
The follicular variants of papillary carcinoma are The typical nuclear morphology of conventional
completely or partially encapsulated or nonencapsulated papillary carcinoma such as powdery chromatin, micro-
and infiltrative. They vary in size from microcarcinomas nucleoli, nuclear grooves, and inclusions may not be a
to large tumors. Histologically, as the name implies, a universal feature in a given case of a follicular variant of
predominantly or exclusively follicular growth pattern papillary carcinoma. If the fi ne needle targets the areas
characterizes the follicular variant (e-Fig. 13.8). The fol- lacking these classic nuclear features within a tumor, a
licles vary in size and shape from round to elongated, correct diagnosis of the follicular variant of papillary car-
and many are distended with colloid. The lining epithe- cinoma is not possible. The follicular architecture and the
lium may show infolding, forming rudimentary papillae. lack of typical nuclear morphology will lead to a diag-
Their nuclei, however, exhibit the typical morphology of nosis of a follicular lesion or a follicular neoplasm, par-
conventional papillary carcinoma. The colloid within the ticularly in the absence of intranuclear inclusions (Figs.
follicles is often dense, deep-staining, and shows periph- 13.51A and B). In the last two decades, there has been a
eral scalloping. A clear cell pattern may be present. The surge of reports on the cytologic diagnosis of follicular
Follicular Variant of Papillary Carcinoma (See Figs. 13.50 to 13.60)
A B
C D
E F
Figs. 13.50A to F. A: Follicular variant of papillary carcinoma. Both, the hypercellularity and the follicular pattern
are striking (low power). B: Higher magnification. The lining cells of the follicles present classic nuclear features of
papillary carcinoma. Note that many nuclei have intranuclear inclusions. The colloid within the follicular lumina
is dense. C: Follicular variant of papillary carcinoma. Note the hypercellularity and the striking follicular pattern
(low power). D: Angulated, curvaceous syncytial tissue fragment with component cells exhibiting nuclear features
of papillary carcinoma. E: Several monolayered syncytial tissue fragments consisting of cells with nuclear features of
papillary carcinoma. A follicular pattern is also evident (arrow). F: FNA of a follicular variant of papillary carcinoma
(Diff-Quik). (Courtesy of Dr. Mariza de Peralta-Venturina, Cedar-Sinai Hospital, Los Angeles, California.)
A B
Figs. 13.51A and B. A: FNA of a follicular variant of papillary carcinoma. The cellular aspirate contains several
syncytial tissue fragments of follicular cells with a follicular pattern. The nuclei are enlarged, crowded and contain
coarsely granular chromatin. Nuclear grooves or inclusions are not present. This aspirate will be interpreted as a
cellular follicular neoplasm. B: FNA of a follicular variant of papillary carcinoma. The follicular cells are enlarged,
forming syncytial tissue fragments with a trabecular and follicular pattern. The angulations are usually seen in fol-
licular variant of papillary carcinoma. However, all the nuclear characteristics of papillary carcinoma are not present.
Minimal cytologic criteria of papillary carcinoma are not universally present in every case of follicular variant of
papillary carcinoma. Aspirates of areas lacking these features such as seen here are apt to be interpreted as cellular
follicular neoplasm.
TABLE 13.13 CYTOPATHOLOGIC FEATURES OF FOLLICULAR VARIANT OF PAPILLARY CARCINOMA
Presentation Neoplastic cells in loosely cohesive groups or in syncytial tissue fragments
Architecture of the Syncytial tissue fragments with follicular pattern; varying-sized individual follicles, empty or containing
Tissue Fragments dense-staining globules of colloid; monolayered tissue fragments with or without branching; syncytial
tissue fragments without any architectural patterns; twisted tubular structures; papillary or papillary
architecture not present.
Cells Round to cuboidal; medium-sized; poorly defined cell borders; N/C ratios high
Nucleus Variably enlarged, pleomorphic, round, oval, ovoid; nuclear membrane irregularity ⫹/⫺; pale nuclei with
powdery to finely granular chromatin; occasionally coarsely granular chromatin; micronucleoli, nuclear
grooves, pseudoinclusions
Cytoplasm Scant and pale
Psammoma Bodies ⫹/⫺
Background Dense-staining, stringy or globules of colloid, lymphocytes ⫹/⫺; histiocytes ⫹/⫺
variants of papillary carcinoma. Its diagnostic accuracy,

Tall Cell Variant of Papillary Carcinoma
as reported, varies from 40 to 86%. Many cases of follicu-
lar variants of papillary carcinoma have been interpreted The tall cell variant comprises approximately 10% of pap-
as nodular goiter or follicular neoplasms. The problem is illary carcinomas of the thyroid. These tumors occur in
compounded by the fact that the histologic criteria used elderly patients with a male:female ratio of 1:5. The tall
to identify this variant are also inconsistent. There is con- cell variant is often large and bulky, frequently exceeding 6
siderable interobserver variation in the histologic diagno- centimeters in diameter, with areas of necrosis, extrathyroi-
sis of follicular variants of papillary carcinoma, indicating dal extension, and vascular invasion (42%). The biologic
difficulties in a precise classification. behavior is more aggressive than that of the conventional
type with a higher incidence of recurrences, cervical lymph tissue fragments with various architectural configura-
node involvement (75%), and distant metastasis (17%). tions, in loosely cohesive groups and as isolated cells. The
Death occurs in 25% of the cases. Histologically, the neoplastic cells are tall, elongated, and columnar with
growth pattern is papillary with complex branching. The well-defi ned cell borders containing abundant, oxyph-
follicles are elongated, often aligned in parallel lines, and ilic to cyanophilic cytoplasm, which is often dense and
referred to as “railroad tracks.” The hallmark of the tall sometimes pale and granular (Fig. 13.52). Their nuclei are
cell carcinoma is the neoplastic cells that are twice as tall large, but the N/C ratios remain low due to the abundant
as they are wide, containing abundant, eosinophilic, dense cytoplasm and are eccentric in elongated cells but may be
cytoplasm. Mitotic activity may be prominent. Colloid central. The nuclei are round to oval with smooth to irreg-
is scant, and the carcinoma is frequently associated with ular nuclear membranes and exhibit the typical cytologic
lymphocytic infiltrate. Histologically, tall cell carcinomas features of conventional papillary carcinoma. Intranuclear
require at least 30% of the cell population to be of the tall inclusions are seen much more frequently in aspirates of
cell type. tall cell variants of papillary carcinomas. Nuclear inclu-
sions can be multiple within any given nucleus, impart-
Cytopathologic Features of the Tall Cell Variant of Pap- ing a soap bubble appearance. The differential diagnoses
illary Carcinoma. The aspirates of the tall cell variant of the tall cell variant of papillary carcinoma include the
(Table 13.14) are usually cellular, consisting of syncytial oxyphilic variant of papillary or papillary Hürthle cell
carcinoma.

TALL CELL VARIANT OF PAPILLARY CARCINOMA Macrofollicular Variant
The macrofollicular variant is characterized by the pres-
Cellularity Usually very cellular
ence of large, varying-sized colloid-filled macrofollicles
that are mixed with the follicular variant of papillary
Presentation Cells isolated, in loosely cohesive
groups and in syncytial tissue
carcinoma. The colloid within the follicles is often scal-
fragments loped or vacuolated. The nuclei of the cells lining the fol-
licles may be hyperchromatic. The classic nuclear pattern
Architecture of the Predominantly papillary with or of conventional papillary carcinoma is seen in foci scat-
Tissue Fragments without branching, monolayered, tered throughout the tumor. The large colloid-filled fol-
follicular pattern infrequent licles may also contain abortive papillae, lined by atypical
cells. Due to the presence of large, distended follicles with
Cells Large, elongated to columnar, appear abundant colloid, this variant may be easily confused with
round to polygonal when seen multinodular goiter or a macrofollicular adenoma, both
on cross section; well-defined cell grossly and histologically. A higher incidence of insular
borders; N/C ratios lower than cells component associated with the macrofollicular variant of
of conventional or follicular variant
papillary carcinoma has been reported.
carcinoma cells
The cytologic features of macrofollicular papillary
carcinomas are similar to those of the conventional or fol-
Nucleus Usually eccentric, may be central;
large, round to oval, with smooth licular variant, with abundant colloid in the background
to irregular membranes; chromatin (Figs. 13.53A and B). This variant must be differentiated
dusty, powdery to finely granular; from a nodular goiter with abundant colloid or a macro-
micro/macronucleoli; grooves; follicular adenoma.
intranuclear inclusions present in
larger numbers than other variants;
Solid and Trabecular Variants
multiple inclusions within a single
nucleus giving a “soap bubble” As the name implies, these subtypes are characterized by
appearance; rare mitoses a solid growth pattern composed of polygonal cells with
abundant pink cytoplasm and nuclei with typical charac-
Cytoplasm Abundant, dense-staining cyanophilic teristics of conventional papillary carcinoma. The solid
or oxyphilic; may be pale and pattern comprising 70% of the tumor is usually associ-
granular and amphophilic
ated with common morphologic types, and it blends
with the papillary and follicular areas as well as with
Psammoma Bodies Very rare
squamous metaplasia. These tumors with a solid growth
Background Colloid infrequent, lymphocytic
pattern must be differentiated from poorly differentiated
infiltrate ⫹/⫺ or undifferentiated carcinomas. The features that favor
papillary carcinoma include irregular fibrous trabeculae
A B
Figs. 13.52A and B. A: Tall cell variant. The papillary carcinoma cells are pleomorphic and elongated. Their nuclei
demonstrate conspicuous inclusions that are sharp and bordered by condensed chromatin. Some inclusions are single
and some nuclei have multiple small inclusions like a soap bubble. B: FNA of a different case of tall cell variant of
papillary carcinoma. The large, malignant cells with abundant granular to dense cytoplasm form a monolayered but
syncytial tissue fragments. The nuclei demonstrate typical features of papillary carcinoma.
A B
Figs. 13.53A and B. Macrofollicular variant. A: Marginally cellular specimen with few large tissue fragments in the
background of abundant colloid, low power. B: Higher magnification showing syncytial architecture with nuclei
exhibiting typical feature of papillary carcinoma.
within the tumor and the occasional psammoma body, colloid is minimal to absent, and psammoma bodies are
and most importantly, the nuclear morphology. rare. The immunoprofi le includes negative reactivity to
Cytologically, these carcinomas contain malignant thyroglobulin in the majority of the reported cases and
cells that are isolated and in syncytial tissue fragments positive reactivity to cytokeratin.
without any papillary or follicular architecture. However,
the nuclear morphology is characteristic (Fig. 13.54). Cytopathologic Features of the Columnar Cell Variant of
Papillary Carcinoma. The aspirate of the columnar cell
variant shows syncytial tissue fragments with a papillary
Columnar Cell Variant of Papillary Carcinoma
pattern composed of elongated columnar cells, which may
The columnar cell variant is an extremely rare, morpholog- show pale, tapering cytoplasm at one end (Figs. 13.55A
ically distinct type of papillary carcinoma. The histologic and B, 13.56A to D). The oval and oblong nuclei show
features are characterized by an extreme papillary growth stratification and palisading at the periphery of the tissue
pattern formed by tall columnar cells, nuclear stratifica- fragments. They are hyperchromatic, have micronucleoli,
tion, presenting a strong morphologic resemblance to and contrast sharply with the dusty, powdery chromatin of
endometrioid carcinoma (e-Fig. 13.9). The nuclei, aligned the cells seen in conventional or other morphologic vari-
perpendicular to the surface, are darker than and lack the ants. Intranuclear inclusions or nuclear grooves are usu-
empty look of classic papillary carcinoma cells. Increased ally absent. The cells of the columnar cell variant possess
mitotic activity may be present, but necrosis is rare. The scant and pale to clear cytoplasm. The ancillary features
Fig. 13.54. Solid variant. FNA showing syncytial tissue fragments

of large cells without any architectural configurations. Their nuclei
are large and show an occasional intranuclear inclusion.
A B
Fig. 13.55A and B. Columnar cell cariant. Fine needle biopsy of this columnar cell variant of papillary carcinoma.
The tumor cells are delicate and columnar, with pale cytoplasm and tapered ends, round to oblong nuclei with coarse
chromatin, and micronucleoli. Intranuclear inclusions or grooves are not identified.
A B
Figs. 13.56A to B. Columnar cell variant of papillary carcinoma. FNA of a massively enlarged thyroid with multiple
enlarged cervical lymph nodes. A: Overwhelmingly cellular aspirate consisting of several papillary tissue fragments
with complex branching. The background shows single and groups of cells, low power. B: Higher magnification
of the tissue fragment shows minimally enlarged round nuclei with granular chromatin and micronucleoli; their
cytoplasm is scant. (continued)
C D
Figs. 13.56C to D. (continued) C: Different field showing a tissue fragment of malignant cells with papillary-like
pattern. Their nuclei have deep-staining coarsely granular chromatin. Some exhibit nucleoli. The cells demonstrate
variable cytoplasm. D: The neoplastic cells are small to medium-sized, present isolated and in syncytial tissue frag-
ments. Their cell borders are poorly defined and the cytoplasm is scant. The nuclei are round and uniform, containing
granular chromatin and micronucleoli.
Fig. 13.57. Oxyphilic variant of papillary carcinoma. FNA of a cys-

tic thyroid nodule. The syncytial tissue fragments consist of cells
with abundant pale cyanophilic cytoplasm. The nuclei contain finely
granular chromatin, micronucleoli, grooves and inclusions, Thyroi-
dectomy revealed a large cystic tumor with residual in the wall,
which on histologic examination confirmed a papillary carcinoma,
oxyphilic cell variant.
such as psammoma bodies, multinucleated foreign-body grooves, and inclusions. This variant may also demon-
type giant cells, and colloid are not described or seen in strate a follicular growth pattern, are usually encapsu-
these tumors. lated, and may or may not show capsular invasion. The
The lack of typical nuclear features of papillary car- biologic behavior of the oxyphilic variant parallels that of
cinoma may lead to diagnostic diffi culties, and it may be a conventional papillary carcinoma.
mistyped as other neoplasms such as medullary carci- The papillary Hürthle cell carcinomas demonstrate a
noma. Columnar cell carcinoma morphologically resem- papillary growth pattern; however, they lack some of the
bles tall cell carcinoma. However, the cytoplasm in tall above-mentioned nuclear features such as powdery chro-
cell carcinomas is dense and eosinophilic, and their nuclei matin and micronucleoli but show a prominent cherry–
demonstrate typical features of papillary carcinoma. red macronucleolus. Inclusions are present in both and
do not serve as a differentiating feature. These are more
aggressive, clinically, with 16% mortality and are in keep-
Oncocytic or Oxyphil Cell Variant
ing with Hürthle cell carcinomas.
The oncocytic variant of papillary carcinoma is uncom- Cytologic specimens from the oncocytic variant of pap-
mon, with the reported incidence ranging from 3.5 to illary carcinomas show a Hürthle cell population. The neo-
11%. There are two types of oncocytic papillary carcino- plastic cells are variable in size, may be discrete, and occur
mas. Both have a papillary growth pattern. in loosely cohesive groups and syncytial tissue fragments
The oncocytic variant of papillary carcinoma demon- with a papillary configuration; a follicular pattern may be
strates typical nuclear features of conventional papillary evident (Fig. 13.57). Their nuclei demonstrate nuclear fea-
carcinoma such as powdery chromatin, micronucleoli, tures seen in papillary carcinomas such as powdery, dusty
chromatin; micronucleoli; grooves; and inclusions. The fi brovascular tissue with histiocytes and inflammatory
oxyphilic cells contain abundant granular cytoplasm simi- cells. The stromal spindle cells have plump nuclei with
lar to that seen in cells of the tall cell variant. Psammoma a fi nely granular bland chromatin pattern. The amount
bodies may or may not be present in the background. of stroma can be extensive and exuberant. The papillary
carcinoma may present follicles, papillae, and trabeculae,
Diffuse Sclerosing Variant separated by variable stroma. The nuclear features are
that of a typical conventional papillary carcinoma. Psam-
The diffuse sclerosing variant is more frequently seen
moma bodies may occasionally be seen. The spindle cell
in children and adolescents and accounts for 2.3% of
component is immunoreactive to vimentin and negative
all thyroid papillary carcinomas. The characteristic fea-
to cytokeratin.
tures include the diffuse involvement of one or both lobes
rather than a dominant nodule, numerous small papillary Cytopathologic Features. Because of the fibrous stroma,
formations within cleft-like spaces, the probable presence the aspirates of this variant tend to be paucicellular with
of lymphatics, extensive squamous metaplasia, many minimal epithelial component. This subtype cannot be
psammoma bodies, marked lymphocytic infiltration, and identifi ed from cytologic samples due to the absence of
prominent fibrosis. This variant shows a greater incidence the stromal component. The aspirates, however, exhibit
of cervical lymph node involvement and pulmonary the typical cytopathologic features of the conventional or
metastasis. The metastatic deposits are not as distinctive follicular variants of papillary carcinoma.
as primary tumor and resemble the classic type of papil-
lary carcinoma.
Diffuse Follicular Variant
Cytopathologic features of the diffuse sclerosing
variant are rarely documented. The aspirates consist of The diffuse follicular variant occurs predominantly in
syncytial tissue fragments of medium-sized cells con- women who may be hyperthyroid and presents grossly as
taining nuclei with the typical features of papillary car- a goiter. The enlarged thyroid gland is diffusely involved
cinoma. The neoplastic cells form morulae, reminiscent by a neoplasm showing the follicular pattern and nuclear
of metaplastic squamous cells. Many psammoma bodies morphology of papillary carcinoma. The clinical course is
are conspicuous in the background of heavy lymphocytic described as aggressive with distant metastasis. Although
cells (Fig. 13.58). This morphologic variant cannot be the cytologic features have not been reported, they con-
detected from the cytologic samples since areas of fibro- ceivably will present the cytomorphology of papillary
sis are not visualized, and the samples will be interpreted carcinoma.
as papillary carcinoma in the background of lymphocytic
thyroiditis. Encapsulated Variant
The encapsulated variant is characterized by total encap-
Papillary Carcinoma with Exuberant Nodular
sulation, with or without the invasion of the capsule by
Fasciitis-Like Stroma
the tumor. Because of this encapsulation, it is referred to
This variant of papillary carcinoma is characterized by as “papillary adenoma.” The histomorphology may be
abundant fasciitis-like stroma consisting of spindle cells typical of the conventional variant or the follicular vari-
arranged in fascicles in a background of vascularized ant with corresponding cytologic features.
A B
Figs. 13.58A and B. Diffuse sclerosing variant of papillary carcinoma. A: The malignant cells are pleomorphic, with
the characteristic nuclear features of papillary carcinoma. Lymphocytes are present in the background. B: A tissue
fragment of malignant cells incorporating psammoma bodies.
This morphologic variant is strictly based on com-

plete encapsulation, identifi ed only in surgically excised
specimens; hence, it can be interpreted only as papillary
carcinoma from cytologic samples.
Papillary Carcinoma with Clear Cell Change

Some consider papillary carcinomas with clear cell change
as an expression of morphologic variance. The clear cyto-
plasm is a result of glycogen accumulation or vesicular for-
mation. Histologically, clear cell change is more frequent
with a follicular variant. Cytologically, the cells with clear
change show poorly defined cell borders tend to appear
discrete, and frequently appear as stripped nuclei. Their
cytoplasm is barely discernible; the enlarged nuclei exhibit Fig. 13.59. Cribriform morular variant. Two large squamous moru-
the typical features of a papillary carcinoma. Because of lae presenting a typical whorled pattern. The background features
the single-cell pattern, these aspirates may be misinter- were of conventional papillary carcinoma.
preted as medullary carcinoma.
Cribriform-Morular Variant abundant eosinophilic cytoplasm. The fibrous stalks of

the papillary fronds are packed with lymphoid cells. The
The cribriform-morular variant as a distinct variety of
neoplastic cells demonstrate the typical nuclear morphol-
papillary carcinoma was fi rst described in association
ogy of conventional papillary carcinoma. The aspirates
with familial adenomatous polyposis syndrome. This
may show features of papillary carcinoma but exact typ-
association has been confirmed in other studies.
ing is not possible.
Histologically, cribriform-morular variant is charac-
terized by an intricate blending of cribriform, follicular,
Papillary Microcarcinoma and Occult Carcinoma
papillary, trabecular, and solid patterns with morular
(squamoid) areas. The cribriform pattern is formed by The terms “microcarcinoma” and “occult carcinoma”
anastomosing bars and arches of cells without the inter- are frequently used synonymously, creating consider-
vening stroma and resembles breast duct carcinoma. able confusion among pathologists, endocrinologists, and
Discrete cribriform structures are scattered in sclerotic surgeons alike. Papillary microcarcinoma is defined as
stroma. The follicular structures are usually devoid of col- a tumor that is less than 10 millimeters in size (WHO).
loid. The neoplastic cells are tall with abundant eosino- Lesions ranging from 5 to 10 millimeters are visible to
philic cytoplasm and frequent pseudostratification. Also the naked eye, can be visualized by ultrasound, and can
present are a trabecular arrangement of spindle cells that be palpated by an endocrinologist (unless deeply situated)
are reminiscent of hyalinizing trabecular adenoma. and even biopsied.
Colloid is scant to absent. The cells vary from cuboi- An occult carcinoma is defined as a carcinoma that is
dal to columnar and display the typical nuclear morphol- discovered subsequent to its presentation at a metastatic
ogy of papillary thyroid carcinoma. The tumor is immu- site, which is, more often than not, to the cervical lymph
noreactive to thyroglobulin. nodes. An occult carcinoma is not necessarily a micro-
carcinoma. Papillary thyroid carcinomas discovered inci-
Cytologic Features. The classic histologic features are dentally in thyroidectomy specimens or at autopsy should
not readily reproduced in aspirates. Thus, this variant is be considered latent carcinomas. Like occult carcinoma,
difficult to type (Fig. 13.59). a latent carcinoma is not necessarily a microcarcinoma.
A common incidental fi nding in several series based on
autopsy studies is that the incidence of latent (incidental)
Papillary Hürthle Cell Carcinoma with Lymphocytic
carcinoma varies from 4% to as high as 35 to 60%.
Stroma (Warthin-Like Tumor of the Thyroid)
Papillary occult carcinomas usually manifest as cer-
A recent addition to the long list of morphologic variants vical lymph node metastases. The latter often present as
of papillary carcinoma, this variant, referred to as “papil- cystic lesions in the neck. Fine needle biopsy is able to
lary Hürthle cell carcinoma with lymphocytic stroma,” is establish a correct diagnosis in the majority of cases.
characterized by a papillary growth pattern that is inti- Microcarcinoma may be solitary, multifocal, unilateral
mately mixed with a heavy lymphoid infiltrate, bearing or bilateral, circumscribed, or well-defined with or without
a striking resemblance to Warthin’s tumor of the salivary encapsulation. They may be infiltrative in the surround-
gland. Histologically, it consists of a papillary architecture ing parenchyma and may be sclerotic; they are sharply
formed by cuboidal to columnar Hürthle cells containing defined from the adjacent normal parenchyma. Very small
microcarcinoma may be missed upon gross examina- preted as a follicular lesion or a follicular neoplasm; 2)
tion. A small microcarcinoma may resemble a scar due to the oxyphil variant, typed as a Hürthle cell tumor; 3) the
desmoplasia. columnar cell variant, where the identification of thyroid
Histologically, microcarcinomas may present fea- origin is diffi cult on routinely stained specimens; and 4)
tures of conventional papillary carcinoma or a follicular the macrofollicular variant, which may be interpreted as
variant. They may be seen as microscopic foci formed nodular goiter or a colloid adenoma.
by the aggregates of a few follicles exhibiting the typi- The diagnostic problems with follicular variants of
cal nuclear features of papillary carcinoma and are fre- papillary carcinoma were already discussed earlier. The
quently observed as incidental fi ndings in thyroidectomy differentiating features are listed in Table 13.8. The cells
specimens. Lymph node metastases can occur with micro- of the oxyphilic variant lack powdery chromatin and
carcinoma and distant metastases are also reported. micronucleoli but exhibit the typical features of Hürthle
As mentioned earlier, the cytologic detection of the cell carcinoma. The exact designation, whether it is the
various morphologic variants depend upon the sampled oxyphilic variant of papillary thyroid carcinoma or a
areas. Some variants may be identified while some do not Hürthle cell carcinoma, is probably not significant for
lend themselves to typing. Table 13.15 summarizes the patient management. The cells of the columnar cell variant
cytologic features of some of the morphologic variants of not only lack the nuclear features of papillary carcinoma
papillary carcinoma. but may be nonreactive to thyroglobulin. This subtype is
extremely rare and may be interpreted cytologically as a
Diagnostic Difficulties in Papillary Carcinomas “carcinoma not otherwise specified.”
The macrofollicular variant of papillary carcinoma
An adequate cellular sample with the characteristic cyto- can be a diagnostic problem, since, grossly and micro-
pathologic features of papillary carcinoma facilitates a scopically, it resembles involuted goiter, except for the
correct diagnosis in most instances (Figs. 13.60A and B). nuclei, which show characteristics of conventional papil-
Diagnostic difficulties do arise in several settings listed in lary carcinoma. The macrofollicular pattern may be seen
Table 13.16. The first two settings represent a typing prob- in parts of the tumor and may yield abundant colloid.
lem. Some of the subtypes of papillary carcinoma share Many believe that the abundance of colloid is a diagnos-
morphologic similarities with other thyroid neoplasms, tic feature of nodular goiter; thus, the nuclear morphol-
both benign and malignant. The remaining three repre- ogy is overlooked.
sent major diagnostic dilemmas and constitute important
reasons for both false-positive and false-negative diagno- Papillary Carcinoma with a Single-Cell Pattern
ses. Each of these settings is discussed below in detail.
Papillary carcinomas often have solid areas. Aspirates from
these foci yield mostly single dispersed cells ranging from
Morphologic Subtypes Presenting
round to cuboidal to short columnar forms. The neoplas-
Diagnostic Difficulties
tic cells do exhibit powdery chromatin and intranuclear
The morphologic subtypes that present diagnostic prob- inclusions. Because of a single-cell dispersed pattern with
lems include 1) the follicular variant, which may be inter- intranuclear inclusions, a diagnosis of medullary thyroid
A B
Fig. 13.60A and B. Papillary thyroid carcinoma. Minimal cytologic criteria. These two images show syncytial tissue
fragments of follicular cells without any specific architectural configuration. The cells display varied shapes and are
pleomorphic in size, but their nuclei are enlarged containing fine powdery chromatin with nucleoli, grooves, and
inclusions.
TABLE 13.15 CYTOPATHOLOGIC FEATURES OF MORPHOLOGIC VARIANTS OF PAPILLARY CARCINOMA
Papillary
Carcinoma Warthin’s–
Cytopathologic Diffuse Cribriform– Like Tumor
Features Conventional FVPCa Tall Cell Sclerosing Macrofollicular Oxyphilic Solid Columnar Morular Typeb of Thyroidb
Tissue Fragments Syncytial with Syncytial Syncytial Syncytial Syncytial with or Syncytial with Syncytial Syncytial without Syncytial with a Syncytial
or without with or without a without a without a or without without a a follicular cribriform pattern without a
a follicular without a follicular follicular follicular pattern a follicular follicular pattern follicular
pattern follicular pattern pattern pattern pattern pattern
pattern
Papillary with Papillary Papillary Papillary Not Papillary with Not Papillary without Papillary with or Papillary with
or without a fragments without uncommon present or without present a core without central or without
central core of not central cores core cores central cores
fibrovascular present
tissue
Monolayered ⫹/⫺ Monolayered Monolayered Monolayered Monolayered Rare Not present Monolayered Monolayered
tissue fragments tissue
not present fragments ⫹/⫺
Cells Pleomorphic Round to Large Medium– Round to Round to Medium– Columnar Round to Round to
cuboidal polygonal, sized, round cuboidal polygonal sized, cuboidal; spindle cuboidal
squamoid or round to cells frequent
Hürthleoid cuboidal
Cytoplasm Variable in Scanty, Abundant, Variable Scanty, Abundant, Variable, Clear with Variable in Variable in
quality and pale dense pale granular pale to cytoplasmic quality and quality and
quantity dense tailing quantity quantity;
abundant
eosinophilic
cytoplasm,
resembling
Hürthle cells
Nucleus Size Enlarged Enlarged Enlarged Enlarged Enlarged Enlarged Enlarged Enlarged Enlarged Enlarged
Chromatin Fine, powdery Fine, Fine, Fine, powdery Fine, powdery to Fine, powdery Fine, Coarse Powdery to finely Powdery to
to granular powdery powdery to to granular granular to granular powdery granular finely granular
to granular to
granular granular
Nucleoli Micro/macro Micro Micro/macro Micro/macro Micro Macro Micro/ Micro Micro/macro
macro
Grooves Present Present Present Present Present Present Present Not present Present Present
Inclusions Present Present Present Present Present Present Present ⫹/⫺ Present Present
Squamous ⫹/⫺ ⫹/⫺ Generally Marked Generally not Not present ⫹/⫺ Not present Morulae Not present
Metaplasia not present present characteristic
(Morulae)
Colloid Ropy strands Blobs Generally ⫹/⫺ Abundant Generally not Not Not present Not conspicuous Absent
⫹/⫺ of dense not present present present
viscous
colloid
⫹/⫺
Psammoma ⫹/⫺ ⫹/⫺ ⫹/⫺ Abundant Rare ⫹/⫺ Rare Not present ⫹/⫺ Not described
Bodies
Lymphocytes ⫹/⫺ ⫹/⫺ ⫹/⫺ Abundant Not present Not present Not Not present Not present Present in
present variable
numbers
Differential Hyperplastic Follicular Hürthle cell Hashimoto’s Nodular goiter; Hürthle cell Medullary Adenocarcinoma, Adenocarcinoma, Oxyphilic
Diagnoses nodular goiter; adenoma/ carcinoma thyroiditis in follicular carcinoma carcinoma; metastatic metastatic variant;
papillary follicular the absence of adenoma/ follicular papillary
hyperplasia carcinoma psammoma follicular carcinoma Hürthle cell
in follicular bodies carcinoma carcinoma; tall
adenoma; cell variant
Hashimoto’s
thyroiditis
a
FVPC ⫽ Follicular variant of papillary carcinoma.
b
These variants are rare, with sparse documentation of cytologic features.
carcinoma may be rendered (Fig. 13.61B). Immunostain histiocytes with and without hemosiderin pigment, cel-
for calcitonin is negative, while that for thyroglobulin is lular and calcific debris, and detached papillary fronds.
positive. The aspirates of the cystic carcinomas are often diag-
nostic problems. The diagnosis of cystic papillary carci-
Cystic Papillary Carcinoma noma will be accurate in the presence of cellular material
The most common malignant neoplasm of the thyroid with classic cytologic features. However, in cystic papil-
to undergo cystic change is papillary carcinoma and lary carcinomas, the cytologic features are modified by
can be seen in up to 16.6% of papillary carcinomas. the degenerative changes occurring in the fluid milieu.
The carcinoma may be purely or partially cystic, uni- Besides the typical pattern of conventional papillary
locular or multilocular, thin-walled or thick-walled, and carcinoma, the cells in the cystic environment present a
may contain residual tumor in the wall. Following an number of features that are not commonly encountered
aspiration biopsy of any cystic nodule, it is desirable to in aspirates of noncystic papillary carcinomas (Figs.
palpate for a residual mass in the wall and aspirate it, 13.62 to 13.67).
if present. The re-aspiration often provides a diagnostic 1. The specimens are frequently poorly cellular and inad-
specimen. equate for interpretation. The low cellularity may
Histologically, cystic carcinomas show papillary be the result of the failure of the needle to penetrate
fronds projecting into the cystic cavity. The latter is often the thick, fibrous, and often calcified capsule found in
filled with old and new blood and varying numbers of cystic carcinomas.
2. The cellular and infl ammatory debris resulting from
hemorrhage and necrosis obscures the cytomorphol-
TABLE 13.16 DIFFICULTIES IN CYTOLOGIC ogy of neoplastic cells. Interpretation of scanty cellular
DIAGNOSIS OF PAPILLARY CARCINOMA material in the background of extensive cellular debris
can be very challenging.
1. Morphologic subtypes
3. The tissue fragments of malignant cells ball up in the
Follicular variant
fl uid medium, appearing three-dimensional, and often
Oxyphilic variant
Columnar cell variant show an onion–skin pattern.
Macrofollicular variant 4. The tissue fragments of malignant cells often exhibit
2. Papillary carcinoma with single cell pattern scalloped borders and tend to arrange themselves in
3. Papillary carcinoma with cystic change a cartwheel pattern with nuclei at the outer perimeter
4. Papillary carcinoma coexistent with Hashimoto’s (Figs. 13.66A to C).
thyroiditis 5. Degenerating carcinoma cells acquire abundant cyto-
5. Inadequate sample/unsatisfactory cytopreparation plasm that can be bubbly or vacuolated (Figs. 13.63 to
A B
Figs. 13.61A and B. A: Follicular variant of papillary carcinoma. Syncytial tissue fragments of follicular epithelium
with a follicular pattern, enlarged with coarsely granular chromatin and lacking grooves or inclusions. Such an
aspirate is usually interpreted as cellular follicular neoplasm. The typical cytologic features of conventional papillary
carcinoma are not universally present in every case of follicular variant of papillary carcinoma. B: Papillary carcino-
mas with a single-cell pattern in aspirates. The nuclear chromatin is finely granular with micronucleoli and inclusions.
This pattern may be mistaken for medullary thyroid carcinoma.
Cystic Papillary Carcinomas (See Figs. 13.62 to 13.71)
A B
Figs. 13.62A to C. FNA of a cystic papillary carcinoma. A: The

aspirate is bloody and the smear is practically acellular, containing
few histiocytes. B: This field shows a naked psammoma body. The
smear is nondiagnostic. C: The cell block however revealed frag-
ments of papillary carcinoma (H&E). Thyroidectomy confirmed the
C papillary carcinoma.
Fig. 13.63. This aspirate from a cystic papillary carcinoma consists

of tissue fragments of malignant cells obscured by hemosiderin-
containing macrophages. Note a psammoma body. Poor cellular de-
tails will preclude an unequivocal diagnosis of papillary carcinoma.
13.65). The vacuoles may be small, multiple, or large, clues are well-defi ned, almost rigid cell borders and
occupying the entire cell and pushing the nucleus to the dense cytoplasm. The nuclear/cytoplasmic ratios are in
periphery but not indenting it (Figs. 13.65E and H). favor of the nucleus. Also, histiocytes are never seen
6. The degenerating papillary carcinoma cells may be in tissue fragments unlike carcinoma cells. The foamy
discrete (Figs. 13.67A and B), in groups, or in syn- carcinoma cells referred to as histiocytoid carcinoma
cytial tissue fragments. The single cells are difficult cells may be misinterpreted as benign. On the other
to differentiate from the histiocytes. The diagnostic hand, the histiocytic aggregates may be misinterpreted
A B
C D
Figs. 13.64A to D. Clear cyst fluid. The aspirated fluid from this cystic thyroid lesion was grossly clear. A cytospin
preparation salvaged few syncytial tissue fragments with scalloped borders. The nuclear chromatin is pale with
micronucleoli. Note the dense cytoplasm and eccentric nuclei. These features are suspicious for papillary carcinoma.
Thyroidectomy confirmed a cystic papillary carcinoma.
A B
C
Figs. 13.65A to C. FNA of a cystic papillary carcinoma. A, B, C: These tissue fragments are syncytial. The cells
are pleomorphic with well-defined cell borders and contain variable but abundant cytoplasm that is bubbly and
vacuolated as well as dense. The nuclei are pleomorphic in size, containing deep-staining chromatin and prominent
nucleoli. Grooves or inclusions are not present. These cells are difficult to differentiate from the cells of nodular
goiter. (continued)
D E
F G
Figs. 13.65D to H. (continued) D: These two syncytial tissue frag-

ments appear three-dimensional with scalloped borders. The nuclear
chromatin is intensely hyperchromatic and morphology is not visu-
alized. The cells at the periphery have bubbly vacuolated cytoplasm.
E: This syncytial tissue fragment of follicular cells show marked
vacuolization of the cytoplasm (bubblegum vacuoles). This feature
should serve as a red flag to examine the specimen more carefully.
Thyroidectomy confirmed a cystic papillary carcinoma. F: Degen-
erating follicular cells from nodular goiter. Although the cytoplasm
is bubbly, the nuclei are small and very uniform. These histiocytoid
cells may cause diagnostic difficulties. G, H: Cystic papillary carci-
noma. Note the syncytial arrangement of cells and large cytoplas-
H mic vacuoles (Diff-Quik).
as carcinoma cells. The carcinoma cells with foamy 8. Long-standing cystic fluid may be clear and poorly cel-
cytoplasm must also be differentiated from degenerat- lular. Proper cytopreparation is critical to salvage the
ing cells of nodular goiter (Figs. 13.65F and G, 13.68, few neoplastic cells. The author’s laboratory prefers to
13.69, 13.70A to C, 13.71, and 13.72). process clear fluids by cytocentrifugation (Fig. 13.64).
7. The chromatin of papillary carcinoma cell nuclei has the 9. Cyst fl uids are often bloody. Processing the specimen
tendency to stain intensely due to degeneration. The char- by removing the blood will assist in proper cytologic
acteristic fine, powdery chromatin may not be retained. evaluation.
A B
Figs. 13.66A to C. FNA of a cystic papillary carcinoma. The fluid

was grossly blood-tinged. A: Against the background of blood and
a large number of histiocytes, these three syncytial tissue fragments
of follicular cells depict scalloped borders. Many cells at the pe-
riphery demonstrate vacuolated cytoplasm. B, C: Higher magnifi-
cation. The syncytial tissue fragments are composed of elongated
cells with one slender end that is directed centripetally and the
wider outer ends house the nuclei, giving a cartwheel appearance
to the tissue fragment. Some nuclei contain nucleoli. Inclusions and
grooves are not present and the chromatin appears dense. Although
minimal criteria were not observed, this aspirate was interpreted as
suspicious for papillary carcinoma. Thyroidectomy confirmed pap-
C illary carcinoma.
A B
Figs. 13.67A and B. Cystic papillary carcinoma. A: The papillary carcinoma cells in a fluid medium expand due
to abundant vacuolated cytoplasm. These cells also demonstrate well-defined cell borders and dense cytoplasm. The
nuclei are large, pale, and eccentric and lack the features of papillary carcinoma. The presence of such cells should
serve as a red flag for the possibility of papillary carcinoma. B: These cells forming a syncytial tissue fragment show
nuclear features of papillary carcinoma. Note the cytoplasmic vacuoles. The second tissue fragment contains a
psammoma body.
A B
C D
Figs. 13.68A to D. FNA of a cystic nodular goiter misinterpreted as suspicious for papillary carcinoma. A: Monolay-
ered tissue fragments with minimal nuclear overlapping and crowding. The nuclei are slightly enlarged with granular
chromatin and micronucleoli. An occasional nucleus suggested the presence of intranuclear inclusion. B: The back-
ground features were that of a nodular goiter with abundant colloid. The aspirate was interpreted as atypical, papil-
lary carcinoma cannot be ruled out. Thyroidectomy showed cystic nodular goiter. C: Histologic section of the thyroid
showing features of nodular goiter with cystic degeneration (H&E). D: Higher magnification showing mild nuclear
atypia (H&E).
A B
Figs. 13.69A to B. Nodular goiter interpreted as papillary thyroid carcinoma. Different example of a cystic nodular
goiter that was cytologically interpreted as “atypical cells, papillary carcinoma cannot be ruled out.” A, B: These two
images depict tissue fragments of follicular cells with pleomorphic nuclei, granular chromatin, and occasional nuclear
grooves. (continued)
C D
Figs. 13.69C to D. (continued) C: The thyroidectomy revealed a cystic nodular goiter. No papillary carcinoma was
identified. D: The follicular cells in focal areas demonstrated nuclear atypia, representing the source of atypical cells.
A B
Figs. 13.70A and B. Nodular goiter interpreted as papillary thyroid carcinoma. FNA of a cystic nodule.
A: Degenerating follicular cells and histiocytes. B: Tissue fragments of follicular cells with mild nuclear enlargement.
The nuclear atypia suggesting a neoplasm, possibly papillary carcinoma. Thyroidectomy showed nodular goiter
(Diff-Quik). (Courtesy of Dr. Mariza de Peralta-Venturina, Cedar-Sinai Hospital, Los Angeles, California.)
Fig. 13.71. FNA of a surgically confirmed cystic papillary carci-

noma showing hemorrhagic background and tissue fragments of
enlarged follicular cells containing abundant finely vacuolated cy-
toplasm. Their nuclei present degenerative changes and are difficult
to evaluate. Note the suggestion of intranuclear inclusion (arrow).
These cells appear histiocytoid but are suspicious for papillary
carcinoma.
False-Positive Diagnosis of Papillary Thyroid Carcinoma (See Figs. 13.72 to 13.88)
Papillary tissue fragments in follicular adenoma with papillary change versus papillary carcinoma.
Fig. 13.72. FNA of a thyroid nodule. The cellularity of this aspirate

is impressive. The tissue fragments appear papillary and monolay-
ered (low power).
Poorly cellular, clear fl uids as well as bloody speci- provide an unequivocal diagnosis on the basis of subop-
mens are likely to result in both false-negative and false- timal preparations is risky. Partial or complete air-drying
positive interpretations. of cells in a Papanicolaou preparation reveals very pale,
Colloid is absent from aspirates of cystic papillary clear nuclei mimicking those of papillary carcinoma.
carcinoma. Syncytial architecture with a follicular pattern
is also unusual. The presence of psammoma bodies favors
DIAGNOSTIC ACCURACY
a malignant diagnosis. However, care must be taken to
evaluate the nuclear features of the cells forming the tis- The diagnostic accuracy of papillary carcinoma should
sue fragments. Naked psammoma bodies or calcific debris approach 90 to 94%, provided the aspirate obtained by fine
are of no signifi cance, except that careful examination needle biopsy is adequate for cytologic interpretation.
of all the smears is in order when they are encountered. Errors in the cytologic diagnosis of papillary carcinoma
Any visible sediment in a cyst’s fluid may be cell-blocked. can be grouped into three categories: 1) false-negative
Although, routine cell block preparations of thyroid aspi- results, 2) false-positive results, and 3) typing errors.
rates is not recommended, it can be of diagnostic help in
cases of cyst fluids (Fig. 13.62). False-Negative Results
The cells from cystic nodular goiters mimic the cyto-
The cytologic diagnosis of papillary carcinoma may be
logic features of papillary carcinoma and may be dif-
missed only if the specimen is acellular; poorly cellular
fi cult to differentiate from carcinoma cells (Figs. 13.68
and demonstrating insuffi cient diagnostic criteria; or if
and 13.69). Table 13.17 lists the differences between cells
there is a sampling error, poor fixation, and preservation.
of cystic papillary carcinoma and atypical cells in cystic
Acellular aspirates or a poor cellular yield on a fine
nodular goiter.
needle biopsy are inevitable in some instances (e.g., large
cystic papillary carcinoma, marked desmoplasia, or a
Papillary Carcinoma Coexistent with
thick, fibrous, calcified capsule).
Hashimoto’s Thyroiditis
The differentiation of papillary hyperplasia from papillary False-Positive Results
carcinoma in the background of lymphocytic (Hashimoto’s)
False-positive diagnoses of papillary carcinoma are com-
thyroiditis is often very difficult and challenging. The cells
mon diagnostic errors in the practice of thyroid cytopa-
derived from the hyperplastic process may present some of
thology and involve (Table 13.18) the misinterpretation of
the nuclear features of papillary carcinoma. Both false-posi-
aspirates from benign, nonneoplastic diseases of the thyroid
tive and false-negative diagnoses may be rendered. Minimal
as malignant neoplasms when the cytologic features mimic
cytologic criteria must be demonstrated before interpreting
some of the cytologic criteria of papillary carcinoma. The
an aspirate as diagnostic of papillary carcinoma.
same problem occurs with cellular aspirates from a folli-
cular adenoma, particularly with degeneration and pseudo
Inadequate Sample
papillary change. Most often, the errors are made if too
Inadequate samples and poor cytopreparation probably much emphasis is placed on just one cytologic feature, par-
account for most of the diagnostic errors. Attempting to ticularly when the aspirate is overwhelmingly cellular.
TABLE 13.17 CYTOPATHOLOGIC FEATURES DIFFERENTIATING CYSTIC PAPILLARY

CARCINOMA AND CYSTIC NODULAR GOITER
Cytologic Feature Cystic Papillary Carcinoma Cystic Nodular Goiter

Presentation Aspirated fluid clear to turbid to hemorrhagic; Aspirated fluid turbid to hemorrhagic;
predominantly histiocytic cell population mixed predominantly histiocytic cell population mixed
with variable numbers of papillary carcinoma with variable numbers of benign follicular
cells; (malignant cells rarely absent); malignant cells, discrete, in groups or in syncytial tissue
cells discrete, in groups or in syncytial tissue fragments
fragments
Architecture of the Tissue Tissue fragments with varying architectural Small regular follicles; loosely cohesive
Fragments configurations: papillary or papillary-like, with groups or in varying-sized monolayered tissue
scalloped borders; swirls, cart-wheel pattern; fragments; large papillary-like tissue fragments
three-dimensional unusual; when present demonstrate honeycomb
arrangement
Cells Considerable pleomorphism in size; small to Follicular cells without degenerative changes
large; well-defined to rigid cell borders; N/C small, round to cuboidal and normal-sized;
ratios variable; degenerating cells larger in size; cell borders well
to poorly defined
Nucleus Variably enlarged; round with smooth nuclear Nucleus normal-sized to minimally enlarged;
membranes; often eccentric; nuclei located at round, usually centrally located; smooth nuclear
the periphery in tissue fragments with cart- membranes; granular to smudgy chromatin;
wheel pattern; chromatin granular; smudgy nucleoli ⫹/⫺
in degenerating cells; nucleoli ⫹; grooves and
inclusions ⫹
Cytoplasm Variable; pale, bubbly, finely vacuolated to Variable; scant to abundant, granular in
multiple small vacuoles or a single large bubble degenerating cells; hemosiderin ⫹/⫺; nuclear
gum type vacuole pushing the nucleus to the grooves and inclusions rare
periphery but not indenting it; dense cytoplasm
is characteristic; hemosiderin ⫹/⫺
Hürthle Cell Metaplasia Not present ⫹/⫺
Psammoma Bodies ⫹/⫺; naked psammoma bodies not diagnostic; Very rare
must be incorporated in tissue fragments
Background Often bloody; calcific debris ⫹/⫺; colloid absent May be bloody; colloid ⫹/⫺; calcific debris rare
A diagnosis of suspected papillary carcinoma is gen- irregular nuclei with powdery chromatin and
erally given when nucleoli;
b) An occasional follicular cell showing intranuclear
1. The aspirate is marginally cellular, and the cells exhibit
cytoplasmic inclusions;
atypical features suggestive, but not diagnostic, of pap-
c) A rare papillary tissue fragment with crowded nuclei;
illary carcinoma.
d) Tissue fragments of spindle cells forming a whorled
2. The aspirate is adequately cellular with features of a
pattern, with atypical nuclei; or
benign disease (nodular goiter, Hashimoto’s thyroidi-
e) A rare psammoma body.
tis, and follicular adenoma) but, in addition, shows a
few follicular cells with atypia. The above-listed features, if present by themselves as
isolated fi ndings, may be worrisome. Their significance
The features that may be mistaken for papillary car-
must be judged in the context of the background findings
cinoma are
in an adequately cellular aspirate. If such features are pres-
a) An occasional monolayered tissue fragment of folli- ent in the background of a benign disease, they should be
cular cells with abundant, dense cytoplasm and large, interpreted as papillary carcinoma with extreme caution.
Typing Errors and B). Cytologic differentiation between the two neo-
plasms is very difficult (see Table 13.32).
Typing errors are not as consequential as false-positive
Papillary carcinoma is also mistyped as medullary
results because surgery is recommended for most thyroid
carcinoma, particularly when there is a single-cell pat-
neoplasms. Tumors that may be confused with papillary
tern. Both the malignant tumors have morphologic simi-
carcinomas include follicular neoplasms—follicular ade-
larities (see Table 13.32). Other uncommon lesions in the
noma and its special variant, the hyalinizing trabecular
differential diagnoses include parathyroid adenoma and,
adenoma, and follicular carcinoma. The cytologic fea-
very rarely, a metastatic papillary adenocarcinoma of the
tures differentiating follicular adenoma, follicular carci-
lung.
noma, and the follicular variants of papillary carcinoma
are listed in Table 13.8.
Hyalinizing trabecular adenoma is a morphologic MINIMAL CRITERIA FOR
variant of follicular adenoma that displays almost all CYTOLOGIC DIAGNOSIS
the nuclear features of papillary carcinoma (Figs. 13.18A Cytologic preparations of papillary carcinoma have sev-
eral diagnostic features, but not all may be present in
the aspirates of every case. Some features are essential,
whereas others are adjunct. Their frequency also depends
on the histologic pattern of the tumor.
TABLE 13.18 FALSE-POSITIVE DIAGNOSIS OF In a review and analysis of the cytopathologic features
PAPILLARY CARCINOMA of 329 cases of papillary carcinoma, all the features listed
in Table 13.12 were present in only 27 cases. Upon review
Disease Entities Misinterpreted
of 329 cases of papillary carcinomas with adequate cel-
Cytologic Features as PTC
lularity and 65 cases with marginal cellularity, the most
Tissue Fragments consistent features were an enlarged nuclei containing fine,
Papillary powdery, dusty chromatin that appeared pale or watery
● Hyperplastic goiter
● Papillary changes in follicular
(100%); a linear chromatin ridge or groove (88%); single
nodules or follicular adenoma or multiple micro- and/or macronucleoli (100%); and
● Hashimoto’s thyroiditis intranuclear cytoplasmic inclusions (93%). These were
collectively considered to be the minimum cytologic crite-
Monolayered ● Hyperplastic goiter ria for papillary thyroid carcinoma, particularly when the
● Follicular adenoma cytologic material is marginal.
● Follicular hyperplasia in The minimum criteria for the diagnosis of papillary
Hashimoto’s thyroiditis carcinoma thus include a syncytial-type tissue fragment
of follicular epithelium that, regardless of the architec-
Nuclear Features tural pattern, shows a typical nuclear morphology (i.e.,
Powdery Chromatin ● Hyperplastic goiter or nodular pale-appearing enlarged nuclei with fine, dusty, powdery
with Micronucleoli goiter with degeneration and chromatin; a chromatin bar or ridge; single or multiple
cyst formation micro- and/or macronucleoli; and intranuclear cytoplas-
● Hashimoto’s thyroiditis mic inclusions) (Table 13.19; Figs. 13.60A and B). No
● Follicular adenoma single cytopathologic feature is diagnostic of papillary
carcinoma. A diagnosis based on one feature will prove to
Pseudoinclusions ● Hyalinizing trabecular adenoma be a false-positive result.
● Hashimoto’s thyroiditis
● Nodular goiter
Grooves ● Hyalinizing trabecular adenoma
Ancillary Features TABLE 13.19 MINIMAL CRITERIA FOR THE

CYTOLOGIC DIAGNOSIS OF PAPILLARY
Psammoma Bodies ● Hyalinizing trabecular adenoma CARCINOMA
● Nodular goiter
● Hashimoto’s thyroiditis 1. Syncytial tissue fragments with or without any
● Follicular adenoma architectural configurations.
2. Enlarged nuclei with very fine, dusty powdery chromatin.
Inspissated ● Nodular goiter 3. Multiple micro and/or macronucleoli.
Colloid Simulating 4. Intranuclear cytoplasmic inclusions.
Psammoma Body 5. Nuclear grooves.
PAPILLARY CARCINOMA VERSUS PAPILLARY hyperplasia occurring in follicular nodules or lymphocytic

HYPERPLASIA; DIFFERENTIAL DIAGNOSES OF thyroiditis constitutes an important diagnostic pitfall.
PAPILLARY TISSUE FRAGMENTS
Papillary Hyperplasia in Follicular Nodules
Papillary or papillary-like architecture can be seen in
several conditions affecting the thyroid gland that pres- Papillary hyperplasia can occur in follicular adenoma
ent clinically as cold nodules (Table 13.20). Fine needle or in an adenomatous nodule with hyperplastic change.
aspirates of thyroid nodules of any of these diseases yield These hyperplastic nodules are well-circumscribed, with
papillary tissue fragments of follicular epithelium. Their or without encapsulation (Figs. 13.73 to 13.78), and may
occurrence in lesions other than papillary carcinoma, show cystic change centrally. The follicular epithelium is
however, is infrequent. The papillary architecture of the hyperplastic papillary with the papillae directed toward
tissue fragment is one of the most common features in the center of the nodule. The papillae may be edematous
aspirates of papillary carcinomas. Despite its frequency, and contain follicles but lack fibrovascular cores. Their
the diagnosis of papillary carcinoma based on papillary nuclei are basally located, round, and do not exhibit the
architecture alone is diffi cult both cytologically and his- cytologic criteria of papillary carcinoma. The cytologic
tologically. The cytomorphology of the cells forming the differentiation between benign and papillary fragments
papillary tissue fragment is critically important. Papillary and papillary carcinoma is listed in Table 13.20.
TABLE 13.20 CYTOPATHOLOGIC DIFFERENTIATION BETWEEN PAPILLARY HYPERPLASIA

AND PAPILLARY CARCINOMA
Papillary Hyperplasia/Papillary
Change in Nodular Goiter and Papillary Hyperplasia in
Follicular Adenoma Papillary Carcinoma Hashimoto’s Thyroiditis
Cellularity Generally high Generally high Generally high
Presentation Papillary tissue fragments Papillary tissue fragments Papillary tissue fragments
Architecture of Component cells with honeycomb Syncytial arrangement with Honeycomb arrangement; well-
Tissue Fragments arrangement; well-defined crowding and overlapping of defined cell borders; nuclear
cell borders; nuclear polarity nuclei, altered polarity peripheral polarity maintained, peripheral
maintained; peripheral palisading palisading of nuclei; central palisading of nuclei may be
of nuclei present fibrovascular core may be visible present
Nucleus Size Small uniform to slight Enlarged, pleomorphic in size, Slightly enlarged; uniform, round,
enlargement (7–9 ␮m) round; round, dusty powdery chromatin finely granular chromatin
finely granular chromatin
Nucleolus Multiple micronucleoli Multiple micro/macronucleoli Micronucleoli
Grooves Rare in nodular goiter; absent in Present Absent

adenoma
Intranuclear Rare in nodular goiter; absent in Present Rare

Inclusions follicular adenoma
Psammoma Bodies Rare 25% of the cases Rare
Background
Histiocytes ⫹/⫺ ⫹/⫺ ⫺
with or without
Hemosiderin
Multinucleated ⫺ Present Present
Giant Cells
Lymphoid Cells ⫺ ⫹/⫺ ⫹
Fig. 13.73. Higher magnification of Figure 13.72 demonstrating a

honeycomb arrangement of uniform, small round nuclei with gran-
ular chromatin. The overwhelming cellularity and the architecture
of the tissue fragments lead to a positive diagnosis of papillary car-
cinoma. Minimum cytologic criteria for papillary carcinoma are not
present. Thyroidectomy revealed a follicular adenoma with papil-
lary change.
A B
Figs. 13.74A and B. Papillary tissue fragments in nodular goiter versus papillary carcinoma. A: An extremely cellular
aspirate. The large numbers of tissue fragments with papillary and monolayered architecture are highly suggestive of
neoplasia at this low power. Note the abundant colloid in the background. B: The honeycomb arrangement of small
cells with uniform round nuclei, containing compact chromatin supports the diagnosis of hyperplastic goiter.
A B
Figs. 13.75A and B. FNA of a papillary carcinoma for comparison. A: The extreme cellularity is formed by several
large branching tissue fragments of follicular cells in a clean background (low power). B: Higher magnification shows
a monolayered syncytial tissue fragment with characteristic features of papillary carcinoma cell nuclei. Compare this
with Figure 13.74.
A B
C D
Figs. 13.76A to D. Papillary tissue fragments in a cystic nodular goiter versus papillary carcinoma. A: The cellular
aspirate consists of several tissue fragments of follicular cells that appear to be in syncytial arrangement with
crowding and overlapping. The nuclei are round, with coarsely granular chromatin and occasional nucleoli. B: This
tissue fragment of follicular cells demonstrates similar morphology. The background is bloody. A large numbers of
degenerating follicular cells were present in the background (not illustrated). A suspicious diagnosis of papillary
carcinoma was rendered. Thyroidectomy revealed a cystic nodular goiter with papillary hyperplasia. C: Histologic
section at medium power showing a cystic lesion. Papillary architecture is readily apparent (H&E). D: Higher
magnification showing edematous papillae lined by follicular cells containing hyperchromatic nuclei and lacking
the characteristics of conventional papillary carcinoma (H&E).
A B
Figs. 13.77A to B. Papillary tissue fragments in follicular adenoma with papillary change versus papillary carcinoma.
Another example of a false-positive cytologic diagnosis of papillary carcinoma. FNA of an isthmic nodule. A: An
adequately cellular aspirate showing tissue fragments of follicular epithelium with papillary-like architecture. The
honeycomb arrangement is apparent at this power. The follicular cell nuclei are uniform, small, and hyperchromatic.
No grooves or inclusions are present. Thyroidectomy confirmed an encapsulated cystic follicular adenoma.
B: Histologic section at low power to illustrate the nodule with arborizing papillae, directed towards the center
of the cavity (H&E). (continued)
470
PAPILLARY CARCINOMA VERSUS FOLLICULAR not show all the nuclear features exhibited by monolay-
HYPERPLASIA: DIFFERENTIAL DIAGNOSES OF ered tissue fragments of cancer cells seen in papillary car-
MONOLAYERED TISSUE FRAGMENTS cinoma (Figs. 13.69B and 13.79B ; Table 13.21).
Monolayered tissue fragments may also be seen in
Monolayered, syncytial tissue fragments of carcinoma
simple follicular adenomas or Hashimoto’s thyroiditis with
cells (Figs. 13.79 to 13.81; see Figs. 13.82 and 13.83) were
papillary hyperplasia, but they lack the typical nuclear mor-
seen in 60% of the aspirates of papillary carcinoma in our
phology of papillary carcinoma (Figs. 13.82 and 13.84).
series. As described earlier, they probably represent either
Squamous metaplasia occurs not uncommonly in the
the papillary fronds or large follicles seen en face. Being
background of nodular goiter as well as papillary carci-
monolayered, they exhibit a two-dimensional pattern
noma. Large tissue fragments of metaplastic squamous
and share a morphologic similarity to tissue fragments
epithelium appear identical (Figs. 13.85 and 13.86) and
of nodular goiter. An overwhelmingly cellular aspirate of
may lead to a diagnosis of papillary carcinoma.
hyperplastic goiter with myriad monolayered tissue frag-
ments may be mistaken for papillary carcinoma, partic-
FALSE-POSITIVE CYTOLOGIC DIAGNOSIS OF
ularly when viewed under a low-power objective (Figs.
PAPILLARY CARCINOMA DUE TO ATYPICAL
13.69A and 13.79A). However, closer examination will
NUCLEAR FEATURES
reveal a different cytomorphology. The monolayered tis-
sue fragments of nodular goiter have a honeycomb pat- The nuclei of papillary carcinoma cells present a charac-
tern with well-defined cell borders; uniform, small nuclei teristic morphology consisting of enlargement and pleo-
with regular polarity; and compact chromatin. They do morphism, pale to powdery chromatin, micro/macronu-
A B
Figs. 13.79A and B. Differential diagnoses of monolayered tissue fragments. An example of hyperplastic goiter with
a cellular aspirate consisting of a large numbers of monolayered tissue fragments that may lead to false-positive
diagnosis of papillary carcinoma. A: Low power to demonstrate the cellularity and large numbers of tissue fragments.
B: Higher magnification highlights the lack of nuclear features of papillary carcinoma.
A B
Figs. 13.80A and B. FNA Papillary carcinoma A: The cellular aspirate shows several tissue fragments. This
low power view is very similar to Figure 13.79A. B: Higher magnification. The tissue fragment is syncytial with
altered polarity of enlarged nuclei. The chromatin is pale, fine, and powdery. Note the micronucleoli, grooves, and
intranuclear inclusions.
PAPILLARY CARCINOMA VERSUS FOLLICULAR not show all the nuclear features exhibited by monolay-
HYPERPLASIA: DIFFERENTIAL DIAGNOSES OF ered tissue fragments of cancer cells seen in papillary car-
MONOLAYERED TISSUE FRAGMENTS cinoma (Figs. 13.69B and 13.79B ; Table 13.21).
Monolayered tissue fragments may also be seen in
Monolayered, syncytial tissue fragments of carcinoma
simple follicular adenomas or Hashimoto’s thyroiditis with
cells (Figs. 13.79 to 13.81; see Figs. 13.82 and 13.83) were
papillary hyperplasia, but they lack the typical nuclear mor-
seen in 60% of the aspirates of papillary carcinoma in our
phology of papillary carcinoma (Figs. 13.82 and 13.84).
series. As described earlier, they probably represent either
Squamous metaplasia occurs not uncommonly in the
the papillary fronds or large follicles seen en face. Being
background of nodular goiter as well as papillary carci-
monolayered, they exhibit a two-dimensional pattern
noma. Large tissue fragments of metaplastic squamous
and share a morphologic similarity to tissue fragments
epithelium appear identical (Figs. 13.85 and 13.86) and
of nodular goiter. An overwhelmingly cellular aspirate of
may lead to a diagnosis of papillary carcinoma.
hyperplastic goiter with myriad monolayered tissue frag-
ments may be mistaken for papillary carcinoma, partic-
FALSE-POSITIVE CYTOLOGIC DIAGNOSIS OF
ularly when viewed under a low-power objective (Figs.
PAPILLARY CARCINOMA DUE TO ATYPICAL
13.69A and 13.79A). However, closer examination will
NUCLEAR FEATURES
reveal a different cytomorphology. The monolayered tis-
sue fragments of nodular goiter have a honeycomb pat- The nuclei of papillary carcinoma cells present a charac-
tern with well-defined cell borders; uniform, small nuclei teristic morphology consisting of enlargement and pleo-
with regular polarity; and compact chromatin. They do morphism, pale to powdery chromatin, micro/macronu-
A B
Figs. 13.79A and B. Differential diagnoses of monolayered tissue fragments. An example of hyperplastic goiter with
a cellular aspirate consisting of a large numbers of monolayered tissue fragments that may lead to false-positive
diagnosis of papillary carcinoma. A: Low power to demonstrate the cellularity and large numbers of tissue fragments.
B: Higher magnification highlights the lack of nuclear features of papillary carcinoma.
A B
Figs. 13.80A and B. FNA Papillary carcinoma A: The cellular aspirate shows several tissue fragments. This
low power view is very similar to Figure 13.79A. B: Higher magnification. The tissue fragment is syncytial with
altered polarity of enlarged nuclei. The chromatin is pale, fine, and powdery. Note the micronucleoli, grooves, and
intranuclear inclusions.
cleoli, grooves, and inclusions. One or more but not all illary carcinoma cells. Hyperplasia in nodular goiters
of these features may be present in benign diseases and or Hashimoto’s thyroiditis may show micronucleoli as
lead to a false-positive interpretation. Nodular goiter is well as pale chromatin. Nuclear grooves are also rarely
a prime example. Degeneration, hemorrhage, and cystic observed in nodular goiters. Intranuclear inclusions may
changes result in retrogressive as well as reactive/repara- occasionally be seen in follicular cell nuclei in nodular
tive changes that mimic the nuclear morphology of pap- goiters and in Hashimoto’s thyroiditis.
A B
Figs. 13.81A to C. FNA of a very large thyroid nodule showing

syncytial tissue fragments of follicular epithelium with enlarged nu-
clei, containing finely granular chromatin, micronucleoli, grooves,
and inclusions. A diagnosis of papillary carcinoma was rendered.
A total thyroidectomy revealed an encapsulated nodule with over-
all features of a follicular adenoma with a large area that revealed
features of follicular variant of papillary carcinoma. The surgical
C pathologist preferred to call it a follicular adenoma.
A B
Figs. 13.82A and B. Papillary hyperplasia in Hashimoto’s thyroiditis presenting monolayered tissue fragments,
misinterpreted as papillary carcinoma. A: The cellular aspirate shows several large tissue fragments of follicular
epithelium (low power). B: Higher magnification showing a monolayered tissue fragment with syncytial arrangement.
The cells are large with abundant cytoplasm and appear Hürthleoid. The nuclei are round, enlarged with micro and
macronucleoli. The chromatin is granular. Nuclear grooves or inclusions are not present. Lymphocytes are present in
the background. Thyroidectomy failed to show a papillary carcinoma.
A B
Figs. 13.83A to C. Psammoma body in aspirate of follicular ad-

enoma. FNA of a follicular adenoma with monolayered tissue frag-
ments and psammoma bodies. A, B: These tissue fragments of follic-
ular epithelium are syncytial type with follicular pattern. The nuclei
are enlarged with granular chromatin and contain micronucleoli.
Grooves or inclusions are not present. Note the small psammoma
bodies (arrow). Thyroidectomy revealed an encapsulated follicular
adenoma with cystic change. C: Histologic section to demonstrate
multiple small psammoma bodies surrounded by hemosiderin con-
C taining histiocytes (H&E).
SIGNIFICANCE OF INTRANUCLEAR Intranuclear cytoplasmic inclusions are diagnostically

INCLUSIONS important only when present in a proper setting. In thy-
roid aspirates, syncytial tissue fragments of any architec-
Intranuclear inclusions are often considered synonymous
tural pattern with nuclei containing powdery chromatin
with the ground glass or “Orphan Annie” appearance
and cytoplasmic inclusions may be diagnostic of papillary
of the nuclei of papillary thyroid carcinoma. However,
carcinoma. On the other hand, aspirates showing only
ground glass or watery nuclei is more or less a general-
isolated cells with intranuclear inclusions may either be
ized finding in papillary carcinomas involving the entire
a medullary carcinoma of the thyroid or a papillary car-
nucleus due to finely granular, powdery chromatin. Intra-
cinoma or a benign lesion (Fig. 13.87). For this reason, a
nuclear inclusions are morphologically different, seen in
diagnosis of papillary carcinoma should never be based on
both cytologic and histologic sections, but in a smaller
the presence of intranuclear cytoplasmic inclusions alone.
proportion of cells. Ultrastructurally, they are seen as
membrane-bound, spheroidal masses of cytoplasm intrud-
ing into the nuclei and contain cytoplasmic organelles. SIGNIFICANCE OF PALE WATERY NUCLEI
Although a frequent feature of papillary carcinoma, Aspirates from nodular goiter, Hashimoto’s thyroiditis,
intranuclear inclusions are also present in other thyroid and follicular adenoma may all show a few groups of fol-
neoplasms. They are a remarkably consistent finding in licular cells with dusty, powdery chromatin and micronu-
hyalinizing trabecular adenomas, medullary carcinomas, cleoli resembling the cells of papillary carcinoma. However,
and are sometimes seen in Hürthle cell carcinomas, ana- these pale nuclei lack the other features (e.g., grooves and
plastic carcinomas, and benign conditions such as nodu- inclusions) and are not diagnostic of papillary carcinoma.
lar goiter or chronic lymphocytic thyroiditis.
Intranuclear cytoplasmic inclusions are not only present
SIGNIFICANCE OF NUCLEAR GROOVES
in cells of thyroid neoplasms but are also observed in sev-
eral different types of nonthyroid malignancies (e.g., malig- A nuclear groove or crease is a frequent finding in the
nant melanoma, liver cell carcinomas, adenocarcinomas of cells of papillary carcinoma. Seen as a linear crease or a
the lung, breast carcinomas, and soft tissue sarcomas). fold along the long axis of the nucleus (Fig. 13.44E), it
TABLE 13.21 CYTOPATHOLOGIC DIFFERENTIATION BETWEEN MONOLAYERED

TISSUE FRAGMENTS IN THYROID ASPIRATES
Hyperplastic Nodular Simple Follicular

Goiter Adenoma Papillary Carcinoma Hashimoto’s Thyroiditis
Presentation Large number of Large numbers of Large numbers of Large number of
monolayered tissue monolayered tissue monolayered tissue monolayered tissue
fragments; scant or fragments; colloid fragments; colloid fragments; cant to absent
absent colloid variable variable in blobs or colloid, lymphoid cells in
strings the background
Component Honeycomb arrangement Honeycomb arrangement Lack of honeycomb Honeycomb arrangement

Follicular Cells with well-defined cell with well-defined cell arrangement; some with well-defined cell
borders; nuclear polarity borders; some crowding crowding and borders; nuclear polarity
maintained and overlapping; overlapping; cell borders either maintained or
with nuclear polarity may or may not be well- slightly altered
maintained or slightly defined; altered nuclear
altered polarity
Cell Size Normal Normal to slightly Slight to considerable Slightly enlarged

increased enlargement
Nucleus Normal, uniform Slightly enlarged Considerably enlarged; Slightly enlarged; finely
7–9 ␮m; chromatin uniform; chromatin dusty powdery granular chromatin;
finely granular, finely granular, to finely granular multiple micronucleoli
evenly distributed; evenly distributed; chromatin; single/
micronucleoli ⫹/⫺ micronucleoli ⫹/⫺ multiple micronucleoli/
macronucleoli
Intranuclear Extremely rare Extremely rare Present Rarely present

Inclusions
Nuclear Grooves ⫹/⫺ Absent Present ⫹/⫺
Cytoplasm Variable, pale Variable, generally scant Variable, may be Variable, pale
and pale abundant and dense
Psammoma Rarely present Rarely present Present in up to 25% of Rarely present

Bodies the cases
Background Multinucleated giant cells Multinucleated giant cells Multinucleated giant cells Multinucleated giant
absent absent present cells may be present;
features of Hashimoto’s
thyroiditis present
probably represents an irregular infolding of the nuclear tologic material varies from 40 to 60%, but they are not
membrane, as observed ultrastructurally. Its presence is seen with such frequency in cytologic material. We found
by no means diagnostic of papillary thyroid carcinoma as them in 20% of the aspirates from papillary carcinomas.
nuclear grooving can be seen in cells of other nonneoplas- Psammoma bodies are so rarely seen in benign disorders
tic and neoplastic thyroid lesions. of the thyroid. That, according to some, their presence in
an otherwise normal-appearing thyroid gland or even in
a cervical lymph node should be regarded as evidence for
FALSE-POSITIVE CYTOLOGIC DIAGNOSIS
the presence of carcinoma until proved otherwise. Because
OF PAPILLARY CARCINOMA DUE TO THE
of such views, the presence of psammoma bodies in aspi-
PRESENCE OF PSAMMOMA BODIES
rates of thyroid nodules causes a diagnostic dilemma if
Psammoma bodies are considered a pathognomonic fea- other cytologic features of papillary carcinoma are not
ture of papillary carcinoma. The reported incidence in his- present. Can a diagnosis of papillary carcinoma be made
A B
Figs. 13.84A to C. Follicular adenoma versus papillary carcinoma.

A: FNA of a thyroid nodule showing several large monolayered tis-
sue fragments of follicular epithelium, low power. B: Higher magni-
fication showing a monolayered tissue fragment lacking features of
papillary carcinoma. The case was misinterpreted as suspicious for
papillary carcinoma. C: Thyroidectomy revealed an encapsulated
C simple type follicular adenoma (H&E).
A B
Figs. 13.85A and B. Squamous metaplasia in nodular goiter and papillary carcinoma. FNA of a nodular goiter. A: A
large tissue fragment with smooth external contour with papillary-like pattern, medium power. B: Higher magnifica-
tion showing the spindle cell architecture. The nuclei are round, uniform with granular chromatin, with some con-
taining nucleoli.
unequivocally in the above situations? Should a surgical a tissue fragment. Without the minimum criteria of papil-
procedure be recommended to confirm the diagnosis of lary carcinoma, psammoma bodies must be interpreted
papillary carcinoma? As indicated earlier, the minimum with caution since they may also be seen in nodular goiter
criteria for the diagnosis of papillary carcinoma do not (Fig. 13.88A). A psammoma body is diagnostic only if it
include a psammoma body, naked psammoma bodies is incorporated in a tissue fragment of follicular cells that
(Fig. 13.88D), or a rare psammoma body incorporated in exhibit the minimum criteria for malignancy (Table 13.22;
A B
Figs. 13.86A and B. A: FNA of a papillary carcinoma to illustrate squamous metaplasia. Note the large tissue
fragment with cytomorphology similar to that seen in Figure 13.85A. Also note the monolayered tissue fragment
of papillary carcinoma in the field. B: Higher magnification of the tissue fragment with squamous metaplasia.
A B
Figs. 13.87A and B. The presence of intranuclear inclusion by itself is not a diagnostic criterion for papillary carcino-
ma. A: FNA of Hashimoto’s thyroiditis with a papillary-like tissue fragment of follicular cells. The nuclei are crowded
and overlapped. A single cell containing an intranuclear inclusion was identified in the smear (not illustrated). A sus-
picious diagnosis resulted in a thyroidectomy, which showed only Hashimoto’s thyroiditis. B: FNA of Hashimoto’s
thyroiditis interpreted as suspicious for Follicular variant of papillary carcinoma. Note the intranuclear inclusion
(arrow). Lymphoid cells are not seen in this field. Papillary carcinoma was not confirmed.
Fig. 13.88B). A psammoma body can be mimicked by Gross and Histologic Features
dense, inspissated colloid within a follicle or because of
Grossly, insular carcinomas are usually large, bulky, often
its tendency to crack in a linear fashion (Fig. 13.88C).
exceeding 5 centimeters in dimension. They are solid,
grayish white with foci of necrosis. Gross, extrathyroidal
POORLY DIFFERENTIATED (INSULAR)
extension is frequently present.
CARCINOMA
Insular carcinomas demonstrate a distinctive histo-
Insular carcinomas are uncommon, comprising 4 to 7% logic appearance, characterized by a solid growth pattern
of all thyroid malignancies with a male:female ratio of consisting of well-defined nests or the insulae of round
1:2. Insular carcinoma usually occurs in older individuals, to oval, small follicular cells averaging up to 10 nanome-
with the mean age being 55 years. However, it has also ters in diameter. The nests of tumor cells may be solid,
been described in the pediatric age group. These tumors form a trabecular pattern, or show a follicular pattern,
follow an aggressive course with a high mortality rate. often with abortive follicles containing droplets of col-
Most patients demonstrate local and distant metastases loid. Large areas of necrosis are frequent. Mitotic activity
at the time of presentation. is brisk.
TABLE 13.22 DIFFERENTIATING FEATURES BETWEEN PSAMMOMA BODIES IN NODULAR
GOITER AND PAPILLARY CARCINOMA
Psammoma Bodies in Nodular Goiter Psammoma Bodies in Papillary Carcinoma

Number of Psammoma Generally an isolated finding or few in numbers; Usually in significant numbers when present;
Bodies multiple psammoma bodies in a single tissue multiple psammoma bodies in a single tissue
fragment uncommon fragment common
Naked Forms Present Present
Size Usually small Variable, small to large
Characteristics of Tissue Component cells of the tissue fragment have Syncytial arrangement of cells with enlarged
Fragment Incorporating small uniform nuclei with compact to finely nuclei demonstrating the typical features of
the Psammoma Body(ies) granular chromatin, lack the typical nuclear papillary carcinoma
features of papillary carcinoma; syncytial
arrangement absent
Calcific Debris in the ⫹/⫺ ⫹/⫺

Background
Background Background features of nodular goiter Features of papillary carcinoma
A B
C D
Figs. 13.88A to D. A: FNA of a nodular goiter showing a tissue fragment of benign follicular cells containing small
nuclei with compact chromatin, incorporating three psammoma bodies. B: A psammoma body incorporated in a
tissue fragment of follicular cells with features of papillary carcinoma. C: Mimics of psammoma body. FNA of a
nodular goiter with extensive Hürthle cell metaplasia and cystic degeneration. This tissue fragment of follicular cells
contains inspissated colloid simulating psammoma body. The follicular cell nuclei contain micronucleoli but lack
grooves and inclusions. D: Naked psammoma bodies are not diagnostic of papillary carcinoma. These multiple
naked psammoma bodies were aspirated from a nodular goiter.
478
Insular carcinomas are usually associated with well- deep-staining. Excessive parachromatin clearing is also
differentiated follicular/papillary carcinomas or anaplas- appreciated, and micronucleoli are usually conspicuous.
tic carcinomas. Mitotic figures may be present. Insular carcinomas, dedif-
ferentiated from papillary carcinomas may demonstrate
Cytopathologic Features features of papillary carcinoma such as powdery chroma-
tin, nuclear grooves, and intranuclear inclusions. Those
The aspirates of insular carcinomas are generally cellu-
dedifferentiated from follicular carcinomas may demon-
lar consisting of a large population of small, very uni-
strate a follicular pattern. The background may be clean
form malignant cells occurring singly, in loosely cohesive
or necrotic. No colloid is appreciated in the background.
groups, and in syncytial tissue fragments (Table 13.23;
Figs. 13.89A to E). The latter occur as nests, masses; or
trabeculae with intense crowding and overlapping of Immunoprofile
nuclei. The nests are often rounded and sharply defined, The insular carcinoma cells usually react positively to thy-
corresponding to the insulae seen in the histologic sec- roglobulin and TTF-1. Negative reactivity to thyroglobu-
tions. Some syncytial tissue fragments may demonstrate lin is occasionally observed. Insular carcinomas also react
a microfollicular pattern with their lumens at times con- positively to cytokeratins, and do not react to endocrine
taining droplets of colloid (Fig. 13.89B). A dispersed markers.
pattern is also occasionally seen. The cells of the insu-
lar carcinoma are round with poorly defined cell borders
Diagnostic Accuracy and Differential Diagnoses
and are much smaller than those of the differentiated
(follicular papillary) thyroid cancers, averaging 9–10 ␮m The diagnostic accuracy of insular carcinoma is difficult
in diameter. Ocassionally, insular carcinoma cells with to assess. These are uncommon thyroid neoplasms; since it
plasmacytoid features have caused diffi culties in differ- was first described slightly over two decades ago, in 1984,
entiation from medullary carcinoma. Their cytoplasm is the cytologic fi ndings of insular carcinoma are described
scant, indiscernible, and occasionally pale and vacuolated only infrequently, usually as individual case reports or as
with extremely high N/C ratios. The nuclear contours small case series. In most of these reports, the cases were
are smooth, and the chromatin is coarsely granular and interpreted as poorly differentiated carcinomas, and the
TABLE 13.23 CYTOPATHOLOGIC FEATURES OF POORLY DIFFERENTIATED “INSULAR CARCINOMA”
Cellularity and Generally very cellular, malignant cells isolated, in loosely cohesive groups or in syncytial tissue
Presentation fragments; a dispersed pattern is frequent
Architecture Syncytial tissue fragments of small malignant cells with follicular pattern, or forming insulae, nests
or trabeculae; intense crowding and overlapping of nuclei; peripheral palisading not present in the
tissue fragments
Cells Small, monomorphic
Nucleus Approximately 10 ␮m in diameter; round, deep-staining, granular chromatin with parachromatin

clearing; single/multiple micronucleoli; no nuclear molding; mitoses ⫹/⫺; no stretch artifacts
Cytoplasm Scant, indiscernible; pale; vacuoles ⫹/⫺
Background Clean to necrotic; features of pre-existing follicular or papillary carcinoma ⫹/⫺
Immunocytochemical Usually react positively with antibodies to thyroglobulin and TTF-1, occasionally negative; positive
Profile reactivity to cytokeratin; negative reactivity to: calcitonin, neuroendocrine markers, leukocyte
common antigen (LCA)
Differential Diagnoses ● Medullary carcinoma with a small cell pattern

● Other neuroendocrine tumors with small cells
● Malignant lymphoma
● Metastatic small cell malignancy
Small cell carcinoma
Basaloid squamous carcinoma
Poorly Differentiated “Insular” Carcinoma (See Figs. 13.89 to 13.90)
A B
C D
Figs. 13.89A to E. A: FNA of an insular carcinoma. The cellular as-

pirate consists of small malignant cells, in syncytial tissue fragments
with a follicular pattern. Note the dispersed pattern, small uniform
malignant cells with scant cytoplasm, high N/C ratios, and granular
chromatin with micronucleoli in a clean background. B: FNA of an
insular carcinoma consisting of syncytial tissue fragments of small,
uniform, round cells with scant to indiscernible cytoplasm. Note the
follicular pattern (arrows). C: Positive staining with thyroglobulin.
D, E: FNA of an insular carcinoma showing large syncytial tissue
fragments of small uniform malignant cells with extreme crowding
and overlapping. Note the vague follicular pattern. Insular nature
may not be recognized from the cytologic samples, and the carcino-
E ma may be interpreted as poorly differentiated follicular carcinoma.
insular nature was appreciated following the histologic of insulae is not a very common feature. The small size
examination. An accurate cytologic diagnosis of insular of the malignant cells, however, is the key to the diagno-
carcinoma is diffi cult to make unless the aspirate shows sis. The conventional follicular carcinoma cells are much
insulae formed by small, uniform, malignant cells. Most larger. Also, many insular carcinomas are associated with
cases of insular carcinomas are cytologically interpreted differentiated carcinomas of follicular cell origin such as
as poorly differentiated follicular carcinoma because of follicular or papillary type. The aspiration biopsy may
the follicular architecture or papillary carcinomas if fea- sample only the differentiated component, and the diag-
tures of papillary carcinoma are coexistent. The presence nosis of insular carcinoma will be evident only following
surgical excision. On rare occasions, however, multiple soft, fl eshy, and lobulated with areas of necrosis, hemor-
sampling of the neoplasm may demonstrate the coexis- rhage, and cystic degeneration. The tumor often infiltrates
tence of both components. the perithyroidal soft tissues and neighboring organs.
The histomorphology of anaplastic carcinomas var-
Differential Diagnoses ies widely from tumor to tumor and sometimes within
the same tumor. Three basic patterns have been described,
The differential diagnoses of insular carcinoma include
namely, giant cell type, spindle cell type, and squamoid.
neoplasms composed of small malignant cells such as
One of these patterns may predominate, although a com-
medullary thyroid carcinoma with a small cell pattern;
bination of varied types is frequent.
other neuroendocrine tumors such as carcinoid tumors or
The giant cell type is characterized by a solid growth
paraganglioma; malignant lymphoma; metastatic small
pattern consisting of markedly pleomorphic round to
cell (neuroendocrine) carcinoma (Fig. 13.90); or basaloid
oval, large to giant-sized malignant cells containing single
squamous carcinoma. Immunostains are often required to
to multiple bizarre nuclei with prominent nucleoli. Nor-
establish a correct diagnosis. The cytologic differentiating
mal as well as abnormal mitoses are commonly observed.
features are listed in Table 13.24.
Their cytoplasm is variable, scant to abundant, pale to
dense to granular or clear. The giant tumor cells are often
ANAPLASTIC CARCINOMA mixed with smaller mononuclear tumor cells.
The squamoid type of anaplastic carcinoma is com-
Anaplastic thyroid carcinoma (ATC) is one of the most
posed of large, round to polygonal cells resembling the
aggressive malignancies. It comprises 2 to 5% of thyroid
cells of nonkeratinizing, poorly differentiated squamous
malignancies; however, a higher incidence is reported in
carcinoma forming a solid growth pattern. They are more
areas with endemic goiters. Anaplastic thyroid carcinomas
uniform, occasionally showing keratinization and lack the
are more frequent in women, with a male:female ratio of
typical giant tumor cells. The squamoid type anaplastic
1:3 to 1:4. It commonly occurs in older individuals with
carcinoma cells contain abundant eosinophilic cytoplasm.
a median age of 60 years, although anaplastic carcinomas
Both giant cell and squamoid types show prominent vas-
can occur in younger individuals. Patients with anaplastic
culature with curvaceous capillaries within the neoplasm.
carcinomas present with a rapidly growing, painful neck
The spindle cell pattern strongly resembles a soft tis-
mass and pressure symptoms such as dysphagia, dyspnea,
sue sarcoma and is composed of pleomorphic spindle cells
and hoarseness of voice. The thyroid gland is firm to hard
with bizarre nuclei. Fascicles of tumor cells, a storiform
and fi xed. The tumor is widely infi ltrative locally and
pattern, scattered tumor giant cells, and inflammatory
metastasizes to distant organs and is rapidly fatal.
infiltrate mimic the pattern of malignant fibrous histiocy-
toma. Elongated spindle-shaped tumor cells separated by
collagen resemble a fibrosarcoma. Anaplastic carcinomas
Grossly, anaplastic carcinomas are large, bulky tumors often consist of a mixed giant and spindle cell pattern.
extensively infi ltrating the thyroid. The cut surfaces are Squamous differentiation may be present. Hemorrhage,
necrosis, and infl ammatory cell infi ltrate may be seen
with all cell patterns. Anaplastic carcinomas frequently
contain osteoclast-like multinucleated giant cells.
Anaplastic carcinomas generally develop from differ-
entiated follicular/papillary thyroid cancers. Evidence of
preexisting follicular or papillary carcinoma may be seen.
Anaplastic carcinomas may develop from dedifferentia-
tion of Hürthle cell carcinoma. Coexistence of insular and
anaplastic carcinomas is also described. An insular com-
ponent can also be present.
Morphologic variants of anaplastic carcinoma
include paucicellular and rhabdoid types. The paucicel-
lular variants are characterized by extensive desmoplasia
with wide areas of collagenized fibrous tissue. Malignant
cells, usually of the spindle cell type, are few in number,
often seen scattered within the fibrous stroma with areas
Fig. 13.90. Neuroendocrine carcinoma, calcitonin negative, show- of necrosis and infarction. The paucicellular variant, clini-
ing the syncytial tissue fragment of the malignant cells without any cally as well as grossly, mimics Reidel’s thyroiditis. Exten-
architectural pattern. The malignant cells have scant undifferentiated
sive fi brosis is common in both lesions. Needle biopsies,
cytoplasm. Their nuclei are slightly larger than the usual insular
carcinoma cells and bear a strong resemblance to neuroendocrine both fi ne and large, tend to be either acellular or poorly
carcinoma cells. cellular due to fibrosis.
TABLE 13.24 DIFFERENTIAL DIAGNOSES OF POORLY DIFFERENTIATED “INSULAR CARCINOMA”

CYTOPATHOLOGIC FEATURES
Metastatic
Medullary Basaloid
Carcinoma, Small Malignant Metastatic Small Squamous
Insular Carcinoma Cell Type Lymphoma Cell Carcinoma Carcinoma
Presentation Dispersed cell Neoplastic cells Cells mostly Neoplastic cells Neoplastic cells
pattern or cells in discrete, in loosely isolated with isolated, in loosely isolated, in loosely
syncytial tissue cohesive groups, dispersed pattern; cohesive groups cohesive groups or
fragments forming infrequently in rare syncytial and in syncytial in syncytial tissue
nests, insulae syncytial tissue tissue fragments tissue fragments fragments without
or trabeculae; fragments; without any any architectural
microfollicular pseudofollicular architectural pattern
pattern ⫹/⫺ intense pattern ⫹/⫺ patterns
crowding and
overlapping of
nuclei
Cells Small in size, Small, Small, Small pleomorphic Small, pleomorphic

monomorphic, monomorphic monomorphic in size, poorly in size, poorly
round, poorly poorly defined cell poorly defined cell defined cells defined cell borders;
defined cell borders; borders; high N/C borders; high N/C borders; high N/C high N/C ratios
high N/C ratios ratios ratios ratios
Nucleus Approximately Round; smooth Round; smooth to Round, oval, Round, oval to
10 ␮m in diameter, nuclear membranes; irregular nuclear oblong to short oblong; smooth
round, smooth coarsely granular membranes; spindle-shape; nuclear membranes;
nuclear membranes, chromatin; nucleoli finely granular smooth nuclear chromatin coarsely
finely granular ⫹/⫺; nucleus chromatin with membranes; granular and deep-
chromatin with often eccentric; parachromatin compact chromatin; staining; nucleoli
parachromatin no nuclear clearing; nucleolus not ⫹/⫺; no nuclear
clearing; molding; no stretch micronucleoli ⫹; appreciated; molding; mitoses
micronucleoli artifacts; mitoses no nuclear nuclear molding ⫺; stretch artifacts
⫹/⫺; no nuclear ⫺; intranuclear molding; characteristics; ⫺; intranuclear
molding; no stretch inclusions ⫹/⫺; mitoses ⫹; stretch mitoses ⫹; inclusions ⫺;
artifacts; mitoses nuclear grooves ⫺; artifacts ⫹; stretch artifacts nuclear grooves ⫺
⫹/⫺; intranuclear karyorrhexis ⫺ intranuclear ⫹; intranuclear
inclusions ⫹/⫺; inclusions ⫺; inclusions ⫺;
nuclear grooves ⫹/; nuclear grooves nuclear grooves ⫺;
karyorrhexis not ⫺; karyorrhexis ⫹ karyorrhexis ⫹
observed
Cytoplasm Scant, insignificant; Scant, insignificant; Scant, Scant, indiscernible Scant; indiscernible
may contain small rudimentary indiscernible
vacuoles cytoplasmic tailing
Colloid Absent Absent Absent Absent Absent
Amyloid Absent ⫹/⫺ Absent Absent Absent
Background Clean or necrosis Clean Clean or necrotic Necrosis Necrosis ⫹/⫺

debris
(continued)
Metastatic
Medullary Basaloid
Carcinoma, Small Malignant Metastatic Small Squamous
Insular Carcinoma Cell Type Lymphoma Cell Carcinoma Carcinoma
Immunoprofile
Thyroglobulin ⫹ ⫺ ⫺ ⫺ ⫺
TTF-1 ⫹ ⫺ ⫺ ⫺ ⫺
Cytokeratin ⫹ ⫹ ⫺ ⫹ ⫹
Calcitonin ⫺ ⫹ ⫺ ⫺ ⫺
Neuroendocrine ⫺ ⫺ ⫺ ⫺ ⫺
Markers
LCA ⫺ ⫺ ⫹ ⫺
TABLE 13.25 CYTOPATHOLOGIC FEATURES OF ANAPLASTIC CARCINOMA
Cellularity Variable; usually very cellular; low in paucicellular variant or necrotic tumors
Presentation Malignant cells isolated, in loosely cohesive groups or in syncytial tissue fragments without any
architectural patterns; may run in fascicles
Cells Extremely pleomorphic in size and shape; small to giant forms; round, polygonal, spindle-shaped,
caudate, tadpoles; well to poorly defined cell borders; N/C ratios variable, usually high
Nucleus Large to giant-sized; round, elongated to spindle-shaped; bizarre forms; bi-multinucleation frequent;
deep-staining coarsely granular to clumped chromatin with excessive parachromatin clearing;
multiple micro-macronucleoli; intranuclear cytoplasmic inclusions; mitotic figures ⫹
Cytoplasm Variable; scant to abundant; clear, pale, vacuolated to dense; emperipolesis frequent
Background Cellular and necrotic debris; acute inflammatory cells ⫹/⫺; osteoclast-like giant cells ⫹/⫺
Features of Preexisting May be present, depending on the sampling

Papillary, Follicular, or
Insular Carcinoma
Immunoprofile Almost always negative reactivity to thyroglobulin and TTF-1; positive reactivity to cytokeratin,
vimentin
The rhabdoid type is a rare morphologic variant, Cytopathologic Features

with only a few cases being reported in the literature.
The cytopathologic features of anaplastic carcinoma are
Histologically, the rhabdoid variant of anaplastic carci-
usually diagnostic on account of neoplastic cells that
noma shows a solid growth pattern with a uniform, large,
present obvious malignant criteria (Table 13.25; Figs.
round cell population containing eccentric nuclei. The
13.91A to F and 13.92A to D).
cytoplasm of the malignant cells contains eosinophilic
Anaplastic carcinomas with the giant cell and squam-
globules that are shown to contain intermediate filaments
oid types yield overwhelmingly cellular aspirates while
ultrastructurally. These also stain positively with desmin
the spindle cell pattern and abundant collagenous stroma
and muscle-specific actin.
Anaplastic Carcinoma (See Figs. 13.91 to 13.92)
A B
C D
E F
Figs. 13.91A to F. A: FNA of an anaplastic carcinoma, giant cell type. The neoplastic cells are discrete, markedly
pleomorphic and are clearly malignant. B: Aspirate showing spindle and giant malignant cells, characteristic of
anaplastic carcinoma. C: Anaplastic carcinoma consisting of pleomorphic giant malignant cells. D: A discrete giant
spindle-shaped malignant cell in the background of inflammatory cells. E: FNA of a spindle cell anaplastic carcinoma
consisting of several tissue fragments of malignant cells. (Courtesy of Mithra Baliga, M.D., University of Mississippi,
Jackson, Mississippi.) F: Anaplastic carcinoma, showing gigantic cells with markedly enlarged nuclei, high N/C
ratios, coarse clumpy chromatin, and macronucleoli. Phagocytosis of neutrophils by the malignant cells is prominent
(Thin Prep). (Courtesy of Dr. Claire W. Michael, University of Michigan Health System, Ann Arbor, Michigan.)
A B
Figs. 13.92A to C. Paucicellular variant of anaplastic carcinoma.

Three attempts at fine needle biopsy of the hard, fixed enlarged thy-
roid in a 41-year-old male failed to yield an adequate aspirate. From
over 40 smears from three aspirates, rare but pleomorphic spindle
and giant cells were identified that raised a question of anaplastic
carcinoma. The surgical resection showed a paucicellular anaplastic
carcinoma with considerable desmoplasia, explaining the difficulties
in obtaining an adequate aspirate. A, B, C: The malignant cells are
discrete, highly pleomorphic with variable cytoplasm, spindle, to gi-
C ant forms.
tend to be paucicellular or even acellular. Carcinomas with clear cytoplasm and may demonstrate emperipolesis. The
extensive necrosis may yield unsatisfactory samples. The dense cytoplasm imparts a Hürthleoid appearance. How-
spectrum of cytologic features is extremely wide although ever, ultrastructurally, mitochondria are few or absent. An
the anaplastic nature is conspicuously apparent. admixture of pleomorphic smaller malignant cells is often
The malignant cells range in size from small, medium, noted. The squamoid type of anaplastic carcinomas yield
and large to giant forms reaching enormous dimensions. cellular aspirates composed of medium to large malig-
Their shape, likewise, demonstrates extreme variations nant cells occurring discrete, in loosely cohesive groups,
from round, oval, plasmacytoid, polygonal, caudate, and or in syncytial tissue fragments without any architectural
racket-shaped to spindle type. The malignant cells are patterns. The malignant cells are round to polygonal with
usually discrete, in discohesive groups, or infrequently, in appreciable pale to dense cytoplasm. Squamous differen-
syncytial tissue fragments without any architectural pat- tiation and keratinization may be focally evident.
terns. Arborizing blood vessels may be seen in the back- The carcinoma cells in spindle cell type of anaplastic
ground. A given aspirate may present only one cell pat- carcinoma vary in number and may present as discrete
tern or a combination of one or more patterns. cells in aggregates or present as syncytial tissue fragments,
The aspirates of giant cell anaplastic carcinomas show occasionally forming fascicles (Figs. 13.91B to E). The
pleomorphic giant tumor cells containing bizarre nuclei cell borders may be poorly to well-defined. The nuclei
with irregular nuclear membranes with scalloping (Figs. vary from round, oval, and elongated to spindle shape,
13.91E and F). The nuclei are large with coarsely granu- often with irregular nuclear membranes. The nuclear fea-
lar to clumped, deep-staining chromatin and excessively tures are similar to those seen in the giant cell type. With
clear parachromatin. Nucleoli are prominent and intra- marked desmoplasia, the aspirate may yield the fragments
nuclear inclusions are often present. Exuberant mitotic of collagenized stroma in which are embedded discrete
activity is refl ected by the presence of both normal and malignant cells and may be difficult to recognize.
abnormal mitotic figures. Multilobulation and multinucle- Osteoclast type multinucleated giant cells have been
ation are very common. The malignant cells of the giant described in some anaplastic carcinoma. The background
cell type contain abundant pale to dense and, sometimes, usually shows necrosis, inflammation, and tumor diathesis
with cellular debris. Extensive necrotic debris may obscure TABLE 13.26 DIFFERENTIAL DIAGNOSES OF
the isolated malignant cells and result in a false-negative ANAPLASTIC CARCINOMA
diagnosis (Fig. 13.91D).
The clear cell variant demonstrates malignant cells Thyroiditis
with the cytologic features of giant cell type anaplastic
carcinoma with clear cytoplasm, which is appreciated bet- Acute thyroiditis with abscess
ter in histologic sections than in cytologic preparations.
Their nuclei are often seen as naked due to the disruption Subacute or granulomatous thyroiditis
of the cell membranes and cleared cytoplasm. The cyto-
plasm is abundant and often very pale. Fibrous variant of Hashimoto’s thyroiditis
The paucicellular variant because of the extensive des-
Reidel’s thyroiditis
moplastic stroma tends to yield poorly cellular aspirate,
predominantly consisting of pleomorphic spindle-shaped
Nodular goiter
malignant cells (Figs. 13.92A to D). The rhabdoid type
shows undifferentiated malignant cells containing abundant
Proliferating fibroblasts from granulation tissue
cytoplasm with vimentin-positive globules, which ultra-
structurally contain whorls of filaments. The aspirates may
Degenerating follicular cells in nodular goiter
also include the cellular features of a preexisting follicular/
Hürthle cell, papillary carcinoma, or an insular carcinoma. Radiation induced changes
Immunoprofile Megakaryocytes from ossified cartilage

Anaplastic carcinoma cells fail to react to thyroglobulin in
almost all cases. Keratin is the most useful marker since it is Medullary thyroid carcinoma
consistently positive. Carcinoembryonic agent (CEA) and
Poorly differentiated primary squamous carcinoma
epithelial membrane antigen (EMA) are of limited diagnos-
tic value. Anaplastic carcinoma cells are also nonreactive to
Poorly differentiated metastatic carcinomas
calcitonin and leukocyte common antigen (LCA); however,
they are useful in differentiating anaplastic carcinomas Malignant lymphoma
from several other poorly differentiated neoplasms.
Malignant melanoma
With adequate cellularity, the cytologic presentation of Soft tissue sarcomas (primary and secondary)
anaplastic carcinomas in fi ne needle aspirates usually
offers no diagnostic challenge. The diagnostic accuracy
is reported in the range of 85 to 90%. False-negative well as subacute thyroiditis. Degenerative changes in the
diagnosis results from inadequate aspirate, usually from benign follicular cells in nodular goiters or radiation-induced
paucicellular spindle cell variants containing excessive changes may also mimic anaplastic carcinoma cells.
collagenized stroma. Extensive necrosis may also result in Acute infections with abscess are uncommon examples
a false-negative diagnosis since the single malignant cells that masquerade clinically as anaplastic carcinoma. Rarely,
obscured by the inflammatory and cellular debris preclude megakaryocytes aspirated from the ossified laryngeal or
the diagnosis. Sampling only a preexisting differentiated thyroid cartilage may be mistaken for anaplastic carcinoma.
cancer in anaplastic carcinoma is also another reason for Malignant neoplasms mistyped as anaplastic carcinoma
a missed diagnosis. Up to 71% of anaplastic carcinomas include medullary thyroid carcinoma, malignant lymphoma,
arise as dedifferentiation of an existing differentiated car- poorly differentiated primary squamous carcinoma, poorly
cinoma, either follicular or papillary. The cytologic sam- differentiated metastatic carcinomas, metastatic malignant
ples may or may not contain both components. melanoma, and soft tissue tumors. The cytologic features
In general, the characteristic cytomorphology of ana- of various diagnostic entities in the differential diagnosis of
plastic carcinoma with extreme pleomorphism of the malig- anaplastic carcinoma are listed in Table 13.27.
nant cells containing bizarre nuclei lends itself to accurate
diagnosis and cannot be misinterpreted as any other neo-
SPINDLE CELLS IN THYROID ASPIRATES
plasm. The converse is not true. Several types of benign cells
as well as some malignant neoplasms may be misinterpreted The normal thyroid gland contains limited stromal com-
as anaplastic carcinoma (Table 13.26). Benign cells that can ponent. The presence of spindle-shaped cells of mesen-
be misinterpreted as anaplastic carcinoma include prolifer- chymal origin in fine needle aspirates of epithelial lesions
ating fibroblasts and stromal tissue fragments in Reidel’s as of the thyroid is not a common occurrence. Infrequently,
TABLE 13.27 DIFFERENTIAL DIAGNOSES OF ANAPLASTIC CARCINOMA CYTOLOGIC FEATURES
Diagnostic Entity Cytopathologic Features

Acute thyroiditis Acute inflammatory (neutrophilic) exudate; histiocytes; cellular and necrotic debris
Subacute thyroiditis Large numbers of multinucleated foreign-body-type giant cells, some enormously large with
(granulomatous multiple, uniform nuclei in tens and hundreds; often seen in the vicinity of blobs of colloid,
thyroiditis) forming granuloma, epithelioid cells ⫹/⫺; varying numbers of spindle cells with bland nuclei, tissue
fragments of stroma; benign follicular and Hürthle cells with or without nuclear atypia; lymphocytes
in the background; neutrophils and cellular debris in acute phase
Reidel’s thyroiditis Acellular aspirate; no follicular cells; stromal tissue fragments; spindle cells, lymphocytes
Nodular goiter Degenerating follicular cells with marked nuclear atypia, with pyknosis; spindle-shaped cells with
bland nuclear chromatin; nuclear inclusions and grooves ⫹/⫺
Radiation-induced Pleomorphic follicular cells with spindle shapes; stromal spindle cells, bland nuclear chromatin or
changes with degenerative changes with pyknosis; bare nuclei in the background
Megakaryocytes Pleomorphic, large with multilobulated (not multinucleated) nuclei with clumped chromatin;
hematopoietic cells in the background
Medullary thyroid Pleomorphic cell pattern with spindle and large polygonal cells; spindle cells may be in fascicles;
carcinoma high N/C ratios; dense cytoplasm; coarsely granular chromatin; nuclear inclusions ⫹; nucleoli
inconsistent; grooves ⫺; mitotic activity not present; background clean; amyloid ⫹; neoplastic cells
reactive to calcitonin
Poorly differentiated Pleomorphic cell pattern with spindle and large polygonal cells; spindle cells may be in fascicles;
squamous carcinoma high N/C ratios; dense cytoplasm; coarsely granular chromatin; nuclear inclusions ⫹; nucleoli
inconsistent; grooves ⫺; mitotic activity not present; background clean; amyloid ⫹; neoplastic cells
reactive to calcitonin
Poorly differentiated Malignant cells pleomorphic; clearly malignant nuclei; mitotic activity ⫹; cytoplasm with no
metastatic carcinoma differentiating features; immunostains necessary to identify the origin
Malignant large cell Medium-sized round cells with scant cytoplasm; round nuclei with granular chromatin,
lymphoma parachromatin clearing, multiple nucleoli; mitotic activity brisk; karyorrhexis ⫹; LCA ⫹
Malignant melanoma Pleomorphic malignant cell population; fine to coarsely granular chromatin; macronucleoli; mitoses ⫹,
nuclear inclusions ⫹; melanin pigment in the cytoplasm ⫹/⫺; HMB-45 – positive reactivity
Soft tissue tumors Spindle cell population, cells discrete or in fascicles; pleomorphism common; nuclear morphology
(primary or secondary) depending on the type of neoplasm and range from bland to clearly malignant; mitotic activity ⫹/⫺;
negative reactivity to thyroglobulin and cytokeratin; positive to vimentin and soft tissue tumor
markers (muscle specific actin, HHF 35, Desmin)
Anaplastic carcinoma Extremely pleomorphic malignant cell population, ranging from medium-sized, large to giant forms;
round, polygonal to spindle-shape; discrete, in groups or in syncytial tissue fragments with no
architectural patterns, large nuclei, often with irregular outlines; coarsely granular chromatin with
excessive parachromatin clearing; multiple micro/macronucleoli; mitotic activity ⫹ intranuclear
inclusions ⫹
TABLE 13.28 SPINDLE CELLS IN THYROID the epithelial cells, in nonneoplastic as well as both
ASPIRATES benign and malignant neoplastic lesions acquire the spin-
Stromal
dle shape. The stromal and epithelial spindle cells origi-
nate from diverse sources (Table 13.28). They present
Nonneoplastic Nodular goiter considerable diagnostic diffi culties when encountered in
aspirated specimens from thyroid nodules and may result
Chronic lymphocytic thyroiditis in a false-positive diagnosis of malignancy because of sev-
eral cytologic abnormalities. Table 13.29 lists the differ-
Granulomatous thyroiditis (subacute entiating features between benign and malignant spindle
and infectious) cells of both mesenchymal and epithelial origin.
Reidel’s thyroiditis (extremely rare)
NONNEOPLASTIC SPINDLE CELLS OF
Post ¹³¹I therapy MESENCHYMAL ORIGIN
Benign spindle cells of mesenchymal or stromal origin
Proliferating granulation tissue
with fibroblastic and endothelial are encountered in nodular goiters, in Hashimoto’s thy-
proliferation roiditis, and from desmoplastic stroma in papillary or
anaplastic carcinomas (Table 13.28). In nodular goiters,
Leiomyocytes (blood vessel) they may be derived from fibrosis occurring as a result of
episodes of hemorrhage, necrosis, and subsequent organi-
Desmoplastic stroma of papillary or zation of the granulation tissue. They may also be derived
anaplastic carcinoma from reparative processes, particularly in cases of cystic
degeneration. The cystic change and the fibrotic lesions
Neoplastic Soft tissue neoplasms, primary or are a frequent source of stromal cells in thyroid aspi-
metastatic rates. Fibrosis has also been described in large follicular
Epithelial
adenomas, although it is not very common. The thyroid
parenchyma along the needle biopsy track or from the
Nonneoplastic Reparative/regenerative follicular cells infarcted lesions may show fi broblastic proliferation and
in nodular goiter may be seen in aspirated samples. Desmoplastic stroma in
papillary or anaplastic carcinoma is yet another source of
Squamous metaplasia benign spindle cells. Tissue fragments of connective tissue
stroma may also be seen in aspirates of Hashimoto’s thy-
Nodular goiter roiditis, particularly in late stages of the disease.
Hashimoto’s thyroiditis Cytopathologic Features

Papillary carcinoma The spindle cell of stromal origin in thyroid aspirates pres-
ent diverse morphology (Figs. 13.93 to 13.97). The latter
Neoplastic Hyalinizing trabecular adenoma depends on whether the area biopsied is an old fibrotic
nodule or an actively organizing stroma with proliferat-
Papillary carcinoma ing fi broblasts and capillaries. The spindle cells from the
fibrotic nodule are usually few in number and have bland
Medullary thyroid carcinoma nuclei, while those from the organizing stroma show atyp-
ical nuclei with pleomorphism and nucleoli. The spindle
Anaplastic carcinoma cells, by their sheer presence, cause diagnostic concern,
more so with atypical morphology, and are often misin-
Poorly differentiated squamous terpreted as neoplastic.
carcinoma (sarcomatoid type) In thyroid aspirates of nodular goiters or Hashimo-
to’s thyroiditis, the stromal cells or fi brocytes are gener-
Spindle cell thyroid tumor with
ally present in small numbers isolated, in groups, or in
thymus-like elements (settle)
tissue fragments separated by collagen (Fig. 13.93A).
Spindle cell type, intrathyroidal They have elongated, spindle-shaped nuclei with pale,
thymoma uniformly distributed fi nely granular chromatin, occa-
sionally containing micronucleoli (Figs. 13.93 and 13.94).
Metastatic carcinosarcoma The nuclear membrane is smooth, thin, and may show a
notch as well as intranuclear inclusions (Fig. 13.95). The
stromal cells or fi brocytes are bipolar with variable, pale
TABLE 13.29 DIFFERENTIATING FEATURES BETWEEN BENIGN AND MALIGNANT SPINDLE CELLS
Benign Spindle Cells Malignant Spindle Cells

Presentation In tissue fragments or loosely cohesive groups; In tissue fragments, loosely cohesive groups or
isolated cells infrequent isolated cells; may be in fascicles
Arrangement In fascicles with palisading of nuclei, directional May be in fascicles, swirling arrangement or
flow to the cytoplasm; swirling arrangement; cells storiform pattern ⫹/⫺
may be separated by collagen
Cells Large, mildly pleomorphic Markedly pleomorphic
Cytoplasm Abundant, pale Variable with high N/C ratios
Nuclei Round, oval, oblong, spindle to cigar-shaped, Marked anisonucleosis with bizarre shapes,
uniform to mildly pleomorphic, smooth nuclear irregular nuclear membranes, coarsely granular
membranes, notch on the membrane ⫹/⫺, compact chromatin with excessive parachromatin
to evenly dispersed, finely granular chromatin; clearing; multiple, irregular, micro-macronucleoli;
multiple micro- macronucleoli ⫹/⫺; intranuclear intranuclear inclusions ⫹/⫺; mitoses regular and
inclusions ⫹/⫺; mitoses regular ⫹/⫺ irregular ⫹/⫺
Background Clean to inflammatory; features of nodular goiter Clean to necrotic

or Hashimoto’s thyroiditis
Differential Diagnosis of Anaplastic Carcinoma and Spindle Cells in Thyroid Aspirates (See Figs. 13.83 to 13.100)
A B
Figs. 13.93A to C. A: FNA of a nodular goiter showing several

elongated spindle-shaped stromal cells separated by collagen. Note
that the nuclei are oblong to spindle-shaped containing bland chro-
matin. B: This aspirate from a case of nodular goiter shows a large
population of spindle cells, isolated and in aggregates. The cells ap-
pear monomorphic with bland nuclei. This pattern may be misinter-
preted as a soft tissue tumor or a medullary carcinoma. C: A group
of delicate stromal spindle cells with long cytoplasmic processes and
spindle-shaped nuclei. A small number of these types of cells in the
C background of nodular goiter should cause no concern.
A B
Figs. 13.94A and B. FNA of a nodular goiter showing a group of spindle-shaped cells with atypical nuclei.
The background showed features of nodular goiter (not illustrated).
A B
C D
Figs. 13.95A to D. A: A group of very abnormal appearing spindle and round cells with enlarged nuclei containing
finely granular chromatin. Note the intranuclear inclusion (arrows). A malignant diagnosis was rendered. Thyroidec-
tomy showed nodular goiter. B, C, D: FNA of a nodular goiter with retrogressive changes. These groups of spindle
and round cells are probably reactive/reparative follicular cells and may offer diagnostic difficulties. Hemosiderin-
containing macrophage is present in the background. (continued)
E
Figs. 13.95E. (continued) E: An excellent example of squamous Fig. 13.96. FNA of a nodular goiter showing longitudinally sec-
metaplasia in FNA of nodular goiter. This tissue fragment of fol- tioned blood vessel with a fascicle of spindle cells containing pali-
licular cells exhibit enlarged nuclei, containing coarsely granular sading, uniform, cigar-shaped nuclei consistent with leiomyocytes.
chromatin. Note the transition to spindle and polygonal forms with
cytoplasmic processes resembling spider cells (arrow) described for
metaplastic squamous cells.
A B
Figs. 13.97A to C. A: FNA of Hashimoto’s thyroiditis. Note the

spindle-shaped stromal cells in a background of inflammatory cells.
B, C: More examples of a tissue fragment of stromal cells from
C Hashimoto’s thyroiditis.
cytoplasm that may extend into processes. The N/C ratios The aspirate from an actively organizing granula-
are low. At times, the stromal cells are displayed in small tion tissue yields proliferating fibroblasts and endothe-
fascicles that appear fl at with a directional fl ow to the lial lining cells of the proliferating capillaries. These
cytoplasm. The collagen appears fibrillar or homogeneous present as elongated or large, round cells that are
in Papanicolaou-stained preparations (Fig. 13.93A) while loosely cohesive, sometimes arranged in fascicles that
it appears as ragged, membranous fragments staining may interdigitate (Fig. 13.98). Their elongated to oblong
metachromatically red in air-dried Romanowsky-stained nuclei are enlarged with a moderate increase in the N/C
preparations. The background often shows hemosiderin ratios. The nuclear membrane is smooth, thin, and crisp,
containing histiocytes and inflammatory cells. and the chromatin is finely granular and evenly distrib-
The benign spindle cells of stromal origin are frequently uted. The micronucleoli may be conspicuous. These
present in aspirates from Hashimoto’s thyroiditis (Figs. spindle cells have abundant, pale cytoplasm with distinct
13.97A and B). Again, the morphology of these cells is very long cytoplasmic processes. Because of the increased N/C
similar to that seen in stromal cells from nodular goiters. ratios and prominent nucleoli, the proliferating fibro-
It is not uncommon to find benign stromal tissue frag- blasts or endothelial lining cells may be misinterpreted as
ments in aspirates from papillary carcinoma or anaplastic malignant, particularly in anaplastic thyroid carcinoma,
carcinomas. They originate from the desmoplastic stroma. medullary carcinoma, or a soft tissue tumor. Systemic
Morphologically, the benign stromal cells are distinctly administration of radioactive iodine (¹³¹I) can induce
benign as compared to the malignant cells from the same changes in both the follicular cells and the stromal tissue
aspirate, which demonstrate obvious malignant features. of the thyroid (Fig. 13.99). Aspiration biopsy shows both
A B
C D
Figs. 13.98A to D. FNA of a painful thyroid nodule. A, B: The cells are spindle-shaped, with very pleomorphic,
atypical nuclei. Malignant diagnosis was rendered. The thyroidectomy revealed the nodule to be totally composed of
proliferating granulation tissue, probably representing an organizing hematoma. Note the actively proliferating fibro-
blasts and capillaries. C: FNA of a thyroid nodule in an elderly woman. These degenerating follicular cells with atypi-
cal nuclei were considered to be an anaplastic carcinoma. Thyroidectomy did not confirm the diagnosis. D: Anaplastic
Carcinoma versus Medullary Carcinoma. FNA of a medullary carcinoma depicting a very pleomorphic cell pattern
that can be misinterpreted as anaplastic carcinoma. (continued)
E F
Figs. 13.98E to F. (continued) E: Anaplastic Carcinoma versus Metastatic Malignant Melanoma. FNA of metastatic
melanoma to the thyroid. Melanoma cells can be very pleomorphic with bizarre nuclei. In the absence of melanin
pigment, melanoma cells cannot be differentiated from anaplastic carcinoma cells without the aids of ancillary tests.
F: Anaplastic Carcinoma versus Malignant Lymphoma. FNA of large cell malignant lymphomas of the thyroid. These
discrete large lymphoma cells must be differentiated from anaplastic carcinoma by immunostains and flow cytometry.
A B
Figs. 13.99A and B. Radiation (I-131) induced changes. Pleomorphic follicular cells with bizarre nuclei. The patient
had ¹³¹I therapy for Graves’ disease. Without taking the clinical information into account, these cells may be inter-
preted as anaplastic carcinoma.
epithelial and stromal type spindle cells with karyocy- of the blood vessels. The smooth muscle cells are arranged
tomegaly, deep-staining, smudgy, structureless chroma- in a palisading fashion and are aligned in parallel rows.
tin and occasional intranuclear inclusions. Their cyto- Their nuclei are cigar-shaped with blunt ends and a bland
plasm is variable, sometimes abundant and vacuolated, chromatin pattern (Fig. 13.96).
and may contain neutrophils. Bare, pleomorphic but
pyknotic nuclei are also seen frequently.
NEOPLASTIC SPINDLE CELLS OF
Another source of benign spindle cells is granuloma-
MESENCHYMAL ORIGIN
tous or subacute thyroiditis. Aggregates of epithelioid
and stromal spindle cells may be present with or without The spindle cell pattern is one of the morphologic charac-
accompanying multinucleated giant cells (Fig. 13.97C). teristics of both benign and malignant soft tissue tumors.
Cytologic identification is generally easy, particularly when These primary soft tissue neoplasms are very rare in the
considered in context with the clinical features, laboratory thyroid gland. The reported cases include schwannoma,
data, and radionuclide imaging findings. Reidel’s thyroidi- leiomyosarcoma, liposarcoma, hemangioendothelioma,
tis or fibrosing thyroiditis—an extremely rare condition synovial sarcoma, and osteosarcoma. The thyroid gland
of the thyroid will yield scant aspirate on needle biopsy— may also be the site of metastatic sarcoma. Soft tissue
represented by only stromal cells. Spindle cells in thyroid tumors in the neck may clinically simulate thyroid nod-
aspirates may also originate from the smooth muscle wall ules and be aspirated.
NONNEOPLASTIC SPINDLE CELLS OF metastatic poorly differentiated squamous carcinomas,

EPITHELIAL ORIGIN sarcomatoid type, and metastatic carcinosarcoma.
Nonneoplastic spindle cells of epithelial origin include
reactive/reparative follicular cells in nodular goiters and MEDULLARY CARCINOMA
squamous cell metaplasia. The reactive follicular cells in
Medullary carcinoma of the thyroid arises from the calci-
nodular goiters with degeneration may acquire a spindle
tonin-producing C-cells, parafollicular cells, or clear cells.
shape, enlarge in size, and may contain pleomorphic
Medullary carcinoma comprises 3 to 10% of all thyroid
nuclei. These cells usually occur in small numbers, seen
malignancies. It occurs in two forms: roughly 20% are
either isolated or in loosely cohesive groups (Figs. 13.95A
familial, and the remaining ones are sporadic forms. The
to E). Their nuclei have fi nely granular chromatin and
hereditary form of medullary carcinomas, transmitted as
micronucleoli and also occasionally exhibit inclusions and
an autosomal dominant trait, includes three types: MEN
grooves, causing a great deal of concern. The cytologic
IIA (Multiple Endocrine Neoplasia), MEN IIB, and non-
features of the atypical cells included: Flat tissue frag-
MEN familial type. The MEN II syndromes are associated
ments, distinct cell borders, nuclear enlargement, nuclear
with tumors of the other endocrine organs. The sporadic
grooves, dense granular cytoplasm, small distinct micro-
form of medullary carcinoma occurs more commonly in
nucleoli, fine chromatin, and elongate to spindle cytomor-
women, primarily in older individuals with a mean age
phology. These cells were immunoreactive to cytokeratin
of—fi ve to six decades. They clinically present as a uni-
and thyroglobulin while negative for CD68 and smooth
lateral palpable nodule and have a high incidence (up to
muscle actin, suggesting follicular origin.
50%) of cervical lymph node metastases. Distant metas-
The metaplastic squamous cells are sometimes
tases via hematogenous spread to the liver, the lungs, the
encountered in the aspirates of thyroid lesions such as
bone, and occasionally, to the brain occur in roughly 15%
nodular goiter, particularly with cystic change in thy-
of the cases. Familial forms are common in males and
roids subjected to ¹³¹I therapy and chronic lymphocytic
occur at a younger age. The main secretory product of
thyroiditis of Hashimoto’s type. Squamous metaplasia
the C-cells is the hormone calcitonin, increased levels of
is also reported in 10 to 50% of papillary carcinomas
which serve as a sensitive marker for the presence of med-
and may be present in cytologic specimens from papil-
ullary carcinomas.
lary carcinomas. The metaplastic squamous cells occur
as tight groupings of cells forming morulae; or with a
Radiologic Features
whorled arrangement; or as loosely cohesive, elongated
cells with abundant cytoplasm and tapered ends (Fig. Medullary carcinomas present as hypofunctioning cold
13.95E). Occasionally, squamous metaplasia presents nodules. The plain X-rays of the neck may show dense
as large monolayered tissue fragments. Their nuclei are calcifi cation. Ultrasound shows hypoechoic mass. Imag-
centrally located, containing granular chromatin and ing with ultrasonography using ¹³¹I metaiodobenzyl-
low N/C ratios. The presence of micronucleoli is not guanidine (MIBG) demonstrates a positive uptake and is
consistent. The metaplastic squamous cells are large and a useful diagnostic tool.
polygonal to spindle-shaped with well-defined cell bor-
ders. Multiple cytoplasmic processes, referred to as “spi- Gross and Histologic Features
der cells” as described in cervical smears, may also be
The sporadic form of medullary carcinoma occurs as a
encountered. Their cytoplasm is variable but abundant
unilateral, well-defi ned, nonencapsulated solitary nodule
and pale to dense.
that is variable in size, ranging from less than 1 centimeter
to several centimeters and may replace the entire lobe. Its
cut surface is tan–white to gray or pink, usually flat. The
NEOPLASTIC SPINDLE CELLS OF
consistence is soft to fi rm, and sometimes gritty without
EPITHELIAL ORIGIN
areas of hemorrhage and necrosis. Calcification may be
Neoplastic spindle cells of epithelial origin may be seen in present. The hereditary forms are usually multifocal and
benign neoplasms such as hyalinizing trabecular adenoma bilateral.
or in malignant neoplasms (e.g., papillary carcinomas The histologic spectrum of medullary carcinoma
[Fig. 13.100A], medullary carcinoma [see Figs. 13.105 to is extremely wide and varies from tumor to tumor and
13.108], or anaplastic carcinoma [see Fig. 13.91B]). Some within the same tumor, often mimicking other types of
very infrequent examples of thyroid epithelial neoplasms follicular-cell derived tumors such as follicular, papillary,
with a spindle cell pattern include intrathyroidal thymomas insular, Hürthle cell, or anaplastic carcinomas. The his-
(Fig. 13.100B), referred to as “thyroid carcinoma,” show- tologic patterns are similar in both the familial type and
ing thymus-like element (CASTLE) and a spindle epithelial the sporadic type. The medullary carcinoma shows mul-
tumor of the thyroid with thymus-like elements (SETTLE) tiple growth patterns such as lobular, insular, trabecular,
(Fig. 13.100C). Other rare examples include primary or solid, and rarely follicular, or papillary. The spindle cells
A B
Figs. 13.100A to C. A: Papillary carcinoma showing spindle-

shaped cells with their nuclei demonstrating features of papillary
carcinoma. B: FNA of surgically proven case of thyroid carcinoma
showing Thymus-like elements (CASTLE) depicting spindle-shaped
neoplastic cells. (Courtesy of W.K. Ng, M.D., Department of Pathol-
ogy, University of Hong Kong, Queen Mary Hospital, Hong Kong.)
C: FNA of a thyroid mass showing interdigitating fascicles of spin-
dle cells with bland nuclei. The pattern is suggestive of a spindle
cell neoplasm and the diagnosis of medullary thyroid carcinoma
was considered. Surgical excision confirmed the diagnosis of spindle
epithelial tumor with thymus-like differentiation (SETTLE). (Cour-
tesy of Reně Gerhard, M.D., Department of Pathology, Hospital das
C Clinicas, University of Sao Paulo, SP, Brazil.)
form fascicles, simulating a sarcomatous pattern. The Ultrastructure

nests of tumor cells vary in size, separated by stromal tis-
sue, imparting an organoid pattern. The cell types vary Ultrastructurally, medullary carcinoma cells demonstrate
as well and include small, round to oval carcinoid-like the characteristic membrane-bound secretory granules.
cells; polygonal or epithelioid; and plasmacytoid to spin-
dle shapes; and they vary considerably in size from small,
medium to large with occasional giant forms. Their cell The aspirates of medullary carcinoma present either a
borders are well to poorly defined and, the cytoplasm var- pleomorphic pattern or a monomorphic pattern, with the
ies from scant to abundant, clear, and pale to dense. The former being more frequent (Table 13.30; Figs. 13.101
nuclei are pleomorphic, round, oval, and oblong to spin- to 13.113C). The aspirates are usually cellular; scant cel-
dle shape with stippled to coarsely granular chromatin lularity is encountered with carcinomas containing exten-
and, sometimes, contain cytoplasmic inclusions. Hemor- sive amyloid deposits and calcification.
rhage, necrosis, and mitotic activity are infrequent find- The smear of an aspirate from a medullary carci-
ings. A given tumor may show a predominant cell type noma of the thyroid generally shows malignant cells,
or pattern; mixed patterns are more frequent with sev- either isolated or in loosely cohesive groups, presenting a
eral cell types. However, a monomorphic pattern is also dispersed cell pattern. Syncytial-type tissue fragments are
encountered. infrequent. The spindle cells may be present in fascicles,
The medullary carcinoma is characterized by the dispersed, or in aggregates with intertwining cytoplasmic
presence of amyloid deposits in the stroma in up to 80% processes.
of cases. The amyloid shows green birefringence under Medullary carcinoma cells are very pleomorphic; any
crossed polarized light when stained by Congo red and size or shape may be present. The carcinoma cells can be
green fl uorescence under ultraviolet light when stained small, round to cuboidal, reminiscent of carcinoid tumor
by thiofl avin T. The carcinoma may also contain a sig- cells, or oval to plasmacytoid. They may be triangular,
nifi cant amount of collagenous stroma with or without polyhedral, racket-shaped, or spindle-shaped. Their size
calcification. also varies: the small, round cells are slightly larger than
TABLE 13.30 CYTOPATHOLOGIC FEATURES OF MEDULLARY CARCINOMA
Cellularity Usually Very Cellular

Presentation Cells mostly isolated, in aggregates and rarely in tissue fragments forming nests and trabeculae;
follicular or papillary architecture not present; pseudofollicular pattern rarely present;
dispersed pattern characteristic; aggregates of spindle cells may present a “fish-school” pattern
or occur in fascicles
Cells Uniform to markedly pleomorphic; size ranging from small, medium-sized to large with
frequent giant forms; varied shapes: round, cuboidal, plasmacytoid, polygonal, caudate, racket-
shaped, triangular, short to elongated spindle-shaped; unipolar cells; admixture of various
types is characteristic; cell borders well to poorly defined; variable N/C ratios
Nucleus
Location Always eccentric with extreme marginal location

Numbers Bi-multinucleation frequent
Shape Round, oval, oblong to spindle-shaped; smooth nuclear membranes
Chromatin Deep-staining, coarsely granular to chunky
Parachromatin Clearing Not common
Nucleoli ⫹/⫺
Nuclear Grooves Not observed
Intranuclear Inclusions Almost always present
Mitotic Activity Generally absent
Cytoplasm Variable; scant, indiscernible to abundant; clear, pale, granular to dense; drawn into
cytoplasmic processes; rudimentary tailing to delicate intertwining processes; azurophilic
cytoplasmic granules in Romanowsky stained preparations
Psammoma Bodies Rare
Background Hyaline, amorphous, fluffy acellular material staining positive for amyloid (Congo red or
thioflavin T); strongly resembles colloid; usually clean; necrosis generally absent
Histochemistry Argyrophilic granules in the cytoplasm
Immunoprofile Positive reactivity to: calcitonin, low molecular weight keratin, CEA, neuroendocrine markers
(chromogranin A, synaptophysin, somatostatin, neuron specific enolase) and TTF-1; negative
reactivity to thyroglobulin
Ultrastructure Electron dense, membrane-bound neurosecretory granules
the follicular cells, and the larger cells are several microns characteristic of neuroendocrine tumors. The presence of
in their largest dimension with occasional giant forms. A nucleoli is not a consistent finding. Bizarre nuclei, such as
cellular aspirate with a dispersed cell pattern formed by those seen in anaplastic carcinomas, are rare. A remark-
pleomorphic cells is virtually pathognomonic of medul- able and consistent feature is the presence of intranuclear
lary carcinoma, whereas a monomorphic pattern com- cytoplasmic inclusions.
prising only one type of cell is not frequently observed. The cytoplasm of medullary carcinoma cells is variable.
The latter does cause typing difficulties. In small round cells, it is very scant and hardly discernible,
The nuclei of medullary carcinoma cells are always whereas in plasmacytoid or large polyhedral cells, it is
eccentric, regardless of the cell shape or size or the num- abundant. It generally stains pale and has a fibrillar qual-
ber of nuclei. Extreme marginal location of the nucleus ity. The cytoplasm is often drawn out in a delicate process,
is characteristic of the plasmacytoid cell type, and bi- which may be rudimentary in cuboidal cells. The spindle
and multinucleation occur very frequently. The nuclei cells of medullary carcinoma are usually and characteristi-
are round, sometimes oval, and occasionally oblong or cally unipolar with eccentric nuclei. A group of spindle cells
elongated in spindle-shaped cells. Their chromatin is with delicate intertwined cytoplasmic processes is a char-
coarse, stippled with a salt & pepper pattern, which is so acteristic finding in smears from medullary carcinoma.
Medullary Thyroid Carcinoma (See Figs. 13.101 to 13.113)
Fig. 13.101. FNA of a medullary thyroid carcinoma showing the Fig. 13.102. FNA of a medullary carcinoma showing a giant tumor
characteristic dispersed cell pattern showing discrete, medium-sized, cell with bizarre nucleus.
pleomorphic and plasmacytoid neoplastic cells.
Fig. 13.103. Medullary carcinoma cells exhibiting marked pleo- Fig. 13.104. Medullary carcinoma cells exhibiting the nuclear chro-
morphism in cell size and shape. Note the admixture of small round matin pattern so characteristic of a neuroendocrine tumor. The nu-
carcinoid type cells, plasmacytoid cells, polygonal and triangular clei are round, ovoid to spindle-shaped with “salt & pepper” chro-
cells. The nuclei are consistently eccentric. Also note the multinucle- matin. Note that the nucleoli are not appreciated. The cells possess
ation. delicate cytoplasmic processes.
Fig. 13.105. Medullary carcinoma with a dominant spindle cell Fig. 13.106. Medullary carcinoma cells with pleomorphic spindle
pattern. The carcinoma cells are discohesive and possess delicate cells, eccentric bland nuclei, and fibrillar cytoplasm with unipolar
cytoplasmic processes. processes.
Fig. 13.107. FNA of a medullary thyroid carcinoma, with an exclu- Fig. 13.108. FNA medullary carcinoma cells are spindle-shaped
sive spindle cell pattern raising the possibility of a soft tissue tumor. and in fascicles. Note the acellular cyanophilic material in close as-
Calcitonin stain was positive. Medullary carcinoma was confirmed sociation with carcinoma cells and probably represents amyloid.
on thyroidectomy.
Fig. 13.109. FNA of a medullary carcinoma cells with extremely Fig. 13.110. FNA medullary carcinoma showing pleomorphic ma-
pleomorphic cells containing large nuclei resembling anaplastic lignant cells. Note the multinucleation and intranuclear inclusion.
carcinoma. The background shows abundant dense acellular material that
probably represents amyloid. In Papanicolaou stained smears, amy-
loid resembles colloid.
Fig. 13.111. FNA medullary carcinoma showing pleomorphic ma-

lignant cells. Note the multinucleation and intranuclear inclusion.
The background shows abundant dense acellular material that
probably represents amyloid. In Papanicolaou stained smears, amy-
loid resembles colloid.
Fig. 13.112. FNA of a medullary thyroid carcinoma showing

marked cellularity with a dispersed cell pattern. The isolated neo-
plastic cells are small round and slightly pleomorphic in size. The
cell borders are well-defined and the cytoplasm is scant, indis-
cernible to dense, cyanophilic thin rim. The nuclei are round with
coarsely granular chromatin. There is no nuclear molding. With a
monomorphic pattern of small cells, malignant lymphoma must be
considered in the differential diagnosis.
A B
Figs. 13.113A to C. FNA of a medullary carcinoma. A: The cells are

in syncytial tissue fragments (Romanowsky). B: These medullary
carcinoma cells contain the characteristic azurophilic granules in
their cytoplasm (Romanowsky). C: Loosely cohesive clusters of cells
with eccentric nuclei, slight nuclear membrane irregularity, evenly
distributed chromatin and small nucleoli (ThinPrep). (Courtesy of
Dr. Claire W. Michael, University of Michigan Health System, Ann
C Arbor, Michigan.)
Another feature of diagnostic importance is the pres- One of the characteristic features of medullary carci-
ence of azurophilic granules in the cytoplasm of med- noma is the presence of stromal amyloid. It can be seen in
ullary carcinoma cells, which are seen only in air-dried cytologic preparations as fluffy, fi nely granular, or dense
preparations stained by the Romanowsky method (Fig. acellular material in the background. The amyloid has
13.113B) and not in Papanicolaou-stained preparations. the same staining characteristics as the colloid in Papan-
These granules are present in approximately 5 to 10% icolaou-stained preparations and cannot be differenti-
of the neoplastic cell population and probably represent ated from it without special stains such as Congo red or
cytoplasmic calcitonin. thioflavin T.
Immunoprofile may also cause diagnostic pitfalls. The presence of benign

spindle cells of stromal origin in cases of nodular goiters,
The immunocytohistochemical profi le of medullary car- when present in large numbers, may mimic the cytologic
cinoma includes positive reactivity to calcitonin, neu- pattern of medullary carcinoma. The rare cases of amyloid
roendocrine markers, TTF-1, and low-molecular weight goiter in patients with systemic amyloidosis are another
keratin. example of diagnostic pitfall (Fig. 13.117).
Diagnostic Accuracy
METASTATIC MALIGNANCY TO THYROID
The cytologic typing of medullary carcinoma can be
achieved with a high degree of accuracy. However, they The thyroid gland is a rare site for metastatic malignancy.
can be mistyped as various different types of thyroid can- Clinically signifi cant metastatic disease is not commonly
cers, both histologically and cytologically. encountered.
Typing errors are generally due to inexperience and A thyroid nodule occurring in a patient with a history
unfamiliarity with the varied cytopathologic features of of extrathyroidal cancer may be a diagnostic problem
medullary carcinoma. Medullary carcinoma also tends
to be overdiagnosed cytologically. The monomorphic
cell population of Hürthle cell carcinomas, the single-cell TABLE 13.31 DIFFERENTIAL DIAGNOSES OF
pattern in papillary carcinomas, and the spindle cells in MEDULLARY CARCINOMA
anaplastic carcinomas may all be mistaken for medullary
Nodular goiter
carcinoma.
A cytologic diagnosis of medullary carcinoma must
Follicular cell hyperplasia
be confirmed by the following:
1. Immunostain for calcitonin. Spindle-shaped stromal cells
2. Serum calcitonin levels.
Amyloidosis or amyloid goiter
Poor cellularity is likely to result in a false-negative
diagnosis. A diligent search is necessary in poorly cellu- Follicular neoplasms
lar specimens with abundant amyloid to identify medul-
lary carcinoma cells. Immunostains for calcitonin, as well Hyalinizing trabecular adenoma
as serum calcitonin levels, should help to confirm the
diagnosis. Cellular follicular adenoma
Differential Diagnoses Follicular carcinoma
The pleomorphic cell pattern is characteristic and diag- Hürthle cell carcinoma
nostic of medullary carcinoma and is more frequently
encountered, allowing an accurate cytologic diagnosis. A Papillary carcinoma
monomorphic cell pattern, composed of only one cell type
such as small round cells, plasmacytoid cells, and spindle- Poorly differentiated “insular carcinoma”
shaped cells, is not common and may be mistaken for other
types of thyroid neoplasms and vice versa (Tables 13.31 Anaplastic (undifferentiated) carcinoma
and 13.32). Neoplasms such as Hürthle cell carcinomas
are often confused with medullary carcinoma because of Other neuroendocrine tumors
the plasmacytoid cells (Figs. 13.114 and 13.115). Folli-
cular neoplasms (e.g., hyalinizing trabecular adenoma, Carcinoid tumor
follicular adenomas, and carcinomas) have been misin-
terpreted as medullary carcinomas (Figs. 13.116A and B). Paraganglioma
Extreme pleomorphism with bizarre nuclei or a spindle
cell pattern may be mistaken for anaplastic carcinoma. A Calcitonin-free oat cell carcinoma (neuroendocrine
spindle cell pattern can also be confused with soft tissue carcinoma)
tumors. Medullary carcinomas demonstrate a morpho-
Soft tissue tumors (primary or metastatic)
logic overlap with other neuroendocrine tumors such as
carcinoid tumors or paragangliomas. The small cell pat-
Malignant lymphoma
tern may also be mistyped as poorly differentiated insular
thyroid carcinoma, metastatic small cell (neuroendocrine) Malignant melanoma
carcinoma, or a malignant lymphoma. Benign conditions
TABLE 13.32 DIFFERENTIAL DIAGNOSES OF MEDULLARY CARCINOMA CYTOPATHOLOGIC FEATURES
Hyalinizing Trabecular Follicular Adenoma/ Hürthle Cell

Medullary Carcinoma Anaplastic Carcinoma Adenoma Carcinoma Carcinoma Papillary Carcinoma
Cellularity Variable, usually cellular Generally high, can Variable Variable Highly cellular Highly cellular
be low with markedly
desmoplastic cancer
Presentation Cells mostly isolated Isolated, loosely Cells isolated, in loosely Cells arranged in Cells discrete, in groups Cells mostly discrete,
or in loosely cohesive cohesive; in syncytial cohesive groups and syncytial tissue or in syncytial tissue in groups, rarely
groups with a dispersed tissue fragments in syncytial tissue fragments with and fragments, a dispersed in syncytial tissue
pattern; syncytial tissue fragments, some without follicular pattern is frequent fragments without any
fragments not common; with central acellular pattern; isolated and architectural patterns,
no architectural hyaline material with loosely cohesive groups dispersed pattern
configurations cells springing from less frequent
it; trabecular with
branching
Cells Monomorphic to Variably sized, slender Round, oval, elongated, Small, round to Medium-sized, round, Small, round to
markedly pleomorphic; to plump spindle- spindle shape with cuboidal; ill-defined cell oval to plasmacytoid, cuboidal; to short
round, plasmacytoid, shaped, well-defined bipolar cytoplasmic borders; high N/C ratios uniform in a given case; columnar, ill to well-
bizarre & giant cell borders; N/C ratios processes; well to poorly cell borders well-defined defined cell borders;
forms /, spindle- variable; giant forms defined cell borders; in discrete cells; N/C high N/C variable
shaped with unipolar frequent N/C ratios low ratios very high
cytoplasmic processes;
well to poorly defined
cell borders; N/C ratios
variable
Nucleus Eccentric with extreme Central to eccentric; Central to eccentric; Central location; round Central to eccentric; Eccentric to central;
marginal location; bi- very pleomorphic; round to oval, smooth with smooth nuclear binucleation frequent; round, oval; smooth
and multinucleation multinucleation ; nuclear membranes; membranes; coarsely round, mostly uniform nuclear membranes;
frequent; giant forms coarsely granular bi-multinucleation granular chromatin; with little variation “salt & pepper” type
/; pleomorphic, chromatin with not seen; finely micronucleoli /; in size; smooth granular chromatin;
round, oval, oblong to excessively cleared granular chromatin; intranuclear inclusions nuclear membranes, nucleoli usually not
spindle-shaped, smooth parachromatin; smooth micronucleoli; absent finely granular seen; binucleation not
nuclear membranes; to irregular nuclear perinucleolar halo ; chromatin; macro a feature; intranuclear
“salt & pepper” type membranes; bizarre intranuclear inclusions nucleoli conspicuous; inclusions always
granular chromatin, forms frequent; multiple always present; nuclear intranuclear present
sometimes chunky; micro/macronucleoli grooves inclusions /
nucleoli usually not with irregular forms;
seen. Intranuclear intranuclear inclusions
inclusions always ; mitotic activity
present; grooves not with normal and
appreciated abnormal mitoses
(continued)
Hyalinizing Trabecular Follicular Adenoma/ Hürthle Cell

Medullary Carcinoma Anaplastic Carcinoma Adenoma Carcinoma Carcinoma Papillary Carcinoma
Cytoplasm Variable; scant to Variable, can be Abundant, pale Scant indiscernible Variable, usually scant; Variable, pale clear
abundant; pale, abundant and dense; cytoplasm; no granular to dense; or vacuolated;
granular to dense; cytoplasmic processes cytoplasmic processes azurophilic granules in azurophilic granules in
intracytoplasmic rare Romanowsky-stained Romanowsky-stained
azurophilic granules preparations not present preparations not present
with Romanowsky stain
Background Clean; amorphous, Amyloid ; necrosis Clean; amorphous, Absent Colloid /; amyloid Colloid /; amyloid
acellular, hyaline frequent; stromal tissue acellular, hyaline absent; necrosis/ absent
material confirmed as fragments / material; negative
amyloid with Congo red staining for amyloid;
stain or thioflavin T hyaline material of
basement membrane
origin
Immunoprofile Positive reactivity Calcitonin ; Negative reactivity /; may be present Calcitonin ; Calcitonin ;
to calcitonin and thyroglobulin usually to calcitonin; in the background or thyroglobulin thyroglobulin
neuroendocrine negative positive reactivity to within the follicular
markers; negative thyroglobulin lumens
reactivity to
thyroglobulin
Ultrastructure Neurosecretory granules No neurosecretory No neurosecretory Negative reactivity Abundant mitochondria, No neurosecretory
granules granules to calcitonin; no neurosecretory granules
positive reactivity to granules
thyroglobulin
Differential Diagnoses of Medullary Carcinoma (See figures Figs. 13.114 to 13.117)
A B
Figs. 13.114A and B. Hürthle cell tumor versus medullary carcinoma. A: Hürthle cell tumor. The cellular aspirate
consists of monotonous small to medium-sized cells plasmacytoid cells with high N/C ratios. The pattern is strongly
suggestive of a medullary carcinoma except for prominent macronucleoli. Calcitonin stain was nondiagnostic. Thyroi-
dectomy revealed a Hürthle cell neoplasm. B: FNA of a medullary carcinoma showing cells with morphology similar
to Hürthle cell carcinoma. However, the cells of medullary carcinoma do not contain prominent macronucleoli.
A B
Figs. 13.115A and B. Hürthle cell carcinoma with a differential diagnosis of medullary carcinoma. This cellular aspi-
rate from a Hürthle cell carcinoma showed features that suggested the diagnosis of medullary carcinoma. Calcitonin
stain was negative. Thyroidectomy confirmed Hürthle cell carcinoma.
A B
Figs. 13.116A and B. Medullary Carcinoma versus Follicular Adenoma/Carcinoma. A: Uniform, medium-sized cells
in syncytial tissue fragment with coarsely granular chromatin, can be misinterpreted as a follicular neoplasm. B: This
cellular aspirate consisted of syncytial tissue fragments of round to cuboidal cells with scant cytoplasm. The nuclear
chromatin was uniform and bland, lacking the coarse granularity of medullary carcinoma cell nuclei. Absence of
pleomorphism leads to the diagnosis of a follicular neoplasm. Thyroidectomy revealed a medullary carcinoma.
503
Fig. 13.117. Medullary Carcinoma versus Amyloid Goiter. FNA

of an amyloid goiter. The aspirate is poorly cellular, consisting of
predominantly acellular material that is proven histochemically as
amyloid. (Courtesy of John F. Goellner, M.D., Previously of Depart-
ment of Pathology, Mayo Clinic Rochester, Minnesota.)
since it could either represent a metastasis from an the aspirate shows only malignant cells (Figs. 13.118A
extrathyroidal malignancy, a primary thyroid cancer, or a to H). The thyroid follicular cells are not present in the
benign thyroid lesion. background, and tumor diathesis is frequent particularly
Metastases to the thyroid are most often multifo- in large tumors. Necrosis is a characteristic of metastatic
cal and variable in size in an autopsy series. In a clinical colon carcinomas. Features that favor metastases include
series, they are more commonly solitary and present as 1) the documented history of primary cancer elsewhere in
a nodule, and they may attain large dimensions. Malig- the body; 2) the presence of unremarkable thyroid follicu-
nancy originating in neighboring organs tends to involve lar cells mixed with cancer cells; 3) the functional differ-
a single lobe and tends to present as a large mass. The entiation of the cytoplasm of cancer cells (e.g., keratin or
great majority of the patients with metastatic disease to mucin secretions and melanin); and 4) the characteristic
the thyroid are asymptomatic. Rarely, a metastatic malig- cytomorphology of certain types of neoplasms.
nancy may be masquerade as primary thyroid cancer or
present with symptoms of hyperthyroidism or subacute
thyroiditis. THYROIDITIS
The thyroid gland can harbor a metastatic tumor Thyroiditis—an inflammatory condition of the thyroid—
from any part of the body; four primary sites are listed can be classifi ed according to its etiology, duration, or
as the most common source. These include the kidney, the morphology. As etiologic factors are not clearly estab-
lung, the breast, and malignant melanoma. The other sites lished in most cases, classifi cation by morphology and
include the gastrointestinal tract, particularly the colon, duration is accepted by most (Table 13.34).
genital malignancy, urothelium, salivary glands, neuroen- Any type of thyroiditis can be mistaken clinically for
docrine tumors, malignant lymphomas, and soft tissue a neoplasm. Clinical and gross features such as rapid,
sarcomas. asymmetric enlargement; nodularity; fi rmness; and fixa-
The thyroid gland may also be involved by direct tion to adjacent structures are common to both inflam-
spread from the cancers originating in the neighboring mation and neoplasms. Without a biopsy, the distinction
organs such as the esophagus, the larynx, the pharynx, or between thyroiditis and tumor may be clinically difficult
the trachea. These are usually squamous carcinomas or or impossible.
its morphologic variants. FNA has been valuable in the Of the several types of thyroiditis, two types are fre-
diagnosis of metastatic disease and the management par- quently encountered and will be discussed in this section.
ticularly when the patients have had a history of extrathy- The infectious varieties are very uncommon in the Western
roidal cancer and an advanced disease. world; however, P. jiroveci infection has been described in
Basically, there are three patterns of metastatic immunocompromised individuals. Mycobacterial infec-
involvement of the thyroid: 1) multiple small but discrete tion is frequent in underdeveloped countries.
foci of less than 2 millimeters; 2) a single discrete clinically
palpable nodule; and 3) diffuse widespread parenchymal
Subacute Granulomatous Thyroiditis
involvement (Table 13.33; Figs. 13.118A to H).
With metastatic foci of less than 2 millimeters in size, Subacute or granulomatous thyroiditis (synonyms: de
the cytologic samples show an admixture of malignant Quervain’s thyroiditis, pseudotuberculous thyroiditis, viral
cells and benign follicular cells (Fig. 13.118A) Tumor thyroiditis, nonsuppurative thyroiditis, struma granuloma-
diathesis is rare or absent. With a single, discrete, large tosa, and giant cell thyroiditis) is a spontaneously remitting
palpable nodule or with diffuse widespread involvement, inflammatory disease considered to be of viral origin. It is
TABLE 13.33 CYTOHISTOLOGIC PATTERNS OF METASTATIC MALIGNANCY TO THE THYROID

AND THEIR DIFFERENTIAL DIAGNOSES
Histologic Pattern Cytologic Pattern Differential Diagnoses
A: Multiple small foci of metastatic Admixture of malignant cells and benign Degenerating follicular cells in nodular
tumor, less than 2 mm follicular cells; tumor diathesis absent goiter
B: Single large discrete nodule Large population of malignant cells; no

thyroid follicular cells in the background;
tumor diathesis frequent;
I: Malignant cells with squamous or Consistent with metastatic malignancy
glandular differentiation
1. Anaplastic thyroid carcinoma
II: Medium-sized to large, round to
2. Poorly differentiated primary or
polygonal malignant cells with
metastatic squamous carcinoma
no functional or architectural
3. Poorly differentiated adenocarcinoma
differentiation
4. Malignant melanoma
5. Malignant large cell lymphoma
III: Small malignant cells 1. Anaplastic thyroid carcinoma with
small cell pattern
2. Medullary thyroid carcinoma
3. Basaloid squamous carcinoma
4. Metastatic neuroendocrine carcinomas
including small cell carcinomas
5. Malignant lymphoma
IV: Spindle cell pattern 1. Anaplastic thyroid carcinoma, spindle
cell pattern
2. Medullary thyroid carcinoma
3. Soft tissue sarcoma
4. Metastatic carcinosarcoma
V: Clear cell pattern 1. Anaplastic thyroid carcinoma
2. Metastatic renal cell carcinoma
Metastatic Malignancy to Thyroid (See Figs. 13.118A to 13.118H)
A B
Figs. 13.118A to B. A: Metastatic adenocarcinoma of lung. Note the very pleomorphic malignant cells with benign
follicular cells in the background. B: Metastatic keratinizing squamous carcinoma. (continued)
C D
E F
G H
Figs. 13.118C to H. (continued) C: Metastatic poorly differentiated squamous carcinoma of the oropharynx.
D: Metastatic adenocarcinoma of the colon. E: Metastatic poorly differentiated squamous carcinoma of the
esophagus. F: Metastatic carcinosarcoma of the esophagus. G: Metastatic poorly differentiated carcinoma,
unknown primary. H: Metastatic small cell carcinoma (neuroendocrine carcinoma) of the lung.
reportedly common in women from the second to the fifth formation. The inflammatory infiltrate consists of neutro-
decades. Patients present with clinical symptoms ranging phils and eosinophils as well as lymphocytes and plasma
from fatigue with slight tenderness on palpation of the cells. Lymphoid nodules with germinal center cells have
thyroid gland to an abrupt onset with chills, fever, severe not been described.
neck pain, and symptoms of hyperthyroidism. Results of
laboratory studies may include a high erythrocyte sedi- Cytopathologic Features. Fine needle biopsy as a diag-
mentation rate, normal white blood cell count, and low nostic technique is not routinely used to confirm the diag-
radioiodine level. There may be increased blood levels of nosis of subacute (granulomatous) thyroiditis because
thyroxine and triiodothyronine, depending on the severity the clinical picture and laboratory data are characteristic.
of the disease which usually lasts for 2 to 5 months, and Biopsies are performed in patients with an unusual pre-
recurrence is common. The disease is self-limiting, and sentation to rule out suppurative thyroiditis or anaplas-
thyroid functions gradually return to normal. tic carcinoma. The cytopathologic features of subacute
Usually the entire gland is involved, but initially the thyroiditis (Figs. 13.119A and B) are presented in Table
disease may be focal. In such circumstances, a nodule 13.35. The cellularity of the aspirate varies depending
may be diagnosed. Only one portion of the gland may on the stage of the disease. In the early stages, neutro-
be involved, thus producing asymmetric nodular involve- phils and eosinophils may be seen, along with cellular
ment. The characteristic microscopic features show the and inflammatory debris. The aspirate is characterized by
destruction of the thyroid parenchyma with foreign-body several large multinucleated foreign-body type giant cells
type giant cells around the colloid that result in granuloma containing up to several hundred nuclei (Fig. 13.119).
Some giant cells resemble Langhans’ type in their nuclear
arrangement. The nuclei are generally uniform, small, and
TABLE 13.34 CLASSIFICATION OF THYROIDITIS round to oval with sharp nuclear membranes, finely gran-
ular chromatin, and one or more micronucleoli. These
Acute thyroiditis
giant cells have abundant, granular to dense cytoplasm.
They are often seen in the vicinity of either follicular epi-
Subacute or granulomatous thyroiditis
thelial cells or colloid droplets. Distinct granulomas may
Chronic thyroiditis
be present, characterized by aggregates of epithelioid cells
and multinucleated giant cells.
Infectious thyroiditis
Other inflammatory cells include spindle-shaped and/
or plump epithelioid cells, lymphocytes, and plasma cells.
Fibrosing thyroiditis (Reidel’s thyroiditis) Germinal center cells are not identified. Stromal cells
are often aspirated, particularly in the later stages, with
Hashimoto’s thyroiditis (chronic lymphocytic thyroiditis) a sparse infl ammatory and epithelial component. Giant
cells may be absent during the healing phase.
Thyroiditis (See Figs. 13.119 to 13.121)
A B
Figs. 13.119A and B. A: FNA of subacute thyroiditis highlighting the multinucleated foreign-body-type giant cells.
B: Different case of subacute thyroiditis, showing a granuloma with Langhans’ type giant cell in close proximity to a
colloid droplet.
TABLE 13.35 CYTOPATHOLOGIC FEATURES OF SUBACUTE (GRANULOMATOUS) THYROIDITIS
Cellularity Variable; can be highly cellular
Presentation Varying numbers of large multinucleated foreign-body-type giant cells sometimes reaching enormous
proportions; contain large numbers of nuclei scattered throughout the cytoplasm or arranged around the
perimeter; multinucleated cells discrete or in groups, often around colloid forming granulomas; discrete
granulomas usually identified; epithelioid cells /; lymphocytes in varying numbers; germinal center or
plasma cells or tingible body histiocytes not present; neutrophils in acute stages
Epithelial Cells Follicular and Hürthle cells with or without nuclear atypia in varying numbers
Background Spindle cells of stromal origin; stromal tissue fragments may be seen in late stages; cellular and
inflammatory debris in acute stages
Differential ● Chronic Lymphocytic (Hashimoto’s) Thyroiditis

Diagnoses ● Other Types of Granulomatous Inflammations
● Anaplastic Carcinoma (because of clinical presentation of painful goiter) or the presence of stromal
fibroblasts in later stage
Differential Diagnoses of Granulomatous Thyroiditis. The receptor. Hashimoto’s thyroiditis may be progressive, and
cytologic pattern of an aspirated sample from subacute or it is an important cause of hypothyroidism.
granulomatous thyroiditis has characteristic features, par-
ticularly the presence of large giant cells. However, multi- Radiologic Features. Imaging quite often shows patchy
nucleated giant cells can also be seen in several conditions uptake or cold defects. Innumerable tiny hypoechoic nod-
affecting the thyroid gland. The differentiating features ules in both lobes indicate Hashimoto’s thyroiditis.
between chronic lymphocytic thyroiditis and subacute
(granulomatous) thyroiditis are discussed later in this Gross and Histologic Features. Grossly, the thyroid is sym-
chapter in the section on Hashimoto’s thyroiditis. metrically enlarged two to four times the normal size and
Anaplastic carcinoma is important as a differential both lobes are involved as well as the pyramidal lobe, if
diagnosis clinically because both diseases present with present. Asymmetrical and massive enlargements may also
a painfully enlarged thyroid. Cytologic differentiation occur. The capsule is smooth and tense. The gland feels
between the two is not diffi cult. Occasionally, proliferat- firm and rubbery. The cut surface is pale and meaty with
ing stromal fi broblasts may be mistaken for spindle cell- an accentuated lobular pattern. Degeneration is not seen.
type anaplastic carcinoma, the nuclei of which are bizarre Microscopically, all the lobules are involved but not
and not bland like those of fibroblasts (refer to Anaplastic uniformly and are well-demarcated by bands of increased
Carcinoma versus Granulomatous Thyroiditis). fibrous tissue. Progressive destruction of the thyroid
parenchyma is seen along with interlobular and interfolli-
Chronic Lymphocytic (Hashimoto’s) Thyroiditis cular lymphoplasmacytic infiltrates and lymphoid follicles
with germinal centers. The lymphoid infiltrate varies sig-
Hashimoto’s thyroiditis (synonyms: struma lymphoma- nificantly from gland to gland and within the same gland.
tosa, lymphadenoid goiter, autoimmune thyroiditis, and It can be florid with markedly enlarged lymphoid follicles
chronic lymphocytic thyroiditis) is the most common containing large, expanded germinal centers. The lympho-
form of thyroiditis. It frequently occurs in females with plasmacytic infiltrate may obscure the thyroid follicles.
an M:F ratio of 1:5 to 7 over a wide age range with a The epithelial changes are varied and are character-
peak in middle age. Hashimoto’s thyroiditis is a common ized by the oxyphilic change in the follicular epithelium
cause of thyroid enlargement in adolescents. Patients with (Hürthle cell metaplasia) that can be focal, diffuse, and
Hashimoto’s thyroiditis are at risk of developing malig- sometimes extensive with nodule formations. Oxyph-
nant lymphoma, stated to be 67 to 80 fold. ilic change in the epithelium is considered a hallmark of
Clinically, the disease is characterized by a diffuse firm, Hashimoto’s disease. The follicular epithelium may be
nontender goiter with or without nodularity. The patients hyperplastic, forming varying-sized nodules resembling
may be asymptomatic or present with symptoms of hypo- follicular adenomas. However, these nodules are nonen-
thyroidism. Hashimoto’s thyroiditis is an autoimmune capsulated. Papillary hyperplasia is also present. The folli-
disease with high titers of antithyroglobulin antibodies cles may be small and atrophic with inspissated colloid or
and antimicrosomal antibodies, which are now referred they may be devoid of colloid. The nuclei of the oxyphilic
to as thyroid peroxidase and antibodies to thyrotropin or regular follicular epithelium often show considerable
atypia. The follicular cell nuclei may present an open plasma cells, and lymphoid follicle center (germinal cen-
chromatin pattern, appearing pale and clear, mimicking ter) cells. The latter are characterized by the entire range
nuclear changes of papillary carcinoma. In some instances, of transforming lymphocytes, including immunoblasts
the thyroid may contain aggregates of three to five fol- and histiocytes with phagocytic debris (Fig. 13.120B). The
licles lined by epithelium that is indistinguishable from lymphoid cells, being very fragile, are often distorted and
those seen in conventional papillary carcinoma. Multi- are seen as stretched fi bers, frequently in dark, tangled
nucleated foreign-body type giant cells may be seen infre- masses (Fig. 13.121A). The lymphoid infiltrate may be
quently. Although Hashimoto’s thyroiditis involves the florid with a dense population of lymphoid cells, resem-
entire thyroid gland, focal changes limited to one lobe or bling an imprint or a lymph node aspirate (Fig. 13.120A).
part of the lobe may be seen. In later stages, there may be The lymphoid aggregates, when aspirated, may remain as
marked fi brosis with considerable atrophy of the paren- tight groups of cells and may mimic a tissue fragment of
chyma. Thyroids affected by Hashimoto’s disease may follicular cells (Fig. 13.121B). These may lead to a mis-
exhibit squamous metaplasia—an infrequent occurrence. interpretation of follicular neoplasm if discrete lympho-
Even more rarely, it may show squamous lined cysts that cytes are not visualized. The author had encountered this
are referred to as “lymphoepithelial cysts.” problem on two occasions. Immunostain with leukocyte
The intensity of the changes described above varies common antigen (LCA) on the smear was very helpful to
from lobe to lobe, as well as within a lobe. Variations confirm the lymphoid cells.
from the typical pattern of Hashimoto’s thyroiditis occur Follicular epithelial cells, generally seen in tissue frag-
in children, where oxyphilia is not a prominent feature, ments, can also occur isolated and in aggregates. They
but the lymphocytic infi ltration is diffuse and extensive represent either the Hürthle cells or regular follicular cells
and is referred to as the “juvenile type.” or both (Figs. 13.120 to 13.129). The component cells
of the follicular or Hürthle cell tissue fragments are very
Cytopathologic Features. Aspirates of the thyroid gland cohesive and rather sticky.
involved by Hashimoto’s disease show an admixture of The Hürthle cells are pleomorphic in size and shape
polymorphic infl ammatory cells and epithelial cells in (Figs. 13.120C, 13.22B, and 13.122 to 13.124). Their nuclei
varying proportions (Table 13.36; Figs. 13.120 to 13.129). also vary considerably, often staining hyperchromatic and
The cellularity of the aspirate is variable, depending on the pyknotic. Prominent cherry-red nucleolus—a feature that
stage of the disease and the extent of involvement. Usu- is highly characteristic of Hürthle cell neoplasm—is usu-
ally, the inflammatory cells are composed of lymphocytes, ally not seen.
TABLE 13.36 CYTOPATHOLOGIC FEATURES OF CHRONIC LYMPHOCYTIC THYROIDITIS

(HASHIMOTO’S TYPE)
Cellularity Variable, generally highly cellular; paucicellular in late stages due to atrophy and fibrosis
Presentation An admixture of inflammatory and epithelial cells in varying proportions
Epithelial Cells
Follicular Cells In loosely cohesive groups and in tissue fragments (in sheets and in syncytia); follicular pattern
infrequent; papillary-like pattern /; nuclei round, variable in size; fine to coarsely granular
chromatin; micronucleoli /; intranuclear inclusions rare; nuclear grooves / tissue fragments
may be permeated and/or obscured by lymphoplasmacytic infiltrate
Inflammatory Cells Lymphocytes, plasma cells, and the entire range of transforming lymphocytes (germinal center
cells); plasma cells; tingible body histiocytes; lymphoid tangles and stretched out lymphocytes;
large closely packed aggregates of lymphocytes difficult to differentiate from follicular cells;
multinucleated foreign-body-type giant cells /
Background Clean; scant or absent colloid; stromal cells, tissue fragments of fibrous tissue /; endothelial cells
Differential Diagnoses ● Subacute or granulomatous thyroiditis

● Hürthle cell neoplasms
● Follicular neoplasms (adenoma/carcinoma)
● Papillary carcinoma
● Malignant lymphoma
A B
Figs. 13.120A to C. FNA Hashimoto’s thyroiditis. A: Low power

showing marked lymphoid infiltrate. B: Higher magnification show-
ing cells of a germinal center. C: A different field showing a tissue
C fragment of Hürthle cells in the background of lymphoid cells.
A B
Figs. 13.121A and B. A: This smear from an FNA of Hashimoto’s thyroiditis showing several tissue fragments of
Hürthle cells and a large mass of crushed lymphocytes, so called lymphoid tangles. B: Large aggregate of lymphoid
cells simulating a syncytial tissue fragment of follicular cells, misinterpreted as a follicular neoplasm.
Differential Diagnoses of Hashimoto’s Thyroiditis (See Figs. 13.122 to 13.129)
A B
Figs. 13.122A and B. Hashimoto’s Thyroiditis versus Hürthle Cell Neoplasm. A: FNA of a thyroid nodule. Low
power showing a very cellular aspirate consisting of several tissue fragments of Hürthle cells. The background is
clean. B: Higher magnification showing Hürthle cells lacking macronucleoli. Because no lymphocytes were associated
with these oncocytic cells, a cytologic diagnosis of Hürthle cell tumor was rendered. A core needle biopsy confirmed
Hashimoto’s thyroiditis.
Fig. 13.123. FNA Hashimoto’s thyroiditis demonstrating Hürthle

cells with atypical but markedly pleomorphic nuclei, some with
dense chromatin. Note the sparsely spaced lymphocytes, which fa-
vor the diagnosis of thyroiditis. These Hürthle cells lack the typical
nuclear morphology of Hürthle cells neoplasms.
A B
Figs. 13.124A and B. A: This aspirate from a case of Hashimoto’s thyroiditis contained several tissue fragments of
Hürthle cells. A low power impression would be a Hürthle cell neoplasm. B: Higher magnification showing a mono-
layered sheet of Hürthle cells with uniform nuclei, lacking macronucleoli. There is no dispersed cell pattern.
A B
Figs. 13.125A and B. Follicular hyperplasia in the background of Hashimoto’s thyroiditis. Note the syncytial arrange-
ment and nuclear atypia simulating the cytologic pattern of follicular neoplasm.
A B
Figs. 13.126A and B. FNA of Hashimoto’s thyroiditis showing a syncytial tissue fragments of follicular cells with
variable nuclear enlargement. Note that lymphoid cells are not apparent. This aspirate is likely to be interpreted as a
follicular neoplasm.
Fig. 13.127. A very cellular aspirate consisting of several syncytial Fig. 13.128. Hashimoto’s Thyroiditis versus Follicular Neoplasm.
tissue fragments of follicular cells was interpreted as a follicular FNA of a thyroid nodule with clinically documented Hashimoto’s
neoplasm. Rare lymphocytes in the background were overlooked. thyroiditis. These syncytial tissue fragments of follicular cells show
Thyroidectomy revealed nonneoplastic follicular nodules with florid marked nuclear atypia leading to a diagnosis of follicular carcino-
Hashimoto’s thyroiditis. ma. The presence of lymphoid cells in the background was certainly
a feature in support of Hashimoto’s thyroiditis. Inexperience on the
part of the interpreter led to the misinterpretation. Thyroidectomy
revealed Hashimoto’s thyroiditis.
defects can be seen in both. Cytologically, it is extremely

difficult to differentiate cases of Hashimoto’s thyroiditis
with a coexisting neoplasm from those that do not harbor
any tumors. This is a unique and specific problem in cyto-
logic specimens from Hashimoto’s thyroiditis because, in a
surgically excised specimen, an entire lobe or the gland is
available allowing a thorough examination and the pres-
ence or absence of Hashimoto’s disease does not appear as
a problem. The cytologic evaluation greatly depends on the
area sampled by the biopsy needle.
The incidence of neoplasia in the background of
Hashimoto’s thyroiditis is variably reported from less
than 1% to as high as 38%. It is most difficult to judge the
diagnostic accuracy of Hashimoto’s thyroiditis because,
Fig. 13.129. Hashimoto’s Thyroiditis versus Papillary Carcinoma. in our practice, typical cases are not subjected to biopsy.
Another example of a misinterpreted case of Hashimoto’s thyroidi- In patients with a clinical diagnosis of Hashimoto’s thy-
tis as papillary carcinoma based on papillary-like architecture of
the tissue fragments and the presence of multinucleated giant cells.
roiditis, an aspiration biopsy is performed primarily to
The nuclei did not present typical pattern of conventional papillary rule out a neoplastic process under the following circum-
carcinoma. The core biopsy revealed Hashimoto’s thyroiditis. stances: 1) enlarging goiter with suppression therapy;
2) nodularity with or without cold imaging defects; and
3) enlarging tender goiter.
The follicular cells may be their usual size or hyper- Also, some patients are asymptomatic and present
plastic and are aspirated in tight clusters. When the fol- with clinically palpable or ultrasonically detected inci-
licular cells are of normal size with scanty cytoplasm, dental nodules that are cold on imaging. A diagnosis of
they are diffi cult to differentiate from aggregates of lym- Hashimoto’s thyroiditis is made on a cytologic basis after
phocytes (Figs. 13.125 to 13.129). Tissue fragments of an aspiration biopsy has been performed, and subse-
follicular epithelium rarely show a good follicular pat- quently confirmed by routine studies.
tern. Their nuclei often present pronounced atypia in the Cytologic errors in Hashimoto’s thyroiditis can be
form of pleomorphism in size, hyperchromasia with the grouped into two main categories:
occasional presence of grooves, and nuclear inclusions. 1. False-positive diagnosis (i.e., diagnosis of neoplastic
Markedly hypochromic nuclei may mimic the nuclei of disease made when the cytologic changes of Hashimo-
papillary carcinoma. In fact, an atypical nuclear pattern to’s thyroiditis mimic neoplasia).
of both Hürthle cells and regular follicular cells is more 2. False-negative diagnosis (i.e., failure to identify a neo-
common in Hashimoto’s thyroiditis. The epithelial cells plastic process coexistent with thyroiditis).
are intimately associated with the lymphoplasmacytic
cells and sometimes even obscured by them. On the other Our initial experience in this field revealed many false-
hand, the follicular and/or Hürthle cells may predominate positive as well as false-negative results, reflecting inexperi-
with sparse or absent lymphoid cells. Colloid is usually ence in cytologic interpretations during the learning phase
scanty or absent. In the advanced stage of the disease with and the failure to appreciate subtle differentiating features.
increasing fibrosis, the aspirate is often acellular or poorly In later years, errors have been considerably minimized.
cellular, showing only a few lymphocytes. False-negative diagnoses of epithelial neoplasms in the
Other nonspecific fi ndings include the presence of background of thyroiditis are more often due to sampling
multinucleated foreign-body type giant cells, which are than interpretations. Cytologic diagnosis of low-grade
seen only infrequently. Stromal tissue fragments may be malignant lymphoma is difficult and may be missed.
occasionally seen.
HASHIMOTO’S THYROIDITIS VERSUS
Diagnostic Accuracy and Differential Diagnoses. Hashim- OTHER DISEASES
oto’s thyroiditis as a disease entity presents complex diag-
nostic problems, not only because of the cytologic changes Diagnostic diffi culties can occur when Hashimoto’s thy-
in epithelial cells (follicular and/or Hürthle) or because of an roiditis is mistaken for other diseases. A cytologic diag-
atypical lymphoid infiltrate that mimic various types of neo- nosis of Hashimoto’s thyroiditis is easily made when an
plasia but also because of the coexisting benign and malig- aspirate presents lymphoplasmacytic cells along with
nant thyroid neoplasms that occur frequently in its back- epithelial cells and both components are present in fair
ground. Features such as asymmetric enlargement, firmness, proportions. However, potential errors can occur if an
and nodularity of the thyroid gland are seen in Hashimoto’s inflammatory or epithelial component predominates, and
thyroiditis with or without a coexisting neoplasm. Imaging the usual presentation is absent. Thus, cytologic changes
of Hashimoto’s thyroiditis can be mistaken for other types with Hashimoto’s thyroiditis is reported to be up to 67 to
of thyroiditis or various types of neoplasms. The differen- 80 times higher as compared to a normal individual.
tiating features are summarized in Table 13.37. Primary lymphomas of the thyroid are basically of
two types; they are referred to as extranodal marginal
zone B-cell lymphoma (ENMZBL) and diffuse large B-cell
HASHIMOTO’S THYROIDITIS AND lymphoma (DBCLL).
ASSOCIATED NEOPLASMS MALT lymphomas are low-grade lymphomas; they
remain localized for a long time and may show progres-
Hashimoto’s Thyroiditis and Papillary Carcinoma sion to high-grade lymphomas. They have a tendency to
Of the malignant neoplasms associated with Hashimo- involve the mucosal (extranodal) sites and spare the bone
to’s thyroiditis, papillary carcinoma is the most frequent. marrow. It is felt by some that lymphomas of the thyroid—
In a review of 329 papillary carcinomas of the thyroid referred to as “follicular lymphoma”—such as diffuse
from the author’s laboratory, lymphocytic infiltration was small, cleaved lymphoma, lymphocytic lymphoma, mono-
noted cytologically in 36 cases (10%) and histologically cytoid B-cell lymphoma, and plasmacytoma, that arise in
in 92 cases (28%). the setting of Hashimoto’s thyroiditis indeed represent
variants of MALT lymphoma.
Hashimoto’s Thyroiditis and Malignant Lymphoma Primary malignant lymphomas occur in elderly indi-
viduals in the sixth to seventh decades of life, with it being
The association between Hashimoto’s thyroiditis and more frequent in women where the female:male ratio is
malignant lymphoma is a known fact. Cytologic identifi- 4:1 and the average age is 63 to 65 years. Patients gener-
cation of both diseases is certainly a challenge to the cyto- ally give a history of preexisting goiter of variable dura-
pathologist. Large groups of poorly differentiated lym- tion. Presenting symptoms include a rapidly enlarging,
phoid cells without a mixture of polymorphic germinal tender mass in the neck, often with pressure symptoms
center cells should alert the examiner, even though areas such as dysphagia, hoarseness, or tracheal compression.
on the same slide or sample smears on other slides display These symptoms clinically mimic those of anaplastic
characteristic features of Hashimoto’s thyroiditis. Diag- carcinomas.
nosis of MALT lymphoma may be extremely difficult. Patients often have a history of Hashimoto’s thyroidi-
Other types of malignant neoplasms associated with tis, with the reported incidence being 94%. Antithyroid
Hashimoto’s thyroiditis are not well-documented. Rare antibody levels are often elevated.
tumors such as sclerosing mucoepidermoid carcinomas
with eosinophilia are reported to occur in the background Radiologic Features
of Hashimoto’s thyroiditis. We have seen one case of ana-
plastic carcinoma arising in the background of Hashimoto’s Imaging shows cold nodules, cold areas in diffuse goiters,
disease. or patchy uptake.
Hashimoto’s Thyroiditis and Benign Neoplasms Gross and Histologic Features

Most of the literature has focused on the association The lymphomas are often large, bulky, involving a single
between Hashimoto’s thyroiditis and malignant neo- lobe or both lobes of the thyroid but may present as a
plasms. We find it diffic ult to diagnose follicular or Hürthle solitary nodule. The gland is enlarged, often by several
cell neoplasms cytologically in the presence of lympho- centimeters in its longest dimensions. The cut surface is
cytes. Lymphocytic infiltrate is frequently seen in thyroid bulging, smooth, homogeneous, pale, and pearly–white to
parenchyma, adjacent to a benign neoplasm. Without pink with a “fish fl esh” appearance and may show areas
clinical or laboratory data, the association between the of hemorrhage and necrosis. They feel firm and rubbery
neoplasm and lymphoid infiltrate is difficult to diagnose. to palpation. Malignant lymphomas may extend beyond
the thyroid capsule, involving the surrounding soft tissues
and skeletal muscle.
PRIMARY MALIGNANT LYMPHOMA
MARGINAL ZONE B-CELL LYMPHOMA (MZBL)
Primary malignant lymphomas of the thyroid are con- Histologically, extranodal marginal zone B-cell lymphoma
sidered to be uncommon malignant neoplasms of the (MZBL) (Figs. 13.130A to C) shows either focal or dif-
thyroid. The reported incidence varies from 2 to 5% of fuse areas of confl uent dense lymphoid infiltration with
all thyroid malignancies. Primary malignant lymphomas the effacement of thyroid follicles. Reactive lymphoid fol-
of the thyroid almost always arise in the background of licles are always present and may be extremely promi-
Hashimoto’s thyroiditis and are of B-cell lineage. The rel- nent. The lymphomatous infiltrate is seen in between the
ative risk of developing malignant lymphomas in patients lymphoid follicles, replacing and pushing the thyroid
TABLE 13.37 DIFFERENTIAL DIAGNOSES OF HASHIMOTO’S THYROIDITIS CYTOPATHOLOGIC FEATURES
Chronic Lymphocytic Granulomatous

Thyroiditis (Subacute) De Follicular Adenoma
(Hashimoto’s Type) Quervain Thyroiditis Hürthle Cell Tumor or Carcinoma Papillary Carcinoma Malignant Lymphoma
Cellularity Variable Variable Variable, generally Variable, generally Variable, generally Variable, generally
moderate to marked moderate to marked moderate to marked moderate to marked
Presentation Admixture of Admixture of Neoplastic cells Neoplastic cells mostly Neoplastic cells in Lymphoid cells;
lymphoid and lymphoid cells, isolated, in loosely in tissue fragments isolated, in loosely no follicular cells
epithelial cells in epithelioid, histiocytes, cohesive groups and in cohesive groups, and in (generally)
varying proportions; large multinucleated tissue fragments tissue fragments
follicular cells isolated, foreign-body-type
in loosely cohesive giant cells, epithelial
groups and in tissue cells in varying
fragments proportions; follicular
cells isolated, in loosely
cohesive groups, and in
tissue fragments
Architecture Mostly in monolayered In monolayered sheets In monolayered sheets, Syncytial arrangement Syncytial Rarely present in
of Tissue sheets, occasionally occasionally follicular with crowding and arrangements, syncytial arrangement
Fragments with syncytial pattern overlapping of nuclei; monolayered or
arrangement follicular pattern / papillary with or
without follicular
pattern
Epithelial Cells Either regular follicular Either regular follicular Monomorphic (round, Follicular cell type Pleomorphic in size Absent
cell type or Hürthle cell type or Hürthle oval to polygonal) in a and shape
cell type, pleomorphic cell type; pleomorphic given neoplasm
in size in size
Epithelial Cell Pleomorphic in size; Round, uniform in a Round to oval, Round to oval, Round to oval, –
Nuclei round, fine to coarsely given neoplasm; finely variably enlarged variably enlarged variably enlarged,
granular chromatin; to granular chromatin; but uniform; but uniform; smooth nuclear
smooth nuclear prominent cherry- smooth nuclear smooth nuclear membrane; powdery
membrane; nucleoli red macronucleoli; membrane; finely membrane; finely to finely granular
/; rare intranuclear intranuclear inclusions granular chromatin; granular chromatin; chromatin; multiple
inclusions; nuclear absent; generally nucleoli inconsistent; nucleoli inconsistent; micro/macronucleoli;
grooves absent absent (present in intranuclear inclusions intranuclear inclusions intranuclear inclusions
carcinoma); nuclear absent; generally absent; nuclear grooves present; nuclear
grooves absent absent (present in absent grooves present
carcinoma); nuclear
grooves absent
(continued)
Chronic Lymphocytic Granulomatous

Thyroiditis (Subacute) De Follicular Adenoma
(Hashimoto’s Type) Quervain Thyroiditis Hürthle Cell Tumor or Carcinoma Papillary Carcinoma Malignant Lymphoma
Psammoma Exceptionally rare Absent Rare Absent Frequent Absent
Bodies
Lymphoid Cells With germinal center Mature lymphocytes; Absent Absent Present if coexistent Monomorphic
cells and plasma cells plasma cells absent with chronic population of
lymphocytic thyroiditis immature lymphoid
cells with karyorrhexis
Foreign-Body- Occasionally present; Hallmark of the Absent Absent Present; granulomas Absent
Type Giant Cells granulomas absent disease, enormous size absent
with several nuclei or
Langhans type
Epithelioid-Type Absent Present, particularly 2 Minimal criteria Rapid enlargement,

Histiocytes around blobs of colloid lack of response to
forming granuloma suppressive therapy;
immunoreactivity to
monoclonal antibodies
(kappa or lambda)
Primary Malignant Lymphoma of the Thyroid (See Figs. 13.130 to 13.132)
A B
C D
Figs. 13.130A to D. MALT lymphoma. Core needle biopsy of thyroid. A: The malignant lymphoma cells are infil-
trating the interfollicular area (medium power). Note the darker area represents lymphoid cells of the marginal zone
(H&E). B: Histologic section of MALT lymphoma. Low power showing a nodular pattern due to colonization of the
germinal center by the lymphoma cells (H&E). C: Medium power showing a heterogeneous cell population represent-
ing a mixture of lymphocytes, centrocyte-like cells, monocytoid B-cells and plasma cells (H&E). D: Higher magnifica-
tion of the lymphoid infiltrate of MALT lymphoma.
parenchyma peripherally. This infi ltrate is heteroge- frequent in thyroid MZBL. It may be so pronounced as to
neous or polymorphic, characterized by an admixture of suggest the diagnosis of plasmacytoma.
predominantly small lymphoid cells with variable propor-
tions of centrocyte-like cells, monocytoid B-cells, plasma
Cytopathologic Features of Marginal Zone
cells, and dispersed large transformed lymphocytes or
B-Cell Lymphoma (MZBL)
immunoblasts. Another feature of these lymphomas is the
colonization of the germinal centers of the lymphoid fol- The MALT-type malignant lymphomas are not very com-
licles by the lymphoma cells, often completely replacing mon and their cytopathologic features are sparsely docu-
them. This colonization mimics the follicular pattern of mented (Figs. 13.130D to 13.132B). The aspirates of mar-
reactive lymph nodes. However, they lack the starry-sky ginal zone B-cell lymphoma of a MALT type consist of
pattern of the germinal centers. a heterogeneous population of lymphoid cells, character-
Lymphoepithelial lesions are always present and are ized by an admixture of centrocyte-like cells, monocytoid
characteristic of MALT lymphoma. Two types of lym- B-cells, and plasma cells (Table 13.38). The centrocyte-
phoepithelial lesions are described: one where the lym- like cells are medium-sized lymphoid cells (1.5 times the
phoma cells are infi ltrating and growing into the thyroid small lymphocyte) that have deep-staining nuclei with
follicles and the other one consisting of lymphoma cells condensed chromatin and with irregular outlines. The
fi lling the lumens and expanding the follicles, referred monocytoid B-cells are larger and contain appreciable
to as “MALT balls.” Plasma cell differentiation is more amounts of pale cytoplasm. Plasma cells may be present
in large numbers. Features suggestive of lymphoepithelial lymphoid cells, representing the variants of large B-cell
lesions cannot be appreciated in cytologic samples. lymphomas including centroblast-like, immunoblasts,
The aspirates of marginal zone B-cell lymphoma may monocytoid B-cells, and plasma cell differentiation. Focal
also demonstrate the features of underlying Hashimoto’s Reed-Sternberg-like cells or Burkitt-like cells with brisk
thyroiditis: namely, an epithelial cell component character- mitotic activity, apoptosis, and starry sky pattern may be
ized by Hürthle cells, and follicular cells along with lym- seen. Lymphoepithelial lesions are usually not present.
phoplasmacytic cells. This polymorphic lymphoid infiltrate Morphologic evidence of Hashimoto’s thyroiditis is pres-
of Hashimoto’s thyroiditis is practically impossible to dif- ent in existing thyroid tissue. Some malignant lymphomas
ferentiate from the heterogeneous neoplastic infiltrate of present prominent sclerosis. Lymphoma cells have a ten-
MZBL without the aid of ancillary diagnostic techniques. dency to invade the walls of the blood vessels and extend
into the perithyroidal soft tissues and skeletal muscles.
Areas of progression to DLBCL from MALT lymphomas
DIFFUSE LARGE B-CELL LYMPHOMA (DLBCL) may be identified.
The DLBCL are high-grade lesions and occur more fre-
Cytopathologic Features of Diffuse Large
quently than MZBL, showing massive replacement of
B-Cell Lymphoma (DLBC)
thyroid parenchyma by sheets of poorly differentiated
The cytologic features of DLBCL, being more common
than MALT type lymphomas, have been reported more
frequently. Aspirates of DLBCL tend to be very cellular
(Table 13.38, Figs. 13.133A to E). The cell spreads show
a dense and homogeneous population of poorly differ-
entiated lymphoid cells that are larger than the normal
lymphocytes. Their morphology depends on the morpho-
logic variant. The lymphoma cells are usually discrete
and round with scanty, pale cytoplasm. The nuclei are
large with high N/C ratios and contain finely granular
chromatin that gives an open pattern, in contrast to the
compact nuclei of the mature lymphocytes. Nucleoli are
always present either as small and multiple in a mar-
ginal location (centroblast) or large in a central position
(immunoblast). Mitotic activity is frequent. Karyorrhexis
is a common feature of high-grade malignant lymphoma.
Fig. 13.131. MALT lymphoma. The lymphoid infiltrate is heteroge- Fragmented nuclei are often seen in the background and
neous with many immature forms. also as phagocytized debris in the histiocytes. Another
A B
Figs. 13.132A and B. A: FNA of a 5 cm thyroid mass, enlarging over a period of one year in an 80-year-old to be
composed of small lymphoid cells and was interpreted at an outside hospital as Hashimoto’s thyroiditis. Note that
the cells are heterogeneous, consisting of small lymphocytes some larger and occasional monocytoid B-cells. B: The
aspirate shows predominantly immature lymphoid cells with karyorrhexis. A diagnosis of lymphoma was suggested.
No tingible body histiocytes or follicular/Hürthle component were present in support of Hashimoto’s thyroiditis.
Thyroidectomy confirmed MALT lymphoma.
TABLE 13.38 CYTOHISTOLOGIC FEATURES OF PRIMARY MALIGNANT LYMPHOMAS OF THE THYROID
Extranodal Marginal Zone B-Cell

Lymphoma Diffuse Large B-Cell Lymphoma
FNA: Cellularity Variable Usually high
Cell Population Heterogenous, composed of small Homogeneous population of poorly

lymphocytes, centrocyte-like cells, differentiated lymphoid cells, dependant
monocytoid B-cells, plasma cells, scattered on the morphologic type; high mitotic
centroblasts and immunoblasts in varying activity; karyorrhexis; lymphoglandular
proportions; mitotic activity bodies in Romanowsky stained smears
Histology: Location of the Infiltrate In the marginal zone of reactive B-cell Diffuse sheets and islands of malignant
follicles, extending into the interfollicular cells with effacement of the architecture;
region, and involve parenchyma; necrosis / high mitotic rate
effacement of the architecture /;
colonization of the germinal centers,
eventually replacing it entirely
with lymphoma cells resembling nodular
lymphoma; transition to large cell
lymphoma may be present
Lymphoepithelial Lesions (1) Involvement of the follicles Not present

(2) Formation of “MALT” balls
Vascular Invasion / Easily identified
Evidence of Hashimoto’s Disease in Present Present in the remnants

the Thyroid
Extrathyroidal Extension / Frequent
Immunoprofile CD20, CD79a, CD5, CD10 CD20, CD79a, CD5, CD10
Immunoglobulin Express IgM, less often IgA or IgG with Express IgM, less often IgA or IgG with
light chain restriction light chain restriction
Flow Cytometry Monoclonal Monoclonal
Differential Diagnoses Hashimoto’s thyroiditis Neoplasms composed of small cells

Anaplastic carcinoma
Medullary carcinoma with a small pattern
Insular carcinoma
Metastatic small cell carcinoma
Clinical Behavior Indolent, slow to recurrences, may involve Very aggressive

other extranodal sites
characteristic feature seen only in Romanowsky-stained Hashimoto’s disease, namely, germinal center cells or epi-
preparations is the presence of detached fragments of thelial cells, are conspicuously absent.
the cytoplasm of lymphoma cells; they are about the size
of platelets. They stain basophilic and are referred to as
DIAGNOSTIC ACCURACY, DIAGNOSTIC
“lymphoglandular bodies.” Tumor diathesis is often seen
DIFFICULTIES, AND DIFFERENTIAL DIAGNOSES
in the background. Lymphoma cells are usually seen in
large aggregates or masses. Being very fragile, they may The accuracy of cytopathologic diagnosis of primary malig-
appear as lymphoid tangles. In such areas, features of nant lymphoma of the thyroid depends on several factors.
Cytopathologic Spectrum of Diffuse Large B-Cell Lymphoma (See Figs. 13.133 to 13.135)
A B
C D
Figs. 13.133A to E. A: FNA of malignant lymphoma showing a

dense population of immature lymphoid cells (medium power).
B: Higher magnification to depict the monomorphic population
of poorly differentiated lymphoid cells ( 1,000). C: Diffuse large
B-cell lymphoma. D: Burkitt lymphoma. E: Diffuse large B-cell
E lymphoma.
Lymphoma cells are very fragile and air-dry quickly unless 1. The aspirates from MALT lymphomas show a hetero-
wet-fixed immediately for Papanicolaou stain. Drying geneous population of small lymphocytes, centrocyte-
artifacts prevents proper cytopathologic evaluation. Inad- like cells, monocytoid B-cells, and plasma cells with
equate specimens and/or inexperience are prime reasons variable numbers of transformed lymphocytes. These
for false-negative results. The polymorphic lymphoid infil- cells are difficult to differentiate from lymphoid cells
trate of MALT is extremely difficult to differentiate from of Hashimoto’s thyroiditis (Figs. 13.134 to 13.136). A
the infiltrate of Hashimoto’s thyroiditis, both histologi- large number of transformed lymphocytes as well as
cally and cytologically, for the following reasons. very heavy lymphoid infiltrate should raise the suspicion
of a MALT lymphoma. Any diagnostic concern should MALIGNANT LYMPHOMA VERSUS

be followed by ancillary tests. A repeat aspiration HASHIMOTO’S THYROIDITIS
biopsy is in order if the initial specimen is inadequate. A
Marginal zone or MALT lymphomas are difficult to dif-
large needle biopsy can be quite helpful. In lymphomas,
ferentiate from the lymphoid infiltrate of Hashimoto’s
when involvement is focal, multiple samples may show
thyroiditis, specifically when the aspirates contain an
lymphoma cells on some cell spreads and evidence of
exuberant and dense population of lymphoid cells without
Hashimoto’s thyroiditis on others. Such a diverse pat-
an admixture of epithelial cells. The presence of polymor-
tern is often present. A cytologic pattern of Hashimoto’s
phic germinal center cells favors the diagnosis of Hashim-
disease on one of the specimens should not be a deter-
oto’s thyroiditis. However, MALT lymphomas are charac-
rent to rendering a diagnosis of lymphoma.
2. Phagocytic histiocytes with karyorrhectic debris are terized by a polymorphic lymphoid cell infiltrate and dif-
seen frequently in large cell lymphomas. These should ferentiation from thyroiditis is not possible without the aid
not be mistaken for germinal center cells. of immunocytohistochemistry and flow cytometry. These
3. Lymphoma cells, particularly of the large cell type, cases were interpreted as atypical lymphoid hyperplasia.
may be mistaken for epithelial malignancy.
MALIGNANT LYMPHOMA VERSUS
The differential diagnosis of MALT lymphoma includes
ANAPLASTIC CARCINOMA
Hashimoto’s thyroiditis with florid lymphoid infiltrate
(Table 13.39). The DLBCL may be typed as anaplastic car- Malignant lymphomas have been mistyped as anaplas-
cinoma or poorly differentiated insular carcinoma of the tic carcinomas both histologically and cytologically. The
thyroid, medullary carcinoma with small cell pattern, and large size of the lymphoma cells (Figs. 13.133C and E) as
a metastatic small cell carcinoma (Table 13.40). well as the presence of tissue fragments (Fig. 13.133D)—a
Fig. 13.134. Atypical lymphoid hyperplasia. FNA of a massively

enlarged thyroid showed a dense population of lymphoid cells. No
follicular/Hürthle cells were seen. Higher magnification showing a
mixed cell population with many plasma cells. Because of the dense
lymphoid infiltrate, malignant lymphoma was suspected. Thyroi-
dectomy showed florid Hashimoto’s thyroiditis and no malignant
lymphoma. Immunostains and flow cytometry would have been
helpful in confirming or ruling out malignant lymphoma.
A B
Figs. 13.135A and B. Another example of atypical lymphoid infiltrate on cytology suspected of malignant lymphoma.
A large needle biopsy did not confirm the cytologic diagnosis.
Cystic Lesions of the Thyroid (See Figs. 13.136 to 13.139)
A B
Figs. 13.136A and B. A: Cyst aspirate of an intrathyroidal cyst with mature squamous cells and anucleated squames
consistent with branchial cleft cyst. B: Aspirate of an intrathyroidal cyst with a group of benign follicular cells, sug-
gesting the diagnosis of thyroglossal duct cyst.
TABLE 13.39 DIFFERENTIATING FEATURES BETWEEN HASHIMOTO’S THYROIDITIS AND

MARGINAL ZONE B-CELL LYMPHOMA (MALT LYMPHOMA)
Extranodal Marginal Zone B-Cell

Hashimoto’s Thyroiditis Lymphoma (MALT Lymphoma)
Cellularity Variable, generally highly cellular; paucicellular Variable, usually very cellular
in late stages due to atrophy and fibrosis
Presentation An admixture of inflammatory and epithelial Heavy lymphoid cell population; epithelial
cells in varying proportions cells ⫹/⫺
Characteristics of Heterogenous cell population, consisting of Heterogenous population representing an

Lymphoid Cell lymphocytes, plasma cells, and the entire admixture of small lymphocytes, centrocyte-
Population range of transforming lymphocytes (germinal like cells (1.5 times the size of resting
center cells); plasma cells; tingible body lymphocyte) with deep-staining chromatin
histiocytes; lymphoid tangles and stretched out and irregular nuclear membranes; monocytoid
lymphocytes; large closely packed aggregates B-cells with appreciable pale cytoplasm;
of lymphocytes difficult to differentiate from plasma cells; scattered centroblasts and
follicular cells immunoblasts; mitotic activity insignificant;
karyorrhexis ⫹/⫺
Characteristics of In variable proportions; one type may Same as Hashimoto’s thyroiditis if present in
Epithelial Component predominate; in groups or in tissue fragments, the aspirated sample
(Follicular and with or without nuclear atypia; may be
Hürthle Cells) obscures by lymphocytes
Background Clean; multinucleated foreign- body type giant Clean; no colloid; no multinucleated foreign-
cells ⫹/⫺; scant or absent colloid; stromal body type giant cells; stromal cells or tissue
cells, tissue fragments of fibrous tissue ⫹/⫺; fragments of stroma ⫹/⫺
endothelial cells
Flow Cytometry Polyclonal Monoclonal

TABLE 13.40 DIFFERENTIAL DIAGNOSES OF DIFFUSE LARGE B-CELL LYMPHOMA
Tumor Type Cytopathologic Features

Large B-cell lymphoma Dispersed cell pattern; syncytial tissue fragment very rare; monomorphic population of immature
lymphoid cells; poorly defined cell borders; high N/C ratios; large nucleus with smooth to irregular
nuclear membrane, finely granular chromatin; parachromatin clearing, nucleoli ⫹; mitoses ⫹/⫺;
karyorrhexis ⫹; nuclear molding absent; scant cytoplasm; lymphoglandular bodies in Romanowsky
stained preparations; LCA ⫹; thyroglobulin, TTF-1 and calcitonin negative
Anaplastic carcinoma Variable cellularity; malignant cells isolated and in tissue fragments; size variable; high N/C ratios;
(small round cell type) nucleus round with smooth to irregular membranes; granular chromatin with parachromatin
clearing; single to multiple nucleoli; mitoses with atypical forms ⫹/⫺; karyorrhexis ⫹;
lymphoglandular bodies absent; leukophagocytosis ⫹/⫺; scant, nondescript cytoplasm; cytokeratin
⫹; negative reactivity to: LCA, thyroglobulin, TTF-1, calcitonin, and neuroendocrine markers
Medullary carcinoma Neoplastic cells discrete, in loosely cohesive groups; syncytial tissue fragments infrequent;
with a small cell pattern pseudofollicular pattern ⫹/⫺; small size, monomorphic, poorly defined cell borders; high N/C
ratios; eccentric nuclei; round with smooth nuclear membranes; coarsely granular to chunky
chromatin; nucleoli usually absent; mitoses unusual; karyorrhexis ⫺; no nuclear molding; no
stretch artifacts; intranuclear inclusions ⫹/⫺; nuclear grooves ⫺; scant cytoplasm with rudimentary
cytoplasmic tailing; colloid absent in the background; amyloid ⫹/⫺; positive reactivity to
calcitonin, neuroendocrine markers, cytokeratin; negative reactivity to: LCA, thyroglobulin, TTF-1
Metastatic small cell Marked cellularity; small cells; round to oval; indiscernible cytoplasm; poorly defined cell borders;
carcinoma high N/C ratios; coarse, deep-staining chromatin; nucleoli absent or not appreciated; mitoses
frequent; nuclear molding characteristic; stretch artifacts ⫹; karyorrhexis ⫺; positive reactivity to
cytokeratin, TTF-1, and neuroendocrine markers; negative reactivity to LCA and calcitonin
feature common to epithelial neoplasms—were reasons these malignancies. The secondary involvement is mostly
for mistyping the malignant lymphoma as anaplastic car- microscopic and does not present as thyroid enlargement
cinoma. Immunocytochemical stains and flow cytometry or nodules during life.
are required to confirm the diagnosis.
CYSTIC LESIONS OF THE THYROID
MALIGNANT LYMPHOMA VERSUS
METASTATIC SMALL CELL CARCINOMA Cystic lesions of the thyroid include several diagnos-
(NEUROENDOCRINE CARCINOMA) tic entities (Table 13.41; Figs. 13.136 to 13.139). Most
thyroid cysts are benign, with the reported incidence of
On rare occasions, small cell carcinoma of the lung malignancy varying from 0 to 33%. The most common
(Fig. 13.118H), which is metastatic to the thyroid, may nonneoplastic cysts represent cystic nodular goiters that
be mistaken for malignant lymphoma. The clinical his- develop as a result of degeneration or hemorrhage in a
tory and other diagnostic studies, including immunocy- preexisting nodule of nodular goiter (Fig. 13.138). A folli-
tochemical stains, are necessary for accurate diagnosis. cle hyperdistended with colloid may appear cystic. Other
Rarely, metastatic involvement of the thyroid may be the uncommon benign nonneoplastic cysts include simple
primary presentation of the malignancy. cysts and cysts in chronic lymphocytic thyroiditis, which
are referred to as “lymphoepithelial cysts,” are extremely
PLASMACYTOMA rare. Thyroglossal duct cysts and branchial cleft cysts
Plasmacytomas are rare in the thyroid. It is suggested that may also be encountered as intrathyroidal cysts (Figs.
these lesions probably represent MALT lymphomas with 13.136A and B).
predominant plasma cell differentiation. Cystic change may occur in benign and malignant
neoplasms (e.g., follicular adenoma) (Fig. 13.139) or in a
Hürthle cell neoplasm and frequently occurs in papillary
SECONDARY INVOLVEMENT OF THE
carcinomas (Fig. 13.62 to 13.67) and anaplastic carcino-
THYROID BY MALIGNANCY OF
mas (Fig. 13.91D). The cystic nodular goiter with cellular
THE HEMATOPOIETIC SYSTEM
atypia and cystic papillary carcinomas are common diag-
The thyroid gland is frequently involved by malignan- nostic problems and are discussed in detail in the section
cies of the lymphoid tissue as noted in patients dying of on papillary carcinoma.
TABLE 13.41 DIFFERENTIAL DIAGNOSES OF CYSTIC LESIONS OF THE THYROID
Disease Entity Cytopathologic Features See Fig(s).

Simple cyst Usually, squamous epithelial lined cyst; variable cellularity; epithelial cells may
be atypical
Lymphoepithelial Uncommon multiple cysts in the background of Hashimoto’s thyroiditis; may 13.137A and B
cyst be present without underlying disease process; lined by squamous epithelium
with or without atypia; associated squamous metaplasia
Intrathyroidal Squamous or columnar epithelial lining; aspirated specimen with benign, 13.136A and B
thyroglossal duct mature squamous cells; metaplastic squamous cells ⫹/⫺; anucleated squames;
cyst or branchial thyroid follicular cells ⫹/⫺
cleft cyst
Colloid cyst Abundant colloid; absent or few follicular cells with small pyknotic nuclei 13.157
Cystic nodular Aspirated fluid variable in quantity; thin, clear to amber colored, or thick, 13.138A and C
goiter turbid, “gruel-like”; or hemorrhagic to chocolate colored; variable cellularity,
usually few or no well-preserved follicular cells; occasionally large tissue
fragments; degenerative changes in follicular cells, with cellular and nuclear
enlargement, granular to compact chromatin, micronucleoli, ⫹/⫺; appreciable
cytoplasm, with or without hemosiderin; repair/regenerative changes with
atypical features such as nuclear grooves, intranuclear inclusions, squamous
metaplasia, spindle forms; Hürthle cells ⫹/⫺; variable numbers of macrophages
with and without hemosiderin; multinucleated foreign-body-type giant cells;
calcific debris, stromal cells; oxalate crystals with supravital stain (wet mount)
Cystic follicular Syncytial tissue fragments of follicular cells with or without follicular pattern 13.139
adenoma with mild to moderately enlarged nuclei, containing granular chromatin;
histiocytes with and without hemosiderin in the background
Cystic Hürthle cell Neoplastic Hürthle cells discrete, in groups or in tissue fragments, uniform
tumor nuclei with prominent macronucleoli; transition forms not present; follicular
cells or colloid not present in the background; histiocytes with and without
hemosiderin
Cystic papillary Aspirated contents may be clear to turbid, grossly hemorrhagic to chocolate 13.62 to 13.67
carcinoma colored; cellularity variable; carcinoma cells well-preserved with clearly
diagnostic of papillary carcinoma or with degenerative changes such as
cytoplasmic vacuoles, foamy, bubbly cytoplasm appearing histiocytoid,
hemosiderin ⫹/⫺; psammoma body ⫹/⫺; histiocytes with and without
hemosiderin in large numbers; may obscure carcinoma cells; colloid absent
Anaplastic Profuse inflammatory infiltrate, obscuring carcinoma cells; identification of 13.91

carcinoma with malignant cells may be difficult
cystic degeneration
and necrosis
Branchial cleft cyst Aspirated fluid clear to turbid; polymorphic cell population composed of benign 13.136A
in the neck squamous cells with frequent anucleated forms; ciliated columnar cells ⫹/⫺;
thyroid follicular cells ⫹/⫺; mucoid background; inflammatory cells ⫹/⫺;
macrophages ⫹/⫺; cholesterol crystals ⫹/⫺
Parathyroid cyst Clear fluid, acellular to poor cellularity; small cuboidal epithelial cells with 13.140
uniform, round nuclei; coarsely granular chromatin; difficult to differentiate
from thyroid follicular cells; macrophages ⫹/⫺; positive immunoreactivity to
parathyroid antibody; high levels of parathyroid hormone
A B
Figs. 13.137A and B. A: FNA of a thyroid nodule showing very atypical squamoid cells in the background of
lymphocytes. B: Thyroidectomy showing a lymphoepithelial cyst in the background of Hashimoto’s thyroiditis.
A B
Figs. 13.138A to C. A: Cyst fluid from a degenerated nodular goi-

ter with cholesterol crystals and hemosiderin-containing histiocytes
(wet mount, Toluidine blue). B, C: Cytospin preparation of clear
cyst fluid showing several large tissue fragments of follicular cells
in tissue fragments with follicular pattern and in loosely cohesive
groups. Their cell borders are poorly defined and the cytoplasm is
pale, vacuolated to dense. The nuclei are enlarged, crowded nuclei,
some containing micronucleoli. The cytologic diagnosis was suspi-
cious for papillary carcinoma. The thyroidectomy confirmed nodu-
C lar goiter with cystic change.
MISCELLANEOUS LESIONS OF THYROID

Clinical data and the location of the lesions help in cor-
rect interpretation. Parathyroid cysts, although infrequent The thyroid gland can host many nonneoplastic and
and rarely aspirated, also enter the differential diagnosis neoplastic lesions that are not covered in this chapter.
of thyroid cysts with clear pale fluid (Table 13.42; Figs. The range is so broad and beyond the scope of this atlas
13.140A to D). to describe and illustrate all the lesions. The reader is
Fig. 13.139. FNA of a cystic follicular adenoma consisting of a

syncytial tissue fragment of follicular cells with a follicular pattern.
The nuclei are mildly enlarged. Note the macrophages in the back-
ground.
TABLE 13.42 CYTOPATHOLOGIC FEATURES OF PARATHYROID CYSTS AND THYROID

CYSTS IN NODULAR GOITER
Parathyroid Cyst Thyroid Cyst (Nodular Goiter)

Presentation Aspirated fluid water-clear, thin, occasionally Clear, straw-colored, amber, red-brown to
straw-colored or red-brown hemorrhagic, to thick, sticky
Cellularity Acellular to poorly cellular Variable
Epithelial Cells Rare group or a tissue fragment of very Follicular epithelial cells in varying numbers;
small round to cuboidal cells; microfollicular regular follicles or honeycomb sheets with
pattern or sheets, poorly defined cell borders; well-defined cell borders; uniform round
scant cytoplasm with high N/C ratios; round nuclei with compact to granular chromatin;
nuclei with deep-staining compact chromatin degenerative changes frequent
Hürthle Cell Metaplasia Absent ⫹/⫺
Histiocytes ⫹/⫺ Usually present in variable numbers; with

or without hemosiderin; multinucleated
foreign-body-type giant cells ⫹/⫺
Colloid Absent Variable
Immunoprofile Positive reactivity to parathyroid hormone Positive reactivity to thyroglobulin

and chromogranin
Parathyroid Hormone Levels High Nil
requested to refer to the textbooks and atlases that pro- PPAR may be considered for patients with indeterminate
vide the comprehensive coverage. FNA cytology to help guide management. There is a great
deal of information about this published in the literature
and understanding of the molecular genetics of thyroid
ROLE OF MOLECULAR STUDIES IN
cancer has expanded considerably over the years. This
THYROID CYTOLOGY
knowledge has started to be translated from the bench
Currently, there are no definitive molecular assays used for to clinical practice. This approach has offered significant
clinical management. However, the Revised Management improvement in the preoperative FNA diagnosis of thy-
Guidelines for Patients with Thyroid Nodules and Differ- roid cancer and better tumor prognostication in the dif-
entiated Thyroid Cancer, which was recently released by ferent histologic subtypes of thyroid carcinomas. Major
the American Thyroid Association1, states that molecu- mutations in follicular cell thyroid tumors include RET
lar markers such as BRAF, RAS, RET/PTC, and PAX8/ and NTRK1 gene rearrangements, RAS family point
Parathyroid Gland (See Figs. 13.140 to 13.145)
A B
C D
Figs. 13.140A to D. Parathyroid cyst fluid. A: Tissue fragments of small cuboidal cells with crowding and overlap-
ping of small, uniform, nuclei with compact chromatin. Note their strong resemblance to thyroid follicular cells.
The background shows proteinaceous precipitate. B, C: Monolayered tissue fragments of small cuboidal cells in a
honeycomb arrangement. The nuclei are small and uniform, with compact chromatin. Note their strong resemblance
to thyroid follicular cells. The empty spaces within the tissue fragment probably represent fat cells (Romanowsky).
(Courtesy of Michael Glant, M.D., Director, Diagnostic Cytology Clinic, Indianapolis, Indiana.) D: FNA of a nodular
goiter for comparison. Tissue fragment of benign follicular cells with a honeycomb pattern, lacking extreme crowd-
ing, and overlapping of nuclei. The nuclear size is slightly larger than the parathyroid cells. Note the morphologic
overlap between thyroid follicular cells and parathyroid cells.
mutations, BRAF point mutations (V600E), PTEN muta- There are limitations on molecular testing in cytol-
tions, and PAX8/PPARg rearrangements. Histological ogy samples. The point mutations are relatively easy to
progression to poorly differentiated and undifferentiated diagnose by various methods, but gene rearrangement
carcinoma is thought to be associated with mutations of studies will require good quality RNA for the RT-PCR.
CTNNB1 and TP53, and these are considered to be sec- FISH assay to detect rearrangements may be helpful if
ondary mutations rather than driver mutations. there are adequate lesional cells, but usually FISH is the
Several studies have shown that molecular testing of assay of choice for formalin-fixed paraffin-embedded
FNA samples significantly improves the accuracy of the tissues. Also, a blind FNA sample submitted for molecu-
cytologic diagnosis of thyroid nodules. In a limited sample lar studies has its own limitations with respect to the
of fine needle aspiration cytology where morphology is proportion of lesional cells present in the sample and,
indeterminate for malignancy (e.g., papillary thyroid car- therefore, would affect the false-negative rate. If the
cinoma (PTC) or follicular neoplasm are being consid- lesional cells are identified on cytology and then mac-
ered), mutation analysis for RET-PTC and PAX8/PPAR rodissected, the false-negative rate is logically expected
gene rearrangements and BRAF mutation analysis may to be lower, and then the false-negative rate will depend
be helpful to offer a definitive diagnosis. This will help the on the sensitivity of the molecular assay rather than on
clinician to offer a definitive therapeutic approach. sampling error.
age combined weight is 120 ⫾ 3.5 milligrams in males and

PARATHYROID GLANDS
142 ⫾ 5.2 milligrams in females. Most normal adults have
four parathyroid glands. Due to their intimate anatomic
Fine needle aspiration biopsy is not routinely performed location in the thyroid area, lesions of the parathyroid may
in the evaluation of the parathyroid gland lesions. Con- masquerade as thyroidal lesions. The parathyroid glands are
sequently, information on their cytopathologic findings highly vascularized and thinly encapsulated. Histologically,
is limited. The literature includes mostly individual case the parathyroid gland shows a mixture of parenchyma and
reports, small case series, and very few reviews of a large adipose tissue. The parathyroid parenchyma consists of
number of cases. chief cells and varying numbers of oncocytic cells, as well
Although specimens from the parathyroid lesions are as transitional oncocytic cells. The chief cells form solid
not received in routine cytopathology practice, it is very sheets, branching anastomosing cords, and sometimes,
necessary to be familiar with their cytologic presentations. small acinar structures. The chief cells are polyhedral, 8 to
This is because the parathyroid glands, either in their usual 10 nanometers in diameter, containing round, central nuclei
or in ectopic locations, may clinically and/or radiologically with a sharp nuclear membrane and coarse chromatin.
appear to be of thyroidal origin. Thus, specimens submit- Their cytoplasm is eosinophilic to amphophilic and often
ted as thyroidal lesions may indeed be parathyroidal in appears clear or vacuolated in formalin-fixed tissues. The
origin. Furthermore, the specimens from these parathyroid cells are rich in glycogen and contain variable amounts of
lesions are difficult to recognize accurately because of the neutral lipid in the form of two or three sudanophilic fat
morphologic overlap between thyroid and parathyroid droplets per cell. Eosinophilic periodic acid-Schiff (PAS)-
lesions, which constitutes a common diagnostic problem. positive material resembling colloid may be present within
Some reasons for the infrequent use of fine needle biopsy these acinar structures. The oncocytic cells measure 12 to
in the diagnosis of parathyroid lesions may be as follows: 20 nanometers in diameter and contain deep eosinophilic
cytoplasmic granules. Their nuclei are slightly larger than
1. Functioning parathyroid lesions are subjected to surgi- those of chief cells. The stroma contains mature fat cells,
cal exploration following a clinical diagnosis supported blood vessels, and varying amounts of connective tissue,
by the laboratory data. Preoperative fine needle biop- the proportion of which changes with age. The immuno-
sies are not performed or required in these instances. profile of parathyroid parenchymal cells include positive
2. Although ultrasonography is popularly used in local- reactivity to parahormone and chromogranin.
izing the parathyroid lesions, its sensitivity varies The parathyroid cells secrete a parathyroid hormone,
widely, ranging from 34 to 92%, while the specificity is which, along with the other two hormones—calcitriol
reported to be high (up to 97%). But the difficulties in (produced in the kidney) and calcitonin (produced in the
differentiating between thyroid nodules, parathyroid thyroid)—regulates calcium and phosphorus levels.
glands, and lymph nodes still exist.
3. Small functioning parathyroid lesions may not be detected
by ultrasonography. Radiologic Features
4. Accurate cytologic identification of parathyroid glands Several imaging modalities are used to localize parathy-
offers difficulties because of the morphologic overlap roid gland lesions. These include ultrasonography, CT
between thyroid and parathyroid lesions. scanning, magnetic resonance imaging (MRI), thallium
substation scanning, and the recent technetium-99m ses-
Fine needle biopsies of parathyroid gland lesions have
tamibi imaging. Ultrasonography is the most frequently
been performed in the following situations:
used modality for primary parathyroidism. A normal
1. Enlarged parathyroid glands visualized during a rou- parathyroid gland is typically not seen with ultrasound.
tine ultrasonography of the neck for thyroid. A parathyroid adenoma or carcinoma is seen as a round,
2. Patients with hyperparathyroidism with ultrasound elliptical, or oblong hypoechoic mass. These may contain
localization of the parathyroid glands. cysts and calcifi cations. Hyperplastic glands are usually
3. Suspected parathyroid lesion following an unsuccessful much smaller than adenomas. Ultrasound cannot localize
parathyroid exploration under ultrasound guidance. ectopic parathyroids. Thyroid nodules and lymph nodes
4. Ultrasonography of thyroid bed following thyroi- may be mislabeled as parathyroids.
dectomy.
PARATHYROID CYSTS
NORMAL PARATHYROID GLANDS
Parathyroid cysts are rare. The incidence of parathyroid
The parathyroid glands represent part of the diffuse neu- cysts among cystic neck lesions is stated to be less than
roendocrine system (see Chapter 10). The parathyroid 1% of patients undergoing neck exploration for parathy-
glands are small red–brown, flattened, ovoid structures that roid and thyroid lesions.
generally measure 4 to 6 millimeters in length, 2 to 4 millime- Most parathyroid cysts are located in the lower cer-
ters in width, and 1 to 2 millimeters in thickness. The aver- vical neck region in proximity to the inferior parathyroid
glands; 13% are found in the anterior superior mediasti- PARATHYROID HYPERPLASIA AND ADENOMA
num. Parathyroid cysts are generally asymptomatic, but the
Parathyroid hyperplasia and adenoma may be associ-
larger ones may cause symptoms due to compression of the
ated with primary hyperparathyroidism characterized by
trachea, the esophagus, or the recurrent laryngeal nerve. Up
excess production of parathyroid hormone and hypercal-
to 11% of parathyroid cysts may be associated with hyper-
cemia, along with certain bone changes. Solitary adenoma
parathyroidism. Nonfunctional cysts are more common in
is the most frequent cause (80 to 85% of the cases) of
women. Clinically, parathyroid cysts may present as cervi-
hyperparathyroidism. Primary hyperplasia accounts for
cal nodules that are often mistaken for those of thyroidal
up to 15% of primary hyperparathyroidism.
origin. The results of radionuclide thyroid imaging are often
misleading in the diagnosis of parathyroid cysts. However,
ultrasonography has been quite successful in detecting para-
of Parathyroid Hyperplasia
thyroid cysts, allowing for fine needle biopsy procedures.
Proliferation of parenchymal cells of the parathyroid is
Gross and Microscopic Features referred to as “hyperplasia often taking the form of nod-
ules.” Generally, all four parathyroid glands are involved
Grossly, parathyroid cysts vary in size and may be as large
but not uniformly. The size and weight of each enlarged
as 10 centimeters in diameter and are loosely attached to
gland are variable features, and not all glands are visual-
the thyroid. They can be uni- or multilocular. The cyst
ized by ultrasound. Histologically, the hyperplasia involves
walls are typically thin, translucent, membranous, and
chief cells as well as oncocytic cells. It can be diffuse or
gray-white. Histologically, the wall is fibrous and lined by
nodular and sometimes can form glandular patterns. The
flattened epithelial cells, some containing clear cytoplasm
stromal adipose tissue is reduced or absent.
and resembling chief cells. Trapped islands of chief cells
may also be present in the wall.
Cytopathologic Features The smears are variably cellular, showing tissue fragments
of small parathyroid cells containing round, uniform nuclei
Aspirated cyst fluid can measure up to several milliliters with finely granular chromatin. The cytoplasm of the chief
and is characteristically clear, watery, and occasionally, cells is scant and pale or may be finely vacuolated. The
golden brown in contrast to thyroid cyst fluid, which is oncocytic cells are slightly larger and contain appreciable
straw-colored, amber, hemorrhagic, dark brown, or vis- slightly denser cytoplasm. The stromal fat, if identified in
cous. The fluid is often acellular or poorly cellular, con- the aspirate, will favor the diagnosis of hyperplasia. The
sisting of tissue fragments of small cuboidal cells with cytologic patterns are identical to those of adenomas.
round nuclei containing granular to compact chromatin
(Table 13.42; Figs. 13.140A to C). The cells are arranged Gross and Microscopic Features
in regular microfollicles or honeycomb sheets. Oncocytic of Parathyroid Adenomas
cells and histiocytes are rarely seen, and colloid is absent.
The background shows proteinaceous debris. The para- In contrast to hyperplasia, parathyroid adenoma involves
thyroid hormone levels in cyst fluids are always elevated, a single gland. A typical parathyroid adenoma is a tan
supporting their parathyroid origin and serving as a dif- to reddish brown neoplasm and homogeneous in con-
ferentiating feature between thyroid cysts and cystic nod- sistence with a smooth external surface. Adenomas vary
ular goiter. considerably in size and shape. They may be round, ellip-
soid, bean- or kidney-shaped, or flattened and elongated.
Larger adenomas may undergo cystic change, and the
aspiration biopsy may yield fluid contents.
Both clinically and cytologically, parathyroid cysts can Histologically, adenomas are thinly encapsulated neo-
be mistaken for thyroidal cysts, particularly those of plasms with compressed normal parathyroid parenchyma
degenerating nodular goiters. Parathyroid cells approxi- external to the capsule. The dominant cell type is chief
mate thyroid follicular cells in size, nuclear pattern, and cells that are often larger than their normal counterparts.
in architectural configurations of the tissue fragments. The cell outlines are indistinct. Their cytoplasm ranges
The main differentiating features between these two cysts from faintly eosinophilic to clear and contains abundant
include the gross characteristics of the parathyroid cyst glycogen deposits. The nuclei are round and central with
fl uid and the elevated parahormone levels. The parathy- dense chromatin and occasional nucleoli. A few cells may
roid cells will react positively to parathyroid antibody and contain large, hyperchromatic nuclei. The growth pattern
negatively to thyroglobulin, with the opposite being true consists of closely packed chief cells arranged in anasto-
for thyroid cysts (Table 13.42; Figs. 13.140A to D). The mosing cords, nests, acinar formations, and sheets sepa-
other differential diagnostic entities include cystic lesions rated by a delicate network of sinusoids.
of the neck such as branchial cleft cyst, thymic cyst, or The adenomas frequently contain cystic structures,
thyroglossal duct cyst. which may be empty or filled with PAS-positive, eosinophilic,
homogeneous material that strongly resembles colloid. not been documented by others. The parathyroid chief cells
The parathyroid cells contain glycogen and fat. Argyro- have scanty, pale cytoplasm with ill-defined cell borders and
philic granules in the cytoplasm of adenoma cells have are frequently displayed as stripped nuclei, presenting a lym-
been described. phocyte-like pattern. Occasionally, single vacuoles are noted
within the cytoplasm. The oncocytic cells contain apprecia-
Immunoprofile ble amounts of granular cytoplasm. Although a monomor-
The cells of parathyroid hyperplasia or adenoma exhibit phic pattern is commonly seen in adenomas, pleomorphic
positive reactivity to parathyroid hormone, chromogra- size and shapes may occasionally be encountered. Mitosis
nin A, and low-molecular weight cytokeratin and nega- or karyorrhexis is not present. The background contains
tive reactivity to thyroglobulin and vimentin. delicate, branching, vascularized stromal tissue fragments.
Histiocytes are rarely present, and fat globules are not iden-
Cytopathologic Features tified. The presence of fat globules favors hyperplasia. The
background may contain proteinaceous fluid or colloid-like
Cytologically, a parathyroid adenoma cannot be distin- material. The cytologic features of parathyroid hyperplasia/
guished from parathyroid hyperplasia because both pres- adenoma are summarized in Table 13.43.
ent similar cytologic features. When adequate, the cytologic
material consists of a large population of small, round to Diagnostic Accuracy and Differential Diagnoses
cuboidal epithelial cells displayed singly, in loosely cohesive Recognition of parathyroid lesions from the cytologic sam-
groups, or in thick syncytial-type tissue fragments (Figs. ples has historically presented difficulties. The latter are
13.141 to 13.143). A dispersed cell pattern is also charac- compounded when the location is intrathyroidal or if the
teristic. The tissue fragments present various architectural specimen is submitted as that from a thyroid nodule. Cyto-
configurations. They may be monolayered (two-dimen- logically, many such aspirates from parathyroid lesions are
sional) or syncytial with a trabecular pattern. The tissue interpreted as thyroid neoplasms only to find parathyroid
fragments may appear papillary-like with complex branch- pathology in surgically excised specimens. There is consid-
ing and interdigitating to enclose spaces or a follicular pat- erable cytomorphologic overlap between thyroid lesions
tern. Frequently, the extreme crowding and overlapping of and parathyroid lesions. There are no definite cytologic cri-
nuclei within a tissue fragment result in a three-dimensional teria that help to accurately identify the parathyroid lesions
pattern. Another characteristic feature of parathyroid ade- without the help of ancillary diagnostic techniques, coupled
nomas is the branching network of capillaries, and the neo- with clinical and radiologic data. Although a characteristic
plastic cells are often seen arranged alongside the capillaries. feature, the small uniform size may favor the diagnosis of
The parathyroid adenoma cells are round to cuboidal and nodular goiter. Parathyroid aspirates may be interpreted
slightly smaller than normal thyroid follicular cell nuclei as follicular neoplasms or chronic lymphocytic thyroiditis
(Fig. 13.142), measuring 6 to 7 nanometers in diameter. when a fair number of oncocytic cells are present.
Their nuclei are round, uniform, and contain coarsely gran- The small cell size of parathyroid adenoma cells and
ular chromatin and micronucleoli. Nuclear pleomorphism their presentation in tight, three-dimensional clusters
is occasionally present. Nuclear molding has been described resembles the cytologic pattern of insular carcinoma of
as a hitherto undescribed but diagnostic feature that has the thyroid and is a potential diagnostic pitfall. The same
holds true for medullary thyroid carcinoma with a small
cell pattern.
Differentiation of parathyroid lesions from thyroid
lesions may be attempted based on the current knowledge
of parathyroid cytopathologic features of hyperplasia/
adenomas, as listed in Table 13.43, and the special stains.
Parathyroid cells contain glycogen and argyrophil gran-
ules that can be demonstrated by the PAS reaction and the
silver stain, respectively. Immunoreactivity to parathyroid
hormone will confirm the origin of the cells. The presence
of fat cells will favor parathyroid origin and a hyperplastic
lesion. The diagnostic accuracy of parathyroid lesions from
cytologic specimens, in general, is low but can be maxi-
mized if the parathyroid location is known or suspected, in
which case, the ancillary tests will offer conclusive results.
Parathyroid adenomas may also, on occasion, be diffi-
Fig. 13.141. FNA parathyroid adenoma, showing a dispersed cell
pattern with loosely cohesive and discrete epithelial cells with poorly
cult to differentiate from oncocytic or clear cell neoplasms
defined cell borders. The nuclei are mildly pleomorphic and many of the thyroid and also share morphologic similarities
appear to be stripped off their cytoplasm. with metastatic renal cell carcinoma.
A B
Figs. 13.142A and B. Scrape smear of a parathyroid adenoma. The syncytial tissue fragment consists of small cells
with extreme crowding and overlapping of uniform, round nuclei with granular chromatin. The N/C ratios are very
high. The cell borders are indistinct and the cytoplasm is pale, scant, but variable. Note the follicular pattern.
A B
Figs. 13.143A to C. Fine-needle biopsy of a parathyroid adenoma

submitted as that from a thyroid nodule, seen as a defect on imaging
studies. A: The aspirate is very cellular consisting of large, branch-
ing tissue fragments of epithelial cells, and fibrovascular stroma (low
power). B: Another field showing very large tissue fragments of epi-
thelial cells. C: Higher magnification. The syncytial tissue fragments
of epithelial cells demonstrate no architectural configurations. The nu-
clei are round, with granular chromatin, and contain nucleoli. The cell
C borders are poorly defined, and the cytoplasm is scant.
PARATHYROID HYPERPLASIA/ADENOMA
of both parathyroid hyperplasia/adenoma and follicular
VERSUS FOLLICULAR ADENOMA/CARCINOMA
neoplasms (adenoma/carcinoma). However, the thyroid
In cytologic samples of follicular neoplasms of the thy- follicular cell nuclei in adenoma/carcinoma are consider-
roid, follicular adenoma and follicular carcinoma share ably enlarged. Colloid is usually scant or absent in cel-
morphologic similarities with parathyroid lesions (Table lular follicular neoplasms. The differentiation between
13.43; Figs. 13.144A and B). Syncytial-type tissue frag- the parathyroid lesions and thyroid follicular neoplasms
ments and coarse nuclear chromatin are characteristic are extremely difficult. The diagnostic dilemma may be
TABLE 13.43 DIFFERENTIAL DIAGNOSES OF PARATHYROID HYPERPLASIA/ADENOMA, FOLLICULAR

ADENOMA CARCINOMA, AND PAPILLARY CARCINOMA
Parathyroid Hyperplasia/ Papillary Thyroid Thyroid Cellular Follicular

Adenoma Carcinoma Adenoma/Follicular Carcinoma
Cellularity Generally hypercellular Generally hypercellular Generally hypercellular
Pattern Cells isolated, in loose Cells isolated, in loosely Cells in syncytial tissue
aggregates, or in syncytial cohesive groups and in fragments; bare nuclei is not a
tissue fragments; bare nuclei syncytial tissue fragments feature
frequent with various different
architectural patterns; bare
nuclei is not a feature
Architecture of the Small to large tissue Architectural patterns Syncytial with or without
Tissue Fragments fragments with or without include papillary with follicular patterns; slim to board
branching; trabecular pattern or without branching, trabeculae with or without
frequent; follicular pattern papillary-like with or branching; crowding and
⫹/⫺; extreme crowding without follicular pattern, overlapping of nuclei, intense in
and overlapping of nuclei; monolayered, three- carcinomas
perivascular arrangement of dimensional clusters; swirls
neoplastic cells; branching
network of delicate
capillaries characteristic
Cells Small, round to cuboidal, Variable size; pleomorphic; Larger than parathyroid cells;
poorly defined cell borders; larger than parathyroid variable in size; poorly defined
6–9 ␮m in diameter cells; well to poorly defined cell borders
cell borders
Nucleus Round; smooth nuclear Enlarged; demonstrate Variably enlarged, smooth

membranes; coarsely nuclear criteria of papillary nuclear membranes; fine to
granular chromatin; carcinoma (powdery to pale coarsely granular chromatin;
micronucleoli; high N/C granular chromatin; micro/ nucleoli ⫹/⫺ in adenomas but
ratios macronucleoli; nuclear present in carcinomas
grooves and intranuclear
inclusions)
Cytoplasm Scant, indiscernible to Variable Scant

modest; clear, granular,
occasionally oxyphilic
Psammoma Bodies Absent May be present Absent
Background Clean to proteinaceous No proteinaceous No proteinaceous material or fat

material; fat globules in material or fat globules; globules
hyperplasia macrophages ⫹/⫺
Colloid Absent Colloid ⫹/⫺; dense blobs Colloid ⫹/⫺; may be present in
to stringy follicular lumens
Immunoprofile
Parathyroid Hormone ⫹ ⫺ ⫺
Thyroglobulin ⫺ ⫹ ⫹
Chromogranin ⫹ ⫺ ⫺
A B
Figs. 13.144A to C. Parathyroid adenoma versus follicular neo-

plasm. A: FNA of a cellular follicular adenoma. Note the cellularity
and large tissue fragments of follicular cells. B, C: Higher magnifi-
cation showing syncytial architecture, with and without a follicular
pattern. The cells are slightly larger than those seen in parathyroid
adenoma. The chromatin is granular. This cytologic presentation is
C very similar to that of parathyroid adenoma.
solved by immunostains with either thyroglobulin or ● Unsatisfactory

parathyroid hormone. ● Negative or benign
● Indeterminate
● Suspicious
PARATHYROID HYPERPLASIA/ADENOMA ● Malignant
VERSUS PAPILLARY THYROID CARCINOMA
Subsequently, we introduced one more tier: “inadequate
Aspirates of parathyroid adenoma are sometimes misinter- specimen.” Our reporting system has been very functional,
preted as papillary thyroid carcinoma (PTC) (Table 13.43). is time-tested, and is well-adopted by the endocrinologists
The latter presents a wide spectrum of cytologic features and surgeons in our health system (Table 13.44).
with several characteristics that are not seen in parathyroid Our diagnostic categories are based on our practice
lesions. Branching tissue fragments of epithelial cells with a of triaging follicular and Hürthle cell lesions into nonneo-
papillary-like pattern alone, which are seen in cytologic spec- plastic and neoplastic categories and providing the probabil-
imens of parathyroid adenomas, must not be considered to ities of malignancy. The criteria for triaging were developed
be a diagnostic feature of PTC unless they are accompanied through years of learning experience with a large number
by nuclear features (e.g., enlargement, powdery chromatin, of thyroid aspirates and cytohistologic correlations, by re-
micronucleoli, nuclear grooves, and intranuclear inclusions) reviewing the discordant cases as well as concordant ones,
(Figs. 13.145A and C). Positive immunostains for parathy- and at the request of the endocrinologists. These physicians
roid hormone will confirm the parathyroid origin. were uniformly persistent in receiving the probabilities of
follicular and Hürthle cell neoplasms in order to lessen the
number of unnecessary thyroidectomies.
SPECIMEN ADEQUACY AND REPORTING
The interpretative errors during the learning phase
SYSTEM FOR THYROID ASPIRATES
were not only due to inexperience but due to report-
When we initiated fi ne needle aspiration biopsy of thy- ing inadequate/unsatisfactory specimens as adequate.
roid nodules in 1977, we followed a 5-tier reporting sys- Thus, the criteria for specimen adequacy were developed
tem that included the following categories: and have been followed ever since. Our criteria of 8 to
A B
Figs. 13.145A to C. Papillary thyroid carcinoma versus parathy-

roid adenoma. A: Low power of papillary carcinoma. B: Higher
magnification, showing a syncytial tissue fragment with nuclei dem-
onstrating typical features of papillary carcinoma. C: Parathyroid
adenoma for comparison. The cells are smaller and lack nuclear
C features of papillary carcinoma.
TABLE 13.44 REPORTING SCHEME FOR THYROID ASPIRATES

(HENRY FORD HOSPITAL, DETROIT, MICHIGAN)
Category Observations
Unsatisfactorya ● Acellular smears; no follicular cells; bloody; smears too thick
● Adequate cellularity but poor cell preservation due to air-drying in Papanicolaou stained preparations
Inadequatea ● Scant cellularity with or without mild nuclear atypia

● Abundant colloid with no or few follicular cells
● Cyst fluids with only histiocytes and no or few follicular cells
Negative (Benign) ● Nodular goiter: benign follicular cells, with or without colloid and histiocytes
● Thyroiditis; chronic lymphocytic or Hashimoto’s type
● Subacute or granulomatous thyroiditis
Abnormalb ● Cellular features of follicular adenoma

● Cellular features of Hürthle cell neoplasms
Suspiciousb ● Cellular material inadequate but suggestive of malignancy

● Diagnostic criteria insufficient for a definite diagnosis of malignancy
Positive ● Malignant cells present (Malignancy to be typed)

a
Nondiagnostic: In some reporting schemes, this category includes acellular and inadequate diagnosis.
b
Indeterminate: In some reporting schemes, this category includes follicular neoplasms, Hürthle cell neoplasms, and suspicious diagnosis.
Specimen Adequacy (See Figs. 13.146 to 13.160)
A B
Figs. 13.146A to C. A: An adequately cellular aspirate of thyroid

with at least seven to eight tissue fragments of follicular epithelium
in the background of colloid. B: This aspirate demonstrates sev-
eral well-preserved follicular cells in tissue fragments, with eight to
ten cells in each fragment. C: Well-preserved follicular cells forming
C regular follicles. Note the thin colloid in the background.
10 tissue fragments of well-preserved follicular epithe- sistence in diagnostic criteria and patient management.
lium in at least two smears (Figs. 13.146A to C) may seem The reader should refer to the guidelines for more details.
rigid but help to reduce false-negative diagnostic errors. There is no agreement and uniform recommendation
The adequacy of the specimen is extremely critical. in TBS with regard to specimen collection, processing, and
Various examples of unsatisfactory or inadequate (nonstaining. As indicated earlier in the introduction, criteria
diagnostic) categories are listed in Table 13.45 and illus- based on one type of fixation and staining or one type of
trated in Figures 13.147 to 13.160. processing do not apply to different methods. Misinter-
There have been considerable variations in diagnostic pretation can often be traced to these problems.
criteria, interpretations, adequacy assessment, and man- Our reporting system (Table 13.44) differs from TBS in
agement of patients based on biopsy results from one several categories. Table 13.46 compares both the systems
laboratory to another. A consensus conference sponsored and the diagnostic criteria. TBS is claimed to be simple;
by the National Cancer Institute on diagnostic terminol- it provides a risk of malignancy guide in each category.
ogy and morphologic criteria for the cytologic diagnosis Management guidelines and success is greatly expected.
of thyroid lesions was convened in 2007. The proceedings The reader is referred to the proceedings of The Bethesda
were published and aimed at creating uniformity and con- Conference for Guidelines and Recommendations.
TABLE 13.45 CRITERIA FOR ADEQUACY AND GUIDELINES FOR REPORTING UNSATISFACTORY/
INADEQUATE (NONDIAGNOSTIC) SPECIMENS
Cellular Features Interpretation/Diagnosis Explanation/Recommendations

Acellular, bloody; no thyroid follicular Unsatisfactory for cytologic evaluation Faulty technique; vascular or cystic lesion;
cells desmoplasia (see Table 4.2); repeat the FNA
Acellular, bloody; no thyroid follicular Unsatisfactory for cytologic evaluation Stromal cells or tissue fragments may originate
cells; spindle cells of stromal origin from granulation tissue or fibrosis in nodular
(Fig. 13.147) goiters or Hashimoto’s thyroiditis; rarely
they may represent an anaplastic carcinoma
or a papillary carcinoma with desmoplasia;
review the smear/s carefully; single spindle
cells with bizarre, pleomorphic nuclei may
represent an anaplastic carcinoma with
marked desmoplasia; repeat the FNA; clinical
correlation required
Acellular, bloody; no thyroid follicular Unsatisfactory for cytologic evaluation Probably represents cystic change in nodular
cells; only histiocytes with or without (nondiagnostic) goiter; rarely, a cystic papillary carcinoma
hemosiderin (Figs. 13.148 and 13.149) may present a similar pattern; re-aspirate if
a residual is palpable or if the cyst recurs;
clinical correlation required
Acellular, bloody; no thyroid follicular Unsatisfactory for cytologic evaluation Confirm that the needle was in thyroid and
cells; only lymphocytes (Fig. 13.150) not in the adjacent lymph node; may represent
late stages of Hashimoto’s thyroiditis; repeat
the FNA; clinical correlation required
Acellular; abundant colloid; no thyroid Unsatisfactory for cytologic evaluation Probably represents a colloid nodule
follicular cells (Fig. 13.151) (nondiagnostic) (hyperinvolution in nodular goiter or a
macrofollicular adenoma); clinical correlation
required; repeat FNA may be indicated
Poor cellular preservation due to Unsatisfactory for cytologic evaluation Repeat the FNA
improper fixation (air-drying) (Figs. (regardless of cellularity)
13.152 and 13.153) for Papanicolaou
stained preparations, thick smears,
excessive blood
Histiocytes with or without Suspicious for papillary carcinoma May represent either a nodular goiter with
hemosiderin; few follicular cells with degeneration or a cystic papillary carcinoma;
atypia; some but not all the cytologic repeat FNA or recommend surgery
features of papillary carcinoma (Figs.
13.155A and B, and 13.156)
Abundant colloid, few benign Negative for malignant cells; colloid If the lesion is large, (⬎2 cm in diameter),
follicular cells; histiocytes ⫹/⫺ nodule, (hyperinvoluted nodular adequate sampling may be a problem;
(Fig. 13.157) goiter) or a macrofollicular adenoma lesions yielding abundant colloid and few
benign-appearing cells are rarely if ever
malignant; differential diagnosis includes a
macrofollicular variant of papillary carcinoma;
look for syncytial architecture of the tissue
fragments and nuclear features of papillary
carcinoma; repeat FNA only if the cytologic
atypia is present
(continued)
Cellular Features Interpretation/Diagnosis Explanation/Recommendations

Few (fewer than six to eight) well- Inadequate for cytologic Probably represents nodular goiter; nodule
preserved tissue fragments of follicular evaluation due to scant cellularity; size must be taken into consideration; repeat
cells, honeycomb arrangement, and (nondiagnostic) FNA based on clinical judgment; sometimes
regular follicles; small nuclei ⬍9 ␮m clinically followed
in diameter with compact chromatin;
absent or scant colloid (Fig. 13.158)
Rare group or tissue fragment of Suspicious for a neoplasm Repeat FNA or recommend excision
follicular cells, syncytial arrangement,
nuclei with granular/powdery
chromatin, nucleoli (Figs. 13.159A
and B)
Few groups or tissue fragments of Suspicious for papillary carcinoma Recommend surgery
atypical cells; poor preservation;
some features suggestive of papillary
carcinoma (Fig. 13.160)
Fig. 13.147. The presence of only benign stromal cells in the absence Fig. 13.148. An aspirate of a thyroid cyst containing only histio-
of follicular cells is inconsequential. The aspirate is unsatisfactory/ cytes. Follicular cells are not present. This aspirate is inadequate/
nondiagnostic for evaluation. nondiagnostic for cytologic evaluation.
Fig. 13.149. This cyst aspirate contained only histiocytes in a hemor- Fig. 13.150. Only lymphocytes present in FNA of a documented
rhagic background. Since it recurred, a thyroidectomy was performed case of Hashimoto’s thyroiditis. The aspirate is unsatisfactory/
which revealed a cystic papillary carcinoma. Presence of histiocytes nondiagnostic for cytologic evaluation due to lack of follicular cells.
even in large numbers is not diagnostic of a cyst. A cystic papillary
carcinoma must always be considered in the differential diagnosis.
537
Fig. 13.151. Abundant colloid. No follicular cells. Although this may Fig. 13.152. Poor cytopreparation will result in unsatisfactory
represent a nodular goiter, the aspirate is inadequate/nondiagnostic smear. This aspirate from a papillary carcinoma is very cellular but
due to lack of follicular cells. A clinical correlation is required. air-dried resulting in poor cellular details. The aspirate is unsatisfac-
tory in spite of the cellularity.
Fig. 13.153. This aspirate from Hashimoto’s thyroiditis is air-dried Fig. 13.154. A cyst aspirate containing histiocytes and few benign
resulting in pale nuclei, misinterpreted as suspicious for papillary follicular cells. This aspirate is inadequate/nondiagnostic for cyto-
carcinoma. This preparation should be interpreted as unsatisfactory. logic diagnosis.
Errors are apt to happen when a diagnosis is rendered on a subop-
timal preparation.
A B
Figs. 13.155A and B. Cyst fluid. A: This image shows few follicular cells with poorly preserved nuclei with high N/C
ratios. There are histiocytes in the background. B: The syncytial tissue fragment of follicular cells demonstrates high
N/C ratios, well-defined cell borders with variable foamy cytoplasm. Micronucleoli are occasionally seen. The N/C
ratios are high. The variable cytoplasm is bubbly and foamy. The cell borders are well-defined. The aspirate shows
some but not all the features of papillary carcinoma and should be interpreted as suspicious.
538
Fig. 13.156. This poorly cellular aspirate shows very few discrete Fig. 13.157. Abundant colloid and rare group of benign follicular
follicular cells, pleomorphic in size, and resembles histiocytes. The cells (low power). This is probably benign, hyperinvoluted goiter,
cell borders are well-defined and the cytoplasm is variable dense to but interpreted as nondiagnostic.
vacuolated. The nuclei are enlarged with irregular chromatin along
the nuclear membrane. Micronucleoli are occasionally present. Ex-
perience is required to appreciate the subtle atypical features that
are suspicious for papillary carcinoma.
A B
Fig. 13.158. Scant cellularity, minimal colloid, small numbers of Figs. 13.159A and B. The aspirate is poorly cellular. The tissue frag-
well-preserved follicular cells. This aspirate is inadequate for cyto- ments are syncytial with only a mild increase in the nuclear size.
logic evaluation but may represent nodular goiter. Clinical correla- Note the intranuclear inclusions. This aspirate should be interpreted
tion required. as suspicious.
Fig. 13.160. The cells are air-dried with suboptimal nuclear mor-
phology. The syncytial architecture of the tissue fragment and a
sharp intranuclear inclusion are disturbing features suggesting a
diagnosis of papillary carcinoma. A suspicious diagnosis is justified
in this case.
TABLE 13.46 THYROID REPORTING SCHEMES
The Bethesda System 2007 National Cancer Institute Thyroid Henry Ford Hospital, Cytopathology Laboratory
Fine-Needle Aspiration State of the Science Conference
Nondiagnostic or Unsatisfactory Unsatisfactory.

(1) No follicular cells Specimen acellular (no follicular cells present); bloody, too thick
(acellular), bloody, only stromal cells Stromal cells
(2) Limited cellularity Only lymphocytes
(less than eight to ten tissue fragments of follicular cells on at Poor fixation and reservation
least two smears) Specimen Inadequate
(3) Poor fixation and preservation Scant cellularity
Risk of Malignancy—very low Abundant colloid with no or very few follicular cells
Cyst fluid with macrophages only and with none or with few
follicular cells
Benign (Benign) Negative for Malignant Cells

Nodular goiter Nodular goiter—Benign follicular cells with or without colloid
Chronic lymphocytic thyroiditis and/or histiocytes
Hyperplastic/adenomatoid nodule, or colloid nodule Chronic lymphocytic thyroiditis
Subacute thyroiditis Subacute thyroiditis
Other Other
Risk of Malignancy—0%–3%
Follicular Lesion of Undetermined Significance or Atypia of Minimal atypia exhibited by few cells in the background of benign
Undetermined Significance diseases is reported as a comment in the body of the report; e.g.
Include cases that cannot be classified as benign or a follicular cellular atypia in the background of nodular goiter or chronic
neoplasm. lymphocytic thyroiditis.
Not convincingly benign, yet the degree of cellular atypia or Presence of spindle cells and squamous metaplasia is not considered
architectural pattern not sufficient for an interpretation of atypical but mentioned as a comment.
follicular neoplasm or suspicious for malignancy.
Include focal atypical morphology in the background of benign
aspirate.
Risk of malignancy—5%–15%
Suspicious for Follicular Neoplasm Abnormal/Atypical

Cellular aspirate with follicular cells or follicular patterned lesion (1) Cellular features of follicular adenoma; (admixture of syncytial
Diagnostic possibilities: tissue fragments of follicular epithelium with and without
Hyperplastic goiter follicular pattern and variable nuclear atypia along with follicular
Follicular hyperplasia in thyroiditis epithelium demonstrating features of nodular goiter
Follicular neoplasm (2) Features of cellular follicular adenoma (microfollicular/trabecular
Follicular variant of papillary carcinoma adenoma)
Risk of Malignancy—60%–75% (3) Cellular features of Hürthle cell adenoma
Suspicious for Hürthle Cell Neoplasm

Includes all aspirates with Hürthle cell population
Suspicious for Malignancy Suspicious for Malignancy

Suspicious for papillary carcinoma Cellular material inadequate but suggestive of malignancy
Suspicious for medullary carcinoma Diagnostic criteria insufficient for a definite diagnosis of
Suspicious for metastatic carcinoma malignancy
Suspicious for malignant lymphoma
Risk of Malignancy—60%–70%
Diagnostic of Malignancy Diagnostic of Malignancy (Positive)

Papillary Papillary
Poorly differentiated follicular, including insular type Poorly differentiated follicular
Medullary Insular carcinoma
Hürthle cell carcinoma Medullary carcinoma
Anaplastic carcinoma Hürthle cell carcinoma
Malignant lymphoma Anaplastic carcinoma
Metastatic malignancy Malignant lymphoma
Risk of Malignancy—97% to 99% Metastatic malignancy
SUGGESTED READINGS
Ali SZ, Cibas ES. The Bethesda System for reporting thyroid cyto- El Demellawy D, Nasr A, Alowami S. Application of CD56, P63,
pathology. Definitions, Criteria and Explanatory Notes. New and CK19 immunohistochemistry in the diagnosis of papillary
York: Springer, 2009. carcinoma of the thyroid. Diagn Pathol 2008;3:5.
Balooch ZW, LiVolsi VA, Asa SL, et al. Diagnostic terminology and Gharib H. Changing trends in thyroid practice: Understanding
morphologic criteria for cytologic diagnosis of thyroid lesions: nodular thyroid disease. Endocr Pract 2004;10:31–39.
A synopsis of the National Cancer Institute thyroid fine-needle Kini SR. Thyroid Cytopathology—An Atlas and Text. Philadelphia:
aspiration state of science conference. Diagn Cytopathol Lippincott Williams and Wilkins, 2008.
2008;36:425–437. Kini SR, Miller JM, Hamburger JI, et al. Cytopathology of follicular
Baskin HJ, Duick DS, Levine RA. Thyroid Ultrasound and Ultra- lesions of the thyroid gland. Diagn Cytopathol 1985;1:123–132.
sound Guided FNA. In: Baskin HJ, Duick DS, Levine RA, eds. Kondo T, Ezzat S, Asa SL. Pathogenetic mechanisms in thyroid
2nd ed. New York: Springer, 2008. follicular-cell neoplasia. Nat Rev Cancer 2006;6:292–306.
Casey MB, Sebo TJ, Carney JA. Hyalinizing trabecular adenoma Miller JM, Kini SR, Hamburger JL. Needle Biopsy of the Thyroid.
of the thyroid gland; cytologic features in 29 cases. Am J Surg New York: Prager Publishers, 1983.
Pathol 2004;28:859–867. Nikiforov YE, Steward DL, Robinson-Smith TM, et al. Molecu-
Chow LS, Gharib H, Goellner JR, et al. Non-diagnostic thy- lar testing for mutations in improving the fine needle aspira-
roid fine-needle cytology: management dilemmas. Thyroid tion diagnosis of thyroid nodules. J Clin Endocrinol Metab
2001;11:1147–1151. 2009;94:2092–2098.
Cooper DS, Doherty GM, Haugen BR, et al. Revised management Rosai J, Carcangiu ML, DeLellis RA. Tumors of the Thyroid
guidelines for patients with thyroid nodules and differentiated Gland. Fascicle Five, Third Series, Atlas of Tumor Pathology.
thyroid cancer. Thyroid 2009;19:1167–1214. Washington, DC: Armed Forces Institute of Pathology, 1993.
APPENDIX
The two classifi cations for thyroid neoplasms represent

the traditional one recommended by the World Health MODIFIED HISTOLOGICAL
Organization (1) and the one that was modified by Rosai CLASSIFICATION OF THYROID
and associates (2). The author has followed the modified TUMORS (2)
classification in this atlas.
PRIMARY TUMORS
Tumors of Follicular Cells
WHO HISTOLOGICAL CLASSIFICATION Benign follicular adenoma
OF THYROID AND PARATHYROID Conventional
TUMORS (1) Variants
Malignant: Carcinoma
Differentiated
THYROID CARCINOMAS Follicular carcinoma
Papillary carcinoma
Papillary carcinoma
Conventional variants
Follicular carcinoma
Poorly differentiated
Poorly differentiated carcinoma
Insular
Undifferentiated (anaplastic) carcinoma
Others
Squamous carcinoma
Undifferentiated (Anaplastic)
Mucoepidermoid carcinoma
Tumors of C (and related endocrine) cells
Sclerosing mucoepidermoid carcinoma with eosinophilia
Medullary carcinoma
Mucinous carcinoma
Others
Medullary carcinoma
Tumors of follicular and C cells
Mixed medullary and follicular carcinoma
Sarcomas
Spindle cell tumor with thymus-like differentiation
Malignant lymphoma (and related hematopoietic
Carcinoma showing thymus-like differentiation
neoplasms)
Miscellaneous neoplasms
THYROID ADENOMAS AND
RELATED TUMORS SECONDARY TUMORS
Follicular adenoma
Cytologic features resulting in special tumor types and
Hyalinizing trabecular adenoma
subtypes that cross lines in the above classification for the
tumors of follicular cells and, to a lesser extent, of C cells
OTHER THYROID TUMORS include the following:
Teratoma Tumors with oncocytic (Hürthle cell) features
Primary lymphoma and plasmacytoma Oncocytic adenoma (Hürthle cell adenoma)
Ectopic thymoma Oncocytic carcinoma (Hürthle cell carcinoma)
Angiosarcoma Papillary oncocytic (Hürthle cell) tumors
Smooth muscle tumors Tumors with clear cell features
Peripheral nerve sheath tumors Tumors with squamous features
Paraganglioma Tumors with mucinous features
Solitary fibrous tumor
Follicular dendritic cell tumor 1. DeLellis RA, Lloyd RV, Heitz PU, et al. Pathology and
Langerhans cell histiocytosis genetics of tumors of endocrine organs. In: DeLellis
Secondary tumors RA, Lloyd RV, Heitz PU, et al., eds. World Health
Organization Classifi cation of Tumors. Lyon, France:
IARC Press, 2004.
PARATHYROID TUMORS 2. Rosai J, Carcangiu ML, DeLellis RA. Tumors of the
Parathyroid carcinoma thyroid gland. In: Rosai J, Sobin LH, eds. Atlas of
Parathyroid adenoma Tumor Pathology. Washington, DC: Armed Forces
Secondary tumors Institute of Pathology, 1993;19–20.
14 REACTIVE AND MALIGNANT
LYMPHADENOPATHIES
Kedar
K d V V. IInamdar
d • SSudha
dh RR. Ki
Kinii
Fine needle aspiration biopsy is widely used in the evalu- 6. High chances of false-negative diagnoses due to pauci-
ation of lymphadenopathies. This simple diagnostic pro- cellular aspirates in the case of fibrosclerotic stroma,
cedure is ideally suited for palpable and enlarged lymph as seen in primary mediastinal lymphomas or nodular
nodes in both pediatric and adult clinical practice. Deep- sclerosing Hodgkin disease.
seated lymph nodes can be sampled under radiologic
guidance.
Indications for fine needle biopsy are CYTOLOGY OF NORMAL LYMPH NODES
1. To differentiate a benign process from malignant lym-
phoma in patients with persistent lymphadenopathy, The normal components of a lymph node include small,
particularly in children in whom reactive lymphade- mature lymphocytes; the entire range of transforming
nopathy is a frequent presenting sign. lymphocytes including small centrocytes (small cleaved
2. To identify metastatic disease in patients with known cells), large centrocytes (large cleaved cells), small non-
malignancy. cleaved cells, and large noncleaved cells; immunoblasts;
3. To differentiate between malignant lymphoma and plasma cells; and tingible body histiocytes (Table 14.1).
other metastatic malignancies.
4. To confi rm a recurrent malignancy or in staging a
malignancy.
5. For confirmatory tests on infectious processes. BENIGN LYMPHADENOPATHIES
Despite its simplicity and success, particularly in
the diagnosis of metastatic disease, aspiration cytology Nonneoplastic lymphadenopathy is a common occurrence,
of lymph nodes is faced with certain diagnostic prob- covering a broad spectrum of reactive processes (Table
lems and limitations in reference to primary lymphoid 14.2) in response to diverse etiologic factors such as
malignancies. 1. Idiopathic (or unknown) antigenic stimulation;
The diagnostic problems include 2. Specifi c infectious agents—bacteria, viruses, fungi, or
1. Differentiation of malignant lymphomas from reactive protozoa;
processes. 3. Immunologic disorders;
2. Differentiation of certain types of malignant lympho- 4. Drugs (e.g., Dilantin).
mas from epithelial and mesenchymal malignancies.
3. Difficulty in diagnosing small cell lymphomas from
REACTIVE LYMPHOID HYPERPLASIA
cytologic samples, although high-grade (large cell)
malignant lymphomas are generally recognized readily. Morphologically, the reactive process or reactive lymphoid
4. Inability to defi ne the subclassifi cation of malignant hyperplasia is divided into four categories: 1) follicular
lymphoma based on architectural patterns, such as fol- pattern; 2) sinus pattern; 3) diffuse interfollicular pattern;
licular or diffuse type, from cytologic samples. and 4) mixed pattern. The follicular pattern is encoun-
5. Limited scope of aspiration biopsy, which may not tered most frequently and, in the majority of patients, is
sample the diagnostic areas when there is only partial due to idiopathic antigenic stimulation. It is also seen in
involvement of the lymph node by neoplastic process angiofollicular hyperplasia, rheumatoid arthritis, and the
or if lymph node architecture is partially maintained, early phase of HIV-related lymphadenopathy. The folli-
as in mantle cell lymphoma. cles are greatly enlarged with prominent germinal centers,
543
TABLE 14.1 CYTOMORPHOLOGY OF NORMAL COMPONENTS OF A LYMPH NODE
Cell Type Morphologic Characteristics

Small lymphocyte Small cells; nuclear diameter 7–8 m; nucleus round, uniform, dense compact chromatin; scant to
indiscernible cytoplasm
Small centrocyte Slightly larger than a small mature lymphocyte (1–1.5 times); deep nuclear membrane cleavages;
(small cleaved cells) inconspicuous nucleoli; thin rim of cytoplasm
Large centrocyte Up to 3 times the size of a small lymphocyte; clefted nucleus; irregular, angulated nuclear
(large cleaved cells) membrane; inconspicuous nucleoli; more cytoplasm than the small cleaved
Centroblast Nuclei 3–4 times the size of lymphocyte; nuclei round to oval; two or three prominent nucleoli,
(noncleaved) usually at the nuclear membrane; more lightly stained cytoplasm
Immunoblast Same size as large noncleaved; nuclei slightly eccentric, plasmacytoid; centrally located single
prominent nucleoli; margination of chromatin with irregular nuclear membrane; finely granular
chromatin; dense-staining cytoplasm
Plasma cells Size similar to that of a lymphocyte; eccentric nucleus, perinuclear halo frequent; chromatin
arranged like a face of the clock; moderate amount of cytoplasm at times dense
Tingible body histiocytes Histiocytes with ingested material; oval to round nuclei; finely granular chromatin; nuclei
1–1.5 times the red cell; cytoplasm pale, abundant; nuclear or particulate debris
TABLE 14.2 CYTOPATHOLOGIC FEATURES OF NONNEOPLASTIC LYMPHADENOPATHIES
Lymphadenopathy Cytopathologic Features

Idiopathic reactive hyperplasia Cellular aspirate; polymorphic cell population with lymphocytes and entire range of
(follicular pattern) transforming lymphocytes (germinal center cells); plasma cells, tingible body histiocytes
Virus induced; e.g., Infectious Cellular aspirate; wide range of atypical lymphocytes; various sizes including large forms,
mononucleosis, cytomegalovirus dense cyanophilic cytoplasm; large nuclei with prominent nucleoli; Reed–Sternberg-like
infection cells; increased mitotic activity; confirmation by serology
Early phase, HIV infection (AIDS), Cellular pattern of follicular hyperplasia; numerous mitoses, tingible body histiocytes;
florid follicular hyperplasia starry sky pattern; multinucleated giant cells, Warthin-Finkeldey type
Dermatopathic lymphadenitis; Same as in idiopathic reactive hyperplasia; large number of histiocytes; melanin
nodes draining skin lesions containing, lipid histiocytes, hemosiderin
Lymphadenopathy secondary to Polymorphic cell population: immunoblast, eosinophilic plasma cells, lymphocytes,
Dilantin neutrophils, necrosis, Reed–Sternberg-like cells
Sarcoidosis Noncaseating, nonnecrotic granulomata, aggregates of epithelioid histiocytes,

multinucleated giant cells, fibroblasts, and lymphocytes, positive acid fast stains
Mycobacterial infection Caseating necrosis; amorphous debris, epithelioid cells, Langerhans type giant cells,
fibroblasts; negative image by mycobacteria
Fungal infection, e.g., histoplasma, Granulomata with or without necrosis; organisms detected by special stains
cryptococcus
Cat-scratch disease Granulomata formed by aggregates of epithelioid cells; microabscesses; neutrophilic

infiltrate
Toxoplasma Follicular hyperplasia, epithelioid cells in clusters; tingible body: mitoses; no

multinucleated giant cells; varying numbers of plasma cells, immunoblasts, eosinophils;
identification of the organisms required
544
Chapter 14: Reactive and Malignant Lymphadenopathies 545
demonstrating increased activity along with tingible body

macrophages. MALIGNANT LYMPHOMA
The sinus pattern is characterized by markedly dilated
sinusoids that are fi lled with histiocytic cells containing Malignant lymphomas representing primary malignancies
abundant foamy cytoplasm that may show leukoeryth- of lymphoid tissue are divided into two broad groups: non-
rophagocytosis. This pattern is generally present in lymph Hodgkin lymphoma (NHL) and Hodgkin lymphoma.
nodes draining malignancies.
Lymphoid hyperplasia with effacement of the normal
lymph node architecture characterizes the diffuse pattern. NON-HODGKIN LYMPHOMA (NHL)
The follicles are small or absent; the parenchyma is rep- NHLs have been classified several times based on either
resented by varying proportions of lymphocytes, plasma morphology alone (Rappaport’s classification), on mor-
cells, immunoblasts, macrophages, and dendritic cells. The phology and biologic behavior (working formulation), or
diffuse pattern is seen mostly in viral infections, following most recently, on morphology combined with immuno-
vaccinations, and with dermatopathic lymphadenopathy logic and genetic analysis (Revised European-American
(e-Figs. 14.1 to 14.3). Lymphoma classification, REAL). These former classi-
Mixed patterns of the above-described subtypes may fications have now largely been replaced by the World
be seen in infectious mononucleosis and toxoplasma Health Organization (WHO) classification scheme—
lymphadenitis. Aspiration biopsies of reactive lymph the most recent in its series was published in 2008. The
nodes with follicular hyperplasia generally yield cellu- WHO classification defines each disease entity in terms of
lar aspirates. The diagnostic features of a reactive lymph morphologic, phenotypic, genotypic, and clinical charac-
node include polymorphic lymphoid cell population, teristics. Compared to the previous third edition of 2001,
which covers the entire range of transforming lympho- in the recently published fourth edition in 2008, several
cytes, plasma cells, tingible body histiocytes, along with new entities were added to the category of indolent B-cell
stromal and endothelial cells (e-Fig. 14.1). In drug-in- lymphomas, some old definitions have been revised to
duced or virus-induced lymphadenopathies (e.g., infec- incorporate recent clinical and/or molecular data, and the
tious mononucleosis, Cytomegalovirus infection) (e-Figs. category of aggressive B-cell lymphomas has seen a sig-
14.2 and 14.3), the aspirates show a large number of nificant expansion. Readers are directed to the references
immunoblasts and Reed–Sternberg-like cells, which con- for detailed descriptions of each new and old entity.
stitute a potential diagnostic pitfall. Lymph nodes drain- The classification of malignant NHL is very complex
ing skin lesions often show histiocytes containing melanin since it depends not only on the morphologic type of the cell
pigment. Reactive lymph nodes are immunophenotypi- but also on the architectural pattern of lymph node involve-
cally polyclonal. The morphologic subtypes of reactive ment, immunophenotyping, DNA ploidy analysis, and
lymphadenopathies cannot be recognized from cytologic molecular studies. Familiarity with the above-mentioned
samples. Many reactive processes can be misinterpreted parameters is essential.
cytologically as malignant lymphoma—both Hodgkin The cytologic diagnosis of malignant NHL from aspi-
and non-Hodgkin type. ration biopsy specimen faces many limitations. The small
cell lymphomas are diffi cult to recognize solely on mor-
GRANULOMATOUS LYMPHADENOPATHY phology. The architectural pattern, whether nodular or
diffuse, cannot be determined from cytologic specimens
Granulomatous response in a lymph node is seen in a and needs histological examination. Ancillary studies
wide variety of infectious and noninfectious diseases, require very cellular specimens and may not be feasible
characterized by granulomas formed by aggregates of in every instance. Most criteria for the cytologic diagnosis
oval (epithelioid) to fusiform histiocytes, multinucleated of hematological malignancies and lymphoproliferative
histiocytic giant cells, lymphocytes, plasma cells, and disorders are based on air-dried Romanowsky-stained
fibroblasts. The center of the granuloma may or may not preparations and are not always applicable to alcohol-
show necrosis. With coagulative necrosis, the granuloma fi xed Papanicolaou-stained preparations. In fact, both
is referred to as a caseating type—a feature commonly types of preparations complement each other and should
seen in infections with mycobacterium species. Granu- be employed in any lymphoma work up as a first step.
lomas seen in sarcoidosis are typically noncaseating. The cytologic diagnosis of malignant NHL from
The specific infectious agents may sometimes be iden- aspirated specimens is best achieved by identifying the
tified by using special stains; those seen in cat-scratch morphologic type based on the cell size (Tables 14.1
disease exhibit microabscesses (e-Figs. 14.4A and B). and 14.3) and the cell composition, whether monomor-
Lymph nodes infected by toxoplasma organisms show phic or polymorphic. As indicated earlier, the diagnostic
aggregates of histiocytes forming small granulomas. accuracy of small cell lymphomas is low, but intermedi-
These organisms are rarely, if ever, identified in aspira- ate and high-grade lymphomas can be readily identified.
tion biopsies. (Text continues on page 556)
TABLE 14.3 CYTOLOGIC DIFFERENTIAL DIAGNOSES OF NON-HODGKIN LYMPHOMASa
Type of Malignant Summary of Clinical Cytologic Differential

Lymphoma Features Cytopathologic Features Lineage Immunophenotyping Genetic Features Diagnoses See Fig(s).
Precursor Lymphoid Neoplasms
Lymphoblastic Occurs in adolescents Size 1.5–2 times that B- or T-cell B-lineage: See reference # for Hematogone 14.1A to C
Leukemia/ and young adults, of resting lymphocytes; Positive: detailed descriptions hyperplasia
Lymphoma (ALL, predominantly males; nuclei lobulated, CD19, cytoCD79a, Acute myeloid
B or T lineage) rapidly enlarging convoluted with infoldings cytoCD22, CD10, leukemia
mass; frequently or round to oval; finely TdT, CD99, CD34 Blastic plasmacytoid
presents as mediastinal granular chromatin; T-lineage: Dendritic cell
mass (particularly nucleoli inconspicuous; Positive: neoplasm
T-lineage); bone and high mitotic rate; cytoCD3, CD2,
CNS involvement cytoplasm scant CD4, CD8, CD5,
frequent (B-lineage); CD7, TdT, CD1a,
liver and spleen CD99, CD34
involvement seen
in lymphoblastic
leukemia/lymphoma
of both lineage;
cytopenias,
particularly
thrombocytopenia
and anemia are more
common with B-ALL
Mature B-Cell Non-Hodgkin Lymphomas
Small Cell
Chronic Lymphocytic Approximately 7% Uniform small B-cell Positive: 2 distinct prognostic Reactive hyperplasia 14.2
Leukemia/Small of all NHLs; usually lymphocytes, nucleus surface IgM/IgD subgroups: Follicular lymphoma,
Lymphocytic occurs in older slightly larger than the (dim), CD45, Mutated VH and particularly low-
Lymphoma (CLL/ patients in 6th or 7th resting cell; round to CD19, CD20, CD22 unmutated VH grade
SLL) decades of life but slightly irregular contour; CD79a, Additional clonal
increasingly being clumped to coarsely CD5, CD23, abnormalities
detected in younger granular chromatin; CD43, CD11c include del
population; may inconspicuous nucleoli; no (dim)—by flow 13q14.3, 12,
have stage IV disease tingible body histiocytes; cytometry and imm- del 11q22–23, del
with bone marrow mitoses rare; no necrosis unohistochemistry 17p13
and/or peripheral Negative:
blood involvement; CD10, FMC7,
usually without CD79b, cyclin
symptoms but D1 (by IHC)
lymphadenopathy, Immunophenotypic
hepatosplenomegaly, aberrancies such
autoimmune as loss of CD23 or
hemolytic anemia CD5 and FMC7
may be seen in a few can occur in few
cases; CD38
coexpression of
the neoplastic
lymphocytes
directly correlated
with worse survival
(continued)

Lymphoplasmacytic A majority are seen Small well-differentiated B-cell Positive: cyto IgM Nonspecific changes; Reactive Lymphoid 14.3
Lymphoma in association with lymphocytes admixed IgG IgA, CD45, del 6q in BM disease, Hyperplasia
Waldenström’s with variable number of CD19, CD20, 4 in 20% cases CLL/SLL
macroglobulinemia plasmacytoid lymphocytes CD22, CD79a, associated with WM, Plasmacytoma
(WM); occurs in and mature plasma CD138 (plasma cell 3 and 18 in rare
older patients in sixth cells; the plasmacytoid component) cases
decade with male lymphocytes have Negative: IgD, CD5,
predominance; serum eccentric nucleus with CD10, CD23,
IgM paraproteinemia moderate cytoplasm; CD103
is seen in a lack perinuclear halo
significant majority and cartwheel pattern
of patients however of plasma cell nucleus;
other paraproteins chromatin coarsely
(IgG or IgA) are granular; inconspicuous
also reported; nucleoli; immunoblasts
hyperviscosity present in varying
syndrome in about numbers; no mitoses or
one-third of patients; necrosis
slow development
of generalized
lymphadenopathy,
splenomegaly and
hepatomegaly;
hemolytic anemia,
bleeding diathesis,
renal disease and
amyloidosis; frequent
involvement of bone
marrow
Mantle Cell Occurs in late adult Lymphocytes small or B-cell Positive: CD45, t(11;14)(q13;q32) Reactive lymphoid 14.4
Lymphoma (MCL) life; patients present slightly large with round surface IgM/IgD in nearly 100% hyperplasia
with generalized or irregular cleaved, (strong), CD19, of cases; complex Small lymphocytic
lymphadenopathy; indented nuclei; chromatin CD20, CD5, FMC- karyotype in lymphoma
involvement of liver less coarse than small 7, CD43, cyclin D1 many cases; 12 Small cleaved cell
and spleen and BM is lymphocytic lymphoma; (BCL1), BCL2 in 25% cases, lymphoma
frequent nucleoli inconspicuous; Negative: CD10, frequent TP53 and Lymphoblastic
paraimmunoblasts absent; CD23 (can ATM mutations lymphomas
a histologic diagnosis only, sometimes show Rare cases that are Follicular lymphomas
cytologic diagnosis not weak-staining) negative for BCL1
possible Note: rare cases can and t(11;14)
be negative for both are cyclin D2 or
cyclin D1 as well as D3 and harbor
t(11;14), such cases t(2;12)(p12; p13)
are reported to translocation
express cyclin D2
and/or cyclin D3
(continued)

Marginal Zone 3 distinct entities— The aspirates of marginal B-cell Positive: Surface IgM, MALT lymphoma: In organ related FNA 14.5, 14.6
Lymphoma (MZL) extranodal MZL zone B-cell lymphoma IGA IgG, CD19, t(11;18)(q21; q21) Hashimoto’s
of mucosa- of MALT type consist of CD20, CD79a, most common in thyroiditis
associated heterogenous population CD11c /, CD43 lung and stomach; Myoepithelial
lymphoid tissue of lymphoid cells /, CD21, CD35 t(14;18)(q32; q21) sialadenitis (MESA)
(MALT), nodal characterized by an (also highlight seen in ocular or Reactive hyperplasia
MZL and splenic admixture of centrocyte- FDC meshworks in salivary gland Small cell lymphomas
MZL. like cells, monocytoid addition to tumor lesions; t(3;14)
MALT lymphoma— B-cells and plasma cells) (p14.1; q32) often
multiple cells; the centrocyte-like Negative: CD5, CD10, seen in thyroid,
extranodal sites, cells are medium-sized CD23, cyclin D1, cutaneous and
stomach most lymphoid cells (1.5 times CD103, BCL6 ocular MALT
frequent, other the small lymphocyte), The phenotype is lymphomas
sites include breast, have deep-staining usually the same SMZL: 7q31–32,
thyroid, salivary nuclei with condensed regardless of 3q
gland, ocular chromatin and with site with a few NMZL: 3, 18,
adnexa; frequent irregular outlines; the differences, for 7 seen but less
association with monocytoid B-cells example, CD43 common than in
infectious agents, are larger and contain expression common MALT lymphomas
for example appreciable amounts of in NMZL
Helicobacter pale cytoplasm; plasma
pylori in gastric cells may be present
MALT, Chlamydia in large numbers;
psittaci in ocular, features suggestive of
Campylobacter in lymphoepithelial lesions
small bowel and cannot be appreciated in
Borrelia burgdorferi cytologic samples
in cutaneous MZL
NMZL—peripheral
lymphadenopathy,
older patients
SMZL—manifests
with peripheral
blood
lymphocytosis,
splenomegaly,
anemia, and
thrombocytopenia;
splenic hilar LN
always involved;
peripheral LN
pathy is uncommon
Intermediate Cell
Follicular Lymphoma Represents 20% Low-grade, (Grade B-cell Positive: surface IgM, t(14; 18)(q32; q21) is Reactive follicular 14.8 to
of all NHL cases; 1–2): Predominantly IgD, IgG, CD19, the most commonly hyperplasia 14.12
common in adults composed of CD20, CD79a, observed genetic Mantle cell lymphoma
usually in their centrocytes which are CD10, BCL2, BCL6 abnormality, more Marginal zone
sixties; pediatric cleaved follicle center CD21 and CD23 ( in common in low- lymphoma
follicular lymphomas cells that can be small follicular dendritic grade; BCL6 and
have been reported or large; the proportion cell meshworks in 3q27 abnormalities
and occur mostly of centroblasts follicle structures) more common in
in male children; (noncleaved follicle Negative: CD5, cyclin grade 3 FL; other
predominantly center cells) is small; the D1, CD43, MUM- genetic alterations
a nodal disease centrocytes are 1.5–2 1/IRF-4 include del 1p, 6q,
however involvement times the size of resting Note: CD10 and 10q and 17p
of extranodal lymphocytes; irregular BCL2 can
sites including nuclei with angulated, be negative
retroperitoneum, twisted or cleaved particularly in
spleen, BM, skin, nuclear membranes grade 3 FL; CD5
breast and GI tract is (better appreciated in can be seen in a
also common; stage H&E sections), coarsely subset of cases
III or IV disease at granular chromatin,
presentation occurs in inconspicuous small
over 60% of patients peripheral nucleoli;
mitotic activity absent;
no necrosis
High-grade: Grade
3—Centroblasts
predominate; these are
2–3 times the size of
a normal lymphocyte,
have rounded to oval
nuclear contours with
occasional nuclear
indentation, open
chromatin and 1–3
membrane bound small
nucleoli
Occasionally, neoplastic
cells may exhibit
plasmacytoid,
monocytoid or
signet-ring cell
cytomorphology
(continued)

Burkitt Lymphoma Endemic Burkitt Abundantly cellular B-cell Positive: IgM t(8;14)(q24; q32) Small round cell 14.7
(Endemic and Lymphoma: smears with frequent (strong ), CD19, more common, tumors of
Sporadic and (Africa) Occurs in lymphoglandular bodies CD20, CD79a, followed by t(8;22) childhood
Immunodeficiency- children between and tingible-body CD10, BCL6, (q24; q11) and t(8;2) Lymphoblastic
Associated) 4 and 7 years old, macrophages; cells 1.5–2 CD43, Ki-67 (q24; p12) lymphoma
predominantly times the size of resting (positive in almost Malignant melanoma
male; affects lymphocytes; nuclei 100% tumor cells)
jaws and intra- uniform, round, chromatin Negative: BCL1,
abdominal coarsely granular BCL2, CD43, TdT
nodes; 95% parachromatin clearing;
have evidence of multiple peripheral small
Epstein-Barr Virus nucleoli; high mitotic
(EBV) infection; rate; cytoplasm deeply
aggressive behavior basophilic with numerous
with three-fourth small lipid vacuoles
of patients (Romanowsky stain);
presenting with ill-defined cell borders;
stage III–IV disease necrotic debris
Sporadic Burkitt
Lymphoma:
Occurs in young
adults with median
age at 30 years;
more common
among males; EBV
genome is found
in approximately
30% of cases;
commonly involve
ileo-cecal region,
breast, kidney
Immunodeficiency-
associated; seen
in patients with
HIV infection;
predominantly
involves the
lymph nodes and
bone marrow,
approximately 40%
cases are EBV
CNS involvement
is quite frequent
regardless of the
epidemiologic
subtype
Large Cell
Diffuse Large Of intermediate- Large lymphoid B-cell Positive: CD19, CD20, BCL6 abnormalities Reactive hyperplasia 14.13 to
B-Cell Lymphoma grade malignancy; cells (3–4 times the CD79a, CD10 (in most common; Poorly differentiated 14.14
(DLBCL1)- predominantly in resting lymphocyte); 60%), BCL6 BCL2 is rearranged malignancy
Centroblastic older age group but nucleus round or (60% cases), in approximately Neuroendocrine
can occur at any age irregular; coarsely MUM1/IRF4 1/3rd cases; in tumors
granular chromatin, (30–60%), Ki-67 approximately 20% Melanomas
parachromatin clearing; positive in 40–90% cases harbor both
multiple membrane- of tumor cells. CD5 MYC and BCL2
bound micronucleoli; in a subset of cases rearrangements, the
occasionally irregular (10%); CD30 so-called “double-
nuclear contours with / hit” lymphomas
polylobated nuclei; Negative: CD38,
mitoses; lymphoglandular CD138, TdT,
bodies; cellular debris; cyclin D1, CD34,
cytoplasm scant, pale myeloperoxidase,
S100, cytokeratin
DLBCL— High-grade; 30–40% Large cells; nuclei larger B-cell Positive: CD19, CD20, Reactive hyperplasia 14.15
Immunoblastic of adult NHL; broad than histiocytic CD79a, CD10 (in (polyclonal
age range including nucleus; finely granular 60%), BCL6 markers)
children and chromatin; one or more (60% cases), Granulocytic sarcoma
adolescents; patients nucleoli; distinct rim of MUM1/IRF4 Plasmacytoma
present with rapidly cytoplasm (30–60%), Ki-67 Malignant melanoma
enlarging mass; Immunoblastic; large usually greater than Nasopharyngeal
diffuse cells with eccentric 40% and can range carcinoma
nucleus; paranuclear up to 90–95%. Seminoma
clearing, central CD5 in a subset
prominent nucleolus; of cases (10%);
basophilic cytoplasm CD30 /
(Romanowsky’s Negative: CD38,
stain); high mitotic CD138, TdT, cyclin
rate; lymphoglandular D1, CD34, MPO,
bodies, cellular debris S100, cytokeratin
(continued)

DLBCL—Anaplastic Large pleomorphic cells, B-cell Positive: CD19, CD20,
multinucleated, bizarre CD79a, CD10 (in
nuclear forms that may 60%), BCL6
resemble RS or Hodgkin (60% cases),
cells MUM1/IRF4**
(30–60%), Ki-67
usually greater than
40% and can range
up to 90–95%.
CD5 in a subset
of cases (10%);
CD30 /
Negative: CD38,
CD138, TdT, cyclin
D1, CD34, MPO,
S100, cytokeratin;
CD30 expression is
more frequent than
other subtypes
Mature T- and NK-cell Neoplasms
Peripheral T-cell Uncommon, but a Cellular aspirate; T-cell Positive: CD45, CD4 T-cell receptor genes Reactive hyperplasia
Lymphoma (PTCL), heterogenous group neoplastic lymphoid cells; CD8, CD3, are clonal Lymphocytic depleted
not otherwise of post-thymic small, intermediate, to CD5, CD7 (most Complex karyotype Hodgkin
specified lymphomas that lack large size with varying frequently lost), frequently
features of specific degrees of pleomorphism, CD30 /, involving
entities such as ALCL2, Reed–Sternberg variants; CD56 / chromosomal
SPTCL3, AITL4, and irregular nuclei; Negative: CD5, CD7 regions 7q, 8q,
ATLL5; occurs in all epithelioid histiocytes; (most frequently 17q, and 22q. In
age groups but most eosinophils and plasma show loss of addition, deletions
patients are adults; cells; necrosis / expression), CD19, of various regions
frequent involvement CD20, CD10, in chromosomes
of head and neck BCL6, CXCL13 5, 6, 9, 10 and 12
area; multiple site Rarely, CD8 with are seen
involvement, cervical cytotoxic granule Gene expression
lymphadenopathy expression as well profiling signature
frequent; aggressive as CD4/CD8 of PTCL is distinct
behavior phenotype can be from AITL and
observed in PTCL, ALCL
NOS
Anaplastic Large Cell A rare neoplasm in Varying proportion of T-cell; Positive: LCA (CD45) t(2;5)(p23; q35) Metastatic carcinoma 14.16 and
Lymphoma, ALK elderly but frequently hallmark cells—large Null-cell / CD30 , involving NPM- Malignant melanoma 14.17
occurs in children and cells with pleomorphic EMA , CD3/, ALK most common Lymphocyte depleted
young adults, peak nuclei; round to CD2 , CD4 , translocation Hodgkin
occurrence is in first horseshoe-shaped; CD5 , TIA1 , followed by Soft tissue sarcoma
3 decades; may arise multinucleation; abundant Granzyme B , t(1;2) involving
de novo or with a eosinophilic cytoplasm CD43 , high Ki- TPM3-ALK; other
history of lymphoma with perinuclear halo; 67 expression and uncommon partners
of another type; Reed–Sternberg-like ALK of ALK include TFG,
advanced disease cells; mitoses /, rarely Negative: CD15, CD8, CLTC, MSN, TPM4,
at presentation in erythrophagocytosis PAX5, CD20, CD3, MYH9
majority; peripheral EBV (EBER and
lymphadenopathy LMPI)
with frequent BM
involvement, systemic
and cutaneous
forms, systemic
form with bimodal
age distribution, in
children and adults,
and aggressive
behavior; cutaneous
form in adults, may
regress spontaneously
Anaplastic Large Cell Currently, a Cytomorphologically T-cell; Positive: CD30, CD2, T-cell receptor genes Metastatic carcinoma
Lymphoma, ALK — provisional entity in indistinguishable from Null-cell CD3, CD5, CD43, , nonspecific genetic Malignant melanoma
WHO classification; ALK ALCL TIA1, Granzyme B abnormalities but Lymphocyte depleted
common in adults, Negative: CD8, EMA, distinct genetic Hodgkin
M F; involves LN CD15, CD20, ALK, signature from ALK Soft tissue sarcoma
more than extranodal EBV (EBER and ALCL
sites LMP1)
: more often than
: approximately
** MUM1/IRF4–Multiple myeloma oncogene 1/interferon regulatory factor 4
a
Entities are listed according to the WHO Classification of Tumors of the Hematopoietic and Lymphoid Tissues, 2008.
1
The table enlists the common morphologic variants under the DLBCL, not otherwise specified. Readers are directed to WHO Classification of Tumors of Hematopoietic and Lymphoid Tissues (2008) for
morphologic, immunophenotypic features and other distinct varieties of DLBCL.
2
ALCL-Anaplastic large cell lymphoma
3
SPTCL-Subcutaneous panniculitis-like T-cell lymphoma
4
AITL-Angioimmunoblastic T-cell lymphoma
5
ATLL-Adult T-cell leukemia/lymphoma
Note: This Table enlists selected entities that are commonly encountered in the practice of Cytopathology. For a detailed description of each entity, readers are directed to the above reference.
Adequate specimens do allow ancillary testing for further mas, a detailed list of antibodies for immunophenotyp-
classification. ing, and discussions on DNA ploidy analysis and molecu-
The advent of fl ow cytometric immunophenotyp- lar testing is beyond the scope of this atlas. The reader
ing has yet again revived interest in the utility of fine is referred to the literature for excellent reviews on the
needle aspirations for the diagnosis and classification of cytology of malignant lymphomas.
lymphomas. The diagnostic utility is much higher with The differential diagnoses for various malignant
B-cell than with T-cell lymphomas since, in the latter, the NHLs depend on the morphologic type. The common
abnormal phenotype often requires correlation with mor- diagnostic problem is the differentiation of reactive
phology for further subclassification. Also, sometimes the lymphadenopathies from malignant lymphomas (Table
neoplastic T-cells may not exhibit any immunophenotypic 14.4). The differentiation of malignant lymphoma from
aberrancies. Among B-cell lymphomas, flow cytometry is other malignancies also poses problems and is discussed
particularly useful in the diagnosis and classification of in various chapters.
small and mature B-cell neoplasms because the smaller
lymphocytes survive the fl ow processing and are able to
maintain viability much more effi ciently than the prolif- HODGKIN LYMPHOMA
erating cells of large and aggressive B-cells lymphomas. Hodgkin lymphoma is defi ned as malignant lymphoma
Furthermore, accurate classifi cation of larger B-cell lym- composed of a minority of less than 1% of malignant
phomas requires the correlation of the immunophenotype cells—called Reed–Sternberg cells—and Hodgkin cells
with cytomorphology. Flow cytometric evaluation is not admixed with a mixed polymorphous inflammatory cell
a useful modality when dealing with Hodgkin lymphoma infiltrate.
since the neoplastic cells are scarce. A host of antibodies Hodgkin lymphoma consists of two distinct clini-
are available that can determine the lineage and subtype cal and biologic entities, namely, nodular lymphocyte
of the lymphomas. predominant (NLP) and the classic Hodgkin lymphoma
Since the publication of the WHO classification of lym- (CHL).
phoid neoplasms in 2001 and more recently in 2008, the
role of the molecular assessment of B-cell NHL has become
Classical Hodgkin Lymphoma
increasingly important in the diagnosis of lymphomas. A
variety of molecular techniques including southern blot CHL accounts for 30 to 40% of all malignant lympho-
hybridization, Fluorescence in situ hybridization (FISH), mas, with a slightly higher incidence in males and a male
polymerase chain reaction (PCR), and DNA microarray to female ratio of 4:3. Patients are frequently between the
analysis have been utilized in the diagnosis, classification, second and fourth decades of life but may be of all ages
and sometimes in the management and prognostication and usually present with painless lymphadenopathy. The
of lymphomas. With respect to fine needle aspiration for cervical lymph nodes are more commonly involved, fol-
the evaluation of lymphomas, FISH and, recently, PCR lowed by mediastinal and axillary nodes. Patients may also
techniques have been successfully applied to cytology have fever, malaise, night sweats, and weight loss. During
specimens, increasing the sensitivity and diagnostic accu- the course of the disease, Hodgkin lymphoma may involve
racy of this technique. FISH has been successfully used in several organs in the body with a generalized spread.
fine needle aspirates to demonstrate some of the specific Histologic classification of Hodgkin lymphoma based
translocations associated with different subtypes of B-cell on the relative proportion of lymphoid cells and classic
lymphomas such as the t(14;18) of follicular lymphomas Reed–Sternberg cells includes lymphocyte-rich, mixed
and t(11;14) of mantle cell lymphoma. This technique has cellularity, nodular sclerosis and lymphocyte depletion
gained wide acceptance for use in FNA samples because subtypes.
of its ability to detect genetic alterations in a very small The hallmark of CHL is the presence of Reed–Sternberg
number of cells, its high sensitivity, and negative predictive cells. The classic Reed–Sternberg cells are binucleated con-
value. PCR technique is of value in the detection of IgH or taining mirror image nuclei, each with a prominent single
T-cell receptor gene rearrangements as evidence of mono- macronucleus (Fig. 14.18A) with a halo around the nucle-
clonality in FNAC specimens. While PCR can be highly olus. Reed–Sternberg cells are large and contain abundant
sensitive, caution should be exercised during the interpre- eosinophilic to amphophilic cytoplasm. Apoptotic cells
tation of PCR results since false-positive results can be with pyknotic nuclei are often seen. Morphologic variants
obtained in paucicellular samples, and monoclonal bands of Reed–Sternberg cells include cells with multinucleated or
have been detected in benign lymphoid lesions as well. multilobulated nuclei or mononuclear forms (Figs. 14.18B,
The clinical and cytopathologic features, summary 14.19A to C, 14.20A and B). Lacunar cells are variants
of immunophenotyping, important and recurrent genetic of Reed–Sternberg cells, showing retracted cytoplasm and
abnormalities, and differential diagnoses for more fre- appearing to be in a lacuna. The Reed–Sternberg cell vari-
quently encountered NHLs are listed in Table 14.3 (Figs. ants can be extremely pleomorphic, particularly in a syncy-
14.1 to 14.29). Inclusions of many uncommon lympho- tial variant (Figs. 14.20A to D).
Cytopathologic Features of Various Types of Malignant Non-Hodgkin Lymphoma (See Figs. 14.1 to 14.7)
A B
Figs. 14.1A to C. Precursor lymphoid neoplasms. A: Monotonous

infiltrate of mononuclear cells with high N/C ratios, finely granular
chromatin. B: lymphoblasts with round to oval nuclei; finely granu-
lar chromatin; single prominent nucleoli; scant cytoplasm (Leish-
man, 1000). C: Same case as B, showing monomorphic, immature
C lymphoblastic cells (Papanicolaou).
Fig. 14.2. Chronic lymphocytic leukemia/small lymphocytic lym- Fig. 14.3. Lymphoplasmacytic lymphoma Note the small well-
phoma (CLL/SLL). Note the uniform small lymphocytes with nu- differentiated lymphocytes with plasmacytoid features admixed
cleus slightly larger than the resting cell; round to slightly irregular with mature plasma cells. The former have eccentric nucleus with
contour; clumped to coarsely granular chromatin; inconspicuous moderate cytoplasm; absence of perinuclear halo and cartwheel
nucleoli; no tingible body histiocytes; mitoses rare; no necrosis pattern of plasma cell nucleus; coarsely granular chromatin, and
(1000). inconspicuous nucleoli (1000).
Fig. 14.4. Small mantle cell lymphoma. This is an example of blas-

toid variant of mantle cell lymphoma. Note the pleomorphic nuclei,
markedly irregular nuclear contours, and slightly coarser chroma-
tin. Nucleoli are inconspicuous (H&E, 1000).
A B
Figs. 14.5A and B. A: FNA thyroid nodule. The aspirate is cellular consisting of small lymphoid cells with occasional
monocytoid cells suspicious for malignant lymphoma. The core biopsy followed by thyroidectomy confirmed. B: FNA
thyroid nodule showing a large population of small lymphocytes mixed with large monocytoid cells and plasma cells.
Core biopsy revealed a malignant lymphoma and was confirmed as marginal zone lymphoma on thyroidectomy.
A B
Figs. 14.6A and B. FNA marginal zone lymphoma of the salivary gland. The cellular aspirate consists of a large
population of small lymphocytes with dispersed large centroblasts. Lymphoma can only be suggested and is difficult
to differentiate from myoepithelial sialadenitis without flow cytometry.
Fig. 14.7. Burkitt lymphoma. Monotonous intermediate-sized cells

with round nuclei containing small and multiple nucleoli. The cyto-
plasm is scant (1000).
Follicular Lymphoma (See Figs. 14.8 to 14.12)
Fig. 14.8. FNA showing a cellular aspirate consisting predominantly Fig. 14.9. FNA of this follicular lymphoma consists of an admix-
of small cleaved cells and some large noncleaved cells (1000). ture of cleaved and noncleaved cells (1000).
Fig. 14.10. FNA of a follicular lymphoma consisting of mixed cleaved Fig. 14.11. FNA of a follicular lymphoma consisting of large non-
and noncleaved cells (1000). cleaved cells (1000).
Fig. 14.12. Follicular lymphoma with signet-ring features. Lym-

phoma cells with cytoplasmic vacuoles, indenting the nuclei and
mimicking a signet-ring adenocarcinoma (Leishman, 1000).
Diffuse Large B-cell Lymphoma (See Figs. 14.13 to 14.17)
Fig. 14.13. Centroblastic type. The lymphoma cells are large and Fig. 14.14. Centroblastic type. The lymphoma cells are large and
contain prominent nucleoli (1000). contain prominent nucleoli (1000).
Fig. 14.15. Immunoblastic type. The lymphoma cells are large and Fig. 14.16. Anaplastic large cell lymphoma (ALCL) with charac-
contain prominent centrally located nucleoli (1000). teristic dispersed large pleomorphic cells, with marked variation in
size and shape.
A B
C D
Figs. 14.17A to D. Anaplastic large cell lymphoma. A: Hallmark cell of ALCL with wreath-like nuclear arrangement
(arrow), perinuclear halo, and abundant eosinophilic cytoplasm. B, D: Immunoprofile of this case. A: LCA negative.
B: Keratin negative. C: Vimentin positive.
Cytopathologic Features of Hodgkin Lymphoma (See Figs. 14.18 to 14.21.)
A B
Figs. 14.18A and B. FNA Hodgkin lymphoma. A: showing typical Reed–Sternberg cells (1000). B: Reed–Sternberg
variant cell.
A B
Figs. 14.19A to C. FNA Hodgkin lymphoma showing variants of

Reed–Sternberg cells including mononuclear Hodgkin cells and la-
C cunar cell (arrow).
A B
Figs. 14.20A to D. A, B: FNA Hodgkin lymphoma depicting giant multinucleated Hodgkin cells. (continued)
C D
Figs. 14.20C to D. (continued) C, D: Histologic sections of the involved lymph node showing lymphocyte depletion
and bizarre giant multinucleated Hodgkin cells (H&E).
Fig. 14.21. FNA Hodgkin lymphoma showing LP or popcorn Fig. 14.22. Plasmacytoma. Note the uniform population of medium-
cells. sized cells with eccentrically located nuclei, clumped chromatin, and
abundant eosinophilic cytoplasm with perinuclear hof.
Fig. 14.23. Histiocytosis X. FNA consisting of large histiocytic

mononuclear cells containing round to kidney-shaped nuclei. There
are lymphoid cells in the background. Ultrastructural examination
revealed the presence of Birbeck granules.
A B
Figs. 14.24A and B. Myeloid (granulocytic) sarcoma. Note the small to medium-sized cells with round, irregularly
folded, or lobated nuclei, finely granular chromatin, and micronucleoli.
Fig. 14.25. FNA. Dendritic cell sarcoma presenting as a retroperito-

neal mass. Note the spindle cell proliferation, admixed with numer-
ous lymphocytes. The cells are discohesive and appear large with
rounded to oval nuclei, finely dispersed chromatin, inconspicuous
nucleoli, and variable amount of eosinophilic cytoplasm.
A B
Figs. 14.26A to C. Malignant lymphoma versus small cell carcinoma. A: FNA cervical lymph node showing a cel-
lular aspirate containing small round to oval cells with high N/C ratios, scant indiscernible cytoplasm. The nuclear
chromatin is coarsely granular to compact. Nucleoli are not apparent. The cells are dispersed and some are loosely
cohesive. There is a slight suggestion of nuclear molding. The differential diagnoses included malignant lymphoma
and metastatic small cell carcinoma. B: Positive immunoreactivity to keratin. (continued)
C
Figs. 14.26C. (continued) C: Negative immunoreactivity to LCA, Fig. 14.27. Malignant lymphoma versus poorly differentiated
confi rming the diagnosis of metastatic small cell (neuroendocrine) squamous carcinoma. The discrete small cells of poorly differen-
carcinoma. tiated body-type or lymphoepithelioma with scant cytoplasm and
high N/C ratios may be misinterpreted as malignant lymphoma.
Fig. 14.28. Malignant lymphoma versus epithelial malignancy. FNA

poorly differentiated epithelial malignancy involving the cervical
lymph node misinterpreted as malignant lymphoma. The malignant
cells present a dispersed cell pattern with considerable pleomorphism
in size and shapes. The differential diagnoses were malignant lym-
phoma anaplastic large cell type, malignant melanoma and poorly
differentiated epithelial malignancy. All the tested immunostains
were nondiagnostic. Ultrastructural examination confirmed epithe-
lial malignancy.
A B
Figs. 14.29A and B. Malignant lymphoma versus malignant melanoma. A: FNA of a cervical lymph node clinically
suspected of malignant lymphoma. The aspirate is cellular with a large population of small to medium-sized cells
presenting a dispersed cell pattern. The nuclei are large with scant cytoplasm and high N/C ratios. Some demon-
strated a plasmacytoid pattern and eccentric nuclei. Immunostains confirmed melanin pigment. B: FNA Liver nodule
showing a very cellular aspirate with a dispersed cell pattern formed by very uniform small cells with scant cytoplasm.
Immunostains for lymphoid lineage were negative and HMB45 was positive, confirming malignant melanoma.
TABLE 14.4 DIFFERENTIATING FEATURES BETWEEN REACTIVE LYMPH NODE

AND MALIGNANT LYMPHOMA
Malignant Lymphoma
Reactive Lymphoid Hyperplasia Non-Hodgkin Type
Cellularity Generally high Generally high, low in sclerotic ones,
(e.g., mediastinal lymphoma
Presentation Dissociated cells with or without follicular pattern Dissociated and diffuse pattern
Cells Polymorphic; entire range of transforming Monomorphic; immature lymphoid cells; mitoses
lymphocytes (germinal center cells); tingible body /; tingible body histiocytes /
histiocytes; plasma cells; mitoses /
Background Lymphoglandular bodies absent; no karyorrhexis; Lymphoglandular bodies present; karyorrhexis

stromal and endothelial cells
Immunoprofile Polyclonal Monoclonal (B-cell)
Lymphocytic and histiocytic (L&H) cells, now noses for Hodgkin lymphoma in the mediastinum include
referred to as “LP cells,” are characteristic of NLP Hodg- thymomas, lymphoid hyperplasia, NHL, and germ cell
kin lymphoma. These are large, centroblast-like cells with tumors, while in the retroperitoneum, the differential diag-
complex lobulations of their nuclei, containing peripher- noses of Hodgkin lymphoma with predominant Reed–
ally placed nucleoli, which are smaller than those seen in Sternberg cells include myelolipoma, extramedullary
typical Reed–Sternberg cells and were previously referred hematopoiesis, soft tissue sarcomas, poorly differentiated
to as “popcorn cells” (Fig. 21). carcinomas, malignant melanoma, and peripheral T-cell
The cytologic features of Hodgkin lymphoma are and anaplastic large cell lymphomas (Chapter 21, Table
listed in Table 14.5. In the absence of typical Reed–Stern- 21.8). Virus-induced lymphadenopathies with atypical
berg cells, one should be careful in rendering a definitive lymphoid cells and Reed–Sternberg-like cells constitute
cytologic diagnosis of Hodgkin lymphoma. Even if clas- potential diagnostic pitfalls. The cytologic diagnosis must
sic Reed–Sternberg cells are seen, caution should be exer- be made only upon finding characteristic Reed–Sternberg
cised, since near-perfect mimics of Reed–Sternberg cells cells in the appropriate company of other reactive hema-
or mononuclear Hodgkin cells may be seen in reactive tolymphoid cells.
lymphadenopathies and some NHLs.
MISCELLANEOUS
DIAGNOSTIC ACCURACY AND DIFFERENTIAL
DIAGNOSES OF HODGKIN LYMPHOMA Plasmacytoma
The diagnostic accuracy of Hodgkin lymphoma in fine Plasmacytoma represents localized neoplastic prolif-
needle aspirate specimens is reported to be quite variable eration of plasma cells that are terminally differentiated
(30–92%). False-negative diagnoses result from factors B-lymphocytes, which are capable of secreting immuno-
such as specimen adequacy or sampling issues. In Hodg- globulins. Plasmacytomas may be solitary or constitute
kin lymphomas, the malignant cells comprise less than part of multiple myeloma. Solitary plasmacytomas may
1% of total cell population. This sparse representation be osseous or extramedullary without the bone involve-
of diagnostic malignant cells may not be refl ected in the ment and at an extraskeletal site. Regional lymph nodes
aspirated sample. The sclerotic areas in nodular scleros- may be involved. Solitary plasmacytomas carry a much
ing variant will offer resistance to aspiration and often better prognosis than multiple myeloma.
results in poor cellularity. Aspirates of plasmacytoma are generally cellular
False-positive diagnoses result from misinterpreting consisting of a plasma cell population in various stages
Reed–Sternberg-like cells in cases of reactive processes. of maturity (Fig. 14.22). The differentiated forms may
The differential diagnoses of Hodgkin lymphoma contain cytoplasmic globules or Russell bodies. Amyloid
depend not only on its histologic type but also on the ana- deposits may be present. The cells of plasmacytomas show
tomic site (Table 14.6). For example, the differential diag- monoclonal cytoplasmic immunoglobulins, but do not
TABLE 14.5 CYTOPATHOLOGIC FEATURES OF HODGKIN LYMPHOMA
Cytopathologic Features See Fig(s).

Cellularity Variable, poor in sclerosing types
Presentation Admixture of mature lymphoid cells, plasma cells, eosinophils, epithelioid

histiocytes, and neoplastic cells–Reed–Sternberg and variants of Reed–
Sternberg cells (Hodgkin cells) in varying proportions
Neoplastic Cells
Reed–Sternberg Cells Large to giant forms 40–100 m in diameter, bilobed, binucleated (mirror 14.18A and B
image) or multinucleated; finely granular nuclear chromatin; prominent 17.27
macronucleoli (at least one nucleolus ¼ the size of the nuclear lobe); abundant
pale cytoplasm
Variants of Reed–Sternberg Large round, mononuclear cells; 25–50 m with the nucleus at least 5 times 14.19A to C
Cells (Hodgkin Cells) larger than the resting lymphocyte; finely granular chromatin with prominent 17.20
macronucleoli; scant, pale cytoplasm 18.36
21.27
24.59
Lacunar Cells Variable in size, 20–50 m, lobulated, convoluted, or multinucleated,

surrounded by clear space
LP Cells or Popcorn Cells Large to giant forms, with multilobulated to convoluted nucleus with overlapping 14.21
nuclear segments; granular chromatin and prominent macronucleoli; pale
abundant cytoplasm; seen in nodular lymphocyte predominant Hodgkin
lymphoma (NLPHL)
Background Bare, irregular nuclei; necrosis infrequent; varying proportions of lymphocytes,

eosinophils and plasma cells
Immunoprofile
For Classical Hodgkin Negative reactivity to: CD20, CD45

Lymphoma (CHL) Positive reactivity to: CD15, CD30
Nodular Lymphocyte Negative reactivity to: Leu M1 (CD15), Ber-H2 (CD30)

Predominant Hodgkin Positive reactivity to: CD20, CD45
Lymphoma (NLPHL) Note: CD30 can be expressed by tumor cells of NLPHL
show surface immunoglobulins. They also demonstrate histiocytes (Fig. 14.23) that contain characteristic Birbeck
positive PAS and methyl green pyronine staining. granules. It could present in a localized form or a general-
ized form and may involve the lymph nodes. Please refer
to Chapter 25 for details.
TUMORS OF HISTIOCYTIC AND
DENDRITIC CELL ORIGIN
Extramedullary Myeloid Tumor (EMT)/Myeloid
The most common tumors in this category include (Granulocytic) Sarcoma
Langerhans cell histiocytosis (LCH), extramedullary
Myeloid sarcoma is a localized extramedullary tumor mass
involvement by myeloid and monocytic leukemias, and
composed of myeloid precursors. It is also known as chlo-
the newly described blastic plasmacytoid dendritic cell
roma and can occur anywhere in the body. All types of
(BPDC) neoplasm (Figs. 14.23 to 14.25).
myeloid and monocytic leukemias can present as an EMT
including acute myeloid leukemia (AML)—particularly
Langerhans Cell Histiocytosis
of the monocytic type—chronic myeloproliferative neo-
Langerhans cell histiocytosis, also known as histiocyto- plasms (CMPN) such as chronic myeloid leukemia
sis X, represents the proliferation of benign-appearing (CML), and myelodysplastic syndrome/myeloproliferative
neoplasms (MDS/MPN)—particularly chronic myelo- sarcoma is also included under this group due to mor-
monocytic leukemia (CMML). Microscopically, granulo- phologic similarities; however, its relationship to stromal
cytic sarcoma is characterized by features of an underlying versus dendritic cells is still not entirely clear. They are
disorder but, in general, presents as a diffuse infiltrate of characterized by a spindle cell proliferation admixed with
small to medium-sized cells with round, irregularly folded, numerous lymphocytes (Fig. 14.25). The cells are disco-
or lobated nuclei; finely granular chromatin; and micronu- hesive or can be seen in large groups. They appear large
cleoli (Fig. 14.24). A sprinkling of eosinophilic myelocytes with rounded to oval nuclei, finely dispersed chromatin,
provides an important clue to the diagnosis. Romanowsky inconspicuous nucleoli, and a variable amount of eosino-
stains may be helpful in identifying azurophilic granules or philic cytoplasm. Distinction between these tumors on
Auer rods. Interspersed macrophages may impart a starry morphologic grounds alone is virtually impossible and
sky appearance. The cytoplasm of the leukemic cells may needs extensive use of immunohistochemistry to make a
be granular, unlike lymphoblastic lymphoma. diagnosis. Readers are referred to excellent reviews for
details on each tumor.
Histiocytic Sarcoma
This is a rather rare entity that constitutes a malignant METASTATIC MALIGNANCY
neoplasm with morphologic and immunophenotypic fea-
Lymph nodes are the most common organs to be involved
tures of histiocytes. The patients are generally younger
by metastatic malignancy, particularly of the epithelial
with a higher incidence in males who present with fever,
type. Lymph nodes draining any particular anatomic site
wasting, generalized lymphadenopathy, and hepatosple-
or any organ that is affected by a malignant neoplasm
nomegaly. The malignant cells diffusely infiltrate the
are usually the primary targets for metastatic involve-
organs and are large and pleomorphic with abundant,
ment. Thus, the type of malignancy and the location of
vacuolated cytoplasm and well-defi ned cell borders. The
the lymph node often point to the primary site in cases
nucleus is oval, convoluted, or multilobulated with a high
of unknown malignancy. Malignant lymphomas often
N/C ratio. Nucleoli are prominent. Mitoses are frequent.
mimic cytohistologic patterns of nonlymphoid malignan-
A characteristic feature of malignant histiocytosis is
cies (Figs. 14.26 to 14.30).
leukoerythrophagocytosis.
SQUAMOUS CARCINOMAS
STROMAL TUMORS
Squamous carcinomas in the head and neck area
This group of tumors arises from the reticular network (nasopharynx, oral cavity, and larynx) commonly metas-
of the lymph node microenvironment and includes the tasize to the cervical lymph nodes, while those in the
follicular dendritic cell (FDC) sarcoma and fibroblastic inguinal area are involved by metastatic lesions from the
reticular cell (FRC) sarcoma. Interdigitating dendritic cell cervix, the vagina, the external genitalia, and the skin of
TABLE 14.6 DIFFERENTIAL DIAGNOSES OF

HODGKIN LYMPHOMA
● Thymoma
● Germ cell tumors
● Reactive (virus-induced) lymphadenopathy
● Extramedullary hematopoiesis
● Myelolipoma
● Peripheral T-cell lymphoma
● Poorly differentiated carcinoma
● Soft tissue sarcomas with pleomorphic pattern
● Malignant melanoma
● Anaplastic large cell lymphoma
Fig. 14.30. FNA of an epitrochlear lymph node in a 10-year-old

boy, showing a small round blue cell tumor. X-rays of the hand re-
vealed a deep-seated soft tissue mass that was diagnosed as alveolar
rhabdomyosarcoma (Leishman, 1000).
the lower extremities. A well-differentiated squamous NEUROENDOCRINE TUMORS

carcinoma has a tendency for cystic change with biopsy
Neuroendocrine carcinomas frequently metastasize to
yielding thick cheesy material. Its differentiation from
the lymph nodes. For example, mediastinal lymph nodes
other cystic lesions in the head and neck area is discussed
are the most common site for small cell undifferentiated
in Chapter 12. The poorly differentiated body types (Fig.
carcinoma of the lung. Cervical lymph nodes are a fre-
14.27) including nasopharyngeal carcinoma or lymphoe-
quent site for metastatic medullary thyroid carcinoma.
pitheliomas may offer difficulties in differentiating them
The differentiation of small cell carcinoma from malig-
from malignant lymphomas.
nant lymphoma often requires immunostaining (Figs.
14.26A to C).
ADENOCARCINOMAS
Supraclavicular and axillary lymph nodes are often the pri-
mary sites of metastatic involvement by breast carcinoma, MALIGNANT MELANOMA
while lung adenocarcinomas involve the supraclavicular Malignant melanomas involve the lymph nodes, depend-
and mediastinal areas. Carcinomas of the gastrointestinal ing on the drainage area of the skin that is involved. A
tract and gonads also involve the supraclavicular lymph pigmented malignant melanoma is diagnostically easy,
nodes. Intra-abdominal lymph nodes are target sites for but the same is not true with an amelanotic melanoma
metastatic involvement from the malignancies of intra- (Fig. 14.29A). Melanomas very often mimic the dispersed
abdominal and pelvic organs. Cervical and mediastinal pattern of malignant lymphoma. (Fig. 14.29B).
lymph nodes are frequently involved by thyroid cancers,
particularly the papillary type. The latter is very often
cystic. A papillary carcinoma in a cervical lymph node
SOFT TISSUE TUMORS
offers a differential diagnosis of the thyroid, the lung, the
ovaries, and the kidneys as possible primary sites. Poorly Although most soft tissue malignancies spread via the
differentiated epithelial malignancies mimic lymphoid bloodstream, some neoplasms such as malignant fibrous
malignancies and may be diagnostically challenging (Figs. histiocytomas and alveolar rhabdomyosarcomas involve
14.27 and 14.28). the lymph nodes (Fig. 14.30).
SUGGESTED READINGS
Caraway NP. Strategies to diagnose lymphoproliferative disorders Katz RL. Modern approach to lymphoma diagnosis by fine needle
by fine needle aspiration by using ancillary studies (see com- aspiration: restoring respect to a valuable procedure (see com-
ment). Cancer 2005;105:432–442. ment). Cancer 2005;105:429–431.
Caraway NP, Katz RL. Lymph nodes. In: Koss LG, Melamed MR, Maroto A, Martinez M, Martinez MA, et al. Comparative analysis
eds. Koss’ Diagnostic Cytology and its Histopathologic Bases. of immunoglobulin polymerase chain reaction and flow cytom-
5th ed. Philadelphia: Lippincott-Williams &Wilkins, 2006. etry in fine needle aspiration biopsy differential diagnosis of
Chhieng DC, Cangiarella JF, Symmans WF, et al. Fine needle aspi- non-Hodgkin B-cell lymphoid malignancies. Diagn Cytopathol
ration cytology of Hodgkin disease: A study of 89 cases with 2009;37:647–653.
emphasis on false negative cases. Cancer 2001;93:52–59. Safley AM, Buckley PJ, Creager AJ, et al. The value of fluorescence
Chhieng DC, Cohen JM, Cangiarella JF. Cytology and immuno- in situ hybridization and polymerase chain reaction in the diag-
phenotyping of low and intermediate-grade B-cell non-Hodgkin nosis of B-cell non-Hodgkin lymphoma by fine needle aspira-
lymphomas with a predominant small cell component: A study tion. Arch Pathol Lab Med 2004;128:1395–1403.
of 56 cases. Diagn Cytopathol 2001;24:90–97. Sneige N, Dekmezian RH, Katz RL, et al. Morphologic and
Dey P, Amir T, Jassar AA, et al. Combined applications of fine nee- immunocytochemical evaluation of 220 fine needle aspirates
dle aspiration cytology and flow cytometric immunophenotyp- of malignant lymphoma and lymphoid hyperplasia. Acta Cytol
ing for diagnosis and classification of non-Hodgkin lymphoma. 1990;34:311.
Cyto J 2006;3:24. Stastny JF, Almeida MM, Wakely PE Jr, Kornstein MJ, Frable WJ.
El-Sayed AM, El-Borai MH, Bahnassy AA, et al. Flow cytometric Fine-needle aspiration biopsy and imprint cytology of small
immunophenotyping (FCI) of lymphoma: Correlation with non-cleaved cell (Burkitt’s) lymphoma. Diagn Cytopathol
histopathology and immunohistochemistry. Diagn Pathol 1995;12:201–207.
2008;3:43. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification
Fan YS, Ng W-K, Chan A, et al. Fine needle aspiration cytology in of Tumors of Haematopoietic and Lymphoid Tissues. Lyon,
follicular dendritic cell sarcoma. Acta Cytol 2007;51:642–647. France: IARC, 2008.
Hsi HD. Hematopathology. In: Goldblum JR, ed. Foundations in Troxell ML, Bangs CD, Cherry AM, et al. Cytologic diagnosis of
Diagnostic Pathology. Philadelphia: Churchill Livingstone, 2007. Burkitt lymphoma. Cancer 2005;105:310–316.
Venkataraman L, Catherwood MA, Patterson A, et al. Role of Weiss L. Lymph nodes. In: Weiss L, ed. Cambridge Illustrated Sur-
polymerase chain reaction and immunocytochemistry in the gical Pathology. New York: Cambridge University Press, 2008.
cytological assessment of lymphoid proliferations. J Clin Pathol Young NA. Grading follicular lymphoma on fine needle aspiration
2006;59:1160–1165. specimens—A practical approach. Cancer 2006;108:10–20.
Wakely PE, Cibas ES. Lymph nodes. In: Cibas ES, Ducatman BS, Zhang JR. Fine needle aspiration diagnosis of Hodgkin lymphoma
eds. Cytology, Diagnostic Principles and Clinical Correlates. using current WHO classification re-evaluation of cases 1999–
3rd ed. Philadelphia: Saunders, 2009. 2004 with new proposals. Diagn Cytopathol 2006;34:397–402.
15 SALIVARY GLANDS
The three sets of paired major salivary glands, namely, the differential diagnoses in cytopathologic evaluation may
parotid, submandibular, and sublingual glands, as well not always apply in surgical pathology.
as numerous small accessory salivary glandular tissues Limited Experience and Interpreters’ Skills: Sali-
(minor salivary glands) in the oral cavity and oropharynx vary gland tumors, in general, are uncommon. Most
host a very broad range of nonneoplastic and neoplas- cytotechnologists and cytopathologists have limited
tic pathologic processes that clinically present as swell- experience with salivary gland neoplasms because of
ings (see Appendix). Being readily accessible, they have the infrequency with which the major and minor sali-
become easy targets for the fine needle biopsy procedure. vary glands are encountered in routine practice. Lack
Although proven to be a very useful diagnostic test, cel- of experience and familiarity are principle reasons for
lular samples from FNAs of salivary gland lesions have misinterpretations.
frequently presented diagnostic dilemmas, more so than Cytopreparation: Proper cytopreparatory techniques and
any other organ. The reasons are multiple. They include the adequacy of the specimen are important issues that
the following: cannot be overemphasized.
Factors Inherent to the Salivary Glands: The histologic The choice of fixative and the stain—whether air-dried
structure of the salivary glands is complex and includes for Romanowsky stain or wet fixation with ethyl alcohol
four cell types namely, duct epithelial, acinar, basal and for Papanicolaou stain—remains a personal choice for the
myoepithelial. The interrelationships and participation pathologist. There are pros and cons for both methods,
of one or more cell types, as well as their secretory prod- and the cytopathologist should use the stain he or she is
ucts, result in an extremely broad range of morphologic
most comfortable with. The stromal or matrix material
patterns from one tumor to another and within the same
tumor. A prime example of the morphologic diversity is from pleomorphic adenomas or adenoid cystic carcino-
pleomorphic adenoma. No other tumor presents a better mas stains bright magenta–pink with Romanowsky stain
model for the heterogenicity of the microscopic patterns. and is diagnostically easier to differentiate from the mu-
It is the easiest neoplasm to recognize cytologically and cin. The Papanicolaou stain, on the other hand, is excellent
can simultaneously be mistaken for every possible neo- for architectural patterns and cellular details. The use of
plasm of the salivary gland. both methods is ideal. The author’s lab uses a spray-fixed
Sampling of the Tumor by Fine Needle Biopsy: A funda- Papanicolaou-stained technique almost exclusively, and
mental difference exists between the histologic examina- the cytologic interpretations have not been compromised.
tion of the surgically excised lesion in its entirety and the In general, the diagnostic diffi culties may stem from
cytopathologic evaluation of a microscopic sample repre- similar growth patterns, common cell type, and simi-
senting a small focus within the lesion. An accurate his- lar characteristics of the stroma or similar background.
topathologic diagnosis requires a thorough examination Many salivary gland lesions share several of the following
of the excised tumor, the relationship of the tumor with features:
the surrounding tissues, and a generous sampling of vari-
ous parts of the tumor. The cytologic examination is very A. Growth patterns—cystic, solid, cribriform, papillary,
limited because the needle targets only a small area of the acinar, tubular, trabecular.
neoplasm. The sampled area in aspiration biopsy repre- B. Cell types—duct epithelial cells, myoepithelial cells
sents only one of the patterns if a given neoplasm consists and their varied forms (e.g., small, spindle, basaloid,
of diverse morphology such as that seen in pleomorphic plasmacytoid, clear, oncocytic).
adenomas. The cytologic diagnosis in such cases will be C. Stroma—mucoid, fi brillar, collagenous, hyaline, myx-
completely inaccurate. An accurate histologic diagnosis oid, chondroid.
is established when the constellation of multiple diverse D. Inflammatory cells in the background.
patterns is appreciated only after extensive sampling of
the tumor. Since such an examination is not possible with In this chapter, the differential diagnostic problems
fine needle biopsy, accurate cytologic typing becomes dif- are discussed based on diagnostic entity and common
ficult. Also, note that the diagnostic entities discussed in characteristics, as mentioned above.
571
serous type cells (parotid gland), while that of mucinous

CYTOLOGY OF NORMAL cells is vacuolated (submandibular glands).
CONSTITUENTS The ductal component is characterized by the tissue
fragments of cuboidal cells in a honeycomb arrangement
Aspirates of a normal salivary gland include both the with round nuclei and high N/C ratios. The nuclear chro-
acinar and ductal components along with stromal tissue matin is finely granular.
fragments (e-Figs. 15.1A and B). The myoepithelial cells are not generally appreciated
The acinar tissue consists of intact lobules with acini in cytologic specimens from a normal salivary gland. The
formed by triangular acinar cells containing eccentric, secretory products include glycosaminoglycans and basal
small, round nuclei with low N/C ratios. The nuclear lamina.
chromatin is fi nely granular, evenly distributed, and has The cytohistologic features and immunologic profile of
inconspicuous nucleoli. The cytoplasm is granular in salivary glandular epithelial cells are listed in Tables 15.1
TABLE 15.1 CHARACTERISTICS OF NORMAL EPITHELIAL CELLS OF THE SALIVARY GLAND
Luminal Cells of the Duct; Luminal Cells of the Acini; Nonluminal Nonluminal Cells;
Cuboidal/Columnar Cells Acinar Cell Cells; Basal Cell Myoepithelial Cell
Histology Cuboidal cells line the Roughly triangular or Small cells along Located between the basal
intercalated ducts; scant trapezoidal-shaped cells the basement surface of the intercalated
cytoplasm; amphophilic with the narrow part at the membrane of duct cells and acinar
to eosinophilic cytoplasm; luminal surface; abundant interlobular cells and the basement
uniform, round nuclei granular cytoplasm, staining ducts and membrane, myoepithelial
Columnar cells line the striated eosinophilic to cyanophilic; excretory ducts; cells are flattened stellate and
and interlobular excretory basally located, uniform, round not observed spindle-shaped cells with
ducts; intensely eosinophilic nuclei in striated or cellular processes in basket-
cytoplasm; round uniform intercalated like fashion around the acini
nuclei located centrally or ducts in routine and intercalated ducts; not
in luminal half; fine vertical sections; can be visualized in routine H&E
striations of basement highlighted by sections; can be highlighted
membrane immunostains by immunostains
Cytology Usually seen as tissue fragments Triangular cells forming small Not visualized Not visualized in cytologic
with well-defined cell borders acini, well-defined cell borders; in cytologic preparations
and in honeycomb arrangement; small, uniform, round nuclei preparations
modest amount of eosinophilic with finely granular chromatin;
to cyanophilic cytoplasm; inconspicuous micronucleoli;
uniform, round nuclei with abundant granular cyanophilic
finely granular chromatin cytoplasm
Ultrastructure Cuboidal cells of the Numerous cytoplasmic secretory Flattened, elongated to

intercalated ducts have no granules (zymogen granules) irregular nuclei; cytoplasmic
special features; striated located predominantly in the processes contain
ducts demonstrate extensive apical portion; extensive array microfilaments with focal
vertical folds in the basal of rough endoplasmic reticulum, densities similar to those
plasma membrane and contain basal and lateral to the nucleus; of smooth muscle cells;
numerous mitochondria; numerous mitochondria; mitochondria, endoplasmic
laterally the basal folds form basal plasma membrane with reticulum, Golgi apparatus
complex inter digitations with numerous folds; microvilli concentrated around the
plasma membrane folds of the along luminal surface and also nucleus; desmosomes attach
adjacent cells; small amounts project into intercellular space the myoepithelial cells to
of endoplasmic reticulum continuous with the lumen; the acinar and ductal cells
and Golgi apparatus; also complex inter digitations
contain junctional complexes, with the plasma membrane of
microvilli on luminal surface the adjacent cells; junctional
complexes; desmosomes; no
cytokeratin filaments
Histochemistry Cytoplasmic granules PAS

positive; diastase resistant;
mucicarmine negative
Chapter 15: Salivary Glands 573
TABLE 15.2 IMMUNOHISTOCHEMICAL CHARACTERISTICS OF NORMAL

EPITHELIAL CELLS OF THE SALIVARY GLANDa
Antibody to: Duct Luminal Acinar Basal Myoepithelial

CK7 ⫹ ⫹/⫺ ⫺ ⫺
CK8 ⫹ ⫹/⫺ ⫺ ⫺
CK19 ⫹ ⫹/⫺ ⫺ ⫺
CK14 ⫺ ⫺ ⫹ ⫹
CKs1,5,10,14 ⫹ ⫹ ⫹ ⫹
(34BE12)
EMA ⫹ ⫺ ⫺ ⫺
CEA ⫹ ⫹ ⫺ ⫺
Actin ⫺ ⫺ ⫺ ⫹
Calponin ⫺ ⫺ ⫺ ⫹
P63 ⫺ ⫺ ⫹ ⫹
CD10 ⫺ ⫺ ⫺ ⫹
a
CK ⫽ cytokeratin; CEA ⫽ carcinoembryonic antigen; EMA, epithelial membrane antigen.
and 15.2, respectively, and illustrated in e-Figures 15.1A nantly stromal types (e-Figs. 15.1 to 15.11). There is a
and B. vast array of architectural patterns exhibited by epithe-
lial cells such as acinar, tubular, alveolar, anastomosing
cords, nests, and solid along with cellular and nuclear
pleomorphism (Figs. 15.2 and 15.3). The myoepithelial
PLEOMORPHIC ADENOMA cells usually outnumber them and show a varied mor-
phology (Table 15.3; Figs. 15.4 to 15.13). They may be
Pleomorphic adenomas, also known as mixed tumors, small and round to short spindle-shaped with scant to
account for 60 to 70% of all salivary gland neoplasms. indiscernible cytoplasm, plasmacytoid (hyaline), and
They are most frequent in the parotid glands and are epithelioid containing clear to oncocytic cytoplasm,
also the most common benign neoplasms encountered or they may be elongated spindle-shaped. There may
in other major and minor salivary glands. Pleomorphic be an admixture of all cell shapes and size or one type
adenomas can occur at any age, are more frequent in may predominate. The cytoplasm of the myoepithelial
females, and generally present as slow-growing pain- cells varies from scant to abundant; is pale, clear, or
less masses. vacuolated; and is sometimes dense and eosinophilic,
mimicking oncocytes (Fig. 15.12). The duct epithelial
cells undergo various types of metaplasias—the most
common being the squamous type (e-Fig. 15.10; Figs.
GROSS AND MICROSCOPIC FEATURES
15.14 and 15). The latter can be quite extensive. Ductal
Grossly, pleomorphic adenomas are discrete, well- structures with a lining of metaplastic squamous cells
defined, firm, rubbery nodules with a bosselated surface, may be dilated to form keratin-filled cysts. The aspi-
and they vary considerably in size. They are encapsu- rates show metaplastic or mature squamous cells, with
lated (see e-Fig. 15.3). Most pleomorphic adenomas are or without keratinization. Deep orangeophilic keratin
easily identified both histologically and cytologically pearls appear striking in Papanicolaou-stained prepara-
because of their characteristic biphasic pattern, com- tions. Mucinous metaplasia and sebaceous metaplasia
posed of epithelial–myoepithelial cells and fibromyxo- are also encountered (Fig. 15.15). Crystalline material
chondroid stroma in varying proportions, ranging from such as tyrosine crystals (Figs. 15.16 and 15.17) is often
predominantly or exclusively epithelial to predomi- present. Their delicate needles are arranged to form
TABLE 15.3 CYTOPATHOLOGIC FEATURES OF PLEOMORPHIC ADENOMA
Cellularity Variable, generally very cellular
Presentation Biphasic cell population consisting of duct epithelial cells (luminal) cells and myoepithelial
(nonluminal) cells and fragments of myxoid-fibrillar-Chondroid stroma in varying
proportions; neoplastic cells discrete, in aggregates or in tissue fragments; either epithelial or
stromal component may predominate
Architecture of the Tissue Syncytial arrangement forming nests, chords, tubules, trabeculae, acinar to cribriform
Fragments patterns; fascicles of spindle-shaped myoepithelial cells
Cells
Duct Epithelial Cells (Luminal Duct epithelial cells medium-sized; uniform, round to cuboidal with well-defined cell borders;
Cells) usually present in syncytial tissue fragments forming ductal/glandular structures containing
central lumen; may show single to multiple layers of peripheral myoepithelial cells; nuclei
uniform, centrally located round to oval, with sharp, thin nuclear membranes, finely granular
chromatin and micronucleoli; cytoplasm scant to moderate, eosinophilic to cyanophilic pale;
single ductal or luminal cells not common
Myoepithelial Cells Cells small, medium-sized to large, pleomorphic in shapes ranging from round, oval to
(Nonluminal Cells) plasmacytoid, polygonal to spindle-shaped or stellate; cell borders well to poorly defined;
cell population may be uniform with one type or a combination of types; nuclei variable
in size, round, oval, oblong to spindle-shaped; central or eccentric; binucleation ⫹/⫺; crisp
nuclear membrane with or without irregularity; some with notching similar to that seen in
histiocytes; fine to coarsely granular, deep-staining chromatin, may resemble “salt & pepper”
chromatin of neuroendocrine cells; some with compact and dense chromatin; nucleoli not
common; intranuclear inclusions are occasionally seen; cytoplasm variable; insignificant to
scant to moderate, pale to dense, hyaline in plasmacytoid myoepithelial cells; cytoplasmic
processes rudimentary to long thin or broad; unipolar, bipolar to multipolar in stellate cells,
myoepithelial cells often separated by varying amounts of mucoid-myxoid to fibrillar stroma
Epithelial Metaplasias Squamous metaplasia with or without keratin pearls ⫹/⫺; goblet cell metaplasia ⫹/⫺;
oncocytic ⫹/⫺; sebaceous ⫹/⫺
Stroma Variable, may be abundant; fibrillar, sometimes widely separating stellate and spindle-shaped
cells; mucoid-myxoid, chondroid with or without a network of capillaries, or collagenous;
striking deep magenta colored in Romanowsky stained preparations; pale, lavender,
eosinophilic to cyanophilic with Papanicolaou stain
Degenerative Changes Usually clean; mucoid with degenerative changes; tyrosine crystals ⫹/⫺, nontyrosine
crystals ⫹/⫺
Background Cystic change with histiocytes ⫹/⫺; nuclear atypia in duct epithelial cells ⫹/⫺.
Immunoprofile
Duct Epithelial Cells Reactive for cytokeratins, EMA, CEA
Myoepithelial Cells Reactive for cytokeratins, p-63, calponin, vimentin, S100 protein, GFAP, muscle specific actin
(MSA)
characteristic flower-shaped structures, staining eosino- of pleomorphic adenomas but are seen only rarely.
philic in H&E sections and brownish–yellow to bright They are nonbirefringent, rectangular, sometimes have
orange with Papanicolaou-stained material. Nonty- pointed ends, and are variable in size ranging from 20 to
rosine crystals (Figs. 15.18A and B), seen in inflamma- 300 microns in length and 10 to 100 microns in width.
tory conditions or cysts, are also described in aspirates These crystals occur in the background of proteinaceous
TABLE 15.4 DIFFERENTIAL DIAGNOSES OF material. They stain bright orange with Papanicolaou
PLEOMORPHIC ADENOMA stain and deep blue with Romanowsky stain.
The stromal component varies in proportion, rang-
Chronic sialadenitis
ing from scant and insignificant (cellular pleomorphic
Benign nonneoplastic cysts adenoma) to abundant, presenting different qualities
Warthin’s tumor such as fibrillar, collagenous, and mucoid–myxoid to
chondroid (e-Fig. 15.11; Figs. 15.19 to 15.23). Degenera-
Myoepithelioma tive and cystic changes are not uncommon (Figs. 15.24
Oncocytoma and 15.25).
Basal cell adenoma
Low-grade mucoepidermoid carcinoma CYTOPATHOLOGIC FEATURES
The variations in proportion of duct epithelial cells
Adenocarcinoma, NOS to myoepithelial cells and the wide spectrum of myo-
Epithelia-myoepithelial carcinoma epithelial cell morphology from one tumor to another
and within the same tumor create an endless variety of
Polymorphous low-grade adenocarcinoma histopathologic patterns that is vividly reflected in cyto-
Small cell carcinoma logic samples (Table 15.3; Figs. 15.1 to 15.37). These
variations create a great potential for errors in cytoloic
Multiple myeloma
interpretations (Table 15.3).
Soft tissue tumors and tumor-like lesions
A B
C D
Figs. 15.1A to D. A: FNA of a pleomorphic adenoma. Low power view showing a cellular aspirate with several tis-
sue fragments of epithelial and myoepithelial cells. Also note the matrix material. B: Medium power to demonstrate
the epithelial and myoepithelial cells intimately mixed with the matrix material. C: Higher magnification depicting
spindle-shaped myoepithelial cells. D: Another example of a pleomorphic adenoma. This aspirate is markedly cellular
with cells in tissue fragments, and in loosely cohesive groups. (continued)
Figs. 15.1E. (continued) E: Higher magnification showing predom-

inantly spindle-shaped myoepithelial cells springing from matrix
E material.
Fig. 15.2. FNA of a pleomorphic adenoma showing a tissue frag- Fig. 15.3. A different example of FNA of a pleomorphic adenoma
ment of duct epithelial cells with a glandular pattern. Note that the showing a tissue fragment of duct epithelial cells with a tubular
duct epithelial cells are larger than the myoepithelial cells. pattern.
Fig. 15.4. FNA of a pleomorphic adenoma showing spindle-shaped Fig. 15.5. Pleomorphic adenoma with myoepithelial cells forming
myoepithelial cells, separated by pale-staining matrix material. a cribriform pattern. Note that the spaces contain matrix material.
This pattern resembles an adenoid cystic carcinoma.
Fig. 15.6. These myoepithelial cells are very pleomorphic in size Fig. 15.7. The myoepithelial cells from a pleomorphic adenoma oc-
and shapes. curring singly are plasmacytoid.
Fig. 15.8. Myoepithelial cells with intranuclear inclusions (arrows). Fig. 15.9. FNA of a pleomorphic adenoma showing a tissue frag-
ments of small myoepithelial cells with poorly defined cell borders
and scant cytoplasm. Some are seen surrounding the matrix mate-
rial (arrows). This pattern may be mistaken for either a basal cell
adenoma or an adenoid cystic carcinoma.
Fig. 15.10. FNA of a pleomorphic adenoma showing an unusual Fig. 15.11. FNA of a pleomorphic adenoma showing a tissue frag-
pattern with a large population of very small myoepithelial cells ment of duct epithelial–myoepithelial cells. There is very little ma-
resembling lymphoid cells that can be mistaken for either a benign trix material. A cellular aspirate without significant matrix material
process or a malignant lymphoma. is referred to as cellular pleomorphic adenoma.
A B
Figs. 15.12A to C. A, B: Myoepithelial cells often appear oncocy-

toid with polygonal shapes and abundant dense eosinophilic or cy-
anophilic (with Papanicolaou stain) cytoplasm and well-defined cell
borders. C: Histologic section of the pleomorphic adenoma with
oncocytoid myoepithelial cells. Note the intranuclear inclusions
C (arrows) (H&E).
Fig. 15.13. FNA of a pleomorphic adenoma showing abundant

fibrillar matrix with nests of epithelial–myoepithelial cells.
A B
Figs. 15.14A and B. This aspirate of a pleomorphic adenoma shows squamous metaplasia. A: Low-power showing a
keratin pearl. B: Higher magnification.
Fig. 15.15. Sebaceous metaplasia is occasionally present in aspirate Fig. 15.16. Tyrosine crystals are frequently present in pleomorphic
from pleomorphic adenomas. adenomas. The delicate crystals are arranged as flower petals, stain-
ing brown with Papanicolaou stain.
Fig. 15.17. Another example of a pleomorphic adenoma with ty-

rosine crystals (arrows).
A B
Figs. 15.18A and B. FNA of pleomorphic adenomas depicting the large numbers of eosinophilic stained crystalloids
of varying lengths and thickness. They are elongated with rounded ends. Note the mini crystalloids in the back-
ground. They may be also encountered in pleomorphic adenomas with degeneration. (Courtesy of William Rafferty,
M.D. Department of Pathology, Cooper University Hospital, Camden, New Jersey.)
Fig. 15.19. FNA of a pleomorphic adenoma showing a strikingly Fig. 15.20. The stroma in Papanicolaou stained preparations ap-
bright, magenta-staining matrix in Romanowsky stained prepara- pears pale and mucoid.
tions.
Fig. 15.21. The stroma or the matrix material in pleomorphic ad- Fig. 15.22. FNA of pleomorphic adenoma showing dense collag-
enomas can present several textures. Note the fibrillar pattern and enous stroma. Abundant collagenous stroma renders the gland firm
embedded discrete myoepithelial cells. to hard in consistency on palpation and may be mistaken for chronic
sialadenitis particularly with paucicellular aspirates.
A B
Figs. 15.23A and B. FNA of pleomorphic adenoma showing abundant fluffy stroma. A: Low power view. B: Higher
magnification depicting single small myoepithelial cells in the matrix material.
The aspirates of pleomorphic adenoma generally (Figs. 15.1A to E). This mixed pattern allows easy recog-
tend to be adequately to overwhelmingly cellular (Figs. nition. The cellularity of the aspirate varies, dependant on
15.1A, B, and D) and are typically characterized by a the proportions of epithelial and stromal components
biphasic pattern composed of duct epithelial and myo- ranging from markedly cellular ones with very little stro-
epithelial cells with varying amounts of matrix material ma to predominantly stromal.
Fig. 15.24. FNA of pleomorphic adenoma. Degenerative changes Fig. 15.25. Degenerative changes may also result in nuclear atypia
may result in excessive mucoid material and cyst formation. Such with squamous metaplasia.
an aspirate may be interpreted as a benign cyst.
Differential Diagnoses of Pleomorphic Adenoma (See Figs. 15.26 to 15.29)
Pleomorphic Adenoma versus Chronic Sialadenitis
A B
Figs. 15.26A to C. An aspirate of the submandibular gland with

hard consistency and clinical impression of possible pleomorphic
adenoma. A: Low-power view showing several large fragments of
stromal tissue with groups of epithelial cells (arrows). B: Higher
magnification showing stroma with an attached tissue fragment of
duct epithelial cells and possibly an acinus. C: Higher magnifica-
tion showing duct epithelial cells with uniform round to oval bland
nuclei. The aspirate was interpreted as pleomorphic adenoma. The
C surgical excision revealed extensive chronic sialadenitis.
A B
Figs. 15.27A and B. FNA of a pleomorphic adenoma. A: Medium-power view showing fibrous stroma with
islands of epithelial cells. B: Higher magnification; the cytologic pattern was misinterpreted as chronic sialadenitis.
The surgical excision confirmed a pleomorphic adenoma.
Fig. 15.28. FNA of a pleomorphic adenoma showing excessive col-

lagenized stroma. Such aspirates often are paucicellular and may
result in false-negative diagnosis as a result of sampling error.
A B
Figs. 15.29A and B. The specimen was submitted as an aspirate of neck mass with clinical impression of a pleomor-
phic adenoma. The aspirate consisted of pale eosinophilic to cyanophilic acellular material with isolated stromal cells
and delicate blood vessels. The cytologic pattern suggested pleomorphic adenoma. A: The surgical excision revealed a
localized amyloidoma in the neck. B: Bright green fluorescence of amyloid with thioflavin-T stain.
Pleomorphic Adenomas with a Predominant Duct Epithelial Cell Pattern (See figures 15.30 to 15.32)
A B
Figs. 15.30A and B. FNA of a parotid mass in a 71-year-old woman. A cellular aspirate showing several tissue frag-
ments of duct epithelium without any architectural patterns. Their nuclei are round to oval with uniform finely gran-
ular chromatin and occasional micronucleoli. The cell borders are sometimes apparent and the cytoplasm is variable
and pale. The cytologic impression was either a pleomorphic adenoma or a low-grade adenocarcinoma, not otherwise
specified. Surgical excision revealed extensive chronic inflammation, fibrosis, duct ectasia, and epithelial hyperplasia.
No neoplasm was identified.
Fig. 15.31. FNA of low-grade adenocarcinoma consisting of pre- Fig. 15.32. FNA of a cellular pleomorphic adenoma demonstrating
dominantly tissue fragments of duct epithelial cells with bland nu- tissue fragments of duct epithelial cells. A differential diagnosis of
clear pattern. Note the similarity to cells of ductal hyperplasia. cellular adenoma and low-grade adenocarcinoma should be offered
with such cytologic presentation.
Pleomorphic Adenoma versus Mucoepidermoid Carcinoma (See Figs. 15.33 to 15.37)
Fig. 15.33. The large duct epithelial cell with abundant vacuolated
cytoplasm mimics the cytomorphology of mucin producing cell of
mucoepidermoid carcinoma. There are many inflammatory cells
in the background. The case was interpreted as suspicious for mu-
coepidermoid carcinoma. Surgical excision revealed a pleomorphic
adenoma with degeneration and cyst formation.
583
A B
Figs. 15.34A and B. Degeneration with squamous metaplasia. This aspirate shows syncytial tissue fragments of
enlarged duct epithelial cells having well-defined cell borders, variable cytoplasm, ranging from pale, vacuolated to
dense. Some cells have eccentric nuclei and nucleoli. There was no stromal component. Some cells appear squamoid
while some others appear glandular with eccentric nucleus. The case was interpreted as suspicious for mucoepider-
moid carcinoma. The surgical excision revealed a pleomorphic adenoma.
A B
Figs. 15.35A to C. A, B: FNA of a pleomorphic adenoma show-

ing a squamous pearl with and without keratinization. C: The duct
epithelial cells are enlarged, have well-defined cell borders and con-
tain pale but appreciable cytoplasm. Their nuclei are enlarged, some
containing nucleoli metaplastic squamous cells. The case was inter-
preted as suspicious for mucoepidermoid carcinoma. The surgical
excision revealed pleomorphic adenoma with extensive squamous
C metaplasia.
A B
Figs. 15.36A to C. A, B: FNA of pleomorphic adenoma showing

excessive keratin debris and mature squamous cells. The epithelial–
myoepithelial cell component was sparse. The cytologic features in
this case were interpreted as suspicious for mucoepidermoid carci-
noma. C: The surgical excision revealed a pleomorphic adenoma
with extensive squamous metaplasia of the duct epithelium and
dilatation. The duct lumen is filled with laminated keratin (H&E).
Comment—Mucoepidermoid carcinomas generally do not exhibit
keratinization while squamous metaplasias in pleomorphic ad-
enomas quite often do. The presence of keratin pearls and keratin
C debris thus rules out mucoepidermoid carcinoma.
A B
Figs. 15.37A to C. Mucin from mucoepidermoid carcinoma mis-

taken for stromal matrix. A: Excessive mucin in the background in
this aspirate from mucoepidermoid carcinoma was interpreted as
myxoid stroma. B: Intermediate type and squamous cells with mu-
cin in the background. The nature of these cells as mucoepidermoid
carcinoma was not recognized. C: Epithelial cells with pale, foamy
cytoplasm embedded in the mucin were interpreted as myoepithelial
cells because of their plasmacytoid shapes. On retrospective review
of this case, it was apparent, that the cytologic features of mucoepi-
C dermoid carcinoma were not appreciated.
585
The epithelial component can be seen as dispersed a striking magenta color with Romanowsky stain, while
cells in loosely cohesive groups to syncytial tissue frag- in Papanicolaou-stained preparations, it stains a pale cy-
ments, presenting many architectural configurations such anophilic to lavender color and is sometimes pale eosino-
as nests, cords, trabecular with or without branching, tu- philic as with H&E staining.
bular, acinar, or cribriform (Figs. 15.2 to 15.6, 15.9, and Degenerative and cystic changes are not uncommon
15.11). (Figs. 15.24 and 15.25) and may yield cystic, mucoid ma-
The duct epithelial cells are round to cuboidal with terial in aspirates. Degeneration may also result in atypi-
well-defined cell borders and a modest amount of cyto- cal changes in the epithelial component.
plasm. Their nuclei are round, containing granular chro-
matin with or without micronucleoli. The duct epithelial
cells form a tubular, trabecular pattern or are mixed with
myoepithelial cells. It is the myoepithelial cell compo-
nent, which usually outnumbers the duct epithelial com- Although pleomorphic adenoma is easily recognized
ponent, that presents marked variation in size and shape. from cytologic specimens, it also presents several diag-
They can be very small and lymphoid-like (Fig. 15.10) nostic pitfalls, resulting in both false-negative and false-
with poorly defined cell borders containing scant, insig- positive interpretations. Because of the overlapping cyto-
nificant cytoplasm to plasmacytoid (Fig. 15.7), oval to logic features, pleomorphic adenoma is misinterpreted
round and polygonal to spindle forms. Their cytoplasm not only as various nonneoplastic disorders but also as
varies from scant to abundant, pale, clear, and dense to several types of primary benign and malignant salivary
oncocytic type (Fig. 15.12). It is sometimes difficult to gland neoplasms (Tables 15.4 to 15.7; Figs. 15.26 to
isolate duct epithelial cells from myoepithelial cells. The 15.37). Sampling of areas remains a main problem in
latter may be intimately mixed with the stromal matrix a neoplasm with varied morphology. Adequacy of the
(Fig. 15.13), and myoepithelial cells are often seen spring- sample cannot be overemphasized. Inadequate and/or
ing away from the stroma (Figs. 15.1C and E; Fig. 15.4). poor cytopreparations will preclude proper cytologic
The myoepithelial cells can be seen as small nests buried evaluation.
in the matrix material. The latter often shows a delicate The diagnostic problems arise when the aspirated sam-
network of capillaries. The myoepithelial cell nuclei are ple demonstrates a predominant or exclusive epithelial–
usually very bland with finely granular chromatin. Intra- myoepithelial component or stromal component. A
nuclear inclusions are easily noticeable (Fig. 15.8). predominant duct epithelial component (cellular pleo-
Pleomorphic adenomas often exhibit various types of morphic adenoma) in the absence of a myoepithelial
metaplasias of the duct epithelial cells with the squamous component in a given aspirate may be mistyped as epithe-
type being the most common (Fig. 15.15). The aspirates lial neoplasms (Figs. 15.30 to 15.32), while myoepithe-
show metaplastic or mature squamous cells, with or with- lial-predominant specimens may be mistaken for entities
out keratinization. Deep orangeophilic keratin pearls ap- such as myoepitheliomas or soft tissue lesions (see Figs.
pear striking in Papanicolaou-stained preparations. Mu- 15.48 to 15.58). Neoplasms such as polymorphous low-
cinous metaplasia and sebaceous metaplasia (Fig. 15.15) grade adenocarcinoma or epithelial–myoepithelial carci-
are also encountered. nomas have been mistyped as pleomorphic adenomas. A
Not infrequently, the aspirates exhibit tyrosine crys- predominant basaloid cell component is known to cause
tals that stain brownish–yellow to bright orange with diagnostic difficulties (see section on adenoid cystic
Papanicolaou-stained material (Figs. 15.16 and 15.17) carcinoma and small cell lesions, Table 15.38). Various
and nontyrosine crystals (Figs. 15.18A and B). Nonty- types of epithelial metaplasias may cause a diagnostic di-
rosine crystals (Figs. 15.18A and B), seen in inflamma- lemma. For example, squamous metaplasia can be mis-
tory conditions or cysts, are also described in aspirates interpreted as mucoepidermoid carcinoma (Figs. 15.33
of pleomorphic adenomas but are seen only rarely. They to 15.36). An erroneous diagnosis of mucoepidermoid
are nonbirefringent, rectangular, sometimes with pointed carcinoma may be rendered in the presence of several
ends, and are variable in size ranging from 20 to 300 cytologic features (Table 15.7; Figs. 15.33 to 15.37). A
nanometers in length and 10 to 100 nanometers in width. predominant stromal component may result in a diag-
These crystals occur in the background of proteinaceous nosis of chronic sialadenitis (Table 15.6; Figs. 15.26 to
material. They stain bright orange with Papanicolaou 15.28). The reverse is also true. Duct epithelial hyper-
stain and deep blue with Romanowsky stain. plasia sometimes seen in the presence of chronic sialad-
The stromal component varies in amount, ranging enitis may mimic the pattern of a cellular pleomorphic
from scant and insignifi cant—as in cellular pleomorphic adenoma or a low-grade adenocarcinoma (e-Fig. 15.12).
adenomas—to abundant, and it presents different quali- Amyloid deposits in the parotid gland will simulate
ties such as fi brillar, collagenous, and mucoid–myxoid, the pattern of matrix material of pleomorphic adenoma
to chondroid (Figs. 15.19 to 15.23). The stroma stains (e-Fig. 15.13).
TABLE 15.5 DIAGNOSTIC PITFALLS IN PLEOMORPHIC ADENOMA
Cytologic Features Mistaken For See Fig(s.)/Table

Predominant or an exclusive stromal component Chronic sialadenitis 15.26 to 15.28
Cystic degeneration; mucoid aspirate with low Nonneoplastic cysts 15.210

cellularity; inflammatory cells Mucocele or mucus retention cyst
Branchial cleft cyst
Neoplastic 15.33
Warthin’s tumor 15.34
Predominant or an exclusive duct epithelial Adenocarcinoma, NOS 15.30

component with or without nuclear atypia (cellular Polymorphous low-grade adenocarcinoma
pleomorphic adenoma) Epithelial–myoepithelial carcinoma
Acinic cell carcinoma
Predominant or an exclusive myoepithelial cell Basal cell adenoma/basal cell adenocarcinoma 15.5
component Adenoid cystic carcinoma 15.9; 15.11
Small basaloid cell type Small cell carcinoma 15.10, 15.187, and
Malignant lymphoma 15.188
Epithelioid with abundant eosinophilic cytoplasm Oncocytoma 15.12
Spindle cell type Myoepithelioma 15.7, 15.8

Soft tissue tumors and tumor-like lesions 15.48 to 15.50
Plasmacytoid myoepithelial cells Myoepithelioma 15.7

Plasmacytoma
Excessive myxoid stroma Nonneoplastic cyst 15.24

Warthin’s tumor 15.37
Extensive squamous metaplasia Branchial cleft cyst 15.36

Squamous carcinoma
TABLE 15.6 DIFFERENTIATING FEATURES BETWEEN PLEOMORPHIC ADENOMA

AND CHRONIC SIALADENITIS
Pleomorphic Adenoma with a Predominant or

an Exclusive Stromal Component Chronic Sialadenitis
Firm to hard, well-defined, discrete mass Firm to hard ill-defined mass
Fibrillar stroma with capillary network Fibrillar to collagenous stroma; no capillaries
Discrete or aggregates of epithelial–myoepithelial Islands of epithelial cells not seen merging with the stroma; Small ductules
cells within the stroma and in close proximity, or ducts lined by squamous or oncocytic cells; large tissue fragments of duct
imperceptibly merging with stroma epithelial cells in exuberant duct hyperplasia
Lymphocytic infiltrate not present Variable numbers of lymphocytes and histiocytes; normal acinar tissue ⫹/⫺
Tyrosine crystals ⫹/⫺; nontyrosine crystals ⫹/⫺ Tyrosine crystals ⫺; nontyrosine crystals ⫹/⫺
TABLE 15.7 DIFFERENTIATING FEATURES BETWEEN PLEOMORPHIC ADENOMA AND LOW-GRADE

MUCOEPIDERMOID CARCINOMA
Pleomorphic Adenoma Low-Grade Mucoepidermoid Carcinoma

Admixture of epithelial–myoepithelial cells and fragments of Polymorphic epithelial cell population (mucin-producing,
myxochondroid–fibrillar stroma (matrix material); stroma intermediate, squamous and clear cells) in variable proportions;
may resemble mucoid stroma of mucoepidermoid carcinoma no myoepithelial cells
Duct epithelial cells round to cuboidal, small to large; Epithelial cells variable in size; intermediate cells small to
squamous metaplasia with or without keratinization, keratin medium-sized in syncytial tissue fragments with high N/C ratios,
pearls and keratin debris; no intermediate or goblet cells; with scant cytoplasm; squamous cells and goblet or mucin-
nests of myoepithelial cells in the matrix material producing cells, variable in number and size; no keratinization of
squamous cells; no keratin pearls or keratin debris
Nuclei with finely granular chromatin; generally bland; Nuclei variable in size; finely granular chromatin with
nucleoli not conspicuous; nuclear atypia ⫹/⫺ micronucleoli
Usually clean background; histiocytes and mucoid Usually a cystic neoplasm with inflammatory cells, histiocytes
background with cystic degeneration and mucoid background
TABLE 15.8 MORPHOLOGIC FEATURES OF MODIFIED MYOEPITHELIAL CELLS
Morphologic Type Features

Spindle Cells Delicate, bipolar, spindle-shaped with poorly defined cell borders; scant but variable pale cytoplasm;
round, oval, oblong to spindle-shaped nuclei with smooth nuclear membranes; finely granular to
thready chromatin; nucleoli inconspicuous
Plasmacytoid (Hyaline) Medium-sized to large; well-defined cell borders; appreciable, dense cytoplasm; round to oval,
eccentrically placed nuclei with smooth nuclear membranes; granular chromatin; nucleoli ⫹/⫺;
binucleation frequent; intranuclear inclusions ⫹/⫺; nuclear grooves ⫹/⫺; nuclear striations (zebra
lines) in Romanowsky stained preparations; a dispersed cell pattern frequent
Epithelioid Medium-sized to large; round to polygonal; well-defined to indistinct cell borders; pale to dense
cytoplasm; eosinophilic to cyanophilic staining; low N/C ratios; round to oval nuclei with smooth
nuclear membranes; granular to thready chromatin; nucleoli ⫹/⫺
Clear Medium-sized to large; indistinct cell border; frequently present as naked nuclei; pale indistinct
cytoplasm; round to oval nuclei with smooth nuclear membranes; low N/C ratios; granular to
thready chromatin; nucleoli ⫹/⫺
Stellate Typically present in chondromyxoid areas of pleomorphic adenoma; poorly defined cell borders;
small bland nuclei
rare. They commonly involve the parotid glands but also

MYOEPITHELIOMA AND occur in minor salivary glands. The morphology of the
MYOEPITHELIAL CARCINOMA myoepithelial tumors is diverse because the myoepithelial
cells present as different forms ranging from spindle, plas-
macytoid (hyaline), and epithelioid to clear cells (Table
MYOEPITHELIOMA
15.8; Figs. 15.38A and B). A given case of myoepithe-
Myoepitheliomas and myoepithelial carcinomas, derived lioma may be composed exclusively of one cell type or
from the neoplastic differentiation and proliferation of combinations of multiple cell types. Because of the vari-
myoepithelial cells, are infrequently occurring tumors of the able presentations of the neoplastic myoepithelial cells,
salivary glands. Myoepitheliomas constitute 1.5% of all sal- these tumors mimic several different types of salivary
ivary gland tumors and myoepithelial carcinomas are still gland tumor, as well as nonsalivary gland tumors. Being
Myoepithelioma/Myoepithelial Carcinoma; Cytologic Features (See Figs. 15.38 to 15.47)
A B
Figs. 15.38A and B. A: Morphology and histological markers of the normal (A) and modified myoepithelial cells (B-E).
Myoepithelial cells assume various shapes and size in neoplastic state. (Courtesy of Lippincott Williams and Wilkins,
Philadelphia, Pennsylvania.) B: FNA of a pleomorphic adenoma showing very pleomorphic myoepithelial cells
which almost correspond to the diagram in Figure 15.38A. Small round cells (R), spindle-shaped cells (S), fiber cells
(F), plasmacytoid cells (P), and large epithelioid cells (E).
uncommon, myoepitheliomas are encountered very rarely show exclusively one cell type or the combination of two
in a routine cytopathology practice. or more cell types (Table 15.9; Figs. 15.38B to 15.46). The
neoplastic cells may be isolated, in groups or aggregates,
and in syncytial tissue fragments with varied architec-
Gross and Microscopic Features ture. They may form nests, chords, trabeculae, fascicles,
or syncytia—the latter does not contain any architectural
Myoepitheliomas are well-circumscribed, encapsulated,
patterns. The cell size can vary from very small and round
and solid tan or yellow–tan with a glistening cut surface.
to large spindle and polygonal type. Their cytoplasm may
Histologically, myoepitheliomas may be entirely com-
be scant, indiscernible to abundant, pale, vacuolated to
posed of spindle cells arranged in interdigitating fascicles
dense and eosinophilic. The stroma is variable from scant
with intervening fi brous stroma, resembling a soft tissue
to abundant. Mitotic activity or necrosis is not a feature
tumor. It may be composed of large epithelioid cells with
of myoepithelioma.
oncocytic or clear cytoplasm forming a solid pattern.
Myoepitheliomas may be composed of plasmacytoid cells
or present a pleomorphic pattern with the participation
of different cell types. The neoplasms are usually hyper-
MYOEPITHELIAL CARCINOMA
cellular with limited myxoid to mucoid stroma and may
form microcystic spaces. Amorphous hyaline material Myoepithelial carcinomas are extremely rare. Their aspi-
accumulates between the islands or cords of tumor cells. rates present a cytologic pattern of high-grade malignancy
Myoepitheliomas are usually composed exclusively with diverse morphologic patterns, mimicking high-grade
of myoepithelial cells; however, some may contain up to malignancies of the salivary gland, soft tissue sarcomas,
5% of duct epithelial cells. Myoepitheliomas also lack the squamous carcinomas, malignant melanomas, or plasma-
chondroid matrix. The distinction between a myoepithe- cytomas (Table 15.9; Figs. 15.47A to C). Confirmation of
lial cell predominant pleomorphic adenoma and a myo- the diagnosis requires immunostaining.
epithelioma is not always possible. From the clinical and
patient management perspective, this is irrelevant.
and Differential Diagnoses
The diagnostic accuracy of myoepithelial neoplasms
The cytopathologic features of myoepitheliomas depend is reported to be low. Since the modified myoepithelial
greatly on their tumor cell composition. The aspirate may cells can assume many different morphologic forms,
TABLE 15.9 CYTOPATHOLOGIC FEATURES OF MYOEPITHELIOMA AND MYOEPITHELIAL CARCINOMA
Myoepithelioma Myoepithelial Carcinoma
Cellularity Variable Variable; scant to hypercellular
Presentation Dependent on the histologic pattern and the cell Usually very cellular
composition; neoplastic cells isolated, in loosely
cohesive groups, in syncytial tissue fragments, in
fascicles; variably associated with matrix material
Cell types Monomorphic with either spindle, plasmacytoid, Neoplastic cells isolated, in loosely cohesive groups and
epithelioid, or pleomorphic with a combination of in varying-sized syncytial tissue fragments without any
all types; small, medium-sized to large; cell borders architectural patterns; dissociated cell pattern frequent
well to poorly defined
Nuclei Round, oval, spindle-shaped; granular, evenly Considerable variation in size, but usually smaller with
dispersed chromatin; micronucleoli ⫹/⫺; high N/C ratios; cell borders well to poorly defined;
intranuclear inclusions ⫹/⫺ round, pleomorphic in size; smooth nuclear membranes;
coarsely granular chromatin; prominent single macro to
multiple nucleoli; mitoses ⫹/⫺; intranuclear inclusions
Cytoplasm Variable, pale to clear, oxyphilic Variable; granular to dense; cyanophilic, eosinophilic;
amphophilic to clear
Background Variable matrix material; none to scant to Necrosis ⫹/⫺; matrix material ⫹/⫺
abundant; pale to dense, hyaline, mucoid-myxoid
to watery, sometimes fibrillar; bare nuclei with clear
cell type
Immunoprofile Reactive for cytokeratins, p-63, calponin, vimentin, Reactive for cytokeratins, p-63, calponin, vimentin, S100
S100 protein, GFAP, muscle specific actin (MSA) protein, GFAP, muscle specific actin (MSA)
Differential Pleomorphic adenoma High-grade mucoepidermoid carcinoma

Diagnoses Oncocytoma Salivary duct carcinoma
Plasmacytoma Poorly differentiated carcinoma, primary or metastatic
Spindle cell lesions soft tissue tumors and Lymphoepithelial carcinoma
tumor-like lesions Malignant melanoma
Mucoepidermoid carcinoma Anaplastic large cell lymphoma
Metastatic renal cell carcinoma
A B
Figs. 15.39A to C. A: An example of myoepithelioma of the parotid gland showing a very large tissue fragment of
tightly packed spindle-shaped cells. The background matrix within the tissue fragment is evident. B, C: Different fields
showing delicate spindle cells springing from stroma. The cells have long cytoplasmic processes. Their nuclei are small
with a bland chromatin pattern.
590
A B
Figs. 15.40A and B. FNA of a myoepithelioma with excessive mucoid stromal material that yielded thick viscous
fluid on aspiration biopsy. A: The large tissue fragment in the background of pale, bubbly stroma consists of pleomor-
phic spindle cells with intervening stromal matrix. B: Higher magnification showing myoepithelial cells with bland
nuclei.
Fig. 15.41. FNA of myoepithelioma showing discrete, medium to

large, plasmacytoid neoplastic myoepithelial cells.
A B
Figs. 15.42A and B. FNA of myoepithelioma. The myoepithelial cells do not show any cell borders and appear as
round to oval naked nuclei with compact chromatin. The matrix is dense and stained eosinophilic to cyanophilic. It
is difficult to ascertain whether these cells are myoepithelial cells embedded in the matrix or they are oncocytic cells
with poorly defined cell borders and forming a syncytial tissue fragment.
Fig. 15.43. Oncocytic type myoepithelial cells. FNA of a myoepi- Fig. 15.44. FNA of a myoepithelioma. Large round to polygonal
thelioma showing large polygonal epithelioid type myoepithelial epithelioid forms of myoepithelial cells with abundant cytoplasm.
cells in syncytial tissue fragment. Their cell borders are poorly de- The cell borders are indistinct. The nuclei have granular chromatin.
fi ned. The cytoplasm is variable, abundant and pale to dense. The Also, note the single spindle-shaped myoepithelial cell.
nuclei are round and contain prominent nucleolus. Some myoepi-
thelial cells are discrete and plasmacytoid. Note the dense matrix
material in the background. (Courtesy of Hitoshi Hara, Pathology
Division, Yamanashi Central Hospital, 1–1-1 Fujimi, Kofu, Yama-
nashi 400, Japan.)
Fig. 15.45. FNA of a myoepithelioma depicting pleomorphic large Fig. 15.46. Aspirated material from a myoepithelioma consisting of
epithelioid type myoepithelial cells embedded in a loose matrix ma- loose acellular matrix with a reticular pattern.
terial. The nuclei are large, pleomorphic containing thready to com-
pact chromatin. Nucleoli are absent.
592
A B
Figs. 15.47A to C. Myoepithelial carcinoma. There are no set cri-

teria for the diagnosis of a myoepithelial carcinoma. It may pres-
ent a pattern of high-grade epithelial malignancy or a soft tissue
sarcoma or malignant melanoma. Immunostains are necessary for
establishing a diagnosis A: FNA of a malignant myoepithelioma
of the parotid gland. The aspirate shows large tissue fragments of
spindle and plasmacytoid cells (low power). B: Higher magnifica-
tion to show a population of large round, polygonal, plasmacytoid
and spindle-shaped cells with pleomorphic nuclei exhibiting malig-
nant features. Note the variable matrix in the background. C: The
aspirate also showed large amounts of dense hyaline matrix. Naked
C nuclei are either embedded in the matrix or seen at the periphery.
myoepithelial neoplasms share cytohistologic patterns morphic adenomas”; this designation is no longer used in
with several different types of salivary gland neoplasms current classification schemes.
as well as nonsalivary gland lesions. Its recognition, in
general, is poor. Accurate cytologic diagnosis is usu- Microscopic Features
ally not possible. The differential diagnoses are listed
in Tables 15.9 and 15.10 and are illustrated in Figures Histologically, basal cell adenomas demonstrate four
15.48 to 15.58. growth patterns, namely, solid, trabecular, tubular, and
membranous; the latter is also referred to as a dermal
anlage tumor. The solid type shows sheets and islands of
small basaloid cells with scant cytoplasm and high N/C
BASAL CELL ADENOMA AND BASAL ratios. The tumor cells at the periphery of the islands
CELL ADENOCARCINOMA often demonstrate a palisading of the nuclei. The neoplas-
tic cells of the trabecular type form anastomosing nar-
BASAL CELL ADENOMA row to broad trabeculae, separated by loose stroma. The
tubular pattern is characterized by small lumens lined by
Basal cell adenomas comprise only 2% of all salivary ductal or basaloid cells. The membranous type is noted
gland neoplasms, occurring more frequently in parotid for the production of large amounts of eosinophilic hya-
glands but may also involve the minor salivary glands. line material or basal lamina, forming thick bands at the
Up until recently, basal cell adenoma was included in periphery of the basaloid cell islands.
the group referred to as “monomorphic adenomas,” and
what are now considered morphologic variants of basal
cell adenomas—namely, trabecular–tubular adenoma and
dermal anlage tumors—were reported separately. The The basal cell adenomas are usually cellular consisting of
canalicular adenoma—an exclusively ductal epithelial cell small uniform cells with scant cytoplasm and high N/C
neoplasm—was also lumped into this group of “mono- ratios. The cells may form small nests, trabeculae, or large
TABLE 15.10 DIFFERENTIAL DIAGNOSES OF SPINDLE CELL LESIONS IN SALIVARY GLAND ASPIRATES

Myoepithelioma or Cellularity variable; bundles of elongated spindle-shaped cells with bland nuclei; 15.48 to
Pleomorphic Adenoma with low N/C ratios; pale variable cytoplasm 15.50
an Extensive Spindle-Cell Type
Myoepithelial Component
Fibrous Histiocytoma Cellularity variable; pleomorphic to monomorphic cell population; cells 15.56,
isolated, in aggregates or in fascicles; round to spindle-shaped with bipolar 15.57
cytoplasmic processes; nuclei small, round, oblong to spindle-shaped with finely
granular chromatin; low N/C ratios; Touton-type multinucleated giant cells and
inflammatory cells ⫹/⫺; variable fibrous to collagenous stroma; micronucleoli ⫹/⫺
Schwannoma Variable cellularity; tissue fragments tend to be thick; spindle-shaped cells, either 15.58
discrete or in fascicles or palisading around acellular cores (Verocay bodies);
comma-shaped nuclei characteristic
Nodular Fasciitis Variable cellularity; spindle-shaped cells either discrete, in loose aggregates or in 15.55
fascicles; slender bipolar cytoplasmic processes; well-defined cell borders with
variable pale cytoplasm; nuclei round, oblong to spindle-shaped with finely granular,
evenly dispersed chromatin; micronucleoli ⫹/⫺; low N/C ratios; mitoses ⫹/⫺;
inflammatory cells including histiocytes with or without hemosiderin; multinucleated
giant cells ⫹/⫺; granular, fibrillar or myxoid material in the background
Solitary Fibrous Tumor A rare occurrence, variable cellularity, dependent on growth pattern; generally e-Fig. 7.43
sparse; spindle-shaped cells discrete or in aggregates; bland, oval nuclei; finely
granular, uniformly dispersed chromatin; nucleoli inconspicuous; cytoplasm
variable; fragments of collagenized stroma in the background; vimentin ⫹;
CD34 ⫹; CK ⫺; EMA ⫺; S100 protein ⫺; desmin ⫺
Spindle Cell Squamous Cellular aspirates; malignant cells isolated, in loosely cohesive groups, or in 24.40
Carcinoma syncytial tissue fragments; predominant spindle cells; size variable, small, large to e-Fig. 7.47
giant forms; nuclei very pleomorphic; multinucleation frequent; nuclear chromatin
coarsely granular; nuclear membranes irregular; prominent nucleoli; mitoses
variable; pale to dense cytoplasm; necrosis ⫹; CEA ⫺; CK ⫹; vimentin ⫺
Malignant Melanoma Variable cellularity; cells dispersed, in aggregates; spindle-shaped cells of various 1.4B
sizes; unipolar and bipolar cytoplasmic processes; well-defined cell borders; 11.14B
nuclei eccentric to central; smooth irregular cell borders; fine to coarsely granular
chromatin; parachromatin clearing; prominent micronucleoli/macronucleoli;
intranuclear cytoplasmic inclusions; cytoplasm variable; melanin pigment ⫹/⫺;
background; necrosis ⫹/⫺; S100 protein ⫹; HMB-45 ⫹; vimentin; Melan A
Differential Diagnoses of Myoepithelioma (See Figs. 15.48 to 15.58)
Fig. 15.48. Pleomorphic adenoma with a predominant spindle cell

pattern the cellular aspirate consists of anastomosing fascicles of
spindle-shaped myoepithelial cells. Matrix material can be visual-
ized, separating some cells. No duct epithelial cells were present.
This aspirate of a pleomorphic adenoma cannot be distinguished
from a spindle cell lesion.
594
A B
Figs. 15.49A and B. FNA of a pleomorphic adenoma. A: The aspirate reveals large tissue fragments composed of
delicate small spindle cells with abundant matrix material, evident even at low power. B: Higher magnification
showing delicate spindle cells embedded in the matrix material.
A B
Figs. 15.50A and B. FNA of a pleomorphic adenoma. A: This large tissue fragment is entirely composed of spindle
cells embedded in matrix material. B: Different field from the same case showing loosely cohesive delicate spindle
cells with bland nuclei. There is pale matrix material in the background and in between the neoplastic cells.
Fig. 15.51. FNA of a pleomorphic adenoma, showing large spindle Fig. 15.52. FNA of a pleomorphic adenoma consisting of a large
cells with elongated nuclei and round cells, both suggests the diag- number of myoepithelial cells with abundant dense eosinophilic cy-
nosis of myoepithelioma. Note the abundant matrix material in the toplasm and may be mistaken for myoepithelioma.
background.
A B
Figs. 15.53A and B. FNA of a pleomorphic adenoma with a predominance of myoepithelial cells exhibiting a plasma-
cytoid pattern and typed as myoepithelioma. A: The myoepithelial cells are pleomorphic with bi- and multinucleation.
Intranuclear cytoplasmic inclusions are conspicuous, a feature described in myoepitheliomas as well. Considerable
stromal substance is present in the background. B: Plasmacytoid cells in an FNA of a soft palate mass, interpreted
as plasmacytoma, histologically proven to be a myoepithelioma. This field shows discohesive and aggregates of
plasmacytoid myoepithelial cells with eccentric nuclei and appreciable dense cytoplasm. The nuclear chromatin
appears bland. The background shows myxoid matrix. (Courtesy of Dr. Eiji Katsuyama, The Department of
Laboratory Medicine, Kyoto City Hospital, Kyoto, Japan.)
Fig. 15.54. FNA of a metastatic plasmacytoma to the parotid gland.

Notice the similarity to myoepithelial cells from myoepithelioma.
A B
Figs. 15.55A and B. FNA of a parotid mass proven to be nodular fasciitis. A: Low-power view of an overwhelmingly
cellular aspirate showing large branching tissue fragments of spindle cells in a fibrillar background. B: The cells are
loosely cohesive or discrete with very bland nuclei and low N/C ratios. (Courtesy of Dr. Catherine S. Abendroth,
Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania.)
A B
Figs. 15.56A and B. Fibrous histiocytoma of the parotid gland. A: Tissue fragment of closely packed round and short
spindle cells with poorly defined borders with intervening dense stroma. B: Different example showing discrete mildly
pleomorphic spindle cells with bland nuclei.
A B
Figs. 15.57A and B. FNA of a fibrous histiocytoma of the parotid gland depicting large tissue fragments of spindle
cells. Compare these with Figure 15.49B to appreciate the morphologic overlap.
Fig. 15.58. FNA of a Schwannoma overlying the parotid region.

This morphology consisting of delicate spindle cells and background
of stroma resembles the myoepithelioma in the right setting—in this
case, the parotid area.
branching tissue fragments, with or without the peripheral illustrated in Figures 15.59 to 15.63. The differential diag-
palisading of nuclei. These cells may be extremely small nosis includes all the disease entities that are composed
and nondescript and escape the attention of the reviewer. of small basaloid cells (see Table 15.27). It is difficult to
The nuclei are round and uniform with compact chroma- accurately diagnose a basal cell adenoma from cytologic
tin. Matrix material may be present. The cytologic fea- samples because of the overlapping features between sev-
tures of basal cell adenoma are listed in Table 15.11 and eral diagnostic entities that are composed of small cells.
TABLE 15.11 CYTOLOGIC FEATURES OF BASAL CELL ADENOMA AND BASAL CELL CARCINOMA
Basal Cell Adenoma Basal Cell Carcinoma

Cellularity Variable; scant to hypercellular Variable; scant to hypercellular
Presentation Tight three-dimensional groups, small to large tissue Tight three-dimensional groups, small to large tissue
fragments with cords and trabeculae, some with fragments with cords and trabeculae, some with
branching and anastomosing, often enclosing varying- branching and anastomosing, often enclosing varying-
sized spaces; some tissue fragments with papillary- sized spaces; some tissue fragments with papillary-
like pattern with or without branching; syncytial like pattern with or without branching; peripheral
tissue fragments may demonstrate tubular pattern palisading of nuclei; syncytial tissue fragments may
with lumina; tissue fragments may be bordered by demonstrate tubular pattern with lumina; tissue
acellular material (basement membrane material) fragments may be bordered by acellular material
stained magenta in Romanowsky stained material (basement membrane material) stained magenta in
or cyanophilic to eosinophilic with Papanicolaou Romanowsky stained material or cyanophilic to
method; cells often separated by similar acellular eosinophilic with Papanicolaou method; cells often
material separated by similar acellular material
Cells Usually monomorphic to minimally pleomorphic, Monomorphic to pleomorphic; larger than their
small basaloid cells 1–1.5 times the resting lymphocyte benign counterparts with poorly defined cell borders
with poorly defined cell borders (nonluminal cells) (nonluminal cells) to slightly larger luminal cells
to slightly larger luminal cells with well-defined cell with well-defined cell borders and scant cytoplasm;
borders and scant cytoplasm; monomorphic pattern monomorphic pattern more commonly seen in solid
more commonly seen in solid variants variants; squamoid differentiation ⫹/⫺
Nucleus Round, oval to oblong, angular; smooth nuclear Nuclear pleomorphism; round, oval to oblong,
contour; high N/C ratios; chromatin compact in angular; smooth nuclear contour; high N/C ratios;
basaloid cells and finely granular in larger cells; chromatin deep-staining coarsely granular to compact
micronucleoli infrequent; no nuclear molding; no in basaloid cells; finely granular in larger cells;
mitoses; no karyorrhexis micronucleoli frequent; no nuclear molding; mitoses
frequent
Cytoplasm Indiscernible to scant and may be dense or vacuolated Indiscernible to scant and may be dense or vacuolated
Background Usually very clean; amorphous acellular material may Usually very clean; amorphous acellular material may
be seen bordering the cells be seen bordering the cells; necrosis ⫹/⫺
Immunoprofile Consistent and diffuse reactivity to pancytokeratin Consistent and diffuse reactivity to pancytokeratin
(AE1/AE3); CK14; vimentin; focal reactivity to S100 (AE1/AE3); CK14; vimentin; focal reactivity to S100
protein, smooth muscle actin, and carcinoembryonic protein, smooth muscle actin, and carcinoembryonic
antigen, epithelial membrane antigen and c-kit (CD117) antigen, epithelial membrane antigen and c-kit (CD117)
Basal Cell Adenoma/Basal Cell Carcinoma (See Figs. 15.59 to 15.63)
A B
Figs. 15.59A and B. FNA of a basal cell adenoma. The aspirate is poorly cellular showing a rare syncytial tissue
fragment of very small cells with poorly defined cell borders and indiscernible cytoplasm.
598
A B
Figs. 15.60A and B. The aspirate from this basal cell adenoma of the minor salivary glands of the lip shows dual
population of cells. Note the very small basaloid cells with nuclei containing compact chromatin, present in syncytial
tissue fragments as well as discrete appearing as naked nuclei. The larger cells have nuclei containing pale, granular
chromatin and micronucleoli.
Fig. 15.61. The basaloid cells from the trabecular-tubular type basal
cell adenoma show syncytial arrangement with tubular pattern.
The neoplastic cells are slightly larger than previously illustrated
cases and contain deep-staining chromatin. Note the intercellular
matrix.
A B
Figs. 15.62A and B. A: FNA Basal cell adenoma. Low-power view of syncytial tissue fragments of basaloid cells with
empty microcystic spaces. Also, note the peripheral palisading of the nuclei. B: Monomorphic basaloid cells with
round to oval nuclei containing deep-staining chromatin. (Courtesy of Department of Pathology, Ottawa General
Hospital, Ottawa.)
A B
Figs. 15.63A and B. Basal cell adenoma. A: Low-power view of syncytial tissue fragments of basaloid cells with empty
microcystic spaces. Also, note the peripheral palisading of the nuclei. B: Monomorphic basaloid cells with round to
oval nuclei containing deep-staining chromatin. (Courtesy of Department of Pathology, Ottawa General Hospital,
Ottawa.)
BASAL CELL ADENOCARCINOMA number of cysts exuding clear, mucoid, brown fluid or
caseous, semisolid contents. The cysts vary from slit-like
Basal cell adenocarcinoma is the malignant counterpart
spaces to several centimeters and may occupy the entire
of the basal cell adenoma and is a rare occurrence. It pres-
lesion. The cyst lining has small knob-like excrescences,
ents morphologic characteristics that are very similar to
representing papillary epithelial proliferations. The inter-
that of basal cell adenoma. Cellular and nuclear pleomor-
cystic areas appear tan to white and nodular.
phism, mitosis and necrosis, and invasive characteristics
The histologic features of Warthin’s tumors are dis-
are the main differentiating features from adenoma. Their
tinctive, characterized by papillary proliferations of bi-
cytologic features are listed in Table 15.11 and illustrated
layered oncocytic epithelium with a supporting stroma
in Figures 15.64 to 15.66.
of lymphoid tissue containing germinal centers (e-Fig.
The differential diagnosis is the same as that for
15.14). The tumor is sharply demarcated from the sur-
basal cell adenoma in addition to cutaneous basal cell
rounding parenchyma and is thinly encapsulated. The
carcinoma in the skin overlying the salivary gland tumor
luminal epithelium of the cysts is composed of tall co-
(Fig. 15.67A and B).
lumnar cells often with a palisading of their ovoid nu-
clei located either in the center or in the apical part of
the cells. Sometimes proliferations of mucous cells are
interspersed. The tall columnar cells have finely granu-
WARTHIN’S TUMOR lar, brightly eosinophilic cytoplasm and well-defined cell
borders. The luminal surfaces may show apocrine-like
Warthin’s tumor—also known as papillary cystadenoma secretions in the form of small protuberances. The cyst
lymphomatosum or adenolymphoma—is the second most lumens contain secretions, cellular debris, and some-
common benign tumor of the salivary glands, almost times, laminated bodies resembling corpora amylacea.
exclusively occurring in the parotid glands involving the Beneath and between the columnar cells are small
tail but some occur in the deep lobe. Warthin’s tumors basaloid cells, often triangular with fusiform nuclei,
account for 5 to 15% of salivary gland tumors. perpendicular to the long axis of tall columnar cells.
Warthin’s tumors are more common in males and Their cell borders are poorly defined, and the cytoplasm
occur beyond the fi fth decade of life, with the average is brightly eosinophilic. The proportion of epithelial
age being 67 years. The tumors can be unilateral, bilat- proliferation and lymphoid tissue varies. The foci of
eral, and multicentric. They present clinically as painless, squamous metaplasia are not uncommon. Mucus meta-
sometimes fluctuant, swelling in the lower portion of the plasia is also seen.
parotid gland.
GROSS AND HISTOLOGIC FEATURES
The aspirates of Warthin’s tumor are easily recognized
Grossly, Warthin’s tumor appears as a spherical to ovoid, because of their characteristic cytologic presentation con-
well-circumscribed mass. The cut surface shows a variable sisting of an admixture of oncocytic cells and lymphoid
Basal Cell Adenocarcinoma (See Figs. 15.64 to 15.67)
A B
Figs. 15.64A and B. FNA of a basal cell adenocarcinoma. The syncytial tissue fragments of basaloid cells are tightly
packed and have hyperchromatic nuclei. Note that the nuclear pleomorphism is minimal. The carcinoma cells are
mildly pleomorphic and nucleoli are visible. The tissue fragment presents a three-dimensional architecture, reminiscent
of that seen in adenoid cystic carcinoma. (Courtesy of Department of Pathology, Ottawa General Hospital, Ottawa.)
A B
C D
Figs. 15.65A to D. FNA of a basal cell adenocarcinoma. A: The aspirate is very cellular consisting of large, branching
papillary-like syncytial tissue fragments of basaloid cells (low power). B: The neoplastic cells are basaloid with indis-
tinct cell borders and nondiscernible cytoplasm. The nuclei are moderately pleomorphic in size and are round, oval
to oblong in shape. The nuclear chromatin is deep-staining, coarsely granular associated with nucleoli. C: Same case
as above, stained by Romanowsky method. D: Pleomorphic basal cell adenocarcinoma cells, larger than their normal
counterparts. Note the magenta–colored matrix material. (Courtesy of Dr. Lata Pisharodi, Department of Pathology
and Laboratory Medicine, Brown University, Providence, Rhode Island.)
A B
C D
Figs. 15.66A to D. Basal cell adenocarcinoma. A: Hypercellular aspirate demonstrating large numbers of tissue
fragments with varying architecture such as papillary-like, branching trabeculae enclosing empty spaces and some
without forming any patterns. The background shows discrete and groups of neoplastic cells (low power). B: Me-
dium power depicting papillary-like architecture. The cells appear basaloid. Many tissue fragments lack any specific
architecture. Peripheral palisading of nuclei can be appreciated. C: Basaloid cells with uniform nuclei. Note a filiform
tissue fragment containing a core of hyaline matrix material, bordered by basaloid cells. Note the branching tissue
fragments and magenta stained hyaline matrix (low power). Romanowsky stained preparation. D: Higher magnifica-
tion depicting basaloid cells. (Courtesy of Dr. Nina Dhurander, Department of Pathology, Tulane University Medical
Center, New Orleans, Louisiana.)
A B
Figs. 15.67A and B. FNA of a cutaneous basal cell carcinoma. The tissue fragments are syncytial, composed of
basaloid cells with deep-staining nuclei. The architecture is papillary-like with peripheral palisading of nuclei.
Note the cytomorphology is very similar to basal cell adenocarcinoma. Cytologically, these two entities cannot be
differentiated.
cells in varying proportions (Table 15.12; Figs. 15.68 cytoplasm is abundant and granular, staining eosinophilic,
to 15.78). The oncocytic cells vary in size, occurring sin- cyanophilic, or amphophilic in Papanicolaou-stained
gly, in loosely cohesive groups or in sheets with a hon- preparations. Oncocytic cell nuclei are round and small
eycomb arrangement (Figs. 15.69 and 15.70). Papillary with finely granular chromatin and prominent nucleoli.
confi guration with or without branching may also be Varying numbers of lymphoid cells are present in the
encountered. Their cell borders are well-defi ned, and the background. The latter may be mucoid or dirty with cel-
lular and amorphous debris (Figs. 15.71 and 15.72). The
granular debris presents a characteristic appearance with
a lack of inflammatory cells such as neutrophils and con-
WARTHIN’S TUMOR
tains anucleate forms. With rare oncocytic cells or even
Presentation Aspirate semisolid, viscous, pasty or of fluid in their absence, such debris in aspirates should raise
consistence; an admixture of lymphoid cells suspicion for Warthin’s tumor. Squamous cells, derived
and oncocytic epithelial cells in varying from metaplastic process, with or without nuclear atypia
proportions may be seen, derived from squamous metaplasia. Pre-
dominance or absence of either an epithelial or lymphoid
Arrangement Oncocytic cells isolated, in loosely cohesive component may pose diagnostic problems.
groups, in sheets and in branching tissue
fragments with or without papillary
configurations DIAGNOSTIC DIFFICULTIES AND
Cells Medium-sized to large; cuboidal to polygonal
or columnar with well-defined cell borders The cytologic identifi cation of Warthin’s tumor is easy
when all the key components are present:
Nucleus Uniform, round to oval, central location, 1. Cyst aspirate containing cellular, necrotic, granular,
smooth nuclear membrane, granular chromatin, debris with degenerating cells and mucoid background
prominent macronucleolus; low N/C ratios
2. Oncocytes
3. Lymphoid cells
Cytoplasm Abundant granular, eosinophilic to
cyanophilic, amphophilic, sometimes clear The diagnostic difficulties stem from inadequate
cellularity, absence of one of the components, and the
Background Mucoid; lymphoid cells with or without predominance of the degenerative and metaplastic
germinal center cells, cellular and amorphous changes.
debris; degenerating and anucleated The differential diagnoses of Warthin’s tumor in-
epithelial cells, squamous metaplasia ⫹/⫺;
clude several diagnostic entities (Table 15.13). If the as-
squamous cells with atypical forms, with or
without keratinization; mast cells ⫹/⫺ in
pirates contain predominantly or exclusively oncocytic
Romanowsky stained preparations cells, neoplasms such as oncocytoma, oncocytic papillary
cystadenoma, pleomorphic adenoma with predominant
Warthin’s Tumor (See Figs. 15.68 to 15.73)
A B
Figs. 15.68A and B. A: FNA of a Warthin’s tumor showing a large tissue fragment of oncocytic cells in the back-
ground of lymphocytes (low power). B: Another field showing branching tissue fragments of oncocytic cells. Note
the inflammatory cells in the background.
A B
Figs. 15.69A to C. FNA Warthin’s tumor. A: The oncocytes here

contain abundant cyanophilic cytoplasm. The nuclei are small, round
with prominent cherry-red nucleoli. B: Discrete oncocytic cells in a
mucoid background. C: Oncocytes arranged in a honeycomb sheet
with well-defined cell borders, eosinophilic granular cytoplasm and
C prominent nucleolus.
A B
Figs. 15.70A and B. FNA Warthin’s tumor. A: A low power view depicting several tissue fragments of oncocytes with
lymphocytes in the background. B: Higher power showing the distinctive cytomorphology of the oncocytes with
cherry–red macronucleolus.
A B
Figs. 15.71A and B. FNA of a Warthin’s tumor. A: Granular and amorphous debris. This is a nondiagnostic aspirate
with no epithelial or lymphoid cells. B: However, the cell block contained the diagnostic cellular material with onco-
cytic epithelium and lymphoid cells (H&E).
Fig. 15.72. FNA of a Warthin’s tumor. Abundant granular and Fig. 15.73. Another field from the same case as 15.72 showing
amorphous debris with a few lymphocytes and anucleated forms keratinized squamous cells and degenerating oncocytes. The back-
of epithelial cells should always raise the suspicion for Warthin’s ground shows granular debris and lymphocytes.
tumor in the right setting.
Differential Diagnoses of Warthin’s Tumor (See Figs. 15.74 to 15.78)
Fig. 15.74. FNA of Warthin’s tumor consisting of predominant on- Fig. 15.75. FNA of Warthin’s tumor. Cyst fluid, containing a group
cocytic cells and very sparse lymphocytes will lead to an interpreta- of squamoid cells in the background of lymphocytes with no other
tion of an Oncocytoma. features to support the diagnosis of Warthin’s tumor, may be inter-
preted as a benign lymphoepithelial cyst.
Fig. 15.76. FNA of a Warthin’s tumor containing atypical squamous

cells may lead to a false diagnosis of a squamous carcinoma.
A B
Figs. 15.77A and B. These cells from a parotid cyst fluid may be mistaken for oncocytic cells and the aspirate inter-
preted as Warthin’s tumor. The surgical excision confirmed a mucoepidermoid carcinoma.
A B
Fig. 15.78A to B. FNA of a parotid cyst. A: The aspirate is poorly cellular with a rare tissue fragment of oncocytic
cells. Other cytologic features to support the diagnosis of Warthin’s tumor were not present. B: The surgical excision
revealed an encapsulated cystic lesion (H&E). (continued)
Fig. 15.78C. (continued) C: Higher magnification to show the pap-

C illary oncocytic papillary cystadenoma.
TABLE 15.13 DIFFERENTIAL DIAGNOSES OF WARTHIN’S TUMOR
Cytologic Features Diagnostic Entity Mistaken for See Fig(s).

Cyst fluid, lacking both, epithelial cells (oncocytes) and Nonneoplastic cysts: Mucus retention cyst
inflammatory cells; mucoid background Mucocele
Cyst fluid, lacking oncocytes;

1) Presence of lymphoid cells and mucoid background Nonneoplastic cysts:
Mucus retention cyst
Lymphoepithelial cyst
Lymphoepithelial lesion
2) Presence of squamous cells with or without Branchial cleft cyst 15.72, 15.73
keratinization and with or without nuclear atypia; Squamous carcinoma 15.76
lymphoid cells ⫹/⫺; and mucoid background Mucoepidermoid carcinoma 15.114
3) Lymphoid cells only; no oncocytes; lack dirty, Chronic sialadenitis

necrotic background Intraparotid lymph node
Benign lymphoepithelial lesion
Lymphoproliferative disorder
Oncocytes only; sparse or absent lymphoid cells; clean Oncocytic lesions 15.74
background Oncocytic hyperplasia 15.78
Oncocytoma
Oncocytic papillary cystadenoma
Cyst fluid; histiocytes mistaken for acinic cells; and Acinic cell carcinoma
lymphoid cells in the background
epithelioid type myoepithelial cells, myoepithelioma, and a mucoid background may be paucicellular and misinter-
mucoepidermoid carcinoma must be ruled out. With a preted as a mucocele or mucus retention cyst or even as
predominant lymphocytic component and sparse onco- a branchial cleft cyst (Table 15.13; Fig. 15.73) or cystic
cytes, the aspirate may be interpreted as a benign lym- neoplasms such as pleomorphic adenoma with degen-
phoepithelial lesion (Fig. 15.75), reactive lymphoid pro- eration, low-grade mucoepidermoid carcinoma, or an
liferation, or malignant lymphoma (see Table 15.38). oncocytic cystadenoma (Figs. 15.77 and 15.78). On the
Atypical squamous cells originating from ductal metapla- other hand, these same neoplasms may be interpreted as
sia are sometimes misinterpreted as squamous carcinoma Warthin’s tumor. A cell block preparation has been help-
(Fig. 15.76). The aspirate representing cyst contents with ful in accurate diagnosis particularly when the aspirated
fluid shows only lymphoid cells in a mucoid background peak incidence between the seventh and ninth decades of
or cellular debris with anucleated cells (Fig. 15.71B). life. Oncocytoma occurs equally in both sexes and is more
Rarely is an aspirate of Warthin’s tumor submitted as common in parotid glands. There is a high incidence of
that from a thyroid nodule where the nodule is palpable direct or indirect exposure to radiation.
in the apex of the upper lobe when in fact the lesion is a Clinically the dominant complaint is swelling for
Warthin’s tumor arising at the extreme lower end of the weeks to years and is rarely associated with pain.
parotid gland. A diagnosis of oncocytoma or Hashimoto’s
thyroiditis may be rendered. Table 15.13 lists the poten- Gross and Histologic Features
tial diagnostic pitfalls of aspirates of Warthin’s tumor, and Grossly, oncocytoma is encapsulated, well-circumscribed,
these are illustrated in Figures 15.74 to 15.78. and tan to red–brown. Large neoplasms are prone to degen-
eration, cyst formation, and necrosis as well as infarction.
Microscopically, the tumor shows a solid growth pattern
ONCOCYTOMA AND ONCOCYTIC and is exclusively composed of sheets and nests of large
CARCINOMA round to polygonal cells with abundant, granular, deeply
eosinophilic cytoplasm, separated by delicate and incon-
spicuous capillaries. Their nuclei are small with compact
ONCOCYTOMA chromatin. Clear cells containing glycogen may dominate.
Oncocytoma is a benign neoplasm composed of onco- Larger tumors tend to undergo degenerative changes.
cytic cells with large amounts of granular eosinophilic
cytoplasm containing excessive mitochondria. The neo-
plasm occurs rarely, comprising 2% of all salivary gland The cytologic pattern of oncocytoma is characteristic
tumors. It is rare in patients under 50 years of age with a (Table 15.14; Figs. 15.79 to 15.83) and is presented with a
TABLE 15.14 CYTOLOGIC FEATURES OF ONCOCYTOMA AND ONCOCYTIC CARCINOMA
Oncocytoma Oncocytic Carcinoma

Cellularity Usually very cellular Usually very cellular
Presentation Neoplastic cells isolated, in loosely cohesive groups and Neoplastic cells isolated, in loosely cohesive groups and
in varying-sized syncytial tissue fragments without any in varying-sized syncytial tissue fragments without any
architectural patterns; dissociated cell pattern frequent; architectural patterns; dissociated cell pattern frequent
capillaries traversing through the tissue fragments
Cells Considerable variation in size, low N/C ratios; cell Considerable variation in size, but usually smaller with
borders well to poorly defined high N/C ratios; cell borders well to poorly defined
Nucleus Round, pleomorphic in size; smooth nuclear Round, pleomorphic in size; smooth nuclear
membranes; coarsely granular chromatin; prominent membranes; coarsely granular chromatin; prominent
single macronucleolus; mitoses ⫺; intranuclear single macro to multiple nucleoli; mitoses ⫹/⫺;
inclusions ⫺ intranuclear inclusions ⫹/⫺
Cytoplasm Variable but scant; granular to dense; cyanophilic, Variable but scant; granular to dense; cyanophilic,
eosinophilic; amphophilic to clear eosinophilic; amphophilic to clear
Background Necrosis ⫹/⫺ with large size; anucleated forms stain Necrosis ⫹/⫺, no lymphoid cells
orangeophilic, mimicking keratinizing squamous cells;
no lymphoid cells
Differential Oncocytic hyperplasia Mucoepidermoid carcinoma

Diagnoses Warthin’s tumor Salivary duct carcinoma
Pleomorphic adenoma Undifferentiated carcinoma
Myoepithelioma Lymphoepithelioma
Oncocytic papillary cystadenoma Metastatic poorly differentiated carcinomas
Oncocytoma/Oncocytic Carcinoma (See Figs. 15.79 to 15.83)
Fig. 15.79. FNA of an oncocytoma. Loosely cohesive and discrete, Fig. 15.80. FNA of an oncocytoma showing a uniform population
large, round to polygonal oncocytes with well-defined cell borders, of large oncocytic cells with abundant granular eosinophilic cyto-
abundant, granular cytoplasm and small, round nuclei. Note the plasm. Note the capillaries traversing through the tissue fragment
prominent cherry–red macronucleolus. (arrows).
Fig. 15.81. FNA of an oncocytoma demonstrating a large tissue

fragment of oncocytic cells.
A B
Figs. 15.82A and B. FNA of an oncocytoma. A: This aspirate revealed extensive necrosis. Note the cellular debris
and degenerating oncocytes with dense orangeophilic cytoplasm and pyknotic nuclei resembling squamous cells. An
aspirate from this cystic area may be interpreted as Warthin’s tumor. B: Extensive degeneration and necrosis in an
oncocytic neoplasm with anucleate forms and eosinophilia may lead to misinterpretation of squamous carcinoma.
monomorphic population of large oncocytes that are iso- weakness or paralysis. The tumor may be rapidly grow-
lated and in sheets. The neoplastic cells are large and round ing. Local lymph nodes are often enlarged.
to polygonal with abundant, granular cytoplasm and a
small, central to eccentrically located nucleus with a promi- Gross and Microscopic Features
nent cherry–red macronucleolus (Figs. 15.79 and 15.80).
Grossly, the tumor may be uni- or multinodular, firm, non-
Binucleation is frequent. Capillaries are often seen travers-
encapsulated, gray to gray–brown, and focally necrotic.
ing through the tissue fragments of the neoplastic cells (Fig.
Microscopically, oncocytic carcinoma presents a solid
15.80). Larger neoplasms are prone to degeneration and
growth pattern and is composed of oncocytic cells arranged
cyst formation, yielding cystic aspirate with cellular and
in sheets, islands, and cords or as scattered discohesive indi-
necrotic debris (Fig. 15.82). The cytologic features are listed
vidual cells that have abundant granular cytoplasm and very
in Table 15.14 and illustrated in Figures 15.79 to 15.83.
pleomorphic nuclei with prominent nucleoli. Mitoses are
frequent, and necrosis is common. Some oncocytic carcino-
ONCOCYTIC CARCINOMA mas are composed of smaller cells with high N/C ratios.
Oncocytic carcinoma is a rare malignant neoplasm, five
times less common than its benign counterpart. Oncocytic
carcinoma involves the parotid gland more frequently The cytologic features of oncocytic carcinoma (Table
and rarely involves the submandibular and minor salivary 15.14; Figs. 15.84 to 15.86) differ in many respects
glands. It occurs in older individuals, with the average age from those seen with oncocytomas. One pattern includes
being 63 years. considerable pleomorphism in the cell size, higher N/C
Clinically, oncocytic carcinoma presents as a parotid ratios, larger nuclei with macronucleoli, and the arrange-
mass. Roughly 20% will have associated pain and facial ment of cells in syncytial tissue fragments. Mitoses may
Fig. 15.83. FNA from a very large oncocytoma, showing a thick

tissue fragment of oncocytic cells. The abundant granular deep eo-
sinophilic cytoplasm is characteristic.
Oncocytic Carcinoma (See Figs. 15.84 to 15.86)
Figs. 15.84A and B. An aspirate of a recurrent oncocytic carcinoma

of the parotid gland showing syncytial tissue fragments of malig-
nant cells without any architectural patterns. The malignant cells
are variable in size with poorly defined cell borders. The scant but
granular cytoplasm is stained cyanophilic. Macronucleoli are evi-
dent in some cells.
A B
Figs. 15.85A to C. A, B: An aspirate of an oncocytic carcinoma

demonstrating syncytial tissue fragments of malignant cells with no
architectural patterns and with marked crowding and overlapping
of nuclei. The cells are small with scant but cyanophilic cytoplasm.
The nuclei are round with high N/C ratios and contain prominent
nucleoli. C: Fine needle biopsy of an oncocytic carcinoma. The mor-
phology of these cells is very different from two cases illustrated
above. The cells are larger with greater amount of cytoplasm and
lower N/C ratios. The tissue fragments however show a syncytial
arrangement. This case was interpreted as an oncocytic neoplasm.
C Surgical resection four years later showed oncocytic carcinoma.
Fig. 15.86. Oncocytic carcinoma, same case as above. Syncytial tis-

sue fragments of oncocytic carcinoma cells. Note that the cells are
smaller with high N/C ratios. The nucleoli are very prominent.
be frequent, and necrosis is evident in the background. (Figs. 15.85 and 15.86). The differential diagnoses for
The second pattern consists of very small cells with a dis- oncocytoma include nonneoplastic lesions with a pre-
persed pattern or in syncytial tissue fragments without dominance of oncocytes such as nodular or diffuse onco-
any architectural patterns. Their N/C ratios are very high, cytic hyperplasia (Fig. 15.87), oncocytic papillary cysta-
and macronucleoli are very conspicuous. denoma (Fig. 15.78), and Warthin’s tumor (Fig. 15.70).
Other neoplasms that resemble the morphology include
myoepithelioma with an epithelioid pattern, mucoepi-
dermoid carcinoma, acinic cell carcinoma, clear cell car-
The cytologic differentiation of an oncocytoma from cinoma, and metastatic renal cell carcinoma. The differ-
an oncocytic carcinoma is considered impossible. How- ential diagnostic entities and the differentiating features
ever, certain features such as small cell size, syncytial are listed in Table 15.14 and 15.15 and illustrated in Fig-
arrangement, high N/C ratios should serve as a red flag ures 15.87 to 15.94.
TABLE 15.15 DIFFERENTIAL DIAGNOSES OF ONCOCYTIC LESIONS OF THE SALIVARY GLANDS

Diagnostic Entities Cytomorphology

Oncocytoma Monomorphic population of large oval to polygonal cells; isolated, in loosely cohesive groups, in
sheets or in syncytial tissue fragments; well-defined cell borders; abundant granular cytoplasm; round
to oval nuclei with smooth nuclear membrane, finely granular, evenly dispersed chromatin with
macronucleoli, low N/C ratios; clear cell change ⫹/⫺; no lymphoid cells in the background
Oncocytic Carcinoma Large population of oncocytic cells with considerable pleomorphism in size; cells isolated, in loosely
cohesive groups, or in syncytial tissue fragments; well-defined cell borders; variable, granular to dense
cytoplasm; round to oval nuclei; coarsely granular, chromatin with macronucleoli, high N/C ratios;
clear cell change ⫹/⫺; mitoses ⫹/⫺; background clean to dirty
Oncocytic Papillary Monomorphic population of large oval to polygonal cells; isolated, in loosely cohesive groups,
Cystadenoma in sheets or in syncytial tissue fragments with papillary configurations; well-defined cell borders;
abundant granular cytoplasm; round to oval nuclei with smooth nuclear membrane, finely granular,
evenly dispersed chromatin with macronucleoli, low N/C ratios; no lymphoid cells in the background
Warthin’s Tumor Mucoid to turbid aspirate; admixture of lymphoid cells and oncocytic epithelial cells, isolated, in
loosely cohesive groups, or in varying-sized tissue fragments with honeycomb pattern with or without
branching, cells cuboidal, polygonal to columnar; well-defined cell borders; abundant granular
cytoplasm with low N/C ratios; small round nuclei with granular chromatin and prominent nucleoli;
mucoid background with cellular debris
Mucoepidermoid Lesions may be cystic; cellularity variable; polymorphic cell population; cells discrete, in loosely
Carcinoma with cohesive groups or in syncytial tissue fragments; cells round to oval, columnar, some with well-defined
Oncocytic Features borders; cytoplasm variable, pale, vacuolated to dense; nuclei round with smooth nuclear membranes
and micronucleoli; background clean to mucoid; cellular debris ⫹/⫺; mucin producing cells;
squamous and intermediate type cells
Pleomorphic Adenoma Admixture of epithelial cells (ductal type and myoepithelial type) and tissue fragments of
with Predominant fibromyxochondroid stroma; epithelial cells very pleomorphic, small round, cuboidal, columnar,
Oncocytic Metaplasia spindle-shaped to polygonal with oncocytic features; nuclei small with bland chromatin and
inconspicuous nucleoli; no lymphoid cells in the background
Myoepithelioma Cellular aspirate; malignant cells isolated, in loosely cohesive groups, or in syncytial tissue fragments;
cells medium to large, uniform, round to cuboidal; well-defined cell borders; N/C ratios low; nuclei
mildly pleomorphic round to oval; finely granular chromatin; micronucleoli ⫹; variable pale to dense
granular cytoplasm; background usually clean, matrix material ⫹/⫺
Metastatic Renal Cell Cellular aspirate; malignant cells isolated, in loosely cohesive groups, or in syncytial tissue
Carcinoma fragments; cells medium to large, uniform, round to cuboidal; well to poorly defined cell borders;
N/C ratios variable; nuclei mildly to severely pleomorphic round to oval; finely granular chromatin;
micronucleoli ⫹; variable pale to dense granular cytoplasm; background usually clean
The differential diagnoses for oncocytic carcinomas frequently occurs in parotid glands, is more common in
include all high-grade malignancies (see Table 15.29). females, and can occur at any age including the pediatric
age group. The clinical course depends on the histologic
grade with the low-grade tumor offering an excellent
prognosis.
MUCOEPIDERMOID CARCINOMA
Mucoepidermoid carcinoma, as the name implies,
is composed of mucin-producing cells and epidermoid
Mucoepidermoid carcinoma is the most common malig- (squamous) and other cell types such as intermediate, co-
nant neoplasm of the major salivary glands accounting lumnar, and clear cells in varying proportion (Table 15.16;
for 30 to 35% of all primary malignant neoplasms. It Figs. 15.95A to F). Clinically, mucoepidermoid carcinoma
Differential Diagnoses of Oncocytoma (See Figs. 15.87 to 15.94)
Fig. 15.87. Oncocytic hyperplasia versus oncocytoma. A poorly Fig. 15.88. This aspirate consisted of a large population of onco-
cellular aspirate of a parotid mass consisting of only three tissue cytic cells with a cytologic diagnosis of oncocytoma. Surgical exci-
fragments of oncocytic cells with morphology suggestive of an on- sion revealed Warthin’s tumor with a major epithelial (oncocytic)
cocytoma. A Warthin’s tumor was also considered in the differential component. Lymphocytes were present only in small numbers and
diagnosis. Surgical excision showed nodular oncocytic hyperplasia. were overlooked.
Note that these cells of oncocytic hyperplasia cannot be differenti-
ated from those of neoplastic oncocytes.
Fig. 15.89. Predominant oncocytic type myoepithelial cells in pleo- Fig. 15.90. Acinic cell carcinoma. FNA biopsy of a parotid mass
morphic adenoma versus oncocytoma. Note the streak of plas- consisting of syncytial tissue fragments of large polygonal cells with
macytoid discrete myoepithelial cells. These cells lack prominent abundant eosinophilic cytoplasm and small uniform nuclei. The sur-
macronucleoli. Presence of such cells should favor a diagnosis of gical excision confirmed an acinic cell carcinoma.
pleomorphic adenoma.
Fig. 15.91. Acinic cell carcinoma. The cells of acinic cell carcinoma Fig. 15.92. FNA of a clear cell carcinoma. The neoplastic cells are
have oncocytic cytoplasm and may be mistyped as an oncocytoma. medium-sized, round, many containing oxyphilic cytoplasm.
613
Fig. 15.93. Mucoepidermoid carcinoma. A large tissue fragment of Fig. 15.94. Metastatic renal cell carcinoma. An aspirate of a parotid
intermediate cells with uniform nuclei and scant cytoplasm. mass from a patient with a history of renal cell carcinoma. The ma-
lignant cells are arranged in syncytial tissue fragments. They are large
with abundant dense cyanophilic cytoplasm and contain prominent
macronucleoli. Surgical excision confirmed the metastatic carcinoma.
TABLE 15.16 CELLS OF MUCOEPIDERMOID CARCINOMA
Cell Type Morphologic Features See Fig(s).

Mucin-Producing Medium-sized to large, round with poorly defined cell borders, eccentric nuclei containing 15.95A and C
Cells (Goblet cells) finely granular chromatin and micronucleoli; cytoplasm variable, moderate to abundant,
pale, foamy, bubbly or vacuolated with single (signet-ring-type) or multiple vacuoles.
May be seen isolated, or in tissue fragments sometimes associated with intermediate cells;
vacuoles may indent the nuclei
Intermediate Cells Vary in size from small basaloid type cells, slightly larger than lymphocytes to medium- 15.95A, C,
sized, round to cuboidal with well-defined cell borders; nuclei in basaloid type cells tend to E, and F
have compact chromatin with scant cytoplasm and high N/C ratios; larger cells represent
transition forms with well-defined cell borders, variable cytoplasm that may contain
vacuoles; nuclei central with granular chromatin prominent nucleoli in intermediate-
grade carcinomas; these cells appear bland to obviously malignant; usually seen in tissue
fragments, sometimes in intimate contact with mucous producing cells or squamous cells
Squamous Cells Squamous cells or epidermoid cells are mature squamous cells with pale to dense, 15.95A and C
eosinophilic or cyanophilic cytoplasm, well-defined cell borders and central nuclei;
granular chromatin with or without nucleoli or be pyknotic; nuclei appear clearly
malignant in high-grade tumors; anucleated squames ⫹/⫺; metaplastic forms of squamous
cells ⫹/⫺; keratinization and keratin pearl formations not present
Clear Cells Usually present in small numbers (roughly 10%); large, round with well to poorly defined 15.95A and C
cell borders; abundant, pale to clear cytoplasm; small, central nuclei with high N/C ratios;
granular chromatin with micronucleoli
Columnar Cells Slender elongated cells with one broad end and a narrow tapering end that houses the 15.95B and C
nucleus; these line the cystic or ductal structures and are encountered less often
presents as a solitary painless mass in the preauricular

or submandibular areas with variable duration. Those
involving the minor salivary glands may appear as a Mucoepidermoid carcinomas may be circumscribed and
fl uctuant mass with a bluish smooth surface resembling partially encapsulated in low-grade tumors or poorly
a mucocele. Discharge from these may suggest a dental defined and invasive. The cut surface is usually firm, gray–
abscess. tan yellow or pink and lobulated. Cysts are often seen;
Mucoepidermoid Carcinoma (See Figs. 15.95 to 15.101)
A B
C D
E F
Figs. 15.95A to F. A: This image shows mucus-producing cells (M), discrete intermediate cells (I), squamous cells (S),
and clear cells (C). B: A tissue fragment of uniform intermediate cells with nuclei containing compact chromatin and
high N/C ratios. C: Basaloid type intermediate cells with nuclei containing compact chromatin and high N/C ratios.
D: This image shows many discrete mucus-producing cells (M), and a squamous cell (S). E: This image shows mucus-
producing cells (M), a tissue fragment of intermediate cells (I), squamous cells (S), anucleated squames, and clear cells
(C). F: Larger intermediate cells and clear cells.
TABLE 15.17 CYTOPATHOLOGIC FEATURES OF LOW-GRADE, INTERMEDIATE-GRADE AND

HIGH-GRADE MUCOEPIDERMOID CARCINOMA
Low-Grade Intermediate-Grade High-Grade
Cellularity Variable; often poorly cellular, can Variable; scant to hypercellular Variable; scant to hypercellular
be acellular; may yield clear, turbid,
mucoid or hemorrhagic fluid on
aspiration
Presentation Polymorphic cell population; Cells discrete, in loosely cohesive Malignant cells isolated in loosely
cells discrete, in loosely cohesive groups, or in syncytial tissue cohesive groups or in syncytial
groups or in syncytial tissue fragments; monolayered or tissue fragments without any
fragments; mucin-producing cells trabeculae with or without architectural pattern
predominate; occasional presence branching; strands of stringy mucin
of goblet cells; clear cells ⫹/⫺;
inflammatory cells often obscure
the single isolated neoplastic cells;
intermediate cells and squamous
cells usually low in numbers
Cells Medium-sized to large; round, An admixture of mucin-producing Variably sized, small to large; high
oval, columnar to polygonal; cells, intermediate type cells N/C ratios; cell borders well to
mucin producing, vacuolated and squamous cells in varying poorly defined
signet-ring type; intermediate cells proportions; intermediate type cells
(smaller than squamous cells) with usually predominate; occasional
scant cytoplasm and with high N/C presence of goblet cells; N/C ratios
ratios increased
Nucleus Round to oval; mild to moderate Round to oval mildly enlarged, Round to oval; size variable;
atypia; granular chromatin; uniform, granular chromatin; coarsely granular chromatin with
nucleoli ⫹; mild to moderately pleomorphic; parachromatin clearing; micro-
nucleoli ⫹; intranuclear inclusions and macronucleoli; mitoses ⫹/⫺
rarely present
Cytoplasm Variable depending on type of Depends on the type of cells Variable, pale to dense;
cell; abundant, pale foamy to whether mucin-producing or keratinization absent; occasionally
vacuolated in glandular type cells; intermediate or squamous type with cytoplasmic vacuoles
pale eosinophilic to cyanophilic
in squamous type cells; scant
and dense in intermediate type
cells; clear cells ⫹/⫺; oncocytic
cytoplasm ⫹/⫺
Background Frequent, histiocytes ⫹/⫺; with Macrophages ⫹/⫺; usually clean; Usually clean; necrosis ⫹/⫺;
or without hemosiderin; clean to necrosis ⫹/⫺; cellular debris ⫹/⫺; cellular debris ⫹/⫺; variable
dirty; mucoid ⫹/⫺; cellular debris variable mucin mucin
⫹/⫺; inflammatory cells ⫹/⫺
Immunoprofile Cytokeratin ⫹; EMA ⫹; S100 Same Same

protein, GFAP, MSA, CEA ⫹/⫺
Diagnostic Clues Presence of all three type of cells; Presence of intermediate and
mucin in the background mucin-producing cells
their size and prominence vary, and they often contain glandular differentiation is identifi ed, which is often dif-
viscid, mucoid material that may be blood-tinged or hem- fi cult to appreciate. The presence of intermediate cells,
orrhagic. The tumor size varies from 1 to 12 centimeters. when present, offers diagnostic clues.
Histologically, the tumors are classified into low, inter-
mediate, and high grades based on several features such as Immunoprofile
the relative proportion of the cell types, growth patterns,
The intermediate and epidermoid cells are consistently
degree of invasiveness, pattern of invasion, mitotic rate, ne-
cytokeratin reactive while the clear cells react variably.
crosis, degree of maturation of cellular components, neural
The well-developed mucus cells are cytokeratin negative.
or vascular invasion, and intracystic component.
Most cells are reactive to cytokeratins (see Table 15.21)
The low-grade tumors are characterized by a cystic
and glial fibrillar acidic protein (GFAP).
growth pattern with both microcysts and macrocysts and
the presence of mature squamous and glandular compo-
Diagnostic Difficulties and Differential
nents including mucus cells and abundant extracellular
Diagnoses of Low- and Intermediate-Grade
mucin. The cystic structures are lined by mucin-producing
Mucoepidermoid Carcinomas
goblet cells along with islands of squamous cell prolifera-
tion without keratinization and of intermediate cells. The diagnostic diffi culties are generally related to the
The intermediate-grade mucoepidermoid carcinomas grade and cell composition of the aspirate. The low-grade
show solid nests of cells that are predominantly interme- mucoepidermoid carcinomas, which are often cystic, yield
diate cells, with or without epidermoid differentiation, poorly cellular samples, do not lend themselves to cor-
and sparse mucinous cells. Microcysts are few, and mac- rect diagnosis, and are often interpreted as benign (Fig.
rocysts are absent. The neoplastic cells exhibit a mild to 15.107). The diagnostic accuracy of low-grade mucoepi-
moderate degree of pleomorphism. dermoid carcinomas is reported to be less than 40%. Their
High-grade tumors present a solid growth pattern differential diagnoses include various cystic lesions of the
with and without microcysts and no macrocysts. The tu- salivary glands—nonneoplastic as well as neoplastic. On
mor presents large islands of intermediate to squamous the other hand, atypia of the epithelial cells in various
cells with or without the presence of mucin-producing types of benign cysts and cystic neoplasms of the salivary
cells, markedly pleomorphic nuclei, frequent mitosis, ne- glands mimic the cytologic pattern of low-grade mucoepi-
crosis, and neural invasion (e-Fig. 15.15). dermoid carcinoma, resulting in a false-positive diagnosis
(Table 15.18; Figs. 15.108 to 15.114; also please refer to
Cystic Lesions, Table 15.33).
Benign neoplasms such as Warthin’s tumor (Fig.
The cytologic features of mucoepidermoid carcinomas 15.114) or a pleomorphic adenoma with cystic degenera-
parallel the histologic grades and present a large spectrum tion and mucoid background showing nuclear atypia of
(Table 15.17). The low-grade carcinomas very often have the duct epithelial cells may share morphologic similarities
a nondescript presentation that does not allow accurate with low-grade cystic mucoepidermoid carcinoma cells
cytologic recognition. These tumors being cystic, their and be misinterpreted as such (Figs. 15.33 and 15.34).
aspirates are often of low cellularity consisting of a few Extensive squamous metaplasia in pleomorphic adenoma
large mucin-producing cells with small, bland nuclei and may lead to a false-positive diagnosis of mucoepidermoid
clear cytoplasm, scattered histiocytes, a mucoid back- carcinoma (Figs. 15.33 to 15.36). Chronic sialadenitis
ground, and cellular debris. Squamous and intermediate with squamous metaplasia of the duct epithelium may
type cells may be absent. Since the diagnostic cells are be misinterpreted as mucoepidermoid carcinoma. Exces-
in small numbers, they easily escape attention, and these sive mucin may be misidentified as the matrix material of
aspirates are frequently reported as benign nonneoplastic pleomorphic adenoma, leading to a false-negative diagno-
cystic lesions. The presence of small aggregates or the tis- sis (Fig. 15.37).
sue fragments of intermediate cells of small size contain- Intermediate type mucoepidermoid carcinoma offers
ing dense but scant cytoplasm and nuclei with a compact a better diagnostic accuracy since their aspirates tend to
chromatin pattern may suggest the diagnosis (Figs. 15.96 demonstrate all types of cells (e.g., mucin-producing cells,
to 15.98). intermediate cells, goblet cells, squamous and clear cells).
The aspirates from the intermediate-grade mucoepi- However, predominant intermediate and bland squamous
dermoid carcinoma (Table 15.17) are often recognized cells that appear large and polygonal with abundant cyto-
easily because of the presence of all cell types (Figs. 15.99 plasm have been misinterpreted as oncocytoma, myoepi-
to 15.102). thelioma, and acinic cell carcinoma (Table 15.18).
The high-grade mucoepidermoid carcinomas usually High-grade mucoepidermoid carcinomas share mor-
yield very cellular aspirates, composed of obviously ma- phologic features with all the high-grade malignancies in-
lignant, pleomorphic cell population (Table 15.17; Figs. volving the salivary glands (Table 15.18; Figs. 15.115 to
15.103 to 15.106). Accurate typing is possible only when 15.124; also refer to Table 15.29).
A B
C D
Figs. 15.96A to E. A: This is a classic example of cystic low-grade

mucoepidermoid carcinoma with poor cellularity and inflamma-
tory exudate obscuring few discrete mucus cells. The latter are large
round with poorly defined cell borders and abundant pale cyto-
plasm. Their nuclei are small with finely granular chromatin, con-
taining micronucleoli. These cells strongly resemble histiocytes. This
case was interpreted as a benign cyst. B: Same case as above. The
few isolated epithelial cells in an inflammatory background are eas-
ily overlooked. C: Same case as above. This group of few epithelial
cells in an inflammatory background is poorly preserved. However,
the epithelial nature of the cells with nucleoli should alert to the
possibility of a neoplasm. D: Same case as above. These large epi-
thelial cells with eccentric nuclei and abundant pale cytoplasm are
mucus cells and should alert to the possibility of cystic mucoepider-
E moid carcinoma. E: Cell block interpreted as Warthin’s tumor.
latter. Adenocarcinoma, NOS, is the third most common

ADENOCARCINOMA, NOS malignant neoplasm of the salivary glands, comprising up
to 17% of primary malignant tumors according to the files
Adenocarcinoma, not otherwise specified (NOS), is a of the Armed Forces Institute of Pathology. In spite of this
salivary gland carcinoma that shows glandular or ductal high incidence, there is almost no information on the cyto-
differentiation but lacks the prominence of any histomor- pathologic features of adenocarcinoma, NOS, in the litera-
phologic features that characterizes the other specific types ture. Adenocarcinoma, NOS, occurs more commonly in the
of salivary gland carcinomas. Because most salivary gland parotid gland but can also involve the submandibular gland
malignancies are also adenocarcinomas, the modifying and minor salivary glands, particularly in the hard palate. It
term “not otherwise specified” is used to distinguish the is frequent in females with an average age of 58 years.
A B
C D
Figs. 15.97A to E. Another example of a low-grade mucoepider-

moid carcinoma interpreted as a benign cyst. A: The aspirate yielded
cyst fluid consisting mainly of inflammatory and cellular debris with
large numbers of mature squamous cells. B: There are numerous
histiocytes in the background and a small syncytial tissue fragment
of poorly preserved glandular cells. C: This field depicts a polymor-
phic cell population consisting of columnar cells, squamous cells,
possibly intermediate cells and histiocytes. D: A poorly preserved
group of intermediate cells in the background of histiocytes. E: A
large number of histiocytes may suggest a diagnosis of a mucus re-
E tention cyst or a mucocele.
Fig. 15.98. An example of false-negative diagnosis. This cystic as-

pirate with poorly preserved squamous epithelial cells was inter-
preted as benign. The surgical excision revealed mucoepidermoid
carcinoma.
619
A B
Figs. 15.99A and B. FNA of a mucoepidermoid carcinoma. A: Syncytial tissue fragments of intermediate cells, mixed
with a few global cells. B: Another field from the same case intermediate cells, and goblet cells in the background of
abundant mucin.
A B
Figs. 15.100A to C. FNA of mucoepidermoid carcinoma. A: The

malignant cells are forming syncytial tissue fragments and are of
intermediate type with a layer of goblet cells at the surface (arrow).
There is abundant mucin in the background. B: Mucoepidermoid
carcinoma. Tissue fragments of intermediate cells and glandular
cells with an acinar pattern. C: This syncytial tissue fragment is
forming a glandular pattern. The neoplastic cells have appreciable
pale to vacuolated cytoplasm. Note the goblet cell. There is abun-
C dant mucin in the background.
A B
C D
E F
Figs. 15.101A to F. FNA of a low-grade mucoepidermoid carcinoma. A: Several tissue fragments of epithelial cells
in a background of abundant mucin (low power). B: Higher magnification showing medium-sized intermediate type
cells in a syncytial arrangement with variable cytoplasm and mildly pleomorphic nuclei. Note the intranuclear inclu-
sion (arrow). C: A tissue fragment of intermediate cells with syncytial arrangement with variable, pale cytoplasm.
There is an attempt at acinar pattern (a). An occasional cell shows vacuolated cytoplasm. Note the intranuclear in-
clusion (arrow). D: Another field from the same case showing several tissue fragments of epithelial cells and densely
stained mucin in the background. E: Higher magnification showing squamoid cells with appreciable cytoplasm.
F: FNA of a papillary thyroid carcinoma showing a monolayered syncytial tissue fragment with component cells
exhibiting features of papillary thyroid carcinoma. Compare this with Figure 15.101B. (Note: This case was cytologi-
cally suspected of papillary thyroid carcinoma because of monolayered tissue fragment and intranuclear cytoplasmic
inclusions. The mucinous background was overlooked).
Mucoepidermoid Carcinoma, Intermediate-Grade (See Fig. 15.102)
A B
C D
Figs. 15.102A to D. A: Intermediate-grade mucoepidermoid carcinoma. These two images show glandular cells (arrows),
intermediate cells (I) and squamous cells suggesting the diagnosis of mucoepidermoid carcinoma. B: These two images
demonstrate syncytial tissue fragments of intermediate cells. Note the acinar pattern in the center and the cells with pale
cytoplasm indicating glandular differentiation. C, D: The syncytial tissue fragments of intermediate cells show higher
N/C ratios and prominent nucleoli. Their cytoplasm is scant and dense. This pattern is suggestive of intermediate-grade.
Cytopathologic Features of High-Grade Mucoepidermoid Carcinoma (See Figs. 15.103 to 15.106)
A B
Figs. 15.103A to C. FNA of a high-grade mucoepidermoid carcinoma. These malignant cells have scant cytoplasm
with high N/C ratios. The macronucleoli are very conspicuous. An acinar pattern is noted. Some cells with appre-
ciable dense cytoplasm suggest squamous differentiation (sq). (continued)
C
Figs. 15.103C. (continued) Fig. 15.104. These malignant cells from a high-grade mucoepider-
moid carcinoma are arranged in a syncytial fashion. Their well-
defined cell borders, centrally placed nuclei and appreciable amount
of cytoplasm suggest squamous differentiation. Mucous producing
cells are not seen.
A B
Figs. 15.105A and B. This aspirate from a high-grade mucoepidermoid carcinoma shows large pleomorphic cells
with clearly malignant nuclei. Their abundant cytoplasm is pale and bubbly.
Fig. 15.106. These malignant cells from another case of high-grade

mucoepidermoid carcinoma are arranged in a syncytial tissue frag-
ment with no architectural pattern. They have poorly defined cell
borders and scant cytoplasm and offer no clues as to the typing.
Differential Diagnoses of Low and Intermediate-Grade Mucoepidermoid Carcinoma (See Figs. 15.107 to 15.114)
Many cystic low-grade mucoepidermoid carcinomas yield fl uid with poor cellularity on aspiration biopsy, containing
predominantly histiocytes in an inflammatory and/or mucoid background and are interpreted as mucoceles or retention
cysts. Rare mucus-producing cells are often overlooked as illustrated below.
A B
Figs. 15.107A and B. A: The cyst aspirate shows mostly inflammatory cells and poor cellularity (low power).
B: Higher magnification showing a small number of discrete large mucus-producing cells in an inflammatory back-
ground, which were not recognized as malignant and were interpreted as benign. The surgical excision revealed a
cystic mucoepidermoid carcinoma.
TABLE 15.18 DIFFERENTIAL DIAGNOSES OF MUCOEPIDERMOID CARCINOMAS
Mucoepidermoid Mucoepidermoid Carcinoma

Carcinoma Low-Grade Intermediate-Grade Mucoepidermoid Carcinoma High-Grade
Mucocele Pleomorphic adenoma with squamous Salivary duct carcinoma
metaplasia
Mucus retention cyst Myoepithelioma Poorly differentiated squamous carcinoma, primary

or metastatic
Branchial cleft cyst Oncocytoma Oncocytic carcinoma
Benign lymphoepithelial cyst Acinic cell carcinoma Myoepithelial carcinoma
Chronic obstructive Large cell undifferentiated carcinoma

sialadenitis
Myoepithelioma Malignant lymphoma
Warthin’s tumor Metastatic malignant melanoma
Pleomorphic adenoma with

squamous metaplasia
A B
Figs. 15.108A and B. Mucocele. A large number of histiocytes, some containing mucin from a submandibular gland
retention cyst, may be misinterpreted as mucoepidermoid carcinoma.
Fig. 15.109. Parotid duct cyst. Muciphages from a parotid duct cyst
resemble mucin-producing cells of low-grade mucoepidermoid car-
cinoma.
A B
Figs. 15.110A to B. Branchial cleft cyst versus low-grade cystic mucoepidermoid carcinoma. A, B: The aspirate of
this cystic lesion demonstrated dense mixed inflammatory exudate containing neutrophils and histiocytes along with
many squamous cells. (continued)
C D
E F
Figs. 15.110C to F. (continued) C, D, E: Many of the squamous cells showed remarkable nuclear atypia. A few
cells appeared glandular. The aspirate was interpreted as suspicious for mucoepidermoid carcinoma. A metastatic
squamous carcinoma must also be considered in this setting. F: Also present were keratin debris which should have
ruled out the possibility of a mucoepidermoid carcinoma. The surgical excision showed an inflamed branchial cleft
cyst with reactive changes explaining the nuclear changes.
A B
Figs. 15.111A and B. Branchial cleft cyst. Atypical squamous cells from a branchial cleft cyst may be typed as
mucoepidermoid carcinoma.
A B
Figs. 15.112A and B. Mucoepidermoid carcinoma interpreted as branchial cleft cyst. Compare the morphologic simi-
larity of above cases with these benign appearing mature squamous cells from a cystic low-grade mucoepidermoid
carcinoma, interpreted as a benign cyst.
A B
Figs. 15.113A to C. Lymphoepithelial cyst. Atypical squamous cells

in the background of inflammatory cells and cellular debris. The
C excised parotid gland revealed a benign lymphoepithelial cyst.
A B
Figs. 15.114A and B. Warthin’s tumor. An aspirate from Warthin’s tumor showing tissue fragments of squamous cells
in a mucoid background, lacking lymphoid cells and oncocytes raise the suspicion of mucoepidermoid carcinoma.
Differential Diagnoses of High-Grade Mucoepidermoid Carcinoma (See Figs. 15.115 to 15.124)
A B
Figs. 15.115A to C. Mucoepidermoid carcinoma. A: Pleomorphic

malignant cells from a high-grade mucoepidermoid carcinoma.
The cells have abundant cytoplasm that is vacuolated in some cells
suggesting glandular differentiation. Some cells appear squamoid.
Accurate typing of this carcinoma is difficult. B, C: Pleomorphic
malignant cells from a high-grade mucoepidermoid carcinoma.
The cells have abundant cytoplasm that is vacuolated in some cells
suggesting glandular differentiation. Some cells appear squamoid.
C Accurate typing of this carcinoma is difficult.
Fig. 15.116. FNA biopsy of a metastatic poorly differentiated Fig. 15.117. These malignant cells originated from a poorly differen-
squamous carcinoma to the parotid gland. tiated primary adenocarcinoma, NOS, offer no diagnostic clues as to
their source and may interpreted simply as high-grade malignancy.
Fig. 15.118. Malignant cells from a poorly differentiated meta- Fig. 15.119. Metastatic poorly differentiated carcinoma; unknown
static adenocarcinoma involving the submandibular gland. Without primary. These malignant cells from a parotid gland mass strongly
a known primary, high-grade mucoepidermoid carcinoma must be resembled small cell carcinoma cells. Malignant cells in other fields
considered in the differential diagnosis. showed granular chromatin and nucleoli suggesting the diagnosis of
poorly differentiated carcinoma. Immunostains for neuroendocrine
markers were negative.
Fig. 15.120. This image shows malignant cells from a salivary duct Fig. 15.121. FNA of an oncocytic carcinoma. The malignant cells are
carcinoma. Although histologically, salivary duct carcinomas pres- very pleomorphic and poorly differentiated. With dense cytoplasm
ent a characteristic morphologic pattern and may not be consid- and large sells, differential diagnoses of high-grade mucoepidermoid
ered in the differential diagnosis of high-grade mucoepidermoid carcinoma and salivary duct carcinoma must be considered.
carcinomas, same does not hold true in the cytologic samples. Mere
presence of poorly differentiated malignant cells is not sufficient to
diagnose a salivary duct carcinoma.
629
Fig. 15.122. FNA of a myoepithelial carcinoma. These malignant Fig. 15.123. FNA of a large cell undifferentiated carcinoma. These
cells from a case of myoepithelial carcinoma represent a high-grade undifferentiated large malignant cells may be derived from a high-
malignancy and enter the differential diagnosis of high-grade mu- grade mucoepidermoid carcinoma.
coepidermoid carcinoma.
Fig. 15.124. Malignant melanoma must always be considered in

the differential diagnosis of a high-grade malignancy. Amelanotic
malignant melanomas cannot be differentiated from high-grade ma-
lignancies without special stains.
Clinically, adenocarcinoma, NOS, presents as a soli- is why they are sometimes interpreted as pleomorphic ad-
tary, asymptomatic mass. It may be associated with pain enoma. Mitoses are not present. Necrosis is absent.
and facial weakness and is often fi xed to the skin and The high-grade adenocarcinomas, NOS, tend to be
deeper tissues. more solid with variable glandular differentiation and
may be widely invasive. The malignant cells are vari-
ably pleomorphic with higher N/C ratios. The nuclei are
larger, pleomorphic, and irregular with coarse chroma-
Grossly, adenocarcinoma, NOS, is focally circumscribed, tin and prominent nucleoli. Mitosis and necrosis may be
ranging from 2 to 8 centimeters and is widely infiltrating. conspicuous. The neoplastic cells may show a spindle cell
The cut surface is white to yellowish–white with hemor- pattern.
rhage and necrosis.
Microscopically, several growth patterns are noted:
trabecular, tubular, ductal, mucinous, papillary, cystic, and
solid. The pattern also depends on the histologic grade. In The aspirates of low-grade tumors are generally very cel-
low-grade tumors, the neoplastic cells are medium-sized lular with the cells occurring in syncytial tissue fragments
and round to cuboidal with distinct cell borders. The cy- with or without an acinar pattern. They are characterized
toplasm is abundant and eosinophilic. Globular or linear by uniform, round to cuboidal medium-sized cells with
deposits of hyalinized acellular material may be present in bland nuclei. The chromatin is finely granular and micro-
focal areas. The nuclei are uniform and appear bland with nucleoli may not be readily apparent. Mitosis or necrosis
fi nely granular chromatin and micronucleoli. Low-grade is absent. The background is clean. (Table 15.19; Figs.
adenocarcinomas lack mitotic activity and necrosis, which 15.125 to 15.130).
TABLE 15.19 CYTOPATHOLOGIC FEATURES OF SALIVARY GLAND ADENOCARCINOMA, NOS
Cellularity Variable, usually highly cellular
Presentation Neoplastic cells isolated, in loosely cohesive groups or in syncytial tissue fragments of varying sizes, with or
without an acinar pattern, nests, trabeculae with or without branching and anastomosing enclosing varying-
sized spaces; papillary architecture is not a feature
Cells Medium-sized to large, uniform to variably pleomorphic, round, cuboidal to polygonal; poorly defined cell
borders; high N/C ratios
Nucleus Round to oval; smooth to irregular nuclear membranes, uniformly distributed granular chromatin;
parachromatin clearing; micro/macronucleoli; mitoses in high-grade lesions
Cytoplasm Scant to moderate; pale to dense; secretory vacuoles ⫹/⫺
Background Clean to necrotic; lack the stromal tissue fragments or hyaline material
Immunoprofile CK ⫹; CEA ⫹; EMA ⫹
Differential Low-Grade Adenocarcinoma, NOS

Diagnoses Duct hyperplasia in chronic sialadenitis
Pleomorphic adenoma with a predominant duct epithelial component
Polymorphous low-grade adenocarcinoma
Epithelial–Myoepithelial carcinoma
Salivary duct carcinoma
High-Grade Adenocarcinoma, NOS
Salivary duct carcinoma
Large cell undifferentiated carcinoma
Lymphoepithelial carcinoma
Acinic cell carcinoma, poorly differentiated
Metastatic poorly differentiated carcinomas
Metastatic malignant melanoma
Adenocarcinoma, NOS (See Figs. 15.125 to 15.130)
A B
Figs. 15.125A and B. FNA Adenocarcinoma, NOS. These two images demonstrate syncytial tissue fragments with
marked crowding and overlapping of the nuclei. The cells have poorly defined cell borders with scant cytoplasm. Identifi-
cation of duct epithelial cells is more apparent in some of these cells that contain granular chromatin and micronucleoli.
A B
Figs. 15.126A and B. FNA of a submandibular mass. A: The malignant cells are slightly larger and contain modest
amount of dense cytoplasm. These cells resemble those seen in salivary duct carcinoma. B: Nondescript malignant
cells in syncytial arrangement from the same case as “A”.
Fig. 15.127. FNA Adenocarcinoma, NOS. The aspirate is cellu- Fig. 15.128. FNA of a poorly differentiated adenocarcinoma show-
lar consisting of syncytial tissue fragments of neoplastic cells with ing clearly malignant cells with poorly defined cell borders and scant
marked crowding and overlapping. The cells are uniform, with cytoplasm. Typing of a neoplasm is not possible in this case.
bland nuclei. Some nuclei contain micronucleoli. Note the glandu-
lar pattern (arrows).
Fig. 15.129. An aspirate of high-grade adenocarcinoma, NOS of Fig. 15.130. FNA of a poorly differentiated adenocarcinoma, NOS.
the parotid gland, showing syncytial tissue fragment of poorly dif- Syncytial tissue fragments of malignant cells with round nuclei,
ferentiated malignant cells with no differentiating features. pleomorphic in size with granular chromatin and prominent nu-
cleoli. Their cytoplasm is scant, lacy and variable. Note glandular
lumen and a cribriform pattern.
High-grade lesions show pleomorphic malignant cells DIAGNOSTIC DIFFICULTIES AND

that may be readily recognized as malignant. In aspirated DIFFERENTIAL DIAGNOSES
material, the malignant cells are seen isolated, in loosely
The differential diagnosis of adenocarcinoma, NOS, is
cohesive groups, or in syncytial tissue fragments. They are
dependant on its grade. The well-differentiated adenocar-
round, oval, and polygonal to spindle-shaped with well-
cinoma, NOS, must be differentiated from cellular pleo-
to poorly defi ned cell borders containing variable pale,
morphic adenomas with a predominant duct cell compo-
dense, or clear cytoplasm. The nuclei are pleomorphic in
nent (Figs. 15.131A and B), acinic cell carcinomas (Fig.
size and irregular with parachromatin clearing and prom-
15.132), salivary duct carcinoma (Fig. 15.133), polymor-
inent nucleoli. Mitoses are frequent, and necrosis is often
phous low-grade adenocarcinoma (Figs. 15.134A and
seen in the background.
B), epithelial–myoepithelial carcinoma with prominent
duct epithelial cells (Figs. 15.135A and B), and metastatic
adenocarcinoma (Fig. 15.136). The high-grade adenocar-
IMMUNOPROFILE
cinomas share morphologic similarities with several other
The cells of adenocarcinoma react to epithelial mark- high-grade malignant neoplasms (Table 15.19). Duct
ers such as cytokeratin (CK), carcinoembryonic antigen hyperplasia in chronic sialadenitis may yield a hypercel-
(CEA), and epithelial membrane antigen (EMA) and react lular aspirate resulting in a false diagnosis of adenocarci-
negatively to GFAP. noma, NOS (Figs. 15.31, 15.32, and 15.131A).
Differential Diagnoses of Adenocarcinoma, NOS (See Figs. 15.131 to 15.136)
A B
Figs. 15.131A and B. Adenocarcinoma, NOS, versus cellular pleomorphic adenoma. A: The cellular features of a
low-grade adenocarcinoma as seen here cannot be differentiated from a cellular pleomorphic adenoma. B: FNA
of pleomorphic adenoma. This syncytial tissue fragment of duct epithelial cells without myoepithelial cells or the
stromal matrix resembles the cells of low-grade adenocarcinoma, NOS.
Fig. 15.132. The cells of an acinic cell carcinoma shows morpho- Fig. 15.133. FNA of a low-grade salivary duct carcinoma. These
logic overlap with those of adenocarcinoma cells. malignant cells from a salivary duct carcinoma cannot be morpho-
logically differentiated from the cells of adenocarcinoma, NOS.
A B
Figs. 15.134A and B. FNA of a polymorphous low-grade adenocarcinoma. A: The tissue fragment of malignant
cells show features of low-grade malignancy and cannot be typed as a polymorphous low-grade adenocarcinoma,
Romanowsky stain. B: Scrape preparation of a polymorphous low-grade carcinoma with neoplastic cell population
morphologically consistent with adenocarcinoma. Further typing is not possible.
A B
Figs. 15.135A and B. Epithelial–myoepithelial carcinoma. These two images from a case of epithelial–myoepithelial
carcinoma show only malignant duct–epithelial cells in a syncytial arrangement and tubular pattern. With a predomi-
nant epithelial component, this may be interpreted as adenocarcinoma.
Figs. 15.136. Metastatic adenocarcinoma from the prostate to the

parotid gland. Adequate clinical history and ancillary testing such
as immunostains are necessary to establish a diagnosis of metastatic
carcinoma.
epithelium line the cystic nodules. The cysts formed by

SALIVARY DUCT CARCINOMA malignant cells may attain a large size, often larger than
the salivary gland lobules. The malignant cells are vari-
Salivary duct carcinoma is a rare high-grade malignant able in size, very pleomorphic, cuboidal to polygonal with
epithelial neoplasm of the salivary glands, comprising less moderate to abundant eosinophilic cytoplasm. Their nu-
than 3% of salivary gland malignancies. It is composed clei are round to oval with a smooth to irregular nuclear
of structures that resemble expanded salivary ducts with outline. A single macronucleolus is quite characteristic.
frequent comedonecrosis and a cribriform pattern that The malignant cells lining the cysts display apocrine-like
appears, histologically, very similar to mammary duct car- features with apical globules of eosinophilic cytoplasm
cinomas. Salivary duct carcinomas are common in males and are arranged in small papillary projections. Cytologic
with a peak incidence in the sixth to seventh decades of pleomorphism varies from minimal to marked. Mitoses
life. The parotid gland is more commonly involved. Clini- are frequent. Dense hyalinized stroma may impart an ap-
cally, salivary duct carcinoma usually presents as a rapidly pearance of scirrhous carcinoma.
growing parotid swelling with frequent facial nerve dys-
function and cervical lymphadenopathy. The tumor fol- CYTOPATHOLOGIC FEATURES
lows an aggressive clinical course with local, lymphatic,
and hematogenous spread and a fatal outcome. The aspirates of salivary duct carcinoma tend to be very
cellular with a presentation strongly resembling the aspi-
rates of breast duct carcinoma (Figs. 15.137 and 15.138).
GROSS AND HISTOLOGIC FEATURES The malignant cells are pleomorphic in size ranging from
Grossly, salivary duct carcinomas are unencapsulated, medium to large to giant forms and are round or cuboidal
poorly circumscribed, grayish–white to yellowish–white, to polygonal. They occur singly, in loosely cohesive groups,
multinodular lesions. The cut surface characteristically and in syncytial tissue fragments with an anastomosing
shows several small variably sized cysts and foci of necro- pattern, enclosing spaces, or a cribriform pattern. Papil-
sis. Prominent fi brosis is usually noted. The size varies lary tissue fragments are also seen. Their cell borders are
from a small 1 centimeter to as large as 6 centimeters. well-defined and cytoplasm is variable and pale to dense.
Histologically, the most characteristic feature is the The nuclei are round to oval with a smooth to irregular
presence of variably sized rounded nodules of malignant membrane, granular chromatin with parachromatin clear-
cells strongly resembling breast duct carcinoma. These tu- ing, and multiple micro- and macronucleoli. Intranuclear
mor nodules may be solid or cystic. The larger nodules inclusions and mitosis may be frequent. The background
are irregular and invariably show comedonecrosis (e-Fig. shows necrosis. Cytologic recognition is usually easy. The
15.16). Other growth patterns include trabecular, papil- cytopathologic features are listed in Table 15.20 and illus-
lary, or cribriform. Small papillary projections of ductal trated in Figure 15.137 and Figures 15.139 to 15.144.
Salivary Duct Adenocarcinoma (See Figs. 15.137 to 15.144)
A B
Figs. 15.137A and B. A: Low-power view of a very cellular aspirate from a salivary duct carcinoma. Large tissue
fragments of malignant cells with branching and anastomosing, enclosing varying-sized spaces. This pattern bears a
strong resemblance to the cytologic presentation of mammary duct carcinoma. B: Higher magnification of one of the
tissue fragments from the above, showing a cribriform pattern.
A B
Figs. 15.138A and B. A fine needle aspirate of mammary duct carcinoma. A: Low-power view showing morpho-
logic patterns similar to Figure 15.137. B: Higher magnification. Note the similarity in cytologic patterns between
salivary duct carcinoma and mammary duct carcinoma.
TABLE 15.20 CYTOPATHOLOGIC FEATURES OF SALIVARY DUCT CARCINOMA
Presentation Malignant cells isolated, in loosely cohesive groups and in syncytial tissue fragments, some large,
with branching and anastomosing trabeculae enclosing varied-sized spaces; cytologic pattern
reminiscent of mammary duct adenocarcinoma, tissue fragments with cribriform pattern, papillary-
like architecture with or without branching, nests; cellular and necrotic debris may be a prominent
feature
Cells Very pleomorphic in size and shape; medium-sized, large to giant forms; round, oval, polygonal
with occasional triangular, caudate and elongated forms; well to poorly defined cell borders; N/C
ratios variable
Nucleus Variable in size, uniform medium-sized to pleomorphic, large, sometimes giant forms; round to
oval; central to eccentric location; binucleation and multinucleation ⫹/⫺; fine to coarsely granular
chromatin; nuclear membrane smooth to irregular; prominent, single to multiple micro and
macronucleoli; intranuclear inclusions ⫹/⫺; mitoses ⫹/⫺
Cytoplasm Variable, scant to abundant, pale to dense, cyanophilic or eosinophilic with strong resemblance to
oncocytes, occasionally fibrillar and vacuolated
Background Necrosis; cellular debris; psammoma bodies present but rarely
Immunoprofile CK ⫹; CEA ⫹; EMA ⫹; ER and PR ⫺; vimentin ⫺; S100 protein ⫺
Differential Diagnoses Adenocarcinoma, NOS

High-grade mucoepidermoid carcinoma
Oncocytic carcinoma
Poorly differentiated squamous carcinoma
Adenosquamous carcinoma
Undifferentiated carcinoma
A B
Figs. 15.139A to C. FNA of a salivary duct carcinoma. A: Showing

marked cellularity with several tissue fragments and dispersed cells
(low power). B: Syncytial tissue fragments of malignant cells with
focal glandular pattern. Note the single malignant cells in the back-
ground. C: The malignant cells are forming a cribriform pattern.
C The nuclei are bland.
Fig. 15.140. FNA of a salivary duct carcinoma composed of syn- Fig. 15.141. FNA of a salivary duct carcinoma showing squamoid
cytial tissue fragments of malignant cells containing pleomorphic features with dense cyanophilic cytoplasm. Their nuclei are clearly
nuclei. The cytoplasm is variable, abundant and vacuolated. malignant and represent a high-grade malignancy.
IMMUNOPROFILE ULTRASTRUCTURE
The salivary duct carcinoma cells are immunoreactive to Ultrastructurally, salivary duct carcinoma cells dem-
cytokeratin (CK), carcinoembryonic antigen (CEA), and onstrate features of ductal cells with basal lamina,
epithelial membrane antigen (EMA). They are nonreac- microvilli, desmosomes, tight junctions, a rough
tive to vimentin, actin, S100 protein, and to estrogen endoplasmic reticulum, and moderate numbers of
receptors (ER) and progesterone receptors (PR). mitochondria.
Fig. 15.142. Syncytial tissue fragments of very pleomorphic large Fig. 15.143. FNA of a salivary duct carcinoma. These poorly differ-
malignant cells from another case of salivary duct carcinoma. entiated malignant cells are likely to be interpreted as a high-grade
malignant neoplasm or an undifferentiated carcinoma.
A B
Figs. 15.144A and B. A: A low-power view of FNA of salivary duct carcinoma of the parotid gland, showing a large
number of tissue fragments of malignant cells with papillary-like architecture. Note the cellular debris in the back-
ground. B: This field shows syncytial tissue fragments without any architectural patterns. Note the single malignant
cells in the background. The malignant cells are forming a cribriform pattern. The nuclei are bland.
DIAGNOSTIC DIFFICULTIES AND occur at any age, with the mean age being reported as
DIFFERENTIAL DIAGNOSES 44 years. It is slightly more common in women.
Clinically, acinic carcinomas present as a slow-grow-
The aspirates of salivary duct carcinoma cells are clearly
ing, solitary, unfixed mass. It may be associated with pain
malignant but may not allow accurate typing. The dif-
and tenderness.
ferential diagnostic considerations include all malignant
neoplasms that are poorly differentiated as listed in Table
15.20 (see also Table 15.29).
Grossly, acinic carcinoma ranges from well-circumscribed
to an irregularly shaped mass and may be multinodular.
ACINIC CELL CARCINOMA
The size is variable, ranging from 0.5 to 13 centimeters,
but the majority is 1 to 3 centimeters. The cut surface is
Acinic cell carcinoma is a malignant epithelial neoplasm lobular and tan to reddish with soft to firm consistency
in which the neoplastic cells demonstrate acinar differen- with or without microcysts.
tiation, comprising about 17% of primary salivary gland Histologically, acinic cell carcinomas demonstrate
malignancies, the majority of which involve the parotid various growth patterns, namely, solid, microcystic,
glands. Up to 3% are bilateral. Acinic cell carcinomas papillary-cystic, and follicular. The component cells are
usually the acinar type but other types such as interca- with luminal epithelial proliferations, often with papillary
lated ductal, vacuolated or clear, and oncocytic are also architecture or a solid growth with a microcystic pattern.
encountered. The acinar type cells are large and polyg- The follicular pattern is characterized by multiple cystic
onal instead of a normal triangular shape and are vari- lumens fi lled with eosinophilic proteinaceous material
able in size with abundant granular, lightly basophilic and demonstrates a strong resemblance to thyroid paren-
to reticular, and foamy cytoplasm with uniform, round, chyma. Such follicle-like structures are lined by interca-
eccentric nuclei with bland chromatin and nucleoli. The lated duct-like epithelium.
cytoplasm contains PAS positive, diastase-resistant gran-
ules. The neoplastic cells vary greatly in size and form
either solid sheets or islands, often surrounded by delicate
stroma. The microcystic pattern is characterized by nu- The cytopathologic patterns of acinic cell carcinoma
merous small spaces within sheets or nodules of tumor (Table 15.21; Figs. 15.145 to 15.149) are dependant on
cells. These spaces vary from several micrometers to a the histologic type. The aspirates are usually very cellular
millimeter or more in size. The spaces are usually empty consisting of a large population of neoplastic cells with a
but may contain PAS positive material. The papillary- strong resemblance to normal acinar cells. The abnormal
cystic pattern is characterized by prominent cystic spaces cells are seen in loosely cohesive groups and in syncytial
TABLE 15.21 CYTOPATHOLOGIC FEATURES OF ACINIC CELL CARCINOMA
Presentation The aspirate may be cystic yielding semisolid fluid; cellularity variable; neoplastic cells either
dissociated, in loosely cohesive groups or in monolayered with or without an acinar pattern or
as syncytial tissue fragments of varying sizes from small with no architectural patterns to large,
interdigitating, irregular trabeculae, enclosing varying-sized spaces; acinar pattern resembling an
adenocarcinoma may be present; papillary pattern infrequently present (in papillary-cystic variant);
endothelial lined capillaries with attached acini; may have striking resemblance to normal acini
Cells Great variation in size; medium-sized, round, triangular, to large polygonal; may demonstrate strong
resemblance to normal counterpart; cell borders well to poorly defined; N/C ratios variable
Nucleus Round, small, uniform, to minimally pleomorphic; finely granular chromatin; prominent
micronucleoli; smooth nuclear membranes; mitoses usually absent; monomorphic pattern
Cytoplasm Scant to abundant, granular, vacuolated to clear; pale, cyanophilic to eosinophilic, occasionally
deep-staining oncocytic-like; PAS ⫹, diastase resistant granules
Background Clean, necrosis absent; naked nuclei ⫹/⫺; granular debris in cystic lesions; lymphoid cells with or
without germinal center cells ⫹/⫺; psammoma bodies in papillary-cystic variant; macrophages
Immunoprofile CK ⫹; alpha 1-antitrypsin ⫹; alpha 1-antichymotrypsin ⫹; CEA ⫹; amylase ⫹; Leu-M1 ⫹;

transferrin ⫹; lactoferrin ⫹
Ultrastructure Both ductal and acinar type cells; acinar type cells contain multiple round, electron-dense secretory
granules; numerous mitochondria
Differential Diagnoses Normal or benign acinar

Benign nonneoplastic cyst
Warthin’s tumor
Oncocytoma
Pleomorphic adenoma
Low-grade adenocarcinoma, nos
Metastatic papillary thyroid carcinoma
Benign lymphoepithelial lesion
Myoepithelioma
Acinic Cell Carcinoma (See Figs. 15.145 to 15.149)
A B
Figs. 15.145A to C. FNA of an acinic cell carcinoma of the parotid

gland. A: The cellular aspirate demonstrates branching and interdigi-
tating trabeculae (low power). B: This field shows several varying-
sized tissue fragments of neoplastic cells. A glandular pattern can be
appreciated (arrows). The background is clean, low power. C: Higher
magnification showing a trabecular, cribriform and glandular pat-
terns. The neoplastic cells are medium-sized with poorly defined cell
borders, variable scant cytoplasm with high N/C ratios. The nuclei
are round, mildly pleomorphic in size containing micronucleoli. The
C morphologic pattern is reminiscent of an adenocarcinoma.
A B
Figs. 15.146A and B. Two different examples of acinic cell carcinomas, showing neoplastic cells with poorly defined
cell borders and stripped nuclei which are small, round and uniform. The cell borders of the neoplastic acinar cells
are frayed.
A B
Figs. 15.147A and B. A cellular aspirate of acinar cell carcinoma. Note the morphologic similarity to the normal aci-
nar cells. The cell arrangement however is haphazard and the cell borders are poorly defined. The nuclei are uniform.
A B
Figs. 15.148A and B. A: FNA of an acinar cell carcinoma, depicting syncytial tissue fragments forming interdigitating
trabeculae. The component cells are poorly defined and contain abundant eosinophilic cytoplasm and may be mis-
interpreted as an oncocytic neoplasm. B: Another example of an acinic cell carcinoma with cells containing granular
eosinophilic cytoplasm.
A B
Figs. 15.149A and B. A: FNA of a papillary-cystic variant of an acinic cell carcinoma of the parotid gland depicting
syncytial tissue fragments with papillary-like architecture. B: Higher magnification showing large polygonal cells with
well-defined cell borders and vacuolated cytoplasm. (Courtesy of Dr. Syed Z. Ali, Department of Pathology, Johns
Hopkins Hospital, Baltimore, Maryland.) (continued)
Figs. 15.149C. (continued) C: FNA of an acinic cell carcinoma

with extensive lymphoid infiltrate. This pattern may be mistaken
for a lymphoepithelial carcinoma. (Courtesy of Dr. Mithra Baliga,
Director of Cytopathology Laboratory, University of Mississippi,
C Jackson, Mississippi.)
tissue fragments of varying sizes. Architecturally, the tis- with heavy lymphoid infiltrate may be confused with lym-
sue fragments show large trabeculae with branching and phoepithelial carcinoma or a lymphoepithelial lesion.
anastomosing pattern enclosing varying-sized spaces cor-
responding to the microcystic pattern. Papillary tissue
fragments with central cores of fi brovascular tissue may
ADENOID CYSTIC CARCINOMA
be present. The component cells vary greatly in size from
small and round to large and polygonal and have well- to
poorly defi ned cell borders. Their cytoplasm is variable, Adenoid cystic carcinoma (ACC) is a malignant neoplasm
scant, pale, eosinophilic to abundant, and granular or of the salivary glands that is slow to metastasize but per-
vacuolated. The tissue fragments of polygonal cells with sistent and relentless in growth. It is composed of pre-
granular cytoplasm and eccentric nuclei strongly resem- dominantly nonluminal (myoepithelial-basal) cells with a
ble their normal counterparts except for their haphazard minor component of luminal or duct epithelial cells.
architecture and lack of ductal cells. The nuclei are usually Adenoid cystic carcinoma is the fifth most common
small and minimally pleomorphic with granular chroma- malignant neoplasm of the salivary glands and 7.5% of
tin and may contain prominent micronucleoli. A dissoci- all epithelial malignancies. It is slightly more common in
ated cell pattern with numerous bare nuclei is a common females. All ages are affected with a peak in the fourth to
feature. The background is usually clear. Branching frag- sixth decades of life. ACC most frequently involves the pa-
ments of connective tissue stroma may be present. Necro- rotid gland followed by the submandibular gland. The in-
sis and mitoses are generally not a feature of acinic cell volvement of minor salivary glands is seen in the palate.
carcinoma (Figs. 15.145 to 15.149). Adenoid cystic carcinoma develops as a slowly grow-
ing mass in the preauricular or submandibular region.
It presents as a small movable nodule or a large mass
fi xed to the skin or deeper tissues. Intraoral tumors may
show ulceration of the mucosa. Local tenderness, pain,
The diagnostic accuracy of acinic cell carcinoma is very and facial nerve paralysis frequently develop during the
low and its recognition is very poor, as judged by some of course of the disease. There is a high incidence of nerve
the differential diagnostic entities listed in the literature invasion.
(see Table 15.28).
The differential diagnoses (Table 15.22) of acinic cell
carcinoma mainly include normal acinar tissue that is pres-
ent in aspirates of chronic sialadenitis (Figs. 15.150 and Grossly, adenoid cystic carcinoma usually presents as a
15.151). The other diagnostic possibilities are myoepithe- white to gray–white tumor and may appear to be well-
lioma (Fig. 15.43), oncocytoma (Fig. 15.52), low-grade circumscribed in spite of its invasive properties.
adenocarcinoma, NOS (Fig. 15.145C), polymorphous Microscopically, adenoid cystic carcinomas show
low-grade adenocarcinoma, and mucoepidermoid carci- three types of growth patterns—namely, cribriform, tubu-
noma. Cystic acinic carcinomas are often difficult to iden- lar, and solid—and a given tumor may demonstrate all or
tify due to poorly cellular aspirates. The papillary-cystic any combination of the patterns (e-Fig. 15.17).
variants have been misinterpreted as cystadenocarcino- The cribriform pattern is the most common type,
mas or papillary thyroid carcinomas. Acinic carcinomas imparting a sieve-like or Swiss cheese-like appearance as
TABLE 15.22 DIFFERENTIAL DIAGNOSES OF ACINIC CELL CARCINOMA
Normal Acinar Tissue fragments of acinar tissue with intact lobules like a bunch of grapes; dissociated pattern lacking;
Tissue cells triangular, in acinar arrangement; N/C ratios low; nuclei small, round, uniform, and basally located;
finely granular chromatin; nucleolus inconspicuous; abundant, granular cytoplasm; background clean;
tissue fragments of benign duct epithelial cells
Acinic Cell Overwhelmingly cellular aspirate with dissociated cell pattern; neoplastic cells isolated, in loosely cohesive
Carcinoma groups, or in syncytial tissue fragments with acinar, trabecular, or papillary pattern; strong resemblance to
normal acinar cells, normal-sized to large cells; delicate cell borders; N/C ratios variable; nuclei enlarged,
round with granular chromatin prominent nucleoli; abundant, granular, vacuolated or clear cytoplasm;
background clean to hemorrhagic; histiocytes ⫹/⫺; naked nuclei
Low-Grade Cellular aspirate; malignant cells isolated, in loosely cohesive groups, or in syncytial tissue fragments;
Adenocarcinoma, cells small to medium-sized; uniform, round to cuboidal; well-defined cell borders; N/C ratios high; nuclei
NOS mildly pleomorphic round to oval; finely granular chromatin; micronucleoli ⫹; variable clear to pale
cytoplasm; background usually clean
Myoepithelioma Cellular aspirate; malignant cells isolated, in loosely cohesive groups, or in syncytial tissue fragments;
cells medium to large, uniform, round to cuboidal; well-defined cell borders; N/C ratios low; nuclei mildly
pleomorphic round to oval; finely granular chromatin; micronucleoli ⫹; variable pale to dense granular
Oncocytoma Cellular aspirate; malignant cells isolated, in loosely cohesive groups, or in syncytial tissue fragments;
cells medium to large, uniform, round to cuboidal; well-defined cell borders; N/C ratios low; nuclei mildly
pleomorphic round to oval; finely granular chromatin; macronucleolus ⫹; variable pale to dense granular
Mucoepidermoid Cellular aspirate consisting of syncytial tissue fragments of large polygonal cells with appreciable
Carcinoma cytoplasm; may present a trabecular pattern; presence of intermediate and goblet cells favor
mucoepidermoid carcinoma
Lymphoepithelial Clearly malignant large, mostly discrete cells scattered in the background of variable numbers of lymphoid
Carcinoma cells
Differential Diagnoses of Acinic Cell Carcinoma (See Figs. 15.150 and 15.151)
Fig. 15.150. Normal salivary gland parenchyma, showing uniform Fig. 15.151. Acinic cell carcinoma. Although the architecture ap-
acinar cells forming the acini. pears similar to the normal acinar tissue, the arrangement is hap-
hazard. The nuclei are crowded and overlapped. No duct epithelium
is identified.
seen by islands of neoplastic epithelial cells containing the fragments, staining a striking magenta–pink with a
several small, round pseudocystic structures that vary in Romanowsky stain and pale cyanophilic or eosinophilic
size but are rarely large. These cyst-like spaces are not with a Papanicolaou stain. Mitoses are rare to absent in
true ductal or glandular lumens but are actually contigu- cribriform or tubular types. There is no nuclear molding,
ous with the supporting stroma of the tumor. These con- stretch artifacts, or karyorrhexis. The background is gen-
tain either basophilic or eosinophilic hyalinized material erally clean. The solid variant usually lacks hyaline glob-
or both. Ultrastructurally, the basophilic material repre- ules. The nuclei are larger, with some showing nucleoli.
sents glycosaminoglycans, and the eosinophilic material Mitosis may be present.
is due to the excessive production of basal lamina. The
majority of the neoplastic cells are of nonluminal myo-
IMMUNOPROFILE
epithelial differentiation. Their cell borders are indistinct,
and the cytoplasm is amphophilic to clear but scant with The ductal cells in adenoid cystic carcinoma are immu-
very high N/C ratios. The nuclei are small, round to oval, noreactive to cytokeratin (CK), carcinoembryonic antigen
and uniform in size, varying from darkly basophilic to (CEA), epithelial membrane antigen (EMA), and S100
lightly basophilic with a homogeneous chromatin pat- protein. The myoepithelial cells react to actin, low-molec-
tern. Small micronucleoli are sometimes evident. The tu- ular weight keratin, and S100 protein.
mor often shows the foci of ductal cells surrounding tiny
lumens. The duct epithelial cells have a more eosinophilic
cytoplasm. The tubular pattern is characterized by neo-
plastic cells being arranged in small nests, separated from
one another, and surrounding individual cyst-like spaces An aspirate composed of small uniform cells with high
that may be contiguous with the stroma. True ductal-type N/C ratios, presenting a cribriform or tubular/trabecu-
lumens surrounded by differentiated ductal cells are more lar pattern, three-dimensional spheres, and globules of
conspicuous and, in turn, are surrounded by myoepithe- matrix material are characteristic of adenoid cystic car-
lial type cells. Their nuclei are round, oval, or angular. cinoma. The diagnostic problems arise when all the key
The islands of tumor cells are frequently embedded in a features are not present, either because of an inadequate
hyalinized stroma. The latter can be extensive, reducing specimen or the predominance of one of the diagnostic
the islands to thin cords or trabeculae. features that offer differential diagnostic issues. An aspi-
The solid pattern is characterized by variably sized rate predominantly composed of small neoplastic cells
rounded or lobulated aggregates of tumor cells in which can represent several neoplasms, both benign and malig-
cyst-like spaces are few to absent. The individual cells are nant (Table 15.23; Figs. 15.165 to 15.170; also see Table
morphologically similar to the cribriform or tubular vari- 15.27 and Figs. 15.183 to 15.191 for the differentiating
ety or could be larger with less angular nuclei and larger in features of small lesions). A nonneoplastic entity described
size. The cell population is dominated by basaloid myoep- as chronic sclerosing sialadenitis or Küttner tumor may
ithelial cells but the foci of duct cell differentiation may be yield a poorly cellular aspirate with small proliferating
found. The tumor is more solid, and mitoses are frequent, ductules that may be mistaken for adenoid cystic carci-
as are cellular and nuclear pleomorphism. Tumor cell ne- noma (see Figs. 15.218A to E). Also, a scant aspirate with
crosis is more frequent with the solid type and is not a fea- single cells may be mistaken for benign lymphoid cells.
ture of cribriform or tubular growth pattern. Peripheral
nerve invasion is a hallmark of adenoid cystic carcinomas,
and the invasion of the surrounding tissues is common.
POLYMORPHOUS LOW-GRADE
ADENOCARCINOMA
The aspirates are variably cellular consisting of small Polymorphous low-grade adenocarcinoma (PLGA) of
cells forming nests and three-dimensional cell balls the salivary gland is a low-grade malignant neoplasm
(Table 15.23; Figs. 15.152 to 15.164). Single cells, being that predominantly occurs in the minor salivary glands
small, usually appear as naked nuclei. The cell borders and comprises 11% of all epithelial malignancies of the
are poorly defi ned, and the cytoplasm is very scant to salivary glands; it is most common in the soft palate. The
indiscernible. The nuclei are round with smooth nuclear tumor is more frequent in females and occurs in the older
membranes, the chromatin is compact, and the nucleoli age group with an average age of 59 years.
are inconspicuous. Individual cells are very bland and a Clinically, PLGA presents as a fi rm nontender swell-
poorly cellular aspirate may be misinterpreted as nondi- ing of the hard/soft palate, often at the mucosal junction,
agnostic. The characteristic and diagnostic feature of ade- cheek, or upper lip. There may be some discomfort, bleed-
noid cystic carcinoma is the presence of acellular hyaline ing, and telangiectasia or ulceration of the mucosa. The
globules within the syncytial tissue fragments and outside duration varies from a few weeks to several years.
TABLE 15.23 CYTOPATHOLOGIC FEATURES OF ADENOID CYSTIC CARCINOMA
Presentation Cells mostly in syncytial tissue fragments with intense crowding and overlapping of nuclei; sieve-like (Swiss-
cheese) pattern, enclosing sharp variably sized spaces containing acellular material (hyaline globules) staining
intense magenta-pink with Romanowsky stain and pale, gray, cyanophilic or eosinophilic in Papanicolaou
stained preparations; three-dimensional’ clusters with depth of focus; slender tubular structures or finger-like
tissue fragments with tightly packed small nuclei, with smooth outlines; the tissue fragments of neoplastic
cells may be bordered by hyaline matrix; monolayered tissue fragments or syncytia without any architectural
patterns in solid type; single cells in the background appear small and resemble lymphocytes
Cells Small, round to oval; monomorphic; very high N/C ratios
Nucleus Round to oval; smooth nuclear membranes; coarsely granular to compact chromatin; inconspicuous nucleoli;
no nuclear molding; no mitoses; no karyorrhexis, mild pleomorphism in solid types
Cytoplasm Scant, indiscernible
Background Clean, no necrosis; extracellular hyaline globules similar to those seen within tissue fragments; naked nuclei
either border the globules or embedded within, matrix material may be present as strands or irregular fragments
or appear veil-like
Immunoprofile Cytokeratin ⫹; actin ⫹; vimentin; S100 protein ⫹; anti-basement antibody ⫹; neuroendocrine markers ⫺;
GFAP ⫺
Differential Cellular pleomorphic adenoma with a predominant or an exclusive basaloid cell pattern
Diagnoses Basal cell adenoma/basal cell adenocarcinoma
Epithelial–myoepithelial carcinoma
Small cell (neuroendocrine) carcinoma
Lymphoproliferative disorders
Reactive lymph node
Malignant lymphoma
Chronic sclerosing sialadenitis (Küttner tumor)
Adenoid Cystic Carcinoma (See Figs. 15.152 to 15.164)
Fig. 15.152. Aspiration biopsy of an adenoid cystic carcinoma Fig. 15.153. Same cases as the previous one, showing syncytial
showing the characteristic and diagnostic pattern with varying- tissue fragments of basaloid cells with a cribriform pattern. The
sized, bright magenta-colored sharply defined hyaline globules sur- spaces enclosed by the neoplastic cells are filled with eosinophilic
rounded by basaloid cells (Romanowsky). acellular material; Papanicolaou stain.
Fig. 15.154. Cribriform pattern, adenoid cystic carcinoma. These Fig. 15.155. FNA of an adenoid cystic carcinoma showing finger-
syncytial tissue fragments composed of small basaloid cells are like architecture of the syncytial tissue fragment of neoplastic cells,
forming a cribriform pattern. The spaces contain acellular hyaline with a smooth outline. Note the enclosed pseudocyst (arrow).
material.
Fig. 15.156. FNA of an adenoid cystic carcinoma showing a syncy-

tial tissue fragments of small cells. Focusing up and down, demon-
strates a pseudocyst.
A B
Figs. 15.157A to B. FNA of another case of adenoid cystic carcinoma. A: The syncytial tissue fragments of small
uniform cells demonstrate a cribriform pattern. There is cyanophilic acellular matrix present along the perimeter of
the cells. B: The tissue fragment of neoplastic cells forms finger-like architecture with smooth outline. Acellular matrix
material can be seen the background. (continued)
Figs. 15.157C. (continued) C: Pale, homogeneous, cyanophilic

stromal matrix forming a large globule with sharp outline, contain-
ing small ovoid bare nuclei. The globule is bordered by similar nu-
C clei. Similar acellular matrix is seen in the background (arrows).
A B
Figs. 15.158A and B. This poorly cellular aspirate contained only four groups of small tightly packed cells. A cyto-
logic diagnosis of a possible small cell neoplasm was rendered. The surgical excision confirmed an adenoid cystic
carcinoma. This pattern includes the differential diagnoses of a basal cell adenoma and a pleomorphic adenoma.
A B
Figs. 15.159A and B. FNA of an adenoid cystic carcinoma presenting the typical cytologic pattern. The syncytial
tissue fragments are composed of small basaloid cells with bland nuclei, forming cribriform architecture with spaces
containing acellular material.
A B
Figs. 15.160A and B. Trabecular pattern. A: FNA of an adenoid cystic carcinoma displaying a trabecular pattern.
Note the slender pencil-like structure with smooth external contour (low power). B: Higher magnification depicting
very small tightly packed small basaloid cells. Hyaline material is not evident.
A B
Figs. 15.161A and B. Syncytial tissue fragment of small basaloid cells with no architectural pattern. These represent a
solid growth pattern of adenoid cystic carcinoma that is difficult to differentiate from other salivary gland neoplasms
composed of small cell.
Fig. 15.162. FNA of an adenoid cystic carcinoma composed of very Fig. 15.163. In this tissue fragment from an adenoid cystic carci-
small cells with poorly defined cell borders, indiscernible cytoplasm noma with a solid pattern, the tumor cells are larger, with mildly
and may be mistaken for lymphoid cells or lesions composed of pleomorphic nuclei. The chromatin is granular and nucleoli are
small cells. prominent. This pattern may not allow a correct recognition of ad-
enoid cystic carcinoma.
Fig. 15.164. An aspirate of a poorly differentiated metastatic ad-

enoid cystic carcinoma with marked cellular and nuclear pleomor-
phism. Characteristic cytologic features of adenoid cystic carcinoma
are absent. This pattern is reminiscent of a high-grade malignancy.
Differential Diagnoses of Adenoid Cystic Carcinoma (See Figs. 15.165 to 15.170)
A B
C D
Figs. 15.165A to D. Pleomorphic adenoma versus adenoid cystic carcinoma. A: FNA of a pleomorphic adenoma
with an exclusive basaloid cell component. Note the tubular architecture of the tissue fragment and the intercellular
matrix. These cells may be interpreted either as a basal cell adenoma or adenoid cystic carcinoma. B: A syncytial tis-
sue fragment of small basaloid cells forming a tubular structure from a fine needle aspirate of pleomorphic adenoma.
Note the similarity to adenoid cystic carcinoma of tubular type seen in Figure 15.160A. C: FNA of a pleomorphic
adenoma showing a large eosinophilic globule bordered by basaloid cells. Note the small rosette (arrow). D: Aspirate
of a pleomorphic adenoma with a cribriform pattern formed by basaloid cells. Compare this with adenoid cystic
carcinoma exhibiting similar cytomorphology (Fig. 15.154). (continued)
E F
Figs. 15.165E to F. (continued) E: FNA of a pleomorphic adenoma showing small basaloid cells with a cribriform
pattern and pale eosinophilic matrix material mimicking the cytologic pattern of adenoid cystic carcinoma. F: A dif-
ferent case of pleomorphic adenoma showing a syncytial tissue fragments of very small basaloid cells with compact
nuclei and insignificant cytoplasm. The morphology is similar to that of adenoid cystic carcinoma.
A B
Figs. 15.166A and B. The basaloid cells from the trabecular-tubular type basal cell adenoma show syncytial ar-
rangement with tubular pattern. The neoplastic cells are slightly larger than previously illustrated cases and contain
deep-staining chromatin. Note the intercellular matrix. This cytologic pattern may be mistaken for adenoid cystic
carcinoma.
A B
Figs. 15.167A and B. Adenoid cystic carcinoma versus small cell (neuroendocrine) carcinoma. A: FNA of a small cell
carcinoma. B: The fine needle aspirate of an adenoid cystic carcinoma mimicking the cytologic pattern of a small cell
carcinoma.
A B
Figs. 15.168A and B. Adenoid cystic carcinoma versus polymorphous low-grade adenocarcinoma. A: This tissue frag-
ment of small basaloid neoplastic cells intimately associated with magenta colored hyaline matrix, from an aspirate
of polymorphous low-grade adenocarcinoma morphologically resembles an adenoid cystic carcinoma and cannot be
differentiated (Romanowsky). B: An aspirate from adenoid cystic carcinoma for comparison. Note that the hyaline
globules are more well-defined, sharp and larger as compared to that seen in polymorphous low-grade adenocarci-
noma seen above (Romanowsky).
Fig. 15.169. Adenoid cystic carcinoma versus epithelial–myoepithelial

carcinoma. FNA of an epithelial–myoepithelial carcinoma. A slender
tubule-like structure without a central lumen formed by duct epithe-
lial cells with peripheral myoepithelial cells.
A B
Figs. 15.170A and B. Adenoid cystic carcinoma versus lymphoproliferative disorders. A: FNA of a reactive intrapa-
rotid lymph node showing only mature lymphocytes. B: FNA of intraparotid lymph node involved by malignant lym-
phoma. Compare these two images with the dissociated cell pattern of adenoid cystic carcinoma depicted in Figure
15.162.
GROSS AND MICROSCOPIC FEATURES round to oval and sometimes spindle-shaped with finely
granular chromatin and inconspicuous nucleoli. Their cy-
PLGA usually appears as an ovoid, circumscribed but
toplasm is variable and scant to moderate. Mitoses are
nonencapsulated, uniformly fi rm mass with a homoge-
absent. Intranuclear inclusions have been described. It is
neous, tan, and glistening cut surface. Microscopically,
not unusual to find spindle-shaped cells in aspirates from
PLGA is characterized by a wide variety of morphologic
PLGA. A characteristic feature is the presence of hyaline
growth patterns from one tumor to another and within
globules within the gland-like spaces or lumina in the
the same tumor. Unique combinations of certain archi-
nests of neoplastic cells. The aspirate also reveals varying
tectural patterns and bland nuclear features entail easy
amounts of hyaline matrix that is sometimes intimately
recognition of this tumor. Although PLGA is well-circum-
associated with the neoplastic cells.
scribed, it is locally infiltrative. The central portion of the
tumor is usually solid or lobulated but, in the peripheral
areas, small lobules, islands, and columns of neoplastic IMMUNOPROFILE
cells extend into the surrounding connective tissue or
The neoplastic cells are reactive to cytokeratin, vimentin,
salivary parenchyma. The solid areas frequently resemble
muscle-specifi c actin, epithelial membrane antigen, CEA,
one or more of the several benign and malignant salivary
and GFAP.
gland tumors. The various growth patterns include solid,
trabecular, tubular, cribriform, and cystic papillary.
The characteristic feature is the formation of small DIAGNOSTIC DIFFICULTIES AND
tubular structures with distinct central lumens lined by DIFFERENTIAL DIAGNOSES
a single layer of cuboidal cells, which can occur as an
The differential diagnoses of PLGA include several diag-
isolated structure or in clusters. They are often more nu-
nostic entities because of the overlapping patterns with
merous peripheral to the central area of the tumor where
several primary salivary gland neoplasms. Sampling is one
they infiltrate the salivary parenchyma, connective tissue,
of the important factors that preclude accurate typing. A
and skeletal muscle. These tubular structures are associ-
thorough histologic examination of the entire surgical
ated with and aligned with streaming columns and the
specimen is required to appreciate the varied morphol-
trabeculae of cells displaying concentric whirling, creat-
ogy. Based on the predominant cell type and morphology,
ing a target-like or onion–skin pattern. This concentric
PLGA may be misinterpreted as pleomorphic adenoma,
arrangement is present in 30% of the tumors. The stream-
basal cell adenoma/basal cell adenocarcinoma, adenoid
ing rows and cords of tumor cells are parallel to the con-
cystic carcinoma, epithelial–myoepithelial carcinoma,
vex border of the solid tumor. The majority of the tumor
and low-grade adenocarcinoma, NOS (Table 15.24; Fig.
cells are monomorphic with round, ovoid, or fusiform
15.168; see Table 15.27; Figs. 15.183 to 15.191).
nuclei, fi nely stippled chromatin, and inconspicuous or
slightly enlarged nuclei. Mitoses are rare. The neoplastic
cells have scant eosinophilic cytoplasm and indistinct cell
borders. Oncocytes, clear cells, and rarely, mucus cells EPITHELIAL–MYOEPITHELIAL
are variably present. There may be a limited amount CARCINOMA
of collagenous stroma, but more abundant hyaline or
muco-hyaline stroma often develops around more widely
Epithelial–myoepithelial carcinoma is an uncommon low-
spaced epithelial structures. Perineural infiltration is more
grade malignant epithelial neoplasm composed of variable
frequent.
proportions of ductal and large clear-staining myoepithe-
lial cells. The clear cells are typically arranged peripher-
ally around the ductal cells and are usually predominant.
Epithelial–myoepithelial carcinomas comprise 1% of sali-
The cytologic presentation of polymorphous low-grade vary gland neoplasms and commonly involve the parotid
adenocarcinomas is highly dependant on the area tar- glands. The tumor occurs in older people with an average
geted by the aspiration biopsy needle. The widely differ- age of 60 years and is more common in females.
ent histologic patterns in various areas of the tumor pres- Clinically, the tumor presents as a localized swelling
ent different cytomorphology (Table 15.24; Figs. 15.171 of variable duration and is occasionally associated with
to 15.175). pain and facial weakness.
The aspirates of polymorphous low-grade adenocar-
cinomas are variably cellular, consisting of uniform, me-
dium-sized, round to cuboidal neoplastic cells in syncytial
tissue fragments with various architectural patterns. The The tumors vary from 1 to 12 centimeters with an aver-
latter include papillary confi gurations with branching age of 2 to 3 centimeters and are well-circumscribed and
and nests with or without lumens. The nuclei are usually sometimes multinodular with and without necrosis and
TABLE 15.24 CYTOPATHOLOGIC FEATURES OF POLYMORPHOUS LOW-GRADE ADENOCARCINOMA
Presentation Cell in loosely cohesive groups and in syncytial tissue fragments, some with various architectural patterns:
nests, cords and trabeculae with branching and interdigitating papillary-like, cribriform with bright magenta-
pink (Romanowsky stained preparations) hyaline globules; hyaline matrix intimately associated with neoplastic
cells; centrally placed fibrillar/myxoid matrix with radiating neoplastic cells; single cells infrequent
Cells Duct epithelial cells, medium-sized, round to cuboidal and sometimes spindle-shaped; uniform; cell borders
well to poorly defined; basaloid cells small with poorly defined cell borders, deep-staining nuclei with high N/C
ratios and indiscernible cytoplasm
Nucleus Round, oval, oblong to spindle, with finely granular chromatin and micronucleoli, smooth nuclear membranes;
finely granular to thready chromatin; inconspicuous nucleoli; bland appearing; no mitoses
Cytoplasm Variable; scant to modest; eosinophilic to cyanophilic
Background Fibrillar to myxohyaline matrix, hyaline globules
Immunoprofile Immunoreactive for cytokeratin, vimentin, S100 protein, carcinoembryonic antigen (CEA) glial fibrillar acidic
protein (GFAP), muscle specific actin, epithelial membrane antigen (EMA)
Differential Pleomorphic adenoma

Diagnoses Adenoid cystic carcinoma
Adenocarcinoma, NOS
Papillary cystadenocarcinoma
Epithelial–myoepithelial carcinoma
Myoepithelioma
Basal cell adenoma/carcinoma
Polymorphous Low-Grade Adenocarcinoma (See Figs. 15.171 to 15.175)
A B
Figs. 15.171A to B. A: FNA of a recurrent polymorphous low-grade adenocarcinoma showing several tissue
fragments composed of cells some surrounding varying-sized hyaline globules staining strikingly magenta-pink with
Romanowsky stain. This pattern cannot be differentiated from an adenoid cystic carcinoma. B: The neoplastic cells
here are round to oval with uniform bland nuclei. (continued)
Figs. 15.171C. (continued) C: Another field from the same aspirate

showing fascicles of spindle-shaped a pattern suggestive of pleo-
morphic adenoma. (Courtesy of Dr. Henry F. Frierson, Department
of Pathology, University of Virginia Medical Center, Charlottesville,
C Virginia.)
A B
Figs. 15.172A and B. FNA of a recurrent polymorphous low-grade adenocarcinoma. A: Markedly cellular aspirate
consisting of several syncytial tissue fragments of malignant duct epithelial cells (medium power). B: Higher magnifi-
cation highlighting the tubular architecture and closely packed uniform duct epithelial cells with prominent nucleoli.
Fig. 15.173. Scrape preparation of a polymorphous low-grade ad-

enocarcinoma, showing small uniform cells forming syncytial tissue
fragment with a cribriform pattern.
A B
C D
Figs. 15.174A to D. FNA of a mass involving the tongue. A: Tissue fragments composed of round to spindle-shaped
cells surrounding and springing from a central fibromyxoid stroma with a feathery pattern. B: Higher magnification
highlighting the spindle-shaped myoepithelial cells. A predominance of these cells may favor the diagnosis of a
myoepithelioma. C, D: A different field from the same case showing syncytial tissue fragments made up of uniform
round to cuboidal duct epithelial cells. The nuclear chromatin is finely granular with micronucleoli. (Courtesy of
Dr. Kazuo Watanabe, Division of Pathology, Fukushima Medical University School of Medicine Hospital, Fukushima
City, Japan.)
Figs. 15.175 FNA of a polymorphous low-grade adenocarcinoma

shows tissue fragments made up of cuboidal to elongated cells,
slightly larger and mildly pleomorphic. The nuclear chromatin is
thready and bland. Note the central lumens. (Courtesy of Depart-
ment of Pathology, Ottawa Civic Hospital, Ottawa, Ontario, Canada.)
hemorrhage. The cut surface is gray–white to tan–white. plasm containing uniform, round nuclei that tend to fill
Microscopically, the tumor is composed of a biphasic cell the entire cell. The lumens may contain eosinophilic pro-
population consisting of ductal and myoepithelial cells. teinaceous material. The myoepithelial cells may assume a
Architectural arrangements may be predominantly solid, spindle form. The scattered foci of extracellular material,
tubular, cribriform (focal), and infrequently, papillary. The which are round to oval in contour, may be present in
key feature is the biphasic pattern of tubules with central association with nonluminal cells.
cuboidal to low columnar luminal cells and an outer layer
of clear myoepithelial cells. The myoepithelial cells are
characterized by their larger size, polygonal shape, and
clear-staining cytoplasm. Myoepithelial differentiation of The aspirates are usually very cellular and consist of a
the clear cells is indicated by their peripheral position rel- dual population of cells and are characterized by the
ative to the ductal cells and by immunohistochemical and tissue fragments of neoplastic duct epithelial cells and
ultrastructural evidence. Clear myoepithelial cells may be myoepithelial cells either in combination or exclusively
the dominant cellular component and are identified even (Table 15.25; Figs. 15.176 to 15.178). The duct epithelial
under lower magnification. The ductal elements are com- cells are round to cuboidal with well-defined cell borders,
posed of intercalated duct-like cells that usually border have appreciable pale to dense cytoplasm, and have a
small lumens and are cuboidal with eosinophilic cyto- large round nucleus with fi nely granular chromatin and
TABLE 15.25 CYTOPATHOLOGIC FEATURES OF EPITHELIAL–MYOEPITHELIAL CARCINOMA
Cellularity Variable, usually cellular
Presentation Depends on the composition of the aspirate; biphasic cell population of duct epithelial cells and
myoepithelial cells in variable proportions; neoplastic cells mostly in syncytial tissue fragments with
following three variations:
1) Consisting of only duct epithelial cells with or without forming tubular structures;
2) With duct epithelial cells forming tubules with or without central lumens and surrounded by
myoepithelial cells, forming double-layered tubular structures;
3) Only myoepithelial cells present in monolayered tissue fragments, tubules, trabeculae nests and
aggregates or as naked nuclei, myoepithelial cells may be embedded in acellular hyaline matrix;
the latter may also be seen around the myoepithelial cell groups.
Cells Duct epithelial cells round to cuboidal with well-defined cell borders and appreciable pale to dense
eosinophilic to cyanophilic cytoplasm; myoepithelial cells variable in size with poorly defined cell
borders, scant cytoplasm; clear myoepithelial cells recognized as naked nuclei due to disintegration of
the cytoplasmic borders; myoepithelial cells may be short spindle-shaped
Nucleus Duct epithelial nucleus round, with sharp but smooth nuclear membrane; finely granular chromatin
with prominent nucleoli; myoepithelial cell nuclei round, oval to oblong with dark-staining thready
chromatin with inconspicuous micronucleoli
Cytoplasm Variable; pale to dense or clear
Background Acellular cyanophilic to eosinophilic hyaline material (stains metachromatically with Romanowsky)
either surrounding individual tissue fragments or in the background
Immunoprofile Duct epithelial cells with strong reactivity to CK, EMA; myoepithelial cells react to S100 protein,
calponin, vimentin, p63
Differential Diagnoses Pleomorphic adenoma

Basal cell adenoma
Adenocarcinoma, NOS
Papillary cystadenocarcinoma
Clear cell carcinoma
Epithelial Myoepithelial Carcinoma (See Figs. 15.176 to 15.178)
A B
C D
Figs. 15.176A to E. FNA of an epithelial–myoepithelial carcinoma.

A: Low power view showing several tissue fragments depicting
the characteristic architecture consisting of several small tubules
formed by duct epithelial cells with nuclei containing prominent
nucleoli. The tubules contain deep eosinophilic acellular stromal
substance. Note the several aggregates of myoepithelial cells with
oval nuclei containing denser chromatin, embedded in stroma. B:
Higher magnification showing a large tissue fragment depicting
the characteristic architecture consisting of several small tubules
formed by duct epithelial cells with nuclei containing prominent
nucleoli. The tubules contain deep eosinophilic acellular stromal
substance. Note the several aggregates of myoepithelial cells with
oval nuclei containing denser chromatin, embedded in stroma. C,
D, E: These syncytial tissue fragments consist entirely of malignant
E duct epithelial cells.
prominent nucleoli. The duct epithelial cells may sur-

IMMUNOPROFILE
round small lumens or be present in aggregates without
lumens. The duct epithelial cells, in turn, are surrounded The duct epithelial cells are reactive to cytokeratins, epi-
by myoepithelial cells with poorly defi ned cell borders, thelial membrane antigen (EMA), and carcinoembryonic
scant cytoplasm, and round to oval nuclei with coarser antigen (CEA) and are nonreactive to S100 proteins and
dark-staining chromatin and micronucleoli. The myoepi- actin. The myoepithelial cells are reactive to cytokeratins,
thelial cells may assume spindle shapes. S100 protein, and actin.
A B
Figs. 15.177A and B. FNA of epithelial–myoepithelial carcinoma. A: Ductular structure surrounding matrix
material. B: Tissue fragment of duct epithelial cells.
A B
Figs. 15.178A and B. A: An elongated tubular tissue fragment comprised of duct epithelial cells. Myoepithelial cells
are not apparent. B: A tissue fragment of myoepithelial cells embedded in stromal matrix. (Courtesy of Department
of Pathology, Ottawa Civic Hospital, Ottawa, Ontario, Canada.)
DIAGNOSTIC PROBLEMS AND of epithelial–myoepithelial carcinoma reported in the

DIFFERENTIAL DIAGNOSES cytologic literature have been mistyped as pleomorphic
adenoma.
Epithelial–myoepithelial carcinomas are extremely rare
and only infrequently encountered in routine practice.
Its recognition is poor. Also, varied morphologic pat-
terns within the same tumor and from tumor to tumor
SMALL CELL CARCINOMA
as well as the predominance of either ductal or myo-
(NEUROENDOCRINE CARCINOMA)
epithelial cells provide a setting for sampling issues. An
aspirate with a dual cell population presenting a charac-
teristic pattern formed by a central ductule surrounded Primary small cell carcinomas of the salivary glands
by myoepithelial cells (Fig. 15.176) can be accurately are rare, very aggressive, malignant tumors composed
diagnosed. Neoplasms such as adenocarcinoma, NOS, of small, undifferentiated cells with ultrastructural and
or polymorphous low-grade adenocarcinoma must immunochemical evidence of neuroendocrine differen-
be considered with a predominant duct component. A tiation. They are also referred to as extrapulmonary oat-
predominant myoepithelial component should be dif- cell carcinomas. Small cell carcinomas represent 1.7%
ferentiated from pleomorphic adenoma, adenoid cystic of primary parotid epithelial malignant tumors, 2.2%
carcinoma, and clear cell lesions. In fact, several cases of submandibular malignancies, and 1.8% of all major
salivary gland malignancies. They typically occur in the The malignant cells are round to oval, sometimes oblong,
fifth through the seventh decades of life with a mean age with large nuclei containing coarsely granular chromatin
of 56 years. and inconspicuous nucleoli. Nuclear molding is charac-
Small cell carcinomas clinically present as a nonpain- teristic (Fig. 15.179). The neoplastic cells have scant cyto-
ful parotid mass with a short duration. Local, enlarged plasm. Larger duct epithelial cells may be present as small
lymph nodes are often involved by the tumor. foci. Squamous change may also be seen (Fig. 15.180).
Mitoses are frequent, and tumor necrosis may be focal to
extensive.
Small cell carcinomas grossly appear as a poorly circum-
scribed, fi rm, occasionally multinodular, grayish white
to yellow mass. The histomorphology of small cell car- The cytologic pattern is no different than that seen in pul-
cinomas closely parallel that of small cell carcinomas of monary small cell carcinomas (Table 15.26; Figs. 179 and
the lung. Microscopically, these tumors are composed of 180). The aspirates are usually very cellular consisting of
solid sheets, nests, irregular cords, and islands of closely a diffuse population of small malignant cells that are dis-
packed small, undifferentiated cells that widely infiltrate persed, in groups, or in syncytial tissue fragments with-
the salivary parenchyma and periglandular tissue. The out any architectural patterns. The malignant cells have
larger islands may show a peripheral palisading of the poorly defi ned cell borders with insignificant cytoplasm
nuclei and geographic areas of necrosis (e-Fig. 15.18). and very high N/C ratios. The nuclei show molding and
Small Cell (Neuroendocrine) Carcinoma (See Figs. 15.179 to 15.182)
Fig. 15.179. FNA biopsy of a primary small cell carcinoma of the

parotid gland. The malignant cells are small with indiscernible cyto-
plasm, high N/C ratios with deep-staining nuclei. Note the nuclear
molding.
A B
Figs. 15.180A and B. FNA of primary small cell carcinoma of the parotid gland. A: Fields like these with discrete,
rounded malignant cells may be difficult to differentiate from either benign lymphocytes or a malignant lymphoma.
B: The tissue fragment of small cell carcinoma cells shows squamous differentiation. Note the squamous pearl (arrow).
TABLE 15.26 CYTOPATHOLOGIC FEATURES OF SMALL CELL CARCINOMA

(NEUROENDOCRINE CARCINOMA)
Cellularity Scant to very cellular
Presentation Malignant cells discrete, in aggregates, or in syncytial tissue fragments usually without any architectural
patterns; rosettes infrequent; crush artifacts may be extensive resulting in poor cytopreparation
Cells Small, round, 2.5–3 times the size of a resting lymphocyte to slightly larger, oval to short spindle-shaped, cell
borders poorly defined, and often flush with the nucleus
Nucleus Round, oval to oblong; multinucleation not observed; N/C ratios very high; nuclear membranes smooth;
nuclear chromatin very coarsely granular to compact and deep-staining; nucleoli inconspicuous; nuclear
molding ⫹; mitoses ⫹; karyorrhexis ⫹; stretch artifacts ⫹
Cytoplasm Indiscernible to very scant; paranuclear vacuoles in Romanowsky stained preparations. Squamous
differentiation present occasionally
Background Dirty; necrosis; fragmented forms
Immunoprofile Cytokeratin ⫹; neuroendocrine markers ⫹; TTF-1 ⫹; negative for CK20
Differential Metastatic small cell carcinoma

Diagnoses Merkel cell carcinoma
Metastatic poorly differentiated carcinomas
Basal cell adenoma/basal cell adenocarcinoma
Cutaneous basal cell carcinoma (from skin overlying parotid gland)
Pleomorphic adenoma with a predominant basaloid cell pattern
Reactive intraparotid lymph node
Malignant lymphoma
mitotic activity. Karyorrhexis and necrosis may be promi-

nent. Focal squamous differentiation may be present. UNDIFFERENTIATED CARCINOMAS
IMMUNOPROFILE Undifferentiated carcinomas are uncommon malignant

tumors that lack the specifi c light microscopic morpho-
The cells of small cell carcinoma react to cytokeratin with logic features of other types of salivary gland carcinomas.
characteristic paranuclear globular staining as well as pres- They have neither glandular nor epidermoid features.
ent a dot-like pattern. The neoplastic cells react to Leu-7 Ultrastructurally, undifferentiated carcinomas show some
and neuroendocrine markers such as synaptophysin, neu- features associated with glandular, squamous, or neu-
ron specific enolase (NSE), and chromogranin. There is no roendocrine differentiation in some tumors.
reactivity with CK20, S100 protein, or HMB-45.
LARGE CELL UNDIFFERENTIATED
DIAGNOSTIC DIFFICULTIES AND CARCINOMA
DIFFERENTIAL DIAGNOSES Large cell undifferentiated carcinomas (LCUC) are very
The differential diagnoses include neoplasms with a small rare malignant tumors occurring in the parotid gland
cell pattern (Tables 15.26 and 15.27). Since the morphol- and only rarely involving the minor salivary glands. They
ogy of salivary gland small cell carcinomas is identical to occur in older individuals and present as a rapidly grow-
pulmonary small cell carcinomas (Fig. 15.181) and since ing mass. The neoplasm is aggressive with local and dis-
the latter are more common, a metastatic process must tant metastases.
fi rst be ruled out before establishing the tumor as a pri-
mary lesion. Poorly differentiated epithelial malignancies
are, at times, diffi cult to differentiate from neuroendo- Grossly, LCUCs present as a poorly circumscribed infil-
crine carcinomas (Fig. 15.182). trative tumor with a foci of necrosis and hemorrhage.
TABLE 15.27 DIFFERENTIATING DIAGNOSES OF SALIVARY GLAND TUMORS
WITH SMALL CELL PATTERN
Diagnostic See
Entities Cytopathology Features Fig(s).
Adenoid Cystic Neoplastic cells mostly in syncytial tissue fragments with intense crowding and overlapping, 15.189
Carcinoma forming three-dimensional cell balls or in tight aggregates; cribriform pattern ⫹/⫺; cylindrical
cores of acellular, homogeneous hyaline material within the tissue fragments or in extracellular
locations, staining intensely magenta pink with Romanowsky stain and pale green with
Papanicolaou stain; neoplastic cells small with high N/C ratios; cell borders poorly defined; nuclei
round to oval with smooth nuclear membranes; finely granular to compact chromatin; no nuclear
molding; nucleoli inconspicuous to absent; no mitoses; no necrosis; background clean; bare nuclei
⫹/⫺; immunoprofile: CK ⫹; S100 protein ⫹; anti-basement membrane antibody ⫹
Small Cell Neoplastic cells discrete, in loosely cohesive groups or in syncytial tissue fragments with 15.183
Carcinoma; no architectural patterns; cells small, round to oval; occasionally oblong to spindle-shaped;
Primary or nuclear membranes smooth to irregular; chromatin deep-staining an coarsely granular; nucleoli
Secondary inconspicuous to absent; nuclear molding ⫹; stretch artifacts ⫹; mitoses ⫹; karyorrhexis ⫹;
(Neuroendocrine cytoplasm scant to indiscernible; cellular necrosis ⫹; immunoprofile: CK ⫹; neuroendocrine
Carcinoma) markers ⫹/; S100 protein ⫺; LCA ⫺; CK20 ⫺
Poorly Malignant cells isolated, in loosely cohesive groups or in syncytial tissue fragments with no 15.184
Differentiated architectural patterns; cells small, round, oval to cuboidal; occasionally oblong to spindle- 15.185
Squamous shaped; nuclear membranes smooth to irregular; chromatin deep-staining and coarsely
Carcinoma granular; parachromatin clearing; nucleoli usually conspicuous; no nuclear molding; mitoses ⫹;
(Basaloid karyorrhexis ⫹/⫺; cytoplasm variable, scant to indiscernible; cellular necrosis ⫹; immunoprofile:
Squamous Cell) CK ⫹; neuroendocrine markers ⫺; S100 protein ⫺; LCA ⫺
Basal Cell Aspirate usually cellular; neoplastic cells discrete, in aggregates and in syncytial tissue fragments with 15.59
Adenoma crowding and overlapping of nuclei; cells small, uniform, lymphocyte-like; high N/C ratios; scant
to indiscernible cytoplasm; cell borders poorly defined; nuclei round to oval with smooth nuclear
membranes; finely granular to compact chromatin; no nuclear molding; nucleoli inconspicuous to
absent; no mitoses; no necrosis; background clean; immunoprofile: CK ⫹; S100 protein ⫹
Basal Cell Aspirate usually cellular; neoplastic cells discrete, in aggregates and in syncytial tissue fragments 15.190
Adenocarcinoma with or without branching and with crowding and overlapping of nuclei; peripheral palisading
of nuclei may be present within the tissue fragments; cells small, uniform to slightly pleomorphic
and enlarged; lymphocyte-like; high N/C ratios; scant to indiscernible cytoplasm; cell borders
poorly defined; nuclei round to oval with smooth nuclear membranes; finely granular to compact
chromatin; no nuclear molding; nucleoli inconspicuous to absent; no mitoses; no necrosis;
background clean; bare nuclei ⫹/⫺; immunoprofile: CK ⫹; S100 protein ⫹
Pleomorphic Small basaloid cells, mostly in syncytial tissue fragments or in tight aggregates, acinar pattern 15.187
Adenoma with with hyaline globules ⫹/⫺; cells small with high N/C ratios; poorly defined cell borders; round to 15.188
a Predominant oval nuclei with smooth nuclear membranes; coarsely granular to compact chromatin; nucleoli
Basaloid cell inconspicuous; scant cytoplasm; clean background; fibrillar stroma with aggregates of neoplastic
Pattern cells in a diagnostic clue; immunoprofile: CK ⫹; S100 protein ⫹
Malignant Dissociated cell pattern; lymphoma cells discrete and in aggregates; small, monomorphic pattern 15.191B
Non-Hodgkin with well to poorly defined cell borders; high N/C ratios; nuclei round to oval with smooth to
Lymphoma irregular nuclear membrane; finely granular chromatin with parachromatin clearing; prominent
nucleoli; cytoplasm variable but scant; no nuclear molding; mitoses ⫹; karyorrhexis ⫹;
immunoprofile: CK ⫹; LCA ⫹; neuroendocrine markers ⫺; S100 protein ⫺
Merkel Cell Neoplastic cells discrete, in loosely cohesive groups with no architectural pattern; cells small, 15.186
Carcinoma round to oval; nuclear membranes smooth to irregular; chromatin deep-staining, coarsely
granular; nucleoli inconspicuous to absent; nuclear molding ⫹; stretch artifacts ⫹; mitoses
⫹; karyorrhexis ⫹; cytoplasm scant to indiscernible; necrosis ⫹; immunoprofile: CK20 ⫺;
neuroendocrine markers ⫹; history of Merkel cell carcinoma helpful
Reactive Lymph Polymorphic lymphoid cell population 15.191A

Node
661
Fig. 15.181. Metastatic small cell carcinoma of the lung to the pa- Fig. 15.182. FNA of a parotid mass showing a very cellular aspirate
rotid gland. Morphologically, it is not possible to differentiate a pri- consisting of loosely cohesive cells with neuroendocrine features. Neu-
mary salivary gland small cell carcinoma from a metastatic small roendocrine markers were negative. The tumor was widely dissemi-
cell carcinoma. nated. From cytomorphology alone, poorly differentiated epithelial
malignancies are difficult to differentiate from neuroendocrine tumors.
Differential Diagnoses of Lesions Composed of Small Cells (See Figs. 15.183 to 15.191)
Fig. 15.183. FNA biopsy of a primary small cell carcinoma of the Fig. 15.184. Poorly differentiated squamous carcinoma. This aspi-
parotid gland. The malignant cells are small with indiscernible cyto- rate from a parotid mass was interpreted as small cell carcinoma.
plasm, high N/C ratios with deep-staining nuclei. Note the nuclear The neuroendocrine markers were negative. This patient had en
molding and karyorrhexis. excision of squamous carcinoma of the ipsilateral pinna probably
representing the primary source.
Fig. 15.185. FNA of a basaloid squamous carcinoma in the neck. The

syncytial tissue fragments of small malignant cells with deep-staining
chromatin bears a strong resemblance to small cell carcinoma. Note,
however, that the nuclear molding is absent and some nuclei show
micronucleoli.
Fig. 15.186. Metastatic Merkel cell carcinoma involving the sub- Fig. 15.187. FNA of a pleomorphic adenoma showing exclusively a
mandibular salivary gland. A history of a primary tumor in the head small basaloid cell pattern which raises the possibility of small cell
and neck region is very useful in making a diagnosis. Morphologi- carcinoma.
cally, Merkel cell carcinoma cells strongly resemble small cell car-
cinomas.
Fig. 15.188. FNA of a pleomorphic adenoma with a predominant Fig. 15.189. These cells from an adenoid cystic carcinoma with a
small cell pattern. solid pattern demonstrate morphologic similarity to the small cell
carcinoma cells. Nuclear molding and karyorrhexis are lacking.
Fig. 15.190. This aspirate from a basal cell adenocarcinoma shows

morphologic overlap with cells of small cell carcinoma. Tissue frag-
ments of malignant cells with peripheral palisading and lack of
nuclear molding will rule out a small cell carcinoma.
A B
Figs. 15.191A and B. A: A reactive intraparotid lymph node must be considered in a differential diagnosis of small
cell lesions. B: Malignant lymphomas involving the salivary glands may offer diagnostic difficulties in differentiating
them from small cell carcinomas.
TABLE 15.28 CYTOPATHOLOGIC FEATURES OF LARGE CELL UNDIFFERENTIATED CARCINOMA
Cellularity Usually cellular
Presentation Neoplastic cells isolated, in loosely cohesive groups or in syncytial tissue fragments, without any
architectural patterns
Cells Very pleomorphic in size and shape; medium-sized, large to giant forms; round, oval, polygonal to spindle-
shaped; N/C ratios variable; cell borders well to poorly defined
Nucleus Variable in size; smooth to irregular nuclear membranes; bi- or multinucleation ⫹/⫺; coarsely granular
chromatin with parachromatin clearing; single or multiple, micro- and macronucleoli; intranuclear inclusions
⫹/⫺; mitoses ⫹/⫺
Cytoplasm Variable; scant to abundant; pale, granular to dense; emperipolesis ⫹/⫺
Background Clean to extensive necrosis; bare nuclei; cellular debris
Immunoprofile Cytokeratin ⫹
Differential High-grade mucoepidermoid carcinoma

Diagnoses Salivary duct carcinoma
Poorly differentiated carcinoma, primary or metastatic
Lymphoepithelial carcinoma
Malignant melanoma
Anaplastic large cell lymphoma
Histologically, the LCUC is characterized by solid sheets

or poorly defined trabeculae of discohesive, large, vari-
ably pleomorphic, malignant cells with abundant cyto- The aspirates are usually cellular, composed of disco-
plasm; large, round, irregular nuclei; and prominent hesive, very pleomorphic, malignant cells ranging from
nucleoli. The malignant cells may be polygonal and round to polygonal and medium-sized to large or giant
occasionally spindle-shaped. The cytoplasm may be forms (Table 15.28; Figs. 15.192 to 15.194). Their cell
eosinophilic to amphophilic and sometimes vacuolated borders are well- to poorly defined. The nuclei are round
to clear. Bizarre tumor giant cells and osteoclast-type to oval with smooth to irregular borders. The chromatin
giant cells have been described. Mitosis and necrosis are is granular with parachromatin clearing and prominent
frequent. micro- and macronucleoli. The cytoplasm is variable and
Undifferentiated Carcinoma Large Cell Type (See Figs. 15.192 to 15.195)
A B
Figs. 15.192A to C. Three examples of large cell undifferentiated

carcinomas. A: Loosely cohesive very pleomorphic malignant cells.
B: Discrete pleomorphic malignant cells. Note the prominent macro-
nucleoli. C: A syncytial tissue fragment and groups of undifferenti-
ated, pleomorphic malignant cells with poorly defined cell borders
and indiscernible cytoplasm. The nuclei are large with prominent
C macronucleoli.
Fig. 15.193. FNA of an undifferentiated carcinoma showing ma- Fig. 15.194. The cell block of the aspirate from the case in Fig-
lignant cells with pleomorphic nuclei. There is necrosis in the back- ure 15.193 showing groups of undifferentiated malignant cells in a
ground. (Courtesy of William Rafferty, M.D. Department of Pathol- necrotic background (H&E). (Courtesy of William Rafferty, M.D.
ogy, Cooper University Hospital, Camden, New Jersey). Department of Pathology, Cooper University Hospital, Camden,
New Jersey).
pale to dense to vacuolated. Mitoses are frequent. The Diagnostic Difficulties

background may show cellular and necrotic debris. and Differential Diagnoses
The differential diagnoses include poorly differentiated
Immunoprofile
malignancies either primary in the salivary gland or meta-
Undifferentiated carcinomas are immunoreactive only to static from distant primaries, amelanotic malignant mela-
cytokeratin. noma, and anaplastic lymphoma (Table 15.29).
TABLE 15.29 DIFFERENTIAL DIAGNOSTIC FEATURES OF HIGH-GRADE MALIGNANT LESIONS

OF THE SALIVARY GLANDS

High-Grade Cellular aspirates with clearly malignant cells, isolated, in loosely cohesive groups or in 15.115
mucoepidermoid syncytial tissue fragments, with no architectural patterns; cell; malignant cells pleomorphic in
carcinoma size with well-defined borders; abundant pale to dense cytoplasm with occasional vacuoles;
necrosis ⫹/⫺; alcian blue or PAS ⫹ diastase resistant
Adenocarcinoma, Cellular aspirates with clearly malignant cells, isolated, in loosely cohesive groups or in 15.118
NOS, poorly syncytial tissue fragments, with no architectural patterns or rare glandular formation; 15.129
differentiated malignant cells pleomorphic in size with well-defined borders; abundant pale to dense
cytoplasm with occasional vacuoles; mitoses ⫹/⫺; necrosis ⫹/⫺
Salivary duct Cellular aspirates with clearly malignant cells, isolated, in loosely cohesive groups or in 15.120
carcinoma syncytial tissue fragments with or without branching; cribriform, glandular or papillary
pattern; malignant cells pleomorphic in size with well-defined borders; abundant pale to
dense cytoplasm; mitoses ⫹/⫺; necrosis frequent
Oncocytic Cellular aspirates with clearly malignant cells, isolated, in loosely cohesive groups or in 15.121
carcinoma syncytial tissue fragments with no architectural patterns; malignant cells pleomorphic in size
with well-defined borders; scant to abundant granular cytoplasm; high N/C ratios; uniform
nuclei with prominent macronucleolus; mitoses ⫹/⫺; necrosis frequent
Myoepithelial Cellular aspirates with clearly malignant cells, isolated, in loosely cohesive groups or in 15.122
carcinoma syncytial tissue fragments with no architectural patterns; malignant cells pleomorphic in size
with well-defined borders; abundant pale to dense cytoplasm; mitoses ⫹/⫺; necrosis ⫹/⫺;
calponin ⫹
Undifferentiated Cellular aspirates with clearly malignant cells, mostly isolated cells, in loosely cohesive groups 15.123
carcinoma or in syncytial tissue fragments with no architectural patterns; malignant cells pleomorphic in
size occasionally with giant forms; well-defined cell borders variable pale to dense cytoplasm;
mitoses ⫹/⫺; necrosis ⫹/⫺
Lymphoepithelial Cellular aspirates with clearly malignant cells, mostly isolated cells, in loosely cohesive 12.33A
carcinoma groups; malignant cells pleomorphic in size, large, occasionally with giant forms; well-defined and B
cell borders variable pale to dense cytoplasm; mitoses ⫹/⫺; necrosis ⫹/⫺; lymphoid cells in
the background
Metastatic poorly Cellular aspirates with clearly malignant cells, mostly isolated cells, in loosely cohesive groups 15.116 to
differentiated or in syncytial tissue fragments with no architectural patterns; malignant cells pleomorphic in 15.119
carcinomas size occasionally with giant forms; well-defined cell borders variable; pale to dense cytoplasm;
(squamous or mitoses ⫹/⫺; necrosis ⫹/⫺; h/o primary malignancy elsewhere.
adenocarcinoma)
Metastatic Cellular aspirates with clearly malignant cells, isolated, in loosely cohesive groups or rarely in 15.124
malignant syncytial tissue fragments with no architectural patterns; malignant cells may exhibit marked
melanoma pleomorphism in size, with well-defined borders; abundant, clear, pale to dense cytoplasm;
(amelanotic) mitoses ⫹/⫺; necrosis ⫹/⫺; immunoreactive to HMB-45, S100 protein and Melan-A
LYMPHOEPITHELIAL CARCINOMA pleomorphic malignant cells that may or may not exhibit the
characteristic features of a specific type of salivary gland car-
Lymphoepithelial carcinomas are undifferentiated carci-
cinoma. Prominent hyalinization of the stroma is common.
nomas associated with dense lymphoid stroma. These are
Necrosis and hemorrhage are frequently present.
extremely rare tumors, comprising 0.4% of salivary gland
tumors. The majority occurs in the parotid gland. Cytopathologic Features
Grossly, the tumor is lobulated, firm, tan, may be circum-
scribed but nonencapsulated, and is clearly infiltrative into The cytologic features of carcinoma ex-pleomorphic ade-
the adjacent salivary parenchyma, fat, muscle, and skin. noma may or may not be diagnostic and are dependent
Histologically, lymphoepithelial carcinomas at a on the sampled areas of the tumor. If the sampled areas
lower magnification are characterized by the dense aggre- represent the malignant or carcinomatous foci, the cyto-
gates of lymphoid tissue with germinal centers and with logic diagnosis will be that of a malignant neoplasm. The
an inconspicuous epithelial component. At a higher mag- cytomorphology of the malignant cells may or may not
nification, the malignant epithelial component appears as allow accurate typing. On the other hand, if the sampled
irregular-shaped islands of cells with eosinophilic cyto- areas represent the benign areas, the cytological diagnosis
plasm, syncytial masses, trabeculae, or as isolated cells. will be that of a benign mixed tumor or a pleomorphic
Cytologically, the malignant cells are similar to the adenoma. The origin of a malignant neoplasm in a benign
cells of LCUC. They occur singly or in groups, often ob- pleomorphic adenoma can only be detected following the
scured by a heavy lymphoid cell population. excision of the tumor and histologic examination unless
aspirated samples demonstrate both components (i.e., cel-
lular features of pleomorphic adenoma and carcinoma)
MALIGNANT MIXED TUMORS (e-Figs. 15.19 and 15.20).
CARCINOSARCOMA
Malignant mixed tumors of the salivary glands include
three types of malignant neoplasms: 1) carcinoma ex- Carcinosarcomas are a rare malignant neoplasm of the
pleomorphic adenoma, 2) carcinosarcoma, and 3) metas- salivary gland with malignant epithelial and stromal
tasizing benign mixed tumor. Of these, only carcinoma components.
ex-pleomorphic adenoma is encountered frequently. The
remaining two are extremely uncommon.
METASTASIZING BENIGN MIXED TUMOR
CARCINOMA EX-PLEOMORPHIC ADENOMA These tumors occur very rarely where the benign mixed
tumor metastasizes to the distant organ and demonstrates
Carcinoma ex-plemorphic adenoma is a malignant tumor a similar histologic pattern as that of the parent tumor.
arising in the epithelial component of a pleomorphic ade-
noma or a benign mixed tumor. The carcinomatous ele-
ments may represent any type of epithelial malignancy such
as undifferentiated carcinoma, adenocarcinoma, NOS, or
CLEAR CELL CARCINOMAS
other types of carcinomas—namely, salivary duct carcinoma,
adenoid cystic carcinoma, or mucoepidermoid carcinoma. Clear cell carcinomas are a group of malignant neo-
Adenocarcinoma, NOS, is the most frequent malignant plasms composed of a monomorphic population of cells
tumor arising in carcinoma ex-pleomorphic adenoma. characterized by optically clear cytoplasm with standard
Carcinoma ex-pleomorphic adenomas represent 3.6% hematoxylin and eosin stains. The majority of clear cell
of all salivary gland tumors and 6% of all mixed tumors. It neoplasms of the major salivary glands fall within the
is the sixth most common malignancy of the salivary glands spectrum of epithelial–myoepithelial carcinoma, myoepi-
and occurs commonly in the parotid gland. Roughly 20% thelioma, or myoepithelial carcinoma. A distinct subtype,
of the patients present a history of one or more excisions hyalinizing clear cell carcinoma, arising primarily in minor
for the mixed tumors. Some present as a rapidly growing salivary glands has been described. This type of clear cell
mass and may be associated with pain or facial paralysis. carcinoma lacks evidence of the myoepithelial cell differ-
Some are fixed to the skin. Grossly, these tumors are poorly entiation that characterizes the other three entities. In the
circumscribed, extremely infiltrating, and large with an aver- WHO classification of salivary gland tumors (2005), this
age size of 4 to 5 centimeters. The cut surface of the tumor is entity is referred to as clear cell carcinoma, NOS.
white or tan–gray with hemorrhage, necrosis, and cystic de- In cytologic preparations, if a primary clear cell
generation. Histologically, the prerequisite for the diagnosis carcinoma does not show any characteristics of either
is the presence of tissue that is diagnostic of a benign mixed myoepithelioma, epithelial–myoepithelial carcinoma, or
tumor. The carcinomatous elements infiltrate the surround- hyalinizing clear cell carcinoma, the neoplasm may be
ing tissues. They are clearly malignant, consisting of enlarged classified as clear cell carcinoma, NOS (Fig. 15.195).
Fig. 15.195. FNA of a clear cell carcinoma. The neoplastic cells are
medium-sized with well to poorly defined cell borders. The nuclei
are pleomorphic, round to oval with irregular nuclear membranes.
The chromatin is finely granular with micronucleoli. Note the pres-
ence of nuclear grooves. The cytoplasm is pale to clear and vacu-
olated. The N/C ratios are high.
CLEAR CELL CARCINOMA, NOS carcinoma, papillary-cystic variant of acinic cell carci-
noma, polymorphous low-grade adenocarcinoma, and
Clear cell carcinomas are also referred to as a hyaliniz-
papillary adenocarcinoma.
ing subtype, which involves the minor salivary glands
in 60% of cases. Histologically, these are characterized
by several growth patterns formed by clear cells. These
contain glycogen and have stained negative for mucin. METASTATIC MALIGNANCY TO THE
Immunoreactivity to cytokeratin and S100 protein has SALIVARY GLANDS
been inconsistent.
Several salivary gland neoplasms contain a significant
proportion of cells with clear cytoplasm (Table 15.30). Malignancy secondarily involving the salivary glands may
These include pleomorphic adenoma, clear cell onco- be the result of direct invasion or, more often, of metas-
cytoma (Fig. 15.196), metastatic renal cell carcinoma tases to intra- or peri-salivary gland lymph nodes. The
(Fig. 15.197), epithelial–myoepithelial carcinoma (Fig. parotid gland is the most common site. The submandibu-
15.198), sebaceous adenoma and carcinoma, mucoepi- lar gland is involved much less commonly. The incidence
dermoid carcinoma (Fig. 15.199), acinic cell carcinoma of metastases to the salivary gland comprises roughly
(Fig. 15.200), myoepithelioma/myoepithelial carcinoma 30% of the malignant neoplasms. Squamous carcinoma
(Fig. 15.201), and clear cell squamous carcinoma. and malignant melanoma are the two most common met-
astatic malignancies. Over 60% of the metastases to the
parotid region are from primary tumors of the head and
neck region. And of these, by far the largest majority is
PAPILLARY CYSTADENOMA AND from the skin. Distant primaries include those from the
CYSTADENOCARCINOMA OF THE lung, the kidney, the breast, the colon, the gastrointestinal
SALIVARY GLANDS tract, and the prostate. Metastatic malignant neoplasms
to the salivary glands are illustrated in various chapters
Cystadenoma is a rare benign epithelial tumor charac- (Figs. 15.118, 15.119, 15.124, 15.136, 15.181, 15.184,
terized by a unicystic or multicystic growth pattern with 15.185, and 15.186).
focal intraluminal papillary proliferation. The lining epi-
thelium ranges from cuboidal or columnar to oncocytic.
The cyst aspirates show scant cellularity. Oncocytic epi-
NONNEOPLASTIC LESIONS OF THE
thelium, when present, is diffi cult to differentiate from
SALIVARY GLANDS
Warthin’s tumor or an oncocytoma (Figs. 15.78A to C
and 15.202A to C).
Cystadenocarcinoma is the malignant counterpart Several types of nonneoplastic disorders of salivary glands
of cystadenoma. It is a rare malignant neoplasm char- frequently simulate neoplasms clinically, radiologically,
acterized by cystic and papillary growth patterns. The and sometimes cytohistologically and include various
epithelium varies from cuboidal, columnar, mucinous, or types of cystic lesions, infl ammatory disorders, autoim-
oncocytic type. The differential diagnoses include other mune diseases, and some developmental disorders. Sev-
neoplasms with papillary patterns such as salivary duct eral of these constitute potential diagnostic pitfalls.
TABLE 15.30 CYTOPATHOLOGIC FEATURES DIFFERENTIATING NEOPLASMS

WITH CLEAR CELL CHANGE
Oncocytoma Primary Epithelial/ Metastatic

with Clear Mucoepidermoid Clear Cell Acinic Cell Myoepithelial Renal Cell
Cell Change Carcinoma Carcinoma Carcinoma Carcinoma Carcinoma
Presentation Cells isolated, Low cellularity, Cells isolated, Dissociated Cells isolated or Cells isolated,
in loosely mostly isolated, in in loosely cell pattern, in syncytial tissue in loosely
cohesive loosely cohesive cohesive mixed with fragments with cohesive
groups, groups, or in small groups, or in syncytial tissue acinar pattern groups, or
sheets, or syncytial tissue syncytial tissue fragments in syncytial
syncytial tissue fragments without fragments forming cords, tissue
fragments any architectural trabeculae, or fragments
pattern acinar pattern
Cells Monomorphic Polymorphic cell Medium-sized, Small to large, Dual cell Large
large, round to population; small round, oval, poorly defined population; cuboidal to
polygonal with to large, round to or cuboidal, cell borders; myoepithelial polygonal
well-defined polygonal with poorly defined high N/C ratio as plasmacytoid with ill-
cell borders; well-defined cell cell borders; and spindle cells; defined cell
low N/C ratio borders; low N/C high N/C ratio duct epithelial as borders; low
ratio round to cuboidal N/C ratio
Nucleus Round to oval; Round to oval; Round to oval; Round to Round to oval or Round to
smooth nuclear smooth nuclear smooth nuclear oval; smooth bipolar; granular oval; smooth
membrane; membranes; membrane; nuclear chromatin; nuclear
granular, finely granular finely granular membrane; micronucleoli membrane;
evenly chromatin; chromatin with finely granular finely granular
distributed micronucleoli parachromatin chromatin, chromatin;
chromatin clearing; micronucleoli prominent
prominent nucleoli
nucleoli
Cytoplasm Abundant Abundant, clear; Clear, pale, Clear to pale Variable; Abundant
clear; along (cells with dense bubbly or to granular clear, pale in pale to clear
with cells cytoplasm— vacuolated myoepithelial
containing squamous cells cells; dense in
abundant or intermediate duct epithelial
granular cells—may be cells
cytoplasm present)
Background Clean Mucinous, cellular Clean Naked nuclei Clean or Clean ⫹/⫺
debris, mixed hemorrhagic hemorrhagic
inflammatory ⫹/⫺
cells, including
histiocytes
Confirmatory Tests ⫺ Mucin ⫹ Glycogen ⫹ PAS ⫹ diastase Cytokeratin ⫹ Glycogen ⫹

Histochemistry resistant S100 protein ⫹ lipid ⫹
Immunochemistry ⫺ ⫺ Nondiagnostic Amylase ⫹ ⫺ Cytokeratin ⫺
Ultrastructure Abundant ⫺ ⫺ Zymogen ⫺ ⫺

mitochondria granules
Diagnostic Clues Presence Polymorphic cell ⫺ Strong Dual cell History of

of typical pattern; mucoid resemblance to population primary renal
oncocytic cells background acinar cells carcinoma
Differential Diagnoses of Neoplasms with Clear Cell Pattern (See Figs. 15.196 to 15.205)
Fig. 15.196. FNA of an oncocytoma demonstrating clear cell pat- Fig. 15.197. Metastatic renal cell carcinoma. Higher magnification
tern. These cells may be mistaken for a clear cell neoplasm. showing malignant cells with poorly defined cell borders with nuclei
appearing naked. The nuclear chromatin is very bland. The cyto-
logic pattern is consistent with a metastatic renal cell carcinoma.
Without a history of renal cell carcinoma, a primary clear cell carci-
noma may be considered.
Fig. 15.198. Epithelial myoepithelial carcinoma. A monolayered Fig. 15.199. Mucoepidermoid carcinoma. This fine needle aspirate
tissue fragment of myoepithelial cells. This may be misinterpreted from a mucoepidermoid carcinoma demonstrates malignant cells
as a clear cell carcinoma. with clear cytoplasm.
Fig. 15.200. Acinic cell carcinoma. The cells of the acinic cell carci- Fig. 15.201. Myoepithelioma. The myoepithelioma cells are large
noma have clear cytoplasm. The cytoplasmic borers are ill-defined with clear cytoplasm. There is abundant matrix material in the
and frayed with stripped nuclei. background.
670
A B
Figs. 15.202A to C. Papillary oncocytic cystadenoma. A, B: This

aspirate from a parotid gland mass is very cellular, showing sev-
eral syncytial tissue fragments of medium to large cells with well-
defined cell borders, abundant eosinophilic vacuolated cytoplasm.
The nuclei are round, mildly pleomorphic. The differential diag-
noses included oncocytic lesion and mucoepidermoid carcinoma.
The surgical excision revealed a cystic encapsulated papillary lesion
consistent with papillary cystadenoma. C: Histologic section of the
C papillary neoplasm.
NONNEOPLASTIC CYSTS lymphoepithelial sialadenitis (LESA), and some are asso-

ciated with Human Immunodeficiency syndrome (HIV
The nonneoplastic cysts of the salivary glands are uncom-
infection) or AIDS.
mon, but when they occur, they commonly involve the
parotid glands (Table 15.31). As a group, salivary gland
Benign Lymphoepithelial Cyst. Lymphoepithelial cysts are
cysts comprise approximately 5% of all salivary gland
infrequent and occur in sites such as the floor of the mouth
tumors, but if the cystic neoplasms are excluded, this inci-
and the ventral and posterolateral aspects of the tongue
dence is remarkably reduced. Their importance lies in the
and parotid glands. They are characterized by a capsule
fact that the majority of the cysts are unilateral, and in
separating them from the surrounding salivary tissue. Most
almost one-half of these cases, they have simulated a neo-
are unilocular, lined by nonkeratinizing or keratinizing
plasm, particularly a pleomorphic adenoma (mixed tumor).
stratified squamous epithelium. In the subepithelial tissue,
The nonneoplastic cystic lesions commonly encountered
there is extensive lymphoid tissue, with germinal centers,
in salivary glands include retention cysts, mucoceles, der-
completely encircling the cyst. Lymphoepithelial lesions
moid cysts and epidermal inclusion cysts, branchial cleft
(epimyoepithelial islands) are absent.
cysts, and lymphoepithelial cysts (see Table 15.33).
Cytopathologic Features—The aspirate of the benign
lymphoepithelial cyst contains a heavy population of
Lymphoepithelial Cysts
lymphoid cells with germinal center cells and squamous
The cystic lesions of the major and minor salivary glands epithelial cells with or without keratinization, as well as
that are lined by epithelium along with a major compo- keratin debris (Fig. 15.203).
nent of lymphoid tissue fall into two broad categories.
Some are simple cysts of the duct system with a compo- HIV-Associated Benign Lymphoepithelial Cyst. Patients
nent of lymphoid tissue in the wall and are simply referred with HIV infection and AIDS are prone to the develop-
to as “lymphoepithelial cysts” (Table 15.31). Some are ment of cystic lesions in the salivary glands. These lesions
part of the spectrum of benign lymphoepithelial lesions constitute a separate entity from the benign lymphoe-
(also known as myoepithelial sialadenitis [MESA]) or pithelial cyst or cysts associated with lymphoepithelial
TABLE 15.31 NONNEOPLASTIC CYSTIC LESIONS TABLE 15.32 CYTOPATHOLOGIC

OF THE MAJOR AND MINOR SALIVARY GLANDS FEATURES OF HIV-ASSOCIATED BENIGN
LYMPHOEPITHELIAL CYST
● Mucocele (mucous extravasation phenomenon or mucus
escape reaction) ● Aspirate clear, to turbid; yellow-white to cheesy
● Salivary duct retention cyst (mucus retention and salivary ● Variable cellularity
duct cysts) ● Polymorphic cell population
● Lymphoepithelial cysts • Lymphoid cells with germinal center cells; large
• Lymphoepithelial cysts numbers of immunoblasts; active phagocytosis
• Benign lymphoepithelial lesion-type cyst (cystic • Lymphohistiocytic clusters
benign lymphoepithelial lesion or cystic myoepithelial • Variable number of superficial and intermediate type
sialoadenitis) squamous cells (derived from squamous metaplasia of
• Aids-related parotid cyst (HIV-associated the cyst lining); parakeratotic squamous cells
lymphoepithelial cyst) • Anucleated squames
● Developmental cysts • Foamy macrophages; single or aggregates;
• Polycystic (dysgenetic) disease hemosiderin ⫹/⫺
• Branchial cleft cyst • Multinucleated foreign-body-type giant cells
• Cystic hygroma • Epimyoepithelial islands often permeated by
• Dermoid cyst lymphoid cells
• No oncocytes
• Clean to dirty background with cellular debris; normal
salivary glandular tissue not present
• Differential Diagnoses
Non-HIV-associated benign lymphoepithelial cyst
Mucus retention cyst (salivary duct cyst)
Reactive intraparotid lymph node
Chronic sialadenitis
Warthin’s tumor
Low-grade mucoepidermoid carcinoma
low, clear, sometimes turbid to cheesy fluid. The cellularity

is variable, represented by a lymphoid cell population with
germinal center cells and tissue fragments of squamous
cells with or without nuclear atypia and anucleated forms.
Fig. 15.203. Benign lymphoepithelial cyst. The fine needle aspirate
yielded scant amount of fluid which showed a mixed lymphoid in- The lymphoid population may be quite dense, simulating a
fi ltrate. The surgical excision revealed a cyst with heavy lymphoid malignant lymphoma. Also present are macrophages, lym-
infiltrate in the wall. phohistiocytic clusters, and multinucleated foreign-body
type giant cells. The background may show proteinaceous
fluid and cellular debris. Acinar cells or oncocytes are not
sialadenitis (LESA). The HIV-associated lymphoepithelial seen. The cytologic features of HIV-associated benign lym-
cysts exclusively involve the parotid glands with frequent phoepithelial cysts are listed in Table 15.32 and Figures
bilaterality. The HIV-infected patients harboring lymphoe- 15.204 and 15.205. The differential diagnoses of HIV-
pithelial cysts present with painless unilateral or bilateral associated lymphoepithelial cysts are listed in Table 15.33.
parotid gland swelling ranging from 2 to 4 centimeters. Some cystic neoplasms (e.g., Warthin’s tumor), low-
The cystic swellings are often fl uctuant. Imaging reveals grade mucoepidermoid carcinomas, or those that have un-
complex multilocular cysts. dergone cystic degeneration (e.g., pleomorphic adenoma),
Grossly, the cysts vary in size and contain yellow, must always be considered in the differential diagnosis to
watery to turbid, and sometimes cheesy secretions. Mi- avoid misinterpretation. Table 15.33 lists the clinical and
croscopically, the enlarged gland shows a single cyst or cytopathologic features of nonneoplastic and neoplastic
multiple cysts of varying sizes lined by squamous epithe- cystic lesions. A common denominator for all these cystic
lium. The walls of the cyst reveal fl orid lymphoid hyper- lesions is the presence of an excessive mucoid background.
plasia with germinal centers. Numerous lymphoepithelial Table 15.34 lists entities with a mucoid background, and
lesions (epimyoepithelial islands) are seen throughout the these are illustrated in Figures 15.206 to 15.212.
lymphoid tissue. Acinar tissues are not present. A metastatic squamous carcinoma with cystic degen-
Cytopathologic Features—Aspirates of HIV-associated eration should always be considered in the differential
benign lymphoepithelial cysts yield straw-colored to yel- diagnosis of cystic lesions (Fig. 15.213).
TABLE 15.33 DIFFERENTIAL DIAGNOSES OF CYSTIC LESIONS OF THE SALIVARY GLANDS
Diagnostic Entities Clinicopathologic Features Cytopathologic Features

Mucocele (Mucus Frequently associated with minor salivary glands, particularly Clear to thick mucoid fluid; large numbers
Escape Reactions) the lips; mean age 25 years; well-defined, fluctuant; occurs of foamy histiocytes, multinucleated foreign-
a result of trauma; no epithelial lining; cavity lined by type giant cells; no epithelial cells; mucoid
connective tissue, inflammatory cells and histiocytes background
Mucus Retention Less common than mucocele; a true cyst with epithelial Clear to thick mucoid fluid; large numbers of
Cyst lining; occurs as a result of duct obstruction (e.g., foamy histiocytes, multinucleated foreign-type
sialithiasis) giant cells; Epithelial cells when present may
be cuboidal to columnar; occasionally goblet
and squamous cells; mucoid background
Branchial Cleft Cyst Developmental anomaly; may occur in and around parotid Turbid fluid; mature squamous cells with
glands and ear; may be bilateral; younger age group; cyst and without keratinization; anucleated
lined by stratified squamous epithelium, occasionally forms frequent; lymphocytes may be present;
columnar epithelium; abundant lymphoid tissue with or cellular and/or keratin debris; background
without germinal centers in the wall of the cyst may be clean; columnar epithelial cells rare
Dermoid and Usually occurs in the oral cavity; although frequent in Contents serous to mucoid, mature squamous
Epidermoid Cysts midline, may occur in submandibular triangle; dermoid cysts cells with anucleated forms with and without
are lined by stratified squamous epithelium with dermal keratinization; keratin debris and squamous
appendages; epidermoid cysts lined by keratinized stratified pearls; inflammatory cells; nuclear atypia
squamous epithelium and lack appendages may cause diagnostic difficulties
Benign Simple cysts of the duct system, lined by cuboidal to Mixed lymphoid cell population; mature
Lymphoepithelial columnar or squamous epithelium with lymphoid tissue in squamous cells with or without nuclear
Cysts the wall atypia
HIV-Associated Involve parotid glands; predilection for males at high-risk Grossly, clear to turbid to yellow-white
Benign for AIDS; sharply circumscribed, fluctuant, unilocular, lined and cheesy aspirate; lymphoid cells with
Lymphoepithelial by stratified squamous epithelium; abundant lymphoid or without germinal center cells; large
Cysts tissue in the cyst wall numbers of immunoblasts; lymphohistiocytic
clusters; squamous cells with or without
nuclear atypia; epimyoepithelial islands; no
oncocytes; no normal salivary glandular tissue
Low-Grade Most common malignant neoplasm of the salivary glands, Viscous, mucoid, and occasionally clear,
Mucoepidermoid occur at any age but common in the second to the fifth polymorphic cell population including
Carcinoma decades of life, slightly higher incidence in females; squamous cells, clear cells and mucin
characterized by a cystic growth pattern with both producing cells; bland nuclei; intermediate
micro- and macrocysts, presence of mature squamous and cells⫹/⫺; anucleated cells, macrophages and
glandular components and abundant extracellular mucin; cellular debris and mucin in the background
cystic structures lined by goblet cells, islands of proliferating
squamous cells without keratinization and intermediate cells
Pleomorphic Although the most common tumor of the salivary Mucoid aspirate, admixture of epithelial–
Adenoma with glands, cystic change with degeneration not frequent; myoepithelial cells and fibromyxoid stroma;
Cystic Degeneration biphasic pattern with epithelial–myoepithelial cells and epithelial cells with variable nuclear atypia;
mesenchymal-like cells in varied proportions histiocyte and clear cells
Warthin’s Tumor Always involve parotid glands; bilaterally frequent, Mucoid to turbid fluid; admixture of
common in males beyond the fifth decade of life; well polymorphic lymphoid cells and oncocytic
circumscribed, encapsulated characterized by a papillary epithelial cells, isolated, in loosely cohesive
growth pattern consisting of double layers of oncocytic groups and in tissue fragments; squamous
cells and heavy lymphoid tissue with germinal centers; cysts metaplasia ⫹/⫺
filled with mucoid and cellular debris
Cystic Metastases History of squamous cell cancer in the upper aerodigestive Cheesy, viscous aspirate; pleomorphic
of Keratinizing tract often available squamous cells with dyskeratosis; lamellated
Squamous keratin and keratin pearls; anucleated
Carcinoma squames, malignant squamous cells
A B
Figs. 15.204A and B. HIV-associated cyst. FNA of a parotid cyst from a patient with HIV infection. A: Low-power
view demonstrating a large population of lymphoid cells with tissue fragments of epithelial cells. B: Higher magnification
shows the epithelial cells to be of squamous type.
A B
C D
Figs. 15.205A to D. HIV-associated cyst. A: Different field showing tissue fragments of epithelial cells in the back-
ground of heavy lymphoid infiltrate. B: Higher magnification depicting metaplastic squamous cells (arrow) and a
multinucleated foreign-body-type giant cell (arrowhead). C: Higher magnification showing squamous epithelial cells.
D: Cell block of the aspirate showing strips of stratified squamous epithelium with lymphoid tissue (H&E).
TABLE 15.34 DIFFERENTIAL DIAGNOSES OF SALIVARY GLAND LESIONS WITH MUCOID

BACKGROUND IN FINE NEEDLE BIOPSY ASPIRATES

Mucocele Foamy histiocytes; inflammatory cells; phagocytic multinucleated giant cells; no 15.208
epithelial cells; mucoid background
Mucus Retention Cyst Foamy histiocytes; inflammatory cells; phagocytic multinucleated giant cells; 15.109
epithelial cells ⫹/⫺; mucoid background
Branchial Cleft Cyst Foamy histiocytes; inflammatory cells; squamous cells with or without 15.206
keratinization; anucleated forms ⫹; mucoid background
Chronic Obstructive Fragments of stroma; tissue fragments of hyperplastic duct epithelium with or 15.207
Sialadenitis without squamous metaplasia; mucoid background
Pleomorphic Adenoma with Epithelial–myoepithelial cells; stromal matrix; histiocytes; inflammatory cells; 15.210
Cystic Degeneration mucoid background
Warthin’s Tumor Proteinaceous or mucoid background; lymphoid infiltrate; cellular debris; 15.209
oncocytes; degenerated an anucleated forms
Low-Grade Mucoepidermoid Mucoid background; polymorphic cell population; inflammatory cells and 15.212
Carcinoma histiocytes ⫹/⫺
Myoepithelioma Extensive myxoid matrix, discrete groups and tissue fragments of myoepithelial 15.211
cells with pleomorphic shapes; bland nuclear chromatin
Differential Diagnoses of Salivary Gland Aspirates with Mucoid Stroma (See Figs. 15.206 to 15.213)
Fig. 15.206. FNA of a branchial cleft cyst. The smear demonstrates Fig. 15.207. FNA of chronic sialadenitis with mucoid degeneration.
inflammatory cells and macrophages in a mucoid background, they
also contain cellular debris.
Fig. 15.208. FNA of a cystic lesion mucocele with muciphages and Fig. 15.209. Warthin’s tumor. Abundant mucoid material with his-
abundant mucin. tiocytes and lymphoid cells.
Fig. 15.210. Pleomorphic adenoma. Abundant mucoid stroma from Fig. 15.211. Myoepithelioma with abundant matrix can obscure the
pleomorphic adenoma with degeneration and cyst formation. sparse cellular material and may cause a false-negative diagnosis.
Fig. 15.212. Mucoepidermoid carcinoma with abundant mucoid

stroma.
A B
Figs. 15.213A and B. Cystic keratinizing squamous carcinoma. A: FNA of cystic lesion showing keratin debris,
anucleated keratinized squamous cells in an inflammatory background. B: Well-differentiated squamous carcinoma
cells are at times difficult to identify in thick keratin debris.
INFLAMMATORY LESIONS Cytopathologic Features. The aspirates of salivary glands

Infl ammatory processes involving the salivary glands are with chronic sialadenitis are usually paucicellular consist-
caused by a multitude of etiological factors. The process ing of scant acinar elements, although large tissue frag-
may be acute and may result in an abscess formation, par- ments of acinar tissue with intact lobular architecture are
ticularly as a result of bacterial infection. sometimes seen (Table 15.35; Figs. 15.214 to 15.217). The
acini may be present individually and are usually intact.
Depending on the extent of fibrosis, the aspirate may show
Acute Sialadenitis several large fragments of connective tissue. Also present
are fragments of duct epithelium sometimes with various
Acute sialadenitis can occur as a result of infection due
types of metaplasias such as squamous, columnar, goblet
to staphylococci or streptococci. The aspirates show neu-
cell, and oncocytic (Fig. 15.216C). Goblet cell metaplasia
trophilic exudates and cellular and necrotic debris. Acute
causes increased mucus secretion.
inflammation may also be caused by actinomyces bacteria
Chronic sialadenitis secondary to duct obstruction by
resulting in an abscess formation.
calculi is often associated with the dilatation of the ducts
and cyst formation. The background shows varying num-
Chronic Sialadenitis bers of chronic inflammatory cells usually of lymphoplas-
macytic type. They may present in large numbers, perme-
Chronic sialadenitis may be nonspecifi c, resulting from
ating the acinar tissue and obscuring the cytologic details.
ductal obstruction due to sialolithiasis or external radia-
Heavy lymphoid infiltrate may resemble lymphoprolifera-
tion or may be specifi c, caused by various infectious
tive disorders. Fragments of adipose tissue are sometimes
agents and immunologic disorders. The involvement can
present. The aspirates may also show calcific debris from
be unilateral or bilateral as in viral infections. Because the
the calculi, nontyrosine crystals (Figs. 15.18A and B) and
chronic infl ammatory process leads to hard and nodular
psammoma bodies. Nontyrosine crystals are considered
salivary glands, they are frequently biopsied to rule out
to represent alpha-amylase. They are nonbirefringent,
clinically suspected neoplasms. In fact, chronic sialadeni-
rectangular, sometimes have pointed ends, and are vari-
tis is a commonly encountered entity in fine needle cytol-
able in size, ranging from 20 to 300 microns in length and
ogy of the salivary glands.
10 to 100 microns in width. These crystals occur in the
Histologically, with chronic sialadenitis, there are
background of proteinaceous material. They stain bright
varying degrees of acinar atrophy, lymphoid infiltrate
orange with a Papanicolaou stain and deep blue with a
with or without germinal centers, and fibrosis. The ducts
Romanowsky stain. The duct epithelium may undergo
exhibit dilatation and hyperplasia of the lining epithelium
exuberant hyperplasia yielding tissue fragments of epi-
with various metaplasias. Extensive dilatation will result
thelium that can cause diagnostic difficulties resulting in
in cyst formation. Goblet cell metaplasia produces abun-
false-positive diagnosis (Figs. 15.30A and B).
dant mucin. The lobular architecture is usually main-
tained. An extreme example of obstructive changes with
Chronic Sclerosing Sialadenitis (Küttner Tumor)
marked acinar atrophy is encountered in submandibular
glands and is known as chronic sclerosing sialadenitis or Chronic sclerosing sialadenitis is a chronic inflamma-
Küttner tumor. tory disease more common in submandibular glands due
TABLE 15.35 CYTOPATHOLOGIC FEATURES OF TABLE 15.36 CYTOPATHOLOGIC FEATURES

CHRONIC SIALADENITIS OF KÜTTNER TUMOR (CHRONIC SCLEROSING
SIALADENITIS)
● Cellularity variable but usually scant
● Acinar elements present but in reduced numbers; ● Variable cellularity but usually very scant
may be permeated by and obscured by inflammatory ● Inflammatory cells; lymphoplasmacytic type,
cells; acinar structures intact and may be present germinal center cells, tingible body histiocytes and
individually macrophages
● Lymphoplasmacytic cell infiltrate with or without ● Small ductal structures appearing as tightly packed nuclei
germinal center cells and tingible body histiocytes in a tissue fragment or as elongated tubules, bordered by
● Fragments of fibrous-collagenous stroma and adipose collagen simulating pseudoacinar structures of adenoid
tissue; may contain inflammatory cells cystic carcinoma
● Tissue fragments of small, cuboidal to columnar duct ● Duct epithelial cell nuclei small with compact to finely
epithelium, with or without hyperplasia; squamous granular chromatin, nucleoli not evident
and/or oncocytic metaplasia may be present; nuclear ● Irregular fragments of fibrous stroma in the background
atypia ⫹/⫺ ● Acinar elements absent
● Nontyrosine crystals ⫹/⫺
● Psammoma bodies ⫹/⫺
● Mucin ⫹/⫺
● Differential Diagnoses of Chronic Sialadenitis
Nonneoplastic
Mucocele, mucus retention cyst cells, and multinucleated foreign-body type giant cells
Benign lymphoepithelial cyst along with chronic infl ammatory cells. Culture and spe-
Benign lymphoepithelial lesion cific stains are required for a precise diagnosis.
Intraparotid lymph node Infections are quite frequent in immunologically
Amyloidosis compromised individuals such as patients with HIV
Neoplastic infection. CMV infection of the salivary glands is re-
Warthin’s tumor ported to be a frequent occurrence in these individ-
Pleomorphic adenoma
uals. Duct epithelial atypia in a CMV infection had
Low-Grade adenocarcinoma, NOS
been reported as a diagnostic pitfall for a malignant
Mucoepidermoid carcinoma diagnosis.
Acinic cell carcinoma Sarcoidosis frequently involves the salivary glands.
Asymptomatic enlargement of the parotid, subman-
dibular, and sublingual salivary glands occurs in sar-
coidosis in approximately 6% of the cases. FNA
biopsies reveal noncaseating granulomatous inflamma-
to sialolithiasis. The patients experience recurrent pain tion. Cytologically, the aspirates show cellular debris,
and swelling often associated with food ingestion. His- epithelioid cells, and multinucleated foreign-body
tologically, the gland shows mild focal chronic inflam- type giant cells along with chronic inflammatory cells
mation usually in a periductal location with periductal (Fig. 15.219).
fibrosis. There is marked acinar atrophy with ductal
dilatation. The lobular architecture is usually main- Diagnostic Diffi culties and Differential Diagnoses. The
tained. The ducts may show squamous and/or mucus aspirates from chronic sialadenitis may cause diagnostic
metaplasia. diffi culties (Table 15.35) and may be interpreted as neo-
Cytologically, the aspirates are usually paucicellu- plasms such as pleomorphic adenoma, Warthin’s tumor,
lar with tissue fragments of stromal tissue and variable mucoepidermoid carcinoma, or adenoid cystic carcinoma.
amounts of ductal epithelium, either cuboidal/columnar Chronic obstructive sialadenitis may result in excessive
or with squamous metaplasia (Table 15.36; Figs. 15.218A mucoid aspirate.
to E). The infl ammatory cells are sparse in numbers. The
cytologic presentation is nonspecifi c. The potential diag-
nostic pitfall occurs when the tissue fragments are associ-
Necrotizing Sialometaplasia
ated with ductal epithelium that simulates the cytologic
pattern of an adenoid cystic carcinoma. The differentia- Necrotizing sialometaplasia is a reactive inflamma-
tion between these two entities is described in the section tory condition of the salivary glands characterized by
on adenoid cystic carcinoma. a lobular coagulative necrosis of salivary gland acini,
Chronic sialadenitis is also caused by specific infec- squamous metaplasia of the salivary ductal epithelium,
tious agents such as tuberculosis or actinomyces. Cyto- pseudoepitheliomatous hyperplasia of the overlying
logically, the aspirates show cellular debris, epithelioid or adjacent mucosal epithelium, and inflammation.
Chronic Sialadenitis (See Figs. 15.214 to 15.224)
A B
Figs. 15.214A and B. FNA of the parotid gland. A: Low power showing inflammatory cells only. No acinar tissue is
seen. B: Higher magnification.
Fig. 15.215. Chronic sialadenitis with acinar tissue surrounded by

a few lymphocytes.
A B
Figs. 15.216A to B. FNA of a parotid mass clinically thought to be a pleomorphic adenoma. A: This image depicts a
very large tissue fragment of collagenous stroma with blood vessels and sparse inflammatory cells. Myoepithelial cells
are not present. B: A tubular tissue fragment of benign duct epithelium with a few inflammatory cells in the back-
ground. (continued)
Figs. 15.216C. (continued) C: Higher magnification showing

C squamous metaplasia of the duct epithelium.
Fig. 15.217. Pleomorphic adenoma misinterpreted as sialadenitis

because of excessive collagenized stroma and lack of epithelial–
myoepithelial cells in the aspirate. Surgical excision confirmed
pleomorphic adenoma. Sampling of the tissue is responsible for the
cytohistologic discordance.
A B
Figs. 15.218A to B. Küttner’s tumor. A, B, C, D: Poorly cellular aspirate of a painful submandibular salivary gland
nodule showed tight groups of basaloid calls that appeared to be embedded in the matrix material. Pale cyanophilic
acellular hyaline material was also seen outside the tissue fragment. The cytologic interpretation was suspicious for
adenoid cystic carcinoma. (continued)
C D
Figs. 15.218C to E. (continued) E: The surgical excision failed to

show a neoplasm. The salivary gland was atrophic with loss of
acinar tissue. There was considerable fibrosis and chronic inflam-
mation caused by a sialolith. There was florid hyperplasia of the
intercalated ducts, which on aspiration simulated the nests of basa-
loid cells of adenoid cystic carcinoma and the collagenized stroma
E mimicked the matrix material.
A B
Figs. 15.219A and B. Granulomatous inflammation. A: Lobules of salivary parenchyma with small ductules,
granulomas, and calcific debris (low power). B: Higher magnification showing the noncaseating granuloma with
epithelioid cells. This may represent sarcoid granuloma.
Clinically and histopathologically, necrotizing sialo- The cytologic features are not well-documented in the lit-
metaplasia may simulate malignant neoplasia, leading erature. The aspirates show inflammatory cells and the tissue
to misinterpretation. The majority of these lesions occur fragments of metaplastic squamous cells in the background
in the hard palate and sometimes in the parotid gland. of inflammatory cells and cellular and necrotic debris. The
The involvement is usually unilateral and is common number of squamous cells may be large, and if atypia exists,
in males. the aspirate may be misinterpreted as squamous carcinoma.
Amyloidosis (LESA). It usually manifests in the parotid glands and occa-

sionally affects the submandibular gland. Benign lymphoe-
The salivary glands may be involved in primary or secondary
pithelial lesion commonly occurs in patients with Sjögren’s
generalized amyloidosis and may be a cause for a mass lesion.
syndrome, an autoimmune disorder characterized by a
Amyloid in the stroma may be mistaken for a stroma of the
symptom complex involving lacrimal glands and salivary
pleomorphic adenoma (e-Fig. 15.13 and Figs. 15.29A and B).
glands with typical manifestations of keratoconjunctivitis
sicca and xerostomia but may be present without it. Benign
lymphoepithelial lesion is more common in women in the
LYMPHOID PROLIFERATIONS OF THE
fourth through the seventh decades of life. Patients present
SALIVARY GLANDS
with recurrent firm swelling of the affected gland, with or
without discomfort. Patients with lymphoepithelial sialad-
Lymphoid proliferations (Tables 15.37 and 15.38) of the sal- enitis have a 44-fold increased risk of developing salivary
ivary glands can be reactive, nonneoplastic, or neoplastic. gland or extrasalivary gland non-Hodgkin lymphoma, of
which 80% are a marginal zone/MALT type.
NONNEOPLASTIC LYMPHOID Histologically, benign lymphoepithelial lesion is
PROLIFERATIONS characterized by heavy lymphocytic infiltration with
germinal centers, parenchymal atrophy, and foci of epi-
Reactive Intraparotid Lymph Node thelial proliferation referred to as “epimyoepithelial is-
lands.” The latter are composed of both ductal and myo-
Since the parotid gland normally harbors several lymph epithelial cells and are permeated by lymphocytes. The
nodes, it is not unusual for the glands to be enlarged, latter are larger than the surrounding lymphocytes and
either due to reactive processes or due to metastatic have clear cytoplasm—a feature of monocytoid B-cells of
malignancy involving these intraparotid lymph nodes, MALT. The germinal centers can be sparse to extensive.
and present as parotid gland mass lesions. The aspirates The lymphoid cells are polyclonal with a predominance
in cases of reactive process show a polymorphic lymphoid of T-cells. In the late stages, plasma cells and immuno-
cell population with germinal center cells and tingible cytes become conspicuous. The lobular architecture is
body histiocytes characteristic of a reactive lymph node maintained.
(Figs. 15.191A and 15.221A).
Cytopathologic Features. Cytologically, the aspirates con-
Lymphoepithelial Sialadenitis
tain a polymorphic lymphoid cell population with a pre-
The benign lymphoepithelial lesion previously called dominance of small, mature lymphocytes (Figs. 15.220A
Mikulicz’s disease is currently referred to as Myoepithe- and B). Small clusters of epithelial cells may be present.
lial sialadenitis (MESA) or lymphoepithelial sialadenitis These have round to oval nuclei with a bland chromatin
pattern. Acinar tissue is generally not present. The cytologi-
cal differentiation of LESA from small cell lymphoma may
TABLE 15.37 LYMPHOID PROLIFERATIONS be very difficult. Other diagnostic entities to be considered
OF THE SALIVARY GLANDS in differential diagnoses include nonneoplastic disorders
and neoplasms that contain lymphoid cells; these entities
Nonneoplastic
include chronic sialadenitis, reactive lymphadenitis, lym-
Reactive intraparotid lymph node phoepithelial cyst, branchial cleft cyst, Warthin’s tumor,
and malignant lymphoma (Table 15.38).
Benign lymphoepithelial cyst
HIV-associated lymphoepithelial cyst

MALIGNANT LYMPHOMA OF THE
Lymphoepithelial sialadenitis
SALIVARY GLANDS
Neoplastic
Extranodal marginal zone b-cell lymphoma of mucosa- Primary malignant lymphomas of the salivary gland con-
associated lymphoid tissue type (MALT) stitute 2 to 5% of the salivary gland neoplasms. Approxi-
mately 20% are associated with Sjögren’s syndrome or
Follicular small cleaved or follicular mixed lymphoma LESA. The parotid gland is most commonly involved.
Salivary gland malignant lymphomas include
Diffuse large b-cell lymphoma
● Marginal zone B-cell/MALT lymphoma,
Other nodal type lymphomas ● Follicular lymphoma, and
● High-grade lymphoma.
TABLE 15.38 DIFFERENTIAL DIAGNOSES OF SALIVARY GLAND ASPIRATES WITH

LYMPHOID CELL POPULATION

Reactive Intraparotid Polymorphic lymphoid cell population; no acinar tissue 15.191A
Lymphadenitis
Chronic Sialadenitis Fragments of stroma; tissue fragments of duct epithelium with or without 15.214
squamous metaplasia; acinar tissue scant to abundant; lymphoid cells in 15.215
variable numbers and may permeate the acinar tissue and stroma
Benign Lymphoepithelial Mixed lymphoid cell population; mature squamous cells with or without 15.203
Cysts nuclear atypia
HIV-Associated Grossly, clear to turbid to yellow-white and cheesy aspirate; lymphoid cells 15.204
Lymphoepithelial Cysts with or without germinal center cells; large numbers of immunoblasts; 15.205
lymphohistiocytic clusters; squamous cells with or without nuclear atypia;
epimyoepithelial islands; no oncocytes; no normal salivary glandular tissue
Lymphoepithelial Polymorphic lymphoid population with predominant small lymphocytes; 15.220

Sialadenitis small clusters of squamous epithelial cells with or without nuclear atypia and
permeated by lymphocytes; difficult to differentiate from MALT lymphoma
Warthin’s Tumor Mucoid to turbid fluid; metaplasia ⫹/⫺; admixture of polymorphic 15.209
lymphoid cells and oncocytic epithelial cells, isolated, in loosely cohesive
groups and in tissue fragments; squamous
Malignant Non-Hodgkin Dissociated cell pattern; lymphoma cells discrete and in aggregates; small, 15.191B
Lymphoma monomorphic pattern with well to poorly defined cell borders; high N/C
ratios; nuclei round to oval with smooth to irregular nuclear membrane;
finely granular chromatin with parachromatin clearing; prominent nucleoli;
cytoplasm variable but scant; no nuclear molding; mitoses ⫹; karyorrhexis ⫹;
immunoprofile: CK ⫹; LCA ⫹; neuroendocrine markers ⫺; S100 protein ⫺
Lymphoepithelial Clearly malignant large, mostly discrete cells scattered in the background of See Chapter 12;
Carcinoma variable numbers of lymphoid cells Fig. 12.33A and B
Acinic Cell Carcinoma with Heavy lymphoid infiltrate; may obscure tissue fragments of neoplastic 15.149C
Excessive Lymphoid Stroma acinar tissue
A B
Figs. 15.220A and B. Lymphoepithelial sialadenitis (LESA). A: Low-power view of an aspirate of an enlarged parotid
gland from a 79-year-old male. There are several varying-sized epithelial–myoepithelial islands in the background of
heavy lymphoid cell population (arrows). B: Higher magnification showing the epithelial island to be surrounded by
polymorphic lymphoid cells.
A B
Figs. 15.221A and B. A: FNA of an intraparotid lymph node showing a reactive process. Note the polymorphic
lymphoid cell population with tingible body histiocytes. B: The lymphoid cells are uniform and mature. Follicle
center cells are not seen. This pattern is particularly seen in a late phase of a reactive process. A malignant low-grade
lymphoma may be in consideration. Such cases should always be followed by immunophenotypic studies and flow
cytometry.
MARGINAL ZONE B-CELLS/MALT LYMPHOMA intervening lymphoid tissue. The follicles are composed
predominantly of centrocytes and lack a starry sky pat-
MALT lymphomas of the salivary gland typically produce a
tern, mitotic activity, polarization, and often lack a well-
dense lymphoid infiltrate with the obliteration of acini. The
formed mantle zone.
lesion may form a localized mass or diffusely involve the
gland. There are broad strands of pale immature lymphoid
cells surrounding and extending away from epimyoepithelial NON-HODGKIN LYMPHOMAS, HIGH-GRADE
islands, alternating with dark areas containing small lympho-
Most high-grade lymphomas in the salivary glands are
cytes. The pale-staining lymphoid cells are the monocytoid
diffuse large B-cell lymphomas. The lesion is diffusely
B-cells. Scattered immunoblasts and plasma cells are typically
infiltrative, consisting of malignant cells that are 2 to
present in the interfollicular region. One of the characteristic
3 times the size of normal lymphocytes with a high
features of MALT lymphoma associated with LESA/SS is the
mitotic rate. The cells have scant cytoplasm, round
presence of tight clusters of monocytoid B-cells surrounded
nuclei with crisp nuclear membranes, and finely granu-
by epithelioid histiocytes. MALT lymphomas express mono-
lar chromatin with prominent nucleoli. Demonstration
typic surface immunoglobulin (lymphocytes and monocy-
of leukocyte-associated antigens (CD45 and CD20)
toid B-cells), and in the majority of cases, plasma cells are
and negative reactivity to cytokeratin and other specific
also monoclonal. The tumor cells express pan-B antigens
nonlymphoid markers are useful in differentiating these
(CD20, CD22) and lack CD5 and CD10.
high-grade lymphomas from other poorly differentiated
Cytologically, the diagnosis of malignant lymphoma
malignancies.
is suggested when the aspirates contain a uniform popu-
lation of small lymphocytes without germinal center cells
(Fig. 15.221B). The cytologic diagnosis should always be
confi rmed by immunotyping and fl ow cytometry. Differ- Primary malignant lymphomas of the salivary glands are
entiation from reactive processes may be very difficult. uncommon compared to other types of primary salivary
gland lesions. The literature includes very few documented
reports. The correct identifi cation of a low-grade malig-
FOLLICULAR LYMPHOMA
nant lymphoma solely from cytomorphology is difficult.
Thirty-five to fifty percent of salivary gland lympho- The key is to suspect a malignant lymphoma and follow
mas are follicular lymphomas, usually involving intras- with fl ow cytometry and immunophenotypic studies. All
alivary lymph nodes. Follicular lymphoma has also been the salivary gland aspirates that contain a large lymphoid
reported in or involving Warthin’s tumors of the parotid cell population enter the differential diagnosis as listed in
gland. Follicular lymphoma of the salivary gland most Table 15.38. In addition to these listed entities, a high-
often produces a circumscribed mass, which can often grade malignant lymphoma must be differentiated from
be identified as a lymph node. The histologic features small cell carcinoma and poorly differentiated epithelial
consist of a uniform proliferation of follicles with little malignant neoplasms.
Fig. 15.222. Myeloid leukemic infiltrate involving the parotid Fig. 15.223. Patient with a history of multiple myeloma and a pa-
gland. rotid mass. The aspirate shows a large population of myeloma cells.
SECONDARY INVOLVEMENT OF SALIVARY

GLANDS BY MALIGNANT LYMPHOMA
Salivary glands may be secondarily involved by malignant
lymphomas, leukemias, and other hematologic malignan-
cies (Figs. 15.222 to 15.224). Multiple myeloma (Fig.
15.222) is usually a metastatic process. Note that myoepi-
theliomas with a plasmacytoid pattern may occasionally
be misinterpreted as myeloma. High-grade lymphomas
with systemic involvement can also present as salivary
gland masses. Hodgkin lymphoma when encountered
is more likely to be a secondary process (Fig. 15.224).
Primary Hodgkin lymphoma of the salivary glands is
extremely rare. Leukemias may also affect the salivary
Fig. 15.224. Secondary involvement by Hodgkin lymphoma is more
glands.
frequent than the primary. Note the typical Reed–Sternberg cells.
SUGGESTED READINGS
Ali S. Acinic-cell carcinoma, papillary-cystic variant: A diagnos- Pathologists interlaboratory comparison program in non-
tic dilemma in salivary gland aspiration. Diagn Cytopathol gynecologic cytology. Arch Pathol Lab Med 2005;129:26–31.
2002;27:244–250. Kini, SR, Dardick I. Atlas of Salivary Gland Tumor Cytopathology.
Cheuk W, Chan JKC. Küttner Tumor of the submandibular gland: CD-ROM-1. Ottawa, CA: Pathology Images Inc, 2006.
Fine-needle aspiration cytologic findings of seven cases. Am J Klijanienko J, Vielh P. Salivary gland tumors. In: Orell SR, ed.
Clin Pathol 2002;117:103–108. Monographs in Clinical Cytology. New York: S Karger, 2000.
Chhieng DC, Cohen J-M, Cangiarella JF. Fine-needle aspiration Kocjan G, Milroy C, Fisher EW, Everson JW. Cytologic features of
of spindle cell and mesenchymal lesions of the salivary glands. epithelial-myoepithelial carcinoma of salivary gland. Potential
Diagn Cytopathol 2000;23:253–259. pitfalls in diagnosis. Cytopathol 1993;4:173–180.
Dardick I. Color Atlas/Text of Salivary Gland Tumor Pathology. Miliauskas JR, Orell SR. Fine-needle aspiration cytological find-
New York: Igaku Shoin, 1996. ings in five cases of epithelial-myoepithelial carcinoma of sali-
Dardick I, Bradley G, Lee Linda, Leong I. Atlas of Salivary Gland vary glands. Diagn Cytopathol 2003;28:163–167.
Tumor Oral and Surgical Pathology Cytopathology. CD- Nasuti JF, Yu GH, Gupta PK. Fine needle aspiration of cystic
ROM-1. Ottawa, CA: Pathology Images Inc, 2006. parotid gland lesions: An institutional review of 46 cases with
Darvishian F, Lin O. Myoepithelial cell-rich neoplasms: Cytologic histologic correlations. Cancer Cytopathol 2000;90:111–116.
features of benign and malignant neoplasms. Cancer Cyto- Orell SR. Diagnostic difficulties in the interpretation of fine needle
pathol 2004;102:355–361. aspirates of salivary gland lesions: The problem revisited.
Ellis GL, Auclair PL. Atlas of Tumor Pathology; Tumors of the Cytopathol 1995;6:285–300.
Salivary Glands. Third Series, Fascicle 17. Washington, DC: Orell SR, Nettle WJS. Fine needle aspiration biopsy of salivary
Armed Forces Institute of Pathology, 2008;173–185. gland tumors: Problems and pitfalls. Pathol 1988;20:332–337.
Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck. Wenig BM. Atlas of Head and Neck. 2nd ed. Philadelphia:
2nd ed. Philadelphia: W.B. Saunders, 2001. W.B. Saunders, 2008.
Hughes JH, Volk EE, Wilbur DC. Pitfalls in salivary gland fine-nee-
dle aspiration cytology: Lessons from the College of American
APPENDIX
CLASSIFICATION OF NEOPLASMS
& NONNEOPLASTIC DISORDERS OF THE
SALIVARY GLANDS1
7. Basal cell adenocarcinoma
BENIGN NEOPLASM 8. Epithelial–myoepithelial carcinoma
9. Clear cell adenocarcinoma
EPITHELIAL 10. Cystadenocarcinoma
11. Myoepithelial carcinoma
● Pleomorphic adenoma and variants 12. Salivary duct carcinoma
● Warthin’s tumor 13. Squamous carcinoma
● Basal cell adenoma 14. Adenosquamous carcinoma
● Canalicular adenoma 15. Lymphoepithelial carcinoma
● Myoepithelioma 16. Small cell undifferentiated neuroendocrine carcinoma
● Oncocytoma 17. Large cell (undifferentiated) carcinoma
● Cystadenoma 18. Oncocytic carcinoma
● Ductal papillomas: 19. Mucinous adenocarcinoma
• Sialadenoma papilliferum 20. Sebaceous carcinoma/lymph adenocarcinoma
• Inverted ductal papilloma 21. Sialoblastoma
• Intraductal papilloma
● Sebaceous neoplasms:
• Sebaceous adenoma
• Sebaceous lymphadenoma
NONEPITHELIAL
NONEPITHELIAL 1. Hematolymphoid:
a. Non-Hodgkin malignant lymphoma
● Hemangioma b. Hodgkin lymphoma
● Neurilemoma/neurofibroma 2. Sarcomas
● Lipoma
● Others
METASTATIC OR SECONDARY
MALIGNANT NEOPLASMS NEOPLASMS
EPITHELIAL DEVELOPMENTAL LESIONS/DISEASES

Heterotopias
1. Mucoepidermoid carcinoma Accessory parotid gland
2. Acinic cell adenocarcinoma Adenomatoid hyperplasia
3. Adenocarcinoma, NOS
4. Adenoid cystic carcinoma
5. Polymorphous low-grade adenocarcinoma
6. Carcinoma ex pleomorphic adenoma: TRUE CYSTS
a. Invasive
b. Intracapsular Lymphoepithelial cyst
c. Carcinosarcoma Salivary duct cyst
d. Metastasizing pleomorphic adenoma Polycystic (dysgenetic) disease
1
Wenig BM. Atlas of Head and Neck. 2nd ed. Philadelphia: W. B. Saunders, 2008.
Sialadenosis
NONDEVELOPMENTAL CYSTS
Lymphoepithelial sialadenitis
Necrotizing sialometaplasia
Mucus extravasation phenomenon
Sclerosing polycystic disease
Mucus retention cyst
Ranula Extranodal sinus histiocytosis with massive
lymphadenopathy
Others
METAPLASIAS
Oncocytic metaplasia and oncocytosis
INFECTIOUS, INFLAMMATORY, AND

TUMOR-LIKE
Sialadenitis (infectious, noninfectious, obstructive,

nonobstructive)
Sialolithiasis
16 BREAST
Fine needle aspiration biopsy of palpable breast masses ● Ductal hyperplasia of various grades, including atypi-
has enjoyed great popularity and success for being the sim- cal forms, overlap with intraductal or carcinoma in
plest, cost-effective, reliable, and diagnostically accurate situ (noncomedo type) and well-differentiated inva-
procedure. However, in the last several years, the use of sive ductal carcinomas, NOS, tubular and lobular car-
fine needle biopsies for breast nodules has declined in favor cinomas, as well as cellular fibroadenomas. Cells from
of core needle biopsies. In fact, core needle biopsies have all these lesions demonstrate a small size and bland
practically replaced FNA biopsies in major medical centers chromatin pattern as common denominators. Thus,
in the USA, much to the disappointment of cytopatholo- cytologic differentiation of ductal hyperplasia or a
gists. The use of FNA is currently limited and frequently fibroadenoma with a predominant epithelial compo-
performed as a part of the triple test to confirm a negative nent from carcinomas composed of small cells is not
clinical and radiologic diagnosis. However, FNA biopsies possible. The same holds true for low-grade duct ade-
are still considered diagnostically useful and are still being nocarcinoma, NOS, tubular carcinoma, and lobular
performed in the setup of small clinics where radiologic carcinoma.
assistance may not be available. FNA biopsy is still popu- • Differentiation between in situ and invasive ductal
lar and performed routinely in several parts of the world. carcinomas is diffi cult from cytologic samples. The
The main reasons given for the decline in FNA biop- same holds true for lobular lesions.
sies include 1) the inability to differentiate, cytologically, • Reactive duct epithelial cells from inflammatory
in situ cancer from invasive cancers; 2) core needle biop- breast lesions may demonstrate considerable nuclear
sies can provide tissues for ancillary studies; 3) clinical atypia. Their differentiation from carcinomas under-
trials require histologic diagnosis; and 4) a diagnosis of going necrosis may be a challenge.
malignancy obtained by FNA biopsy still needs to be con- • In some cases of benign cystic lesions, apocrine cells
firmed by core biopsy or frozen section, because surgeons present pronounced nuclear atypia in a cystic envi-
do not want to plan treatments on the basis of cytologic ronment that may mimic apocrine carcinoma.
diagnosis alone. • Papillary lesions are diagnostically difficult. Papillo-
mas and papillary carcinomas demonstrate overlap-
ping features. Although rare in cytologic material,
TYPES OF SPECIMENS FOR radial scar or sclerosing papillomatosis mimics the
CYTOPATHOLOGIC EVALUATION cytologic pattern of papillary carcinomas.
• Pregnancy/lactation changes in breast lesions may
be alarming enough to mimic neoplasia and must
In addition to FNA biopsy, several types of specimens be differentiated from carcinomas occurring in the
from the breast are utilized for the diagnosis of breast lactating breast.
lesions, as listed in Table 16.1; their advantages and dis-
advantages are also described in Table 16.2. Whatever the specimen type, the purpose of cytologic
evaluation is to identify or to rule out a malignant pro-
cess. The adequacy of the specimen is a prerequisite and
cannot be emphasized too strongly. Inadequate samples
GENERAL DIAGNOSTIC PROBLEMS
may result in both under- and overdiagnosis.
The adequacy of a sample depends, to a great extent,
The diagnostic problems incurred in the interpretation on what type of diagnosis is rendered (see Table 16.22,
of an FNA biopsy include differentiating several types Reporting System). There are no set criteria established as
of benign breast lesions from malignant ones. Also, the to how many cells are required for a satisfactory sample
breast can host several types of neoplasms. The broad and to render a negative interpretation. A disease-free
spectrum of benign breast diseases and their overlapping breast will yield only rare tissue fragments of benign duct
features with malignant neoplasms provide several set- epithelial cells. A negative diagnosis must be rendered in
tings for potential errors. the context of clinical and radiologic data.
688
Chapter 16: Breast 689
TABLE 16.1 SPECIMEN TYPES FOR THE CYTOPATHOLOGIC DIAGNOSES OF BREAST

LESIONS ADVANTAGES AND DISADVANTAGES
Specimen Type
FNA of a Palpable Solid Lesion Simple procedure; cost effective; rapid diagnosis; minimal or no complications; high
diagnostic accuracy; specificity ⬎90%; sensitivity 65–98%; dependant on adequacy
Image-Guided FNA of a Nonpalpable Low diagnostic yield

Lesion
Aspiration of Cystic Nodules Serves as a therapeutic procedure for evacuating the cyst; cytologic examination
discouraged by surgeons for low incidence of cancer in cysts; prudent to biopsy the
residual nodule, if present; cytologic exam indicated if the fluid is hemorrhagic
Touch Imprints of Eczematous and May aid in the diagnosis of Paget’s disease
Ulcerated Lesions of the Nipple and
Areola
Direct Smears of the Spontaneous Examination of the spontaneous discharge; smears often poorly cellular; useful in
Nipple Discharge unilateral hemorrhagic discharge particularly in older individuals
Nipple Aspiration Fluid Low sensitivity and specificity; specimens usually of low cellularity; did not gain
much popularity
Duct Lavage Fluid Indicated in women at increased risk of breast cancer or those with abnormal nipple
discharge containing abnormal cells; minimally invasive procedure; superior to
nipple aspirate for intraductal cellular abnormalities; sensitivity and specificity not
yet determined; specimens are often poorly cellular; encouraging results have been
reported by some
Touch Imprints of Axillary Sentinel Results range from over 90% detection and accuracy, when compared with frozen
Lymph Node and Rapid Immunostaining sections, to less than 50%
with Cytokeratin
Strict guidelines must be followed before render- influence the outcome. Fixation and staining depend on
ing an unequivocal diagnosis of malignancy (see Table the pathologist’s preference.
16.21). False-negative and/or underdiagnosis often occur
in the following settings:
NORMAL COMPONENTS
● Desmoplastic tumors do not yield to FNA biopsy,
resulting in scant cellularity. This is particularly true
in lobular or scirrhous duct carcinomas. The small The ducts and ductules of the nonlactating breast are
number of malignant cells in the aspirates can be easily lined by an inner single layer of epithelial cells and an
overlooked. outer layer of myoepithelium. The epithelial cells are low
● Lobular carcinomas, because of their diffuse infiltra- cuboidal with scant cytoplasm and have round to oval
tive growth pattern, are often associated with benign nuclei with compact chromatin. The lobule has a loose
duct cells in FNA biopsy specimens. The presence fibrous stroma surrounding the ductules. An FNA biopsy
of benign cells may overshadow the small groups of a normal breast predominantly yields fragments of
of lobular carcinoma cells that are present in the fibroadipose tissue and very few duct epithelial cells. The
aspirate. duct epithelial cells are small—slightly larger than a red
● The adequacy of the sample is often operator-dependant. blood cell. They may be present in small, tight aggregates
A faulty technique remains a common contributory or in a honeycomb sheet with uniform nuclei containing
factor. compact chromatin. The myoepithelial cells have flat-
● Proper cytopreparation is critical. Factors such as bloody tened nuclei that appear spread out along the basement
samples, smearing techniques, and staining, greatly membrane and contain scant cytoplasm.
TABLE 16.2 SUMMARY OF CLINICOPATHOLOGIC FEATURES OF BREAST CARCINOMAS
Duct
Adenocarcinoma, Lobular Medullary Mucinous Apocrine Papillary Tubular
NOS Carcinoma Carcinoma (Colloid) Carcinoma Carcinoma Carcinoma
Incidence 65–80% 10–15% 5–7% 2% 1% 1–2% 0.8–2.3%
% of Breast bilaterality frequent
Malignancy
Age range Most common in 28–86 yr, median Relatively young, Frequent in older Same as duct Older age group 24–83 yr, median
mid to late fifties, 45–56 yr, more premenopausal age groups, mean adenocarcinoma, for intracystic, late 40s
can occur at any frequent in older 63 yr NOS mean age 63–67 yr,
age from 2nd age group for noncystic
decade of life papillary 57 yr
Clinical Variable Variable Mobile, well- Well-defined mass Mass Bloody nipple Majority
Presentation presentation; presentation, well demarcated discharge, nonpalpable
mass, skin and to poorly defined periareolar mass detected on
nipple retraction, mass or induration mammogram
nipple discharge,
ulceration
Mammographic Spiculated mass Spiculated mass or Well-circumscribed, Circumscribed Spiculated mass Circumscribed Small spiculated
Findings with or without vague architectural resembles mass (mass with stellate mass irregular mass
calcifications distortion fibroadenoma borders)
Pathology Stellate, with Stellate with Smooth rounded Soft gelatinous, Often bulky Well-circumscribed, Majority are small
Gross retracted filtrating infiltrating borders mass, sharply cut surface-moist average size 2–3 cm, with average size
borders or or diffuse with ill- circumscribed, glistening brown to of 1.2–1.6 cm,
circumscribed with defined borders unfixed to hemorrhagic tan to hard, fixed to
rounded or smooth surrounding tissue, gray, mural nodule surrounding breast
pushing borders soft consistency on lining of cyst tissue; cut section
wall may have radial
appearance with
pale streaks of
fibrosis
Average Size Few mm to several 2.4 cm 2.5–3 cm 2 cm Often bulky, 3 cm 3 cm or larger 1.5 cm
cm or larger
Histology Architectural Several Irregularly Abundant Islands of large Predominantly Oval to round
grade—well morphologic bordered islands extracellular round to polygonal fronds with delicate tubular structures
to poorly patterns; cells of carcinoma cells mucin around cells with abundant fibrovascular stalks, with lumina, lined
differentiated small, round; with anastomosis neoplastic cells, eosinophilic complex branching by a single layer
tubules, glands classic—linear and prominent sheets, clusters and granular with neoplastic of an orderly
nests solid areas; growth pattern lymphocytic papillary fragments cytoplasm; high cells arranged in monomorphic
nuclear grade— with cords of infiltrate; of neoplastic cells; nuclear grade cribriform, filiform, epithelium with
bland to markedly cells separated carcinoma cells nuclei bland to trabecular or bland nuclei;
pleomorphic by desmoplastic round, large with pleomorphic solid pattern; cells angulations
with mitoses; stroma; solid, variable cytoplasm; closely packed, or bending of
stroma variable, tubuloalveolar, large round nuclei hyperchromatic; the tubules
desmoplastic to alveolar with prominent mitoses; characteristic;
scant; necrosis ⫹/⫺ macronucleoli myoepithelial cells no myoepithelial
absent cells; collagenized
fibrous stroma;
20% multifocal
Prognosis Depends on stage Intermediate Uncertain Favorable Same as NOS Favorable Favorable
and grade between well-
differentiated
ductal, NOS
& poorly
differentiated
Immunoprofile ER, PR ⫹ ER, PR ⫹ ER, PR ⫹ ER, PR ⫹ ER, PR – ER, PR ⫹ ER, PR ⫹

HER2/neu ⫹ HER2/neu ⫺ HER2/neu HER2/neu ⫺ HER2/neu ⫺ HER2/neu ⫺ HER2/neu ⫺
15–30% GCFP ⫹
P53 ⫹
Except for carcinomas with marked desmoplasia,

CARCINOMAS OF THE BREAST most breast malignancies yield highly cellular aspirates
that allow an accurate diagnosis of malignancy. Adequate
In the last few years, the incidence of breast carcinomas samples, properly prepared smears, and a good staining
has escalated, affecting one in nine American women. In technique not only allow the accurate identification of
2009, approximately 192,370 new cases of invasive duct malignancy but also its typing in the majority of cases
carcinomas were expected in women and 1910 new cases (Figs. 16.1 to 16.23). The cytologic features of most of the
in men. Early detection and appropriate management commonly encountered morphologic variants of breast
(surgery, radiation, and/or chemotherapy) have resulted in carcinomas are listed in Tables 16.3 and 16.4.
prolonged disease-free intervals and higher survival rates.
Mammary carcinomas present a wide spectrum of DUCTAL AND LOBULAR CARCINOMA IN SITU
histologic patterns (see Appendix). The majority of breast
carcinomas fall into the category of ductal carcinomas not Ductal carcinoma in situ (DCIS) is an intraductal epithe-
otherwise specified (NOS), comprising 65 to 80% of breast lial proliferation with minimal to marked atypia and a
cancers. Several morphologic variants constitute the remain- likelihood of progression into invasive carcinoma. Histo-
ing 20 to 35%. Some have a better prognosis than others. logically, four types are recognized: cribriform, micropap-
The clinicopathologic features of some of the more com- illary, comedo, and solid. The low-grade lesions of DCIS
mon types of adenocarcinomas are listed in Table 16.2. cytologically represent a gray zone with considerable
A B
Figs. 16.1A and B. FNA—duct adenocarcinoma, NOS. A: Low power view of an overwhelmingly cellular aspirate
presenting several branching tissue fragments and discrete cell population. B: Higher magnification showing small
malignant cells, discrete and in syncytial tissue fragments with uniform nuclei.
Fig. 16.2. FNA—duct adenocarcinoma, NOS. A cellular aspirate Fig. 16.3. FNA—duct adenocarcinoma, NOS. Discrete and loosely
consisting of syncytial tissue fragments of malignant cells with an cohesive medium-sized adenocarcinoma cells.
acinar pattern.
Fig. 16.4. FNA—duct adenocarcinoma, NOS. The malignant cells Fig. 16.5. FNA—duct adenocarcinoma, NOS. The syncytial tissue
are oval, plasmacytoid, mildly pleomorphic in size with eccentric fragments of malignant cells demonstrate intense crowding and
nuclei. Their nuclei have coarsely granular chromatin. The cyto- overlapping of nuclei with coarse, deep-staining chromatin.
plasm is moderate and pale.
Fig. 16.6. FNA—duct adenocarcinoma, NOS. The malignant cells Fig. 16.7. FNA—duct adenocarcinoma, NOS. The syncytial tissue
are large pleomorphic with high N/C ratios. The nuclei demonstrate fragment of malignant cells exhibit an acinar pattern, mild nuclear
prominent nucleoli and parachromatin clearing. pleomorphism, and high N/C ratios with prominent micronucleoli.
Fig. 16.8. FNA—duct adenocarcinoma, NOS. This syncytial tissue Fig. 16.9. FNA—duct carcinoma, medullary type. The syncytial tis-
fragment is composed of large, clearly malignant cells in syncytial sue fragments of malignant cells exhibit no architectural pattern.
tissue fragments. The cells are medium-sized with scant cytoplasm, uniform nuclei
with granular chromatin, parachromatin clearing and prominent
nucleoli. A few lymphocytes are present in the background.
Fig. 16.10. FNA—Duct carcinoma, tubular type. The malignant Fig. 16.11. FNA—duct carcinoma, mucinous type. A low power
cells are small, forming a syncytial tissue fragment with markedly view showing large amounts of thick mucin drawn into strings. The
crowded and overlapped small uniform nuclei. The contours of the tissue fragments of epithelial cells are embedded within the nuclei.
tissue fragment are smooth and angulated. The malignant nature is
not readily apparent.
A B
Figs. 16.12A and B. FNA—duct carcinoma, mucinous type. A: Low power of an extremely cellular aspirate.
The presence of mucin is readily apparent. B: Higher magnification showing psammoma bodies.
Fig. 16.13. FNA—duct carcinoma, mucinous type. The malignant

cells are discrete embedded in the pale-staining mucin. Note the
capillaries within the mucinous background.
A B
Figs. 16.14A and B. Papillary carcinoma. A: Low power showing a branching papillary tissue fragment.
B: Higher magnification. The papillary fronds are lined by tall columnar cells.
A B
Figs. 16.15A to C. FNA—papillary carcinoma. A: Syncytial tissue

fragment of round small malignant cells and strips of tall columnar
cells. B: Strips of tall columnar cells with elongated nuclei with pali-
sading arrangements. The nuclear chromatin is uniform and finely
granular. C: An admixture of columnar and round malignant cells
C with bland finely granular chromatin.
Fig. 16.16. FNA—duct carcinoma, apocrine type. The malignant Fig. 16.17. FNA—duct carcinoma, apocrine type. The malignant
cells are very pleomorphic ranging from medium-sized to giant cells are larger with appreciable dense cytoplasm.
forms with bi- and multinucleation. Their cytoplasm is variable and
dense.
Fig. 16.18. FNA—duct carcinoma, apocrine type. The large malig- Fig. 16.19. FNA—duct carcinoma, apocrine type. The malignant
nant cells contain dense and vacuolated cytoplasm. cells are large and discrete. Their cytoplasm is scant to modest in
amount and dense.
A B
Figs. 16.20A to B. FNA breast carcinoma, lobular type. A: The carcinoma cells are small, lymphocyte-like with
poorly defined cell borders and insignificant cytoplasm. The cells are discrete and loosely cohesive. The nuclei have
dense compact chromatin with scant cellularity; such an aspirate may be interpreted as negative. B: A syncytial tissue
fragment of small malignant cells with intense crowding and overlapping of nuclei. The N/C ratios are high and their
chromatin is coarsely granular to compact. (continued)
C
Figs. 16.20C. (continued) C: This lobular carcinoma presents a Fig. 16.21. FNA—duct carcinoma with osteoclast type giant cells.
syncytial tissue fragment with slightly larger cells, still with high
N/C ratios. Their chromatin is coarsely granular.
A B
C D
Figs. 16.22A to D. FNA—metaplastic carcinoma. This lesion was cystic, yielding hemorrhagic fluid on aspiration
biopsy. A, B, C, D: The smears show malignant squamous cells. The background is inflammatory. Surgical resection
confirmed a metaplastic carcinoma with malignant squamous component.
Fig. 16.23. FNA—adenosquamous carcinoma. The cellular aspirate

consists of malignant cells with glandular and squamous differen-
tiation.
TABLE 16.3 CYTOLOGIC FEATURES OF CONVENTIONAL BREAST ADENOCARCINOMA
Cellularity Generally high, low in scirrhous carcinomas
Presentation Malignant cells isolated, in loosely cohesive groups and in syncytial tissue fragments
Architecture Small to large syncytial tissue fragments with branching and anastomosing with cyclone fence pattern, or
an acinar pattern, nests, cords
Cells Marked variation in size and shape, small round, cuboidal, plasmacytoid, large polygonal to giant forms;
cell borders poorly defined
Nucleus Variable in size, large with high N/C ratios; bi- to multinucleation; central to eccentric location; nuclear
membranes smooth to irregular; chromatin fine to coarsely granular with parachromatin clearing; single/
multiple micro/macronucleoli; intranuclear cytoplasmic inclusions; mitoses frequent in poorly differentiated
tumors
Cytoplasm Variable, scant to abundant, pale, vacuolated to dense
Background Bare nuclei, cellular debris in high-grade lesions; calcific debris ⫹/⫺
Immunoprofile Positive reaction to estrogen and progesterone receptors (ER, PR) in majority of cases; GCFP usually
positive; HER2/neu expression positive in high-grade carcinomas
overlap with several other diagnostic entities and are dis- outline—retracted and depressed below the surface—or a
cussed in the section on proliferative breast disease. nodular configuration with ill-defined borders, lacking sharp
The term “lobular neoplasia” or “lobular carcinoma circumscription. The consistence is usually hard and gritty.
in situ” refers to the proliferation of small epithelial cells Histologically, the carcinomas present several growth
involving the terminal duct–lobular unit. The cytologic patterns such as solid, trabecular, nesting and alveolar, and
recognition is extremely poor. cystic. The neoplastic cells range in size from small to large
with poorly defined cell borders, variable cytoplasm, and
high N/C ratios. The nuclei, likewise, range in size and are
INVASIVE DUCT ADENOCARCINOMA, NOS
round with smooth to irregular membranes and promi-
nent nucleoli. The stroma may be scant to desmoplastic
with neoplastic cells streaming through the stroma in cords
Grossly, the lesions vary in size, from less than 1 centimeter and nests. Mitoses are usually present in large numbers in
to over 10 centimeters. They can have an irregular stellate poorly differentiated carcinomas. Necrosis is variable.
TABLE 16.4 CYTOPATHOLOGIC FEATURES OF MORPHOLOGIC VARIANTS OF BREAST ADENOCARCINOMAS
Duct Mucinous
Adenocarcinoma, Lobular Medullary Carcinoma Apocrine Papillary Tubular
Cellularity Variable, generally Variable, generally Highly cellular Variable Variable Highly cellular Variable
highly cellular; low due to
sparse cellularity in desmoplastic
scirrhous tumors stroma
Presentation Malignant cells Malignant cells Malignant cells Malignant cells Malignant cells Malignant cells, Malignant cells
isolated, in loosely isolated; in small isolated, in loosely in syncytial tissue isolated, in loosely isolated; in loosely generally in tissue
cohesive groups groups, in short cohesive groups fragments forming cohesive groups or cohesive groups fragments, single
and in syncytial chains or in and in syncytial tight clusters or in syncytial tissue and in syncytial cells infrequent;
tissue fragments syncytial tissue tissue fragments with papillary fragments without tissue fragments tissue fragments
with or without fragments with without any configurations in any architectural with or without syncytial, small to
branching and no architectural architectural pools of mucin patterns branching, some large, elongated
anastomosis; acinar pattern pattern; lymphoid with central cores tubular structures
pattern ⫹/⫺ cells in the of fibrovascular with crowding
background ⫹/⫺ tissue, three- and overlapping of
dimensional nuclei; angulations
clusters of tissue fragments;
pointed at one pole
characteristic
Cells—Size & Variable, small, Small, round with Round, medium to Small to medium- Medium to large- Size variable, small Small to slightly
Shape large to giant high N/C ratios; large; well-defined sized, round, sized with frequent to medium; round enlarged,
forms; round, cell borders well cell borders; high generally uniform; giant forms; round cuboidal and monomorphic with
cuboidal, to poorly defined N/C ratios high N/C ratios to polygonal well- columnar forms high N/C ratios;
plasmacytoid to slightly larger defined cell borders; cell borders poorly
polygonal; cell than normal duct high N/C ratios defined
borders well to epithelial cells, very
poorly defined; high high N/C ratios
N/C ratios
(continued)
Duct Mucinous
Adenocarcinoma, Lobular Medullary Carcinoma Apocrine Papillary Tubular
Nucleus Central to Round to oval, Round to oval, Variation in size, Large round, Minimal variation Round to
eccentric; bi- to central or eccentric; central location, round to oval; central to eccentric, in size, round oval, uniform;
multinucleation nuclear membrane pleomorphic in size; smooth nuclear frequently bi- to oval; smooth smooth nuclear
⫹/⫺; variable smooth to irregular, smooth to irregular membrane; multinucleated; nuclear membranes; membrane; fine to
in size; nuclear coarsely granular nuclear membranes; finely granular nuclear membranes finely granular coarsely granular
membrane smooth chromatin; fine to coarsely chromatin; micro/ smooth to irregular; chromatin; evenly dispersed
to irregular; prominent granular chromatin macronucleoli coarsely granular micronucleoli chromatin; nucleoli
chromatin fine to macronucleolus; with parachromatin chromatin with inconspicuous
coarsely granular nuclear molding clearing; prominent parachromatin
with parachromatin frequent nucleoli clearing; multiple
clearing; micro/macro
multiple micro/ nucleoli
macro nucleoli;
intranuclear
inclusions ⫹/⫺;
mitoses ⫹/⫺
Cytoplasm Variable, scant to Scant; secretory Variable; pale Scant to moderate Abundant, pale, Variable pale Scant, indiscernible
abundant, pale to vacuoles indenting pale to vacuolated granular to dense,
dense the nucleus bubbly, vacuolated
Psammoma Not present Not present Not present ⫹/⫺ Not present ⫹/⫺ Not present
Bodies
Background Necrosis in high- Clean Lymphoid cells Abundant mucin Histiocytes with Bloody ⫹/⫺; Clean
grade lesion; present as strings or and without histiocytes with
cellular debris; bare shrouds; capillaries hemosiderin and without
nuclei traversing through hemosiderin
the islands of
mucin, containing
tight clusters of
tumor cells
Calcification ⫹/⫺ Not present Not present ⫹/⫺ Not present ⫹/⫺ ⫹/⫺
Diagnostic Accuracy high Low diagnostic High diagnostic High diagnostic High diagnostic Difficult to Low
Accuracy with moderately yield due to poor rate, but typing rate rate; may resemble differentiate
to poorly cellularity from NOS squamous between invasive
differentiated carcinoma may carcinoma and noninvasive
carcinomas; be difficult; and from
scant cellularity lymphocytes not papillomas
in desmoplastic always present in
tumors may result sufficient numbers
in false-negative
diagnosis
Differential Depends on the In situ or low-grade Neuroendocrine Mucocolitis lesions Apocrine Papilloma Radial scar
Diagnoses grade, adenocarcinoma carcinoma Mycoid metaplasia with Radial scar Sclerosing adenosis
Low-grade— Tubular carcinoma Malignant degeneration in atypia Metastatic papillary Lobular carcinoma
In situ carcinoma Fibroadenoma lymphoma fibroadenoma carcinoma In situ/well-
Tubular carcinoma Proliferative breast Fibroadenoma differentiated
Lobular carcinoma disease Proliferative breast adenocarcinoma
Fibroadenoma disease Fibroadenoma
Proliferative breast Proliferative breast
disease disease
Cytopathologic Features immunohistochemistry. The scoring of ER/PR stain is done

using different scoring systems such as Allred scoring, which
The aspirates of breast adenocarcinomas, NOS, tend to
includes the intensity of staining and the proportion of nu-
be extremely cellular except in desmoplastic or scirrhous
clei staining positive, leading to a numerical score where
lesions, characterized by a large population of malignant
the score of eight is the highest for individual receptors.
cells that present as isolated with a dispersed pattern, in
HER2/neu status: HER2/neu expression is assessed
loosely cohesive groups, and in syncytial tissue fragments
primarily in most laboratories by immunohistochemistry.
with various architectural patterns. The tissue fragments
In the case of cytology samples, it is recommended to be
can be small to large, branching and anastomosing, resem-
performed on a paraffi n-embedded cytology cell block if
bling a cyclone fence. The tissue fragments may present a
no other routine formalin-fixed paraffin-embedded tissues
cribriform pattern or an acinar pattern, or the cells may
are available. Alcohol-fi xed smears may not be suitable
be cords and nests. The malignant cells present a broad
for HER2/neu status by immunohistochemistry. HER2/
range in size from small to large. They are usually round
neu immunohistochemistry is scored using CAP/ASCO
or oval to plasmacytoid, with poorly defined cell borders
guidelines (0, 1⫹ negative; 2⫹ equivocal, 3⫹ positive). All
containing very scant to appreciable cytoplasm. Their
the 2⫹ positive tumors are subjected to HER2/neu FISH
nuclei are round to oval with smooth nuclear membranes
testing to detect the presence or absence of amplification.
to irregular scalloped ones. The chromatin is granular with
The scoring systems are morphology-driven and can be
parachromatin clearing. Nucleoli are prominent. Mitoses
automated to have an objective scoring. There are several
may be present. Areas of necrosis are present. The cyto-
prognostic/predictive markers currently being evaluated in
logic features of duct adenocarcinoma, NOS, are listed in
a research setting, which may become the standard of care
Table 16.3 and illustrated in Figures 16.1 to 16.8.
in the near future (e.g., VEGF, EGFR, and TOPOII).
Ancillary Studies
The ancillary studies for breast malignancies currently
DIAGNOSTIC MARKERS FOR
include immunocytohistochemistry and molecular studies.
METASTATIC BREAST CANCERS
Immunoprofile
In addition to ER/PR, for diagnosing metastatic breast
The common markers used for diagnostic and prognos-
cancers—particularly when ER/PR immunostains are
tic purposes are steroid hormone receptors: estrogen and
negative—positive staining for mammaglobin, gross cys-
progesterone receptors (ER and PR), epidermal growth
tic disease fluid protein-15 (GCDFP-15), or cytokeratin 7
factor receptor EGFR (HER2/neu), anti-apoptotic protein
(frequently positive in the lung and the upper gastrointes-
Bcl-2, E-cadherin, ␤-catenin, myoepithelial markers such
tinal tract) are useful makers to suggest breast primary.
as S100 protein, smooth muscle actin (SMA), calponin,
and gross cystic disease fluid protein (GCDFP).
The important ones are ER/PR receptors, which are
positive in over 60 to 70% of breast adenocarcinomas, MORPHOLOGIC VARIANTS OF
NOS, reflect a better response to treatment, and offer lon- MAMMARY ADENOCARCINOMAS
ger disease-free survival. The antibody for the epidermal
growth factor is known as HER2/neu and is expressed in
Most morphologic variants have specifi c histologic and
high-grade malignancies. IHC or FISH can be used for the
cytologic patterns that lend to their ready recognition
detection of HER2/neu.
from the aspirates (Table 16.4).
Molecular Biology
MEDULLARY CARCINOMA
Prognostic and Predictive Markers. The current standard
of care for invasive carcinoma is to test all tumors for estro- Medullary carcinomas represent up to 7% of all breast
gen receptor (ER), progesterone receptor (PR), and HER2/ carcinomas. They are characterized by circumscription, a
neu gene expression status using immunohistochemistry solid growth pattern, the absence of a gland-like pattern,
for targeted therapy. In cases of advanced breast cancer, high nuclear grade, high mitotic activity, heavy lympho-
cytology may be the only sample available to determine cytic infiltrate, and negative reactivity to ER/PR as well as
the hormonal status and HER2/neu expression for tailor- to HER2/neu. They are positive to p53.
ing neoadjuvant or adjuvant therapy. In this setting, oncol- The aspirates are usually very cellular with syncy-
ogists would request ER, PR, and HER2/neu testing on a tial tissue fragments of clearly malignant cells with no
cytology sample (FNA of a mass, pleural fluid, etc.). architectural patterns. The nuclei are large with high NC
ER/PR status: Testing for ER/PR is performed on a ratios and very prominent micro-/macronucleoli. The
cytology cell block or even on cytology fixed smears by presence of lymphocytes is not always consistent.
TUBULAR CARCINOMAS shows papillary tissue fragments with branching. Tall

columnar cells singly line the central cores of connective
Tubular carcinomas (e-Fig. 16.1) comprise 0.8 to 2% of all
tissue. Their nuclei are uniform and elongated, contain-
breast carcinomas. Their incidence, however, in mammo-
ing fi nely granular chromatin and micronucleoli (Figs.
graphically obtained core biopsies is reported to be much
16.14 and 16.15). An invasive component is noted by the
higher. Histologically, tubular carcinomas are character-
presence of syncytial tissue fragments of round to cuboi-
ized by small, round to elongated, and sharply angulated
dal malignant epithelial cells. The background is usually
glandular structures with rigid openings. An extension
bloody and may contain psammoma bodies. The papil-
springing from one end like a pan handle is very charac-
lary carcinomas are ER positive.
teristic. The stroma is desmoplastic and can be extensive.
The differential diagnosis includes intraductal papil-
The aspirates demonstrate variable cellularity, usually
loma and several entities that yield papillary tissue frag-
on the low side, consisting of syncytial tissue fragments
ments in aspirates (see Table 16.9; Figs. 16.27 to 16.31).
of small cells that are crowded and overlapped and may
form an acinar pattern. The tissue fragments often appear
tubular with a smooth external contour and sharp angu- MICROPAPILLARY CARCINOMA
lation. The component cells have poorly defined cell bor-
Micropapillary carcinomas account for 1.2 to 2.3% of all
ders; scant, indiscernible cytoplasm; and uniform nuclei
invasive adenocarcinomas. Micropapillary carcinomas are
with bland chromatin (Fig. 16.11; see Fig. 16.41). There is
associated with an increased involvement of lymphatics
no mitotic activity or necrosis, and the background is very
and a high incidence of lymph node metastases. Histologi-
clean. The cells of tubular carcinoma do not present any
cally, micropapillary carcinomas are characterized by solid,
overt features of malignancy and must be differentiated
tubular nests surrounded by a clear space. Their nuclei are
from other lesions that present syncytial architecture with
polarized toward the center, and EMA positivity is noted
small cells (see Table 16.15; Figs. 16.40 to 16.44).
along the periphery—a pattern referred to as “inside out.”
Tubular carcinomas are strongly positive for ER/PR
Micropapillary carcinomas are often associated with ade-
and show negative expression for HER2/neu.
nocarcinoma, NOS. The nuclei are of high grade.
The aspirates are cellular, consisting of syncytial tis-
MUCINOUS CARCINOMA sue fragments with tightly packed nuclei with a smooth
external contour; they lack a central fibrovascular core or
Mucinous carcinomas, also known as colloid carcinomas, acinar pattern. They often appear angulated. The micro-
account for approximately 2% of breast adenocarcino- papillary carcinoma is strongly positive for ER and PR
mas. Cytohistologically, mucinous carcinomas are char- and positive for HER2/neu 45% of the time.
acterized by abundant mucin secretion containing embed-
ded nests and glandular structures of malignant cells that
exhibit a variable degree of nuclear atypia. Papillary APOCRINE CARCINOMA
architecture and psammoma bodies are also identified Apocrine carcinomas account for up to 4% of breast
(Figs. 16.12 to 16.14). One of the characteristic features adenocarcinomas and are required to show apocrine
of the mucinous carcinoma is the arborizing thin-walled differentiation in 90% or more of the carcinoma. The
blood vessels in the mucinous stroma. The differential aspirates are cellular, consisting of syncytial tissue frag-
diagnosis includes lesions rich in mucin production (see ments of large, round, and oval to polygonal cells with
Table 16.17). well-defined cell borders and abundant granular to dense
Mucinous carcinomas are usually ER positive and cytoplasm. Foamy, bubbly cytoplasm with large vacuoles
less so for PR. is frequently noted. The nuclei of apocrine carcinoma
show distinct malignant features (Figs. 16.16 to 16.19).
The apocrine carcinoma cells are ER, PR, and HER2/neu
INVASIVE PAPILLARY CARCINOMA
negative but are positive for GCDFP.
Invasive papillary carcinomas comprise less than 1 to 2% The differential diagnosis includes apocrine metapla-
of breast malignancies. The papillary architecture is lost sia with atypia, which may be remarkable (Table 16.11;
when the lesion becomes invasive, presenting a pattern e-Figs. 16.12 to 16.15).
of adenocarcinoma, NOS. Histologically, the papillary
carcinomas show a papillary growth pattern formed by
LOBULAR CARCINOMA
delicate, arborizing fronds, consisting of delicate fibrovas-
cular connective tissue and covered by a single layer of Lobular carcinomas represent 5 to 15% of invasive breast
tall columnar cells (e-Fig. 16.2). malignancies, characterized by noncohesive malignant cells
The aspirates of invasive papillary carcinomas show that are individually dispersed and infiltrating the desmo-
marked cellularity with both papillary and invasive duct plastic stroma in single files or small aggregates and nests.
adenocarcinoma components. The papillary component These are often associated with lobular carcinoma in situ.
Histologically (e-Fig. 16.3), the classic form shows TABLE 16.5 CYTOPATHOLOGIC FEATURES OF
abundant desmoplastic stroma. The neoplastic cells are METAPLASTIC BREAST CARCINOMA
typically small with poorly defi ned cell borders and high
N/C ratios; they infi ltrate in single fi les and often form Cellularity Variable, low in cystic lesions, high in
whorls. Their cytoplasm is scant and sometimes contains solid tumors
vacuoles, which house eosinophilic inclusions. The mor-
Presentation Cystic yielding fluid aspirate ⫹/⫺;
phologic variants include solid form, alveolar variant, and
cells isolated, in aggregates or fascicles,
pleomorphic forms. or in syncytial tissue fragments;
The aspirates of lobular carcinomas are frequently pleomorphic cell population representing
poorly cellular, leading to unsatisfactory samples as the multiple malignant components –
desmoplastic stroma does not yield to aspiration. With adenocarcinoma, squamous carcinoma
adequate cellularity, the lobular carcinoma cells present and sarcoma
as small round cells that are discrete, in small groups, or
in syncytial tissue fragments with no architectural pat- Malignant Usually high-grade; marked cellular
terns (Figs. 16.20A to C). The individual cells have poorly Glandular and nuclear pleomorphism; obvious
defined cell borders, scant cytoplasm, and sometimes con- Component malignant features
tain vacuoles. Their chromatin is coarsely granular and
the macronucleolus is prominent. Large syncytial tissue Malignant Varying degrees of differentiation;
fragments are seen with the alveolar variant. The pleo- Squamous isolated pleomorphic excessively
Component keratinized cells with malignant nuclei,
morphic variant shows larger cells with nuclear atypia.
anucleate forms to syncytial tissue
There is usually no necrosis or mitotic activity. The differ- fragments of less differentiated malignant
ential diagnosis includes lesions of the breast composed squamous cells, keratin pearls ⫹/⫺
of small cells (Table 16.15; Figs. 16.40 to 16.44).
Sarcomatous Round, polygonal to spindle cells either
Component isolated, or in fascicles; pleomorphic
nuclei, prominent nucleoli; mitoses ⫹;
UNUSUAL MALIGNANCIES cytoplasmic processes; osteosarcomatous
or chondrosarcomatous component ⫹/⫺
CARCINOMA WITH OSTEOCLAST-TYPE
Background Bloody, necrosis ⫹/⫺; histiocytes ⫹/⫺;
GIANT CELLS multinucleated osteoclast-like giant cells
Osteoclast-type giant cells (Fig. 16.21) have been associ-
ated with the usual type of duct adenocarcinoma or any Immunoprofile Keratin ⫹ in epithelial areas; vimentin ⫹
of its variants. These are encountered infrequently. in sarcomatoid areas
METAPLASTIC CARCINOMAS
Metaplastic carcinomas are uncommon malignant neo-
Adenosquamous carcinomas are often cystic, yielding
plasms of the breast, characterized by an intimate admix-
hemorrhagic fl uid with scattered, isolated, keratinized
ture of adenocarcinoma with dominant areas of spindle
squamous cells that must be differentiated from lesions
cells and squamous and/or mesenchymal differentiation.
containing atypical squamous cells, such as benign cysts
The metaplastic spindle cells and squamous carcinoma
with squamous metaplasia or subareolar abscess. Meta-
may present in a pure form without the adenocarcinoma
plastic breast carcinoma with a poorly differentiated
component. The malignant duct epithelial (Table 16.5;
squamous component must be differentiated from meta-
Figs. 16.20 and 16.22) component is usually of high
static squamous carcinoma.
grade with squamous and/or sarcomatous differentiation.
The differential diagnoses of metaplastic breast carci-
In addition, the malignant squamous cells may exhibit a
noma with a mesenchymal component include phyllodes
(pseudo) sarcomatous appearance, while the sarcomatous
tumor and primary or secondary soft tissue tumors (see
component may contain heterologous features such as
Table 16.10; Figs. 16.32 to 16.36).
chondrosarcoma and osteosarcoma.
The diagnosis of metaplastic breast carcinoma is based
on the identification of two or more distinct components
ADENOSQUAMOUS CARCINOMA
and is dependent on the sampling of the representative
areas. Adenosquamous carcinoma is characterized by adenocar-
The differential diagnosis of metaplastic breast carcinoma with areas of squamous differentiation and may
cinomas depends on which component is aspirated. be considered part of metaplastic carcinoma (Fig. 16.23).
ADENOID CYSTIC CARCINOMA A papillary growth is evident in histologic sections,

consisting of a single layer of uniform epithelial cells
Adenoid cystic carcinomas are rare, accounting for less
lining well-defi ned, often sclerotic, fibrovascular stalks,
than 1% of primary breast malignancies. Morphologi-
which may show complex branching (see e-Fig. 16.31). A
cally, they resemble adenoid cystic carcinomas occurring
myoepithelial cell layer is identifi able. Frequent areas of
in the salivary glands (refer to Chapter 15).
apocrine metaplasia are also present.
Cytologically (Table 16.6; e-Figs. 16.4 to 16.6; see
SECRETORY CARCINOMA Figs. 16.29A and B), the aspirates show varying degrees of
(JUVENILE CARCINOMA) cellularity in the background of old as well as fresh blood
and macrophages with or without hemosiderin. The epi-
Although secretory carcinoma was first described in chil-
thelial tissue fragments may show papillary configuration
dren and adolescents, it can occur at all ages. It repre-
with fi brovascular stalks or monolayered sheets with a
sents an unusual variant of duct epithelial carcinoma,
honeycomb arrangement. The cells are uniform, cuboidal
characterized by extensive intracellular and extracellular
with a bland chromatin pattern. The cytoplasm is vari-
secretory material. The malignant cells have abundant
able, often showing vacuolated cytoplasm.
granular cytoplasm with vacuoles and droplets, which
The cytologic features of various papillary lesions
are PAS positive, resistant to diastase, and alcian blue
of the breast overlap, particularly the papillomas and
positive. Their nuclei are regular with a bland chromatin
papillary carcinomas, constituting yet another diagnos-
pattern. Cytologically, secretory carcinoma cells present
tic pitfall in breast cytopathology (Table 16.6). Cellular
as isolated, in aggregates, or in tissue fragments with an
fi broadenomas with papillary branching epithelial tissue
acinar pattern, and contain small amounts of centrally
fragments, in the absence of stroma and bipolar nuclei, as
placed mucoid structures resembling adenoid cystic carci-
well as mucinous carcinoma with papillary features and
noma. The malignant cells are also seen arranged around
metastatic papillary serous cystadenocarcinoma of the
a fibrovascular core. The most characteristic feature is the
ovary are also considerations in the differential diagnosis
prominent intracytoplasmic vacuoles, sometimes inspis-
of papillary breast lesions (see Table 16.9 and Figs. 16.27
sated, appearing as hyaline globules. The nuclei are vari-
to 16.31).
ably atypical.
SIGNET-RING CARCINOMA FIBROADENOMA

Signet-ring carcinomas comprise approximately 2% of all Fibroadenomas are the most common benign neoplasms
breast malignancies and occur in patients in their fifth to of the breast that frequently occur between the ages of 20
sixth decades of life. These tumors may be associated with and 35. These are well-circumscribed and freely mobile
lobular or ductal carcinomas. Cytohistologically, signet- with a rubbery consistency and may enlarge during preg-
ring carcinomas show as discrete or in groups of small nancy. Grossly, fibroadenomas are firm, spherical, or dis-
cells with cytoplasmic vacuoles pushing the nuclei periph- coid with a bulging cut surface that is white, glistening,
erally. The latter appear crescent-shaped and indented. and mucoid with clefts. Their histologic pattern is char-
acterized by a proliferating loose stroma, compressing the
ducts. The duct epithelium is generally double layered but
NEUROENDOCRINE CARCINOMAS may show hyperplasia and apocrine metaplasia.
Primary neuroendocrine carcinomas are rare, representing
2 to 5% of all invasive breast carcinomas. The histologic Cytopathologic Features
types include carcinoid tumor, large cell neuroendocrine,
The aspirates of fi broadenoma present a dimorphic pat-
and small cell type.
tern with epithelial and stromal components in varying
proportions, along with naked bipolar nuclei, constitut-
ing the classic triad that allows easy recognition (Table
BENIGN NEOPLASMS OF THE BREAST 16.7; Figs. 16.24 to 16.26). The epithelial component
can present as large branching epithelial tissue fragments
referred to as a “staghorn” pattern. The epithelium itself
INTRADUCTAL PAPILLOMA
generally shows a honeycomb arrangement with uniform
Intraductal papillomas are benign papillary neoplasms nuclei containing fi nely granular chromatin. The epithe-
that may arise anywhere within the mammary duct sys- lial tissue fragments vary in size and may show varying
tem but are most common in subareolar lactiferous ducts, degrees of nuclear atypia. The stromal tissue fragments
often presenting with serous or bloody nipple discharge, are loose fi brovascular and may be a predominant com-
in which case smears of nipple discharge may show diag- ponent. Naked bipolar nuclei are present in variable num-
nostic cells (see the section on Nipple Discharge). bers. Cystic change and mucoid degeneration may occur.
TABLE 16.6 DIFFERENTIATING FEATURES BETWEEN INTRADUCTAL PAPILLOMA

& PAPILLARY CARCINOMA
Intraductal Papilloma Papillary Carcinoma

Cellularity Variable Generally very cellular
Presentation Cells mostly in tissue fragments, branching Cells isolated, in loosely cohesive groups and in
honeycomb sheets or with papillary syncytial tissue fragments with papillary configuration,
configuration; less often isolated with or without branching; papillary fragments with
central core of fibrovascular tissue
Cells Uniform round to cuboidal; well-defined cell Round, cuboidal to slender, columnar cells
borders
Nucleus Round to oval, smooth nuclear membrane, Round to oval, smooth nuclear membranes, finely
finely granular chromatin; micronucleoli granular chromatin; micronucleoli
Cytoplasm Pale, variable, secretory; vacuoles frequent Variable, pale
Background Bloody, proteinaceous fluid, foamy Bloody, hemosiderin, containing macrophages; apocrine
macrophages with or without hemosiderin; cells absent; psammoma bodies; calcific debris; may be
apocrine cells ⫹/⫺; calcific debris coexistent with duct adenocarcinoma, NOS
TABLE 16.7 CYTOPATHOLOGIC FEATURES OF FIBROADENOMA
Cellularity Variable, sparse to highly cellular
Presentation Admixture of epithelial and stromal elements in varying proportions
Epithelial Component Cells small, mostly in tissue fragments, infrequently isolated and in loosely cohesive groups;
tissue fragments small to large, monolayered with honeycomb arrangement to syncytial, papillary
configuration with or without complex branching, bulbous ends with smooth external contours;
myoepithelial cells with slender or compact nuclei within and along the periphery
Nucleus Small, smooth nuclear membrane, finely granular evenly dispersed chromatin, micronucleoli;
anisonucleosis ⫹/⫺
Cytoplasm Scant, pale
Stromal Tissue Fragments Numbers variable, small to large, loose textures
Background Naked bipolar nuclei in sparse to large numbers; apocrine cells
in situ and invasive well-differentiated duct carcinomas,
The cytologic diagnosis of fibroadenomas is a rather easy NOS, and tubular carcinomas (see Table 16.15; Figs.
one, based on the presence of the cytologic triad. How- 16.40 and 16.45). With papillary and complex branch-
ever, this triad is present in roughly 60% of aspirates from ing of epithelial tissue fragments, a papillary neoplasm
fi broadenomas. The remaining may show an absence of must be excluded (Table 16.9). A biphasic pattern simi-
one of the three components or a predominance of one lar to fibroadenoma is also seen in aspirates from breasts
component. The differential diagnosis of fibroadenoma harboring fibrocystic change and duct hyperplasia (prolif-
depends on its cellular composition (Table 16.8). A cel- erative breast disease). The differentiation of proliferative
lular fi broadenoma with a predominant epithelial com- breast disease from fibroadenoma is often not possible on
ponent must be differentiated from ductal hyperplasia, a cytologic basis (see Tables 16.14 and 16.15).
A B
C D
Figs. 16.24A to D. FNA—fibroadenoma. A: Markedly cellular aspirate with large tissue fragments of epithelial cells
along with fragments of stromal tissue (low power). B: Higher magnification of the epithelial tissue fragment demon-
strates a papillary-like architecture. The component cell nuclei are crowded and overlapped and have bland nuclei.
C: A stromal tissue fragment. D: Stroma with naked bipolar nuclei.
A B
Figs. 16.25A and B. FNA—fibroadenoma. A: An extremely cellular aspirate with a predominant epithelial
component. The epithelial tissue fragments are large and branching. B: Higher magnification of the tissue fragment
showing uniform nuclei. A predominantly epithelial pattern represents duct hyperplasia in fibroadenoma. In the
absence of stromal component, this aspirate may be interpreted as proliferative breast disease.
A B
Figs. 16.26A and B. FNA—fibroadenoma. This aspirate consisted of only duct epithelial cells in syncytial tissue frag-
ments and loosely cohesive groups. The cells are small with scant cytoplasm and high N/C ratios and are suspicious
for adenocarcinoma. Surgical excision confirmed a fibroadenoma.
TABLE 16.8 DIFFERENTIAL DIAGNOSES OF ANGIOSARCOMA

FIBROADENOMA
Angiosarcomas are malignant neoplasms that are derived
A. With Biphasic Pattern from endothelial cells. In the breast, angiosarcomas occur
• Ductal hyperplasia (proliferative breast disease) secondary to lymph edema resulting from radical mas-
B. With Predominant or Exclusive Epithelial Component tectomy and lymph node dissection. It can also occur in
with or without Nuclear Atypia the skin and chest wall following local radiation therapy.
• Ductal hyperplasia (proliferative breast disease) Primary angiosarcomas of the breast are very rare with an
• Papilloma/papillary carcinoma (with papillary tissue incidence of 0.05% of all breast malignancies. The cyto-
fragment) logic pattern is described in Chapter 24 on soft tissues.
• Well-differentiated ductal carcinoma (in situ and
invasive)
• Lobular carcinoma BREAST ASPIRATES WITH A SPINDLE
• Tubular carcinoma CELL PATTERN
C. With Predominant or Exclusive Stromal Component
(Spindle Cell Pattern) Breast lesions that present with a spindle cell pattern
• Phyllodes tumor include the common neoplasms with biphasic morphol-
• Mesenchymal neoplasms ogy such as fibroadenoma, phyllodes tumors, myoepi-
D. With Lactational Change theliomas, and metaplastic carcinomas, as well as mes-
• Adenocarcinoma enchymal lesions such as nodular fasciitis, fibromatosis,
E. With Mucinous Background myofibroblastoma, and soft tissue sarcomas (primary
• Mucocele-like tumor
and metastatic, including angiosarcomas). The inci-
• Mucinous carcinoma
dence of mesenchymal lesions involving the breast is
extremely low. Their features are listed in Table 16.10
and illustrated in Figures 16.33 to 16.36. For more
information on fibromatosis, nodular fasciitis, and soft
PHYLLODES TUMORS tissue sarcomas, please refer to Chapter 24.
Phyllodes tumor, also known as cystosarcoma phyl-
lodes, is a distinctive breast tumor composed of benign
epithelial elements and a cellular spindle cell stroma; it
NONPROLIFERATIVE AND
accounts for less than 1% of all breast neoplasms. Both
PROLIFERATIVE BREAST DISEASE
benign and malignant varieties are encountered, mostly
occurring in an older age group. Both types have a benign
ductal component. However, the benign phyllodes tumor The fibr ocystic disease complex, as it was popularly known
consists of cellular stroma with proliferating spindle cells in the past, consisted of various morphologic alterations in
while the malignant phyllodes tumor contains prolifer- the breast. These included fibrosis, gross and microscopic
ating stroma with malignant features (e-Fig. 16.7; Figs. cyst formations, apocrine metaplasia, fl orid and scleros-
16.32A to E). ing adenosis, epithelial hyperplasia, and papillomatosis.
TABLE 16.9 DIFFERENTIAL DIAGNOSES PAPILLARY EPITHELIAL TISSUE FRAGMENTS

IN BREAST ASPIRATES
Diagnostic Clues/
Diagnostic Entity Cytopathologic Features Ancillary Tests See Fig(s).
Fibroadenoma Branching tissue fragments of epithelial cells; often Mobile well-defined mass; 16.27
with smooth external contours and bulbous ends; stromal tissue fragments and
fibrovascular cores not identified; epithelial cells closely naked bipolar nuclei
packed, uniform to mildly pleomorphic nuclei, finely
granular chromatin, micronuclei; large cytoplasmic
vacuoles not present; stromal tissue fragments and naked
bipolar nuclei
Intraductal Papilloma Branching tissue fragments with or without central Nipple discharge; honeycomb 16.29
fibrovascular stalks; monolayered with honeycomb pattern of tissue fragments of
arrangement or single cuboidal cells lining papillae; duct epithelial cells; few or
myoepithelial cells within tissue fragments; epithelial cell no single cells; cytoplasmic
with vacuolated cytoplasm; hemosiderin or hemorrhagic vacuoles; apocrine metaplasia;
background; apocrine metaplasia frequent myoepithelial cells ⫹
Papillary Carcinoma Syncytial tissue fragments with or without complex Nipple discharge frequent; 16.30
branching and with or without central fibrovascular older age group; two type of
stalks; cells cuboidal and columnar type with bland epithelial cells-cuboidal and
nuclei; psammoma bodies ⫹/⫺; hemosiderin containing columnar
macrophages
Mucinous Carcinoma Syncytial tissue fragments with branching and three- Abundant mucin; lack of 16.31A
dimensional clusters; smooth outlines; fibrovascular columnar cells
stalks not present; nuclei small to large with fine to
coarsely granular chromatin, micro and macronucleoli;
abundant mucin; psammoma bodies ⫹/⫺
Metastatic Ovarian Syncytial tissue fragment with complex branching and History of ovarian carcinoma; 16.31B
Carcinoma with central fibrovascular cores or with acinar pattern; elevated serum levels of CA125
malignant cells also seen isolated and in loosely cohesive increased; lack of two cell types
groups; nuclei pleomorphic; high N/C ratios; granular (cuboidal & columnar)
chromatin, parachromatin clearing, irregular outlines
and with multiple micro/macronucleoli; cytoplasmic
vacuoles may be prominent; psammoma bodies frequent
Duct Hyperplasia Branching tissue fragments of epithelial cells; often Diffuse nodularity 16.39
(Proliferative Breast with smooth external contours; fibrovascular cores not
Disease) identified; epithelial cells closely packed, uniform to
mildly pleomorphic nuclei, finely granular chromatin,
micronucleoli; large cytoplasmic vacuoles not present;
stromal tissue fragments and naked bipolar nuclei ⫹/⫺
Radial Scar Varying-sized syncytial tissue fragments of duct No distinct palpable mass 16.28
epithelium, with or without papillary-like pattern; mild
nuclear enlargement and atypia with micronucleoli; no
columnar cells; no single cells
Differential Diagnoses of Papillary Lesions (See Figs. 16.27 to 16.32)
A B
Figs. 16.27A and B. FNA—fibroadenoma. A: Overwhelmingly cellular aspirate. The epithelial tissue fragments are
huge, with a papillary pattern. The background is loose fibrous (low power). B: Higher magnification of epithelial
tissue fragments.
A B
Figs. 16.28A and B. Radial scar. A: Cellular aspirate with multiple branching papillary tissue fragments. No stromal
tissue is seen in the background. B: Higher magnification showing syncytial tissue fragments composed of small to
medium-sized duct epithelial cells with poorly defined cell borders. The nuclear chromatin is granular with micronu-
cleoli. A diagnosis of papillary carcinoma was made. Breast biopsy revealed a radial scar.
A B
Figs. 16.29A and B. FNA—intraductal papilloma. A: Large branching tissue fragments of duct epithelium
(low power). B: Higher magnification showing honeycomb arrangements of cells with uniform nuclei.
A B
Figs. 16.30A and B. FNA—papillary carcinoma. A: Low power of a cellular aspirate demonstrating a papillary tissue
fragment. The fibrovascular cores are apparent even at this magnification. B: Higher magnification showing a dual
population of tall columnar and cuboidal epithelial cells.
A B
Figs. 16.31A and B. FNA of a metastatic papillary serous cystadenocarcinoma of the ovary. Note the psammoma
bodies.
A B
Figs. 16.32A to B. FNA—cystosarcoma phyllodes. A: A large tissue fragment of stromal tissue (low power).
B: Higher magnification. The tissue fragment is composed of malignant spindle cells with pleomorphic
nuclei. (continued)
C D
Figs. 16.32C to E. (continued) C, D: Pleomorphic, round and spindle-

shaped malignant cells. E: A large tissue fragment of benign duct
E epithelium with a honeycomb pattern.
Dupont and Page from their follow up study of 10,366 appearing as rounded bluish thin-walled tense nodules.
consecutive breast biopsies, separated the morphologic The fl uid contents may be clear, thin, or thick greenish-
changes seen in fibrocystic disease complex into two main brown. The lining epithelium is either flat to attenuated
groups—nonproliferative and proliferative—and assigned or may show apocrine change with or without papillary
risk factors for developing subsequent cancers. The non- hyperplasia (e-Fig. 16.8).
proliferative group included fi brosis, cysts, adenosis, and The cyst aspirate may be acellular or show variable
apocrine metaplasia and were assigned no risk factors cellularity and is composed of an admixture of apocrine
for developing subsequent malignancy compared to nor- cells, duct epithelial cells, histiocytes, and anucleated
mal population. The proliferative group encompassed cells in a background of cellular and amorphous debris.
hyperplasia, both typical and atypical. Risk factors were The apocrine cells vary in number and can be present
assigned to this group dependent on the degree of hyper- in large branching tissue fragments with a honeycomb
plasia and atypia. A detailed discussion on this subject is arrangement. Their cell borders are well-defined, and
beyond the scope of this atlas. The reader may refer to the the cytoplasm is abundant and granular. The nuclei are
extensive literature on the subject. small and very uniform with fi nely granular chromatin
and contain a prominent macronucleolus. The apocrine
cells can also be present in small tissue fragments with
a papillary-like pattern. In a cystic background, the apo-
NONPROLIFERATIVE BREAST DISEASE
crine cells may exhibit considerable nuclear atypia as well
as squamous metaplasia and must be differentiated from
Fibrocystic Change
ductal carcinomas of the apocrine type (Table 16.11; e-
Benign breast cysts are frequent between the third and Figs. 16.9 to 16.15).
fourth decades of life and rare before the age of 25 or
after menopause. Clinically, they may present as a lump Differential Diagnoses of Cystic Lesions of the Breast.
or as diffuse nodularity. They vary in size from a few Most breast cysts (99%) are benign and nonneoplastic,
millimeters to several centimeters in diameter, grossly occurring as a part of fi brocystic change. Some represent
TABLE 16.10 DIFFERENTIAL DIAGNOSES OF SPINDLE CELL LESIONS OF THE BREAST
Summary of Clinicopathologic Diagnostic Clues/

Features Cytopathologic Features Ancillary Tests
Fibroadenoma with Most common benign neoplasm, Variable cellularity; tissue fragments Clinical presentation
Predominant Stromal frequent in 20–35 yr of age; well- of benign duct epithelium and loose Biphasic pattern
Component or circumscribed, freely mobile, fibrovascular stroma; naked bipolar
Giant Fibroadenoma encapsulated 1–15 cm in diameter; nuclei; cells in the stromal tissue
(Benign Cystosarcoma lobulated, bulging cut surface; fragments benign with bland nuclei
Phyllodes) histologically consists of proliferating
loose stroma compressing the
branching ducts and ductules with or
without epithelial hyperplasia
Cystosarcoma Very rare, accounts for less than 1% of Variable cellularity, biphasic; isolated Circumscribed mass
Phyllodes: Phyllodes breast tumors; average age 45 yr; rapid and aggregates of round polygonal on mammography;
Tumor (Malignant) enlargement of pre-existing tumor or to spindle cells in a myxoid stroma; malignant stromal
rapidly growing; histology-discrete, nuclei very pleomorphic, smooth to cells with CEA ⫺
variegated cut surface, soft to firm, tan- irregular outline; coarsely granular Keratin ⫺
gray to gelatinous, lobulated, bulging cut chromatin; single/multiple micro/ Vimentin ⫹
surface with clefts and polypoid areas; macronucleoli; mitoses frequent;
necrosis and hemorrhage; 1–15 cm; epithelial component-small to large
markedly cellular stroma varying tissue fragments of duct epithelium
degrees of pleomorphism, mitoses with honeycomb pattern or branching
separating benign ductal elements with crowding and overlapping of
uniform nuclei with finely granular
chromatin
Myofibroblastoma Rare neoplasm, occurring more Cellular; groups of delicate spindle- Keratin ⫺
frequently in older males; nodules shaped cells in the background of Vimentin ⫹
are firm, 1–5 cm; circumscribed loose myxoid stroma; cells have central Actin ⫹
and nonencapsulated; histologically elongated cigar-shaped nuclei; smooth
composed of broad collagen bands nuclear outline finely granular, evenly
proliferating bundles of spindle cells distributed chromatin, micronucleoli
in a myxoid matrix; nuclei are oval nuclear grooves ⫹/⫺; cytoplasm
to cigar-shaped; bland chromatin; no pale, bipolar delicate processes; clean
mitoses background
Nodular Fasciitis Nonneoplastic localized proliferation Variable cellularity, can be very Mammographically
of fibroblastic cell, very rare in breast; high; plump spindle-shaped cells distinct; mixed
rapid growth, well-circumscribed with tissue culture appearance, inflammatory cells in
nonencapsulated, rapidly growing fibroblasts, multinucleated giant cells the background
and inflammatory cells; stellate cells;
myxoid background, mitoses maybe
numerous
galactocele and traumatic or fat necrosis, as well as is recommended only when 1) the cyst fluid is hemor-
infl ammatory lesions (e-Figs. 16.16 to 16.18; see below rhagic; 2) there is a residual mass following aspiration
in the section on Infl ammatory Lesions). Neoplastic cys- and evacuation of the cyst; and 3) the cyst recurs or is
tic lesions include intraductal papilloma (e-Figs. 16.19A persistent. The differential diagnostic features are listed
and B), intracystic papillary carcinoma, cystic necrosis in in Table 16.12.
a duct carcinoma (e-Fig. 16.20 and 16.21), or a meta-
plastic carcinoma. Due to a low incidence of malignancy
Adenosis
(⬍1%) in cystic lesions, the routine cytologic examina-
tion of fluids remains a controversial issue and it is gener- Adenosis implies an increase in the number of ductules,
ally not requested or performed. The cytologic evaluation in contrast to hyperplasia, which involves the lining
Differential Diagnoses of Spindle Cell Lesions (See Figs. 16.33 to 16.39)
A B
Figs. 16.33A and B. FNA—metastatic liposarcoma with a spindle cell pattern. A: Low power. B: Higher magnification
showing pleomorphic malignant cells in a myxoid stroma.
Figs. 16.34A and B. FNA—myofibroblastoma of the breast. The

aspirate consists of discrete and loosely cohesive spindle and round
cells containing uniform nuclei with finely granular chromatin. The
spindle cells have delicate bipolar cytoplasmic processes. The back-
ground is loose and myxoid.
Fig. 16.35. Fibromatosis. FNA showing aggregates of spindle cells

with mildly atypical, oval to elongated nuclei, containing finely
granular chromatin with micronucleoli. Their cytoplasm is variable,
pale with bipolar processes.
A B
Figs. 16.36A and B. FNA—metaplastic carcinoma with a spindle cell pattern. A: This syncytial tissue fragment of
malignant cells shows poorly differentiated malignant cells with an admixture of spindle cells. B: Different field from
the same case showing predominantly spindle cells and loose stroma.
TABLE 16.11 DIFFERENTIATING FEATURES BETWEEN FLORID APOCRINE METAPLASIA

WITH CYSTIC CHANGE AND APOCRINE CARCINOMA
Cystic Change with Florid Apocrine Metaplasia Apocrine Carcinoma

Cellularity Variable High cellularity
Presentation Cells isolated, in loosely cohesive groups or in Cells isolated, in loosely cohesive groups or in
monolayered sheets with honeycomb arrangement; syncytial tissue fragments with no architectural
occasionally papillary pattern
Cells Medium-sized; generally uniform, occasionally Medium-sized to large; very pleomorphic with
pleomorphic in size; well-defined cell borders; low frequent giant forms; well-defined cell borders; high
N/C ratios N/C ratios
Nucleus Round to oval, generally uniform, central location; Large round to oval, pleomorphic in size with giant
binucleation frequent; multinucleation may be forms; central, to eccentric, bi- to multinucleation;
seen occasional; smooth nuclear membrane; finely nuclear membrane smooth to irregular; coarsely
granular, evenly dispersed chromatin; one or more granular chromatin; multiple micro/macronucleoli;
micronucleoli intranuclear cytoplasmic inclusions ⫹/⫺
Cytoplasm Abundant, granular to dense, biphasic staining ⫹/⫺; Abundant, granular to dense or vacuolated
sometimes vacuolated, single or multiple vacuoles
Background Histiocytes with or without hemosiderin; benign Cellular and/or necrotic debris ⫹/⫺; amorphous
duct epithelial cells ⫹/⫺; cellular and amorphous debris and anucleated cells not present
debris; anucleated cells
epithelium. It most commonly occurs in women in their Adenosis is a microscopic fi nding and the involved
third and fourth decades of life. Adenosis can be florid or area may be inadvertently sampled during a biopsy pro-
sclerosing. Microscopically, it is characterized by elonga- cedure for a palpable nodule or during stereotactic guided
tion and proliferation of ductules with associated myoep- biopsy. The cytologic features of adenosis are nondescript
ithelial and stromal proliferation. With increasing fibro- and not particularly characteristic. The cellularity is low.
sis, there may be extreme distortion. Calcification may be The epithelial cells are benign, present in small tissue
present. fragments, and are associated with myoepithelial cells
TABLE 16.12 DIFFERENTIAL DIAGNOSES OF CYSTIC LESIONS OF THE BREAST
Disease Entity Cytopathologic Features Diagnostic Clues

Cystic Change Fluid clear to turbid; apocrine cells-isolated, in loosely Apocrine cells; multinucleated giant cells;
cohesive groups or in tissue fragments with honeycomb squamous metaplasia with or without
arrangement; papillary configuration may be present; duct nuclear pleomorphism
epithelial cells when present are in small groups or tissue
fragments, size small, scant cytoplasm, high N/C ratios with
compact chromatin; histiocytes; anucleated cells, cellar and
amorphous debris; calcific debris ⫹/⫺
Inflammatory Inflammatory (neutrophilic) exudate, histiocytes; History of trauma ⫹/⫺; deep location
(Abscess) multinucleated foreign-body-type giant cells; duct epithelial
cells when present may show nuclear enlargement
and prominent nucleoli; CAUTION—do not diagnose
malignancy in the presence of neutrophilic exudate
Subareolar Abscess Neutrophilic exudate, histiocytes, keratin debris, squamous Keratin and keratin granulomas
cells with dyskeratosis; duct epithelial cells when present
may exhibit nuclear enlargement and micronucleoli;
multinucleated foreign-body-type giant cells, some with
engulfed keratin
Galactocele Turbid fluid; low cellularity; duct epithelial cells with Poorly cellular; history of pregnancy/
vacuolated cytoplasm; foam cells; background granular and lactation
foamy
Adenocarcinoma, Cellularity variable, extensive necrosis may result in cellular Obvious malignant cells; extensive
NOS with Cystic debris obscuring neoplastic cells; cells single or in loosely necrosis
Change or cohesive groups; poor preservation; obvious malignant
Comedocarcinoma criteria when well-preserved
Metaplastic Cellularity variable, may be low; hemorrhagic background; Keratinized pleomorphic malignant
Carcinoma with malignant cells isolated or in loosely cohesive groups and in squamous cells
Cystic Degeneration syncytial tissue fragments; malignant squamous cells with
or without keratinization, anucleated squames
Papilloma Cellularity variable, generally high; cells in loose aggregates Lack columnar cells; no tissue fragments
or tissue fragments, syncytial or honeycomb arrangement; with fibrovascular cores, secretory
cuboidal cells with low N/C ratio; round to oval nuclei with vacuoles in cytoplasm frequent
finely granular chromatin; micronucleoli; large secretory
vacuoles in the cytoplasm frequent; apocrine metaplasia,
frequent calcific debris; proteinosis fluid, macrophages with
or without hemosiderin
Papillary Carcinoma Cellular aspirates, cells isolated, in loosely cohesive groups Cuboidal and slender columnar cells,
or in syncytial tissue fragments; papillary architecture cytoplasmic secretory vacuoles not
with central fibrovascular core; cell cuboidal to columnar present; apocrine metaplasia not present;
elongated; nuclei, round uniform with finely granular papillary tissue fragments with central
chromatin, micronucleoli obvious malignant cells may cores
indicate invasive process; bloody background; macrophages
with or without hemosiderin; psammoma bodies ⫹/⫺
(e-Figs. 16.22A and B). Adenosis cannot be identified cy- an abscess (e-Figs. 16.19A and B). The cytologic features
tologically and remains a histologic finding. of these various infl ammatory conditions are listed in
The confl uence of multiple foci of adenosis may re- Table 16.13.
sult in palpable nodularity and is referred to as an adeno-
sis tumor.
PROLIFERATIVE BREAST DISEASE
Radial Scar Proliferative breast disease includes a spectrum of non-
A radial scar is a localized, nonencapsulated stellate lesion invasive epithelial proliferations ranging from typical
consisting of a central fi brotic core with radiating bands hyperplasia—graded as mild, moderate, and florid—and
of fi brous connective tissue accompanied by papillary or atypical hyperplasia (Figs. 16.37 to 16.39).
diffuse hyperplasia. A radial scar, like adenosis, is a micro- Mild duct epithelial hyperplasia cytologically demon-
scopic finding and not a palpable lesion. strates varying-sized tissue fragments of duct epithelium
Due to its stellate pattern and entrapped areas of hy- with a honeycomb arrangement (Figs. 16.37A and B). The
perplastic epithelium and distorted tubules, radial scars component cells show well-defi ned cell borders, uniform
may be mistaken for carcinomas, both radiologically and round nuclei with fi nely granular chromatin, and indis-
histologically. tinct or absent micronucleoli. Myoepithelial cells may be
Radial scars may be biopsied under stereotactic ra- identified. Apocrine metaplasia may be present.
diologic guidance. The smears show variable cellularity Moderate to florid duct epithelial hyperplasia in cyto-
(e-Figs. 16.23A to F) containing small uniform duct ep- logic specimens is represented by syncytial tissue fragments
ithelial cells arranged in small tissue fragments with or with crowded and overlapped, uniform, slightly enlarged
without a tubular pattern and angulation. Single cells are nuclei with coarsely granular chromatin and indistinct or
frequent; large branching tissue fragments are unusual. absent nucleoli (Figs. 16.38 and 16.39). Myoepithelial
cells and apocrine metaplasia can also be present.
Inflammatory Lesions of the Breast
Diagnostic Difficulties in Differentiating
Infl ammatory conditions of the breast that may be sub-
Proliferative Breast Lesions and Low-Grade
jected to an FNA biopsy procedure include fat necro-
In Situ/Invasive Duct Carcinoma
sis, acute mastitis with abscess, and chronic subareolar
abscess, silicone mastitis since all of these mimic malig- The histologic criteria for differentiating proliferative
nancy clinically. Chronic granulomatous inflammation, breast lesion with atypical hyperplasia and ductal/lobular
such as tuberculosis or parasitic infections, is not gen- carcinoma in situ are based on architectural patterns and
erally encountered in the United States. Acute mastitis criteria that are quantitative (i.e., the number of involved
and breast abscess usually occur in the early postpar- lobules or ducts and the extent of involvement—partial
tum period, often caused by the Staphylococcus aureus or complete). These criteria cannot be applied to cyto-
or Streptococcus species. The duct epithelial cells, when logic specimens.
present, are few in number but are generally obscured by The aspirates from lesions histologically diagnosed
neutrophilic debris. These epithelial cells may show reac- as ductal hyperplasia, either typical or atypical, and low-
tive changes with prominent nucleoli causing a potential grade carcinoma in situ are variously interpreted cytolog-
diagnostic pitfall (e-Figs. 16.16 and 16.17). Extreme cau- ically as benign duct epithelium, atypical duct epithelium,
tion needs to be exercised while evaluating such aspirates, or suspicious for carcinoma. There exists a considerable
particularly when the biopsy is performed to rule out a overlap between the cytologic features of duct hyperpla-
malignancy. sia without atypia and those with atypia as well as low-
Subareolar abscess is a specifi c clinicopathologic en- grade duct carcinoma in situ. These form a spectrum of
tity, caused by low-grade infection occurring in the sub- cytologic changes that merge imperceptibly. The subject
areolar region. It begins as an area of localized inflamma- of proliferative breast disease with and without atypia
tion beneath the nipple, progressing to form an abscess and the overlap with in situ/invasive low-grade carcino-
with subsequent sinus formation, drainage, and nipple mas have been the subject of great interest with multiple
secretions (see e-Figs. 16.28 and 16.29). Histologically, reviews and extensive reporting.
squamous metaplasia of the lactiferous ducts is frequently Features favoring typical hyperplasia are large tissue
present. The skin excoriations may resemble Paget’s dis- fragments, small nuclear size, a lack of single cells, an ab-
ease and retraction of the nipple simulates malignancy. sence of pleomorphism, uniform nuclei without conspic-
Fat necrosis can be mistaken for malignancy clinically uous nucleoli, the presence of myoepithelial cells within
and on mammography. It occurs as a result of trauma or the tissue fragments, and a clean background. However,
foreign-body reaction due to prior surgical intervention these features are also shared by atypical hyperplasia,
or radiation therapy (e-Fig. 16.18). Cystic neoplasms such ductal carcinoma in situ, fibroadenoma, and tubular
as intraductal papilloma may get infected and present like carcinoma.
TABLE 16.13 DIFFERENTIAL DIAGNOSES OF INFLAMMATORY LESIONS OF THE BREAST
Acute Mastitis Chronic Subareolar

Breast Abscess Abscess Comedocarcinoma Fat Necrosis
Cellularity Variable Variable Variable, generally high Low
Presentation Epithelial cells isolated or Epithelial cells isolated or Epithelial cells isolated, in Varying numbers of
in tissue fragments in tissue fragments loosely cohesive groups neutrophils; high in acute
or in syncytial tissue phase; no epithelial cells
fragments
Duct Epithelial Mild nuclear Mild nuclear Pleomorphic in size; Not present
Cells enlargement, smooth enlargement, smooth medium-sized to large,
nuclear outline, finely nuclear outline, finely round to polygonal; high
granular chromatin; granular chromatin; N/C ratio; obviously
prominent nucleoli; prominent nucleoli; malignant
neutrophils permeating squamous cells with or
the tissue fragments without keratinization
Background Neutrophilic Neutrophilic exudate Cellular and calcific Necrotic adipocytes

exudate with debris; with debris, keratin, debris; neutrophilic in acute phase; lipid
proteinaceous fluid, foreign-body-type exudate ⫹/⫺ laden histiocytes mixed
histiocytes; granulation giant cells; granulation inflammatory infiltrate;
tissue tissue; cholesterol clefts; foreign-body-type
anucleated squames multinucleated giant
cells granulation tissue
with fibroblasts with or
without atypical nuclei
and mitoses
A B
Figs. 16.37A and B. FNA—proliferative breast disease. Mild ductal hyperplasia confirmed on biopsy. A: Very cellular
aspirate consisting of varying-sized tissue fragments of duct epithelium in a clean background. B: Higher magnifica-
tion of these tissue fragments presents honeycomb architecture with uniform nuclei.
A B
Figs. 16.38A and B. FNA—proliferative breast disease with florid duct hyperplasia confirmed on biopsy. The cel-
lular aspirate demonstrates several syncytial tissue fragments of duct epithelium with acinar pattern. The nuclei are
crowded, overlapped and are mildly enlarged. The cell borders are poorly defined; cytoplasm is scant with high N/C
ratios. The nuclear chromatin is granular. No nucleoli are seen. The background is clean. The cytologic pattern cannot
be differentiated from an aspirate of well-differentiated duct carcinoma, NOS, either in situ or invasive.
Fig. 16.39. FNA—proliferative breast disease with marked duct

hyperplasia confirmed on biopsy. The cellular aspirate consists of
branching syncytial tissue fragments of mildly enlarged duct epithe-
lial cells and is suggestive of low-grade adenocarcinoma, NOS. Note
that the background is clean; there are no single cells, and nucleoli
are not apparent.
Small tissue fragments and large nuclei with mild nu- nosis of malignancy with small cell patterns because of
clear pleomorphism and nucleoli favor low-grade in situ/ the potential for errors, particularly with a false-positive
invasive duct carcinoma, tubular carcinoma, and lobular diagnosis.
carcinoma. Similar features may also be seen in typical
ductal hyperplasias and fibroadenomas (Table 16.14).
This overlap precludes the differentiation between
PREGNANCY AND
various grades of hyperplasia and low-grade in situ/inva-
LACTATIONAL CHANGES
sive carcinoma. Along the same lines, in situ carcinoma
cannot be differentiated from invasive carcinomas from
cytologic specimens. This constitutes the most difficult Under hormonal influence, significant morphologic
and problematic area in the aspiration cytopathology alterations take place in the mammary glands that are
of breast lesions. One feature that dominates the cyto- characterized by an increase in the secretory units and
logic pattern of ductal hyperplasias, well-differentiated an accumulation of secretory materials in the cells (e-Fig.
ductal carcinomas—both in situ and invasive—cellular 16.24). Lactating and tubular adenomas are thought to
fibroadenoma, tubular carcinoma, and lobular carcinoma arise de novo during pregnancy. However, these changes
is the small cell size with bland nuclear chromatin. See are also seen in pre-existing lesions such as fibroadenoma,
Table 16.15 and Figures 16.40 to 16.44 for similarities which may increase in size during pregnancy.
and differences between these entities composed of small Pregnancy and lactational cytologic changes (Fig.
cells. It is our practice not to render an unequivocal diag- 16.45A) must be differentiated from adenocarcinoma
TABLE 16.14 CYTOPATHOLOGIC FEATURES BETWEEN FIBROADENOMA AND FIBROCYSTIC

CHANGE WITH DUCT EPITHELIAL HYPERPLASIA
Fibrocystic Change and Duct Hyperplasia

Fibroadenoma (Proliferative Breast Disease)
Clinical Presentation Firm to rubbery, freely movable mass; may be of Diffusely nodular with dominant nodules, ill-
large size defined, limited mobility, bilaterality frequent
Mammographic Circumscribed mass Usually no specific mammographic abnormality;

Presentation a dominant cyst or an aggregate of cysts; present
as circumscribed mass; sometimes presents a
calcifications, calcium oxalate type
Cellularity Variable Variable, aspirate may yield fluid
Presentation Admixture of epithelial and stromal component in Admixture of epithelial and stromal component in
varying proportions varying proportions
Epithelial Cells Mostly in tissue fragments of varying sizes, Cells in small to large tissue fragments,
from honeycomb sheets to complex branching honeycomb sheets to syncytial arrangement;
with papillary configuration with bulbous ends; papillary configuration with complex branching
syncytial arrangement ⫹/⫺; nuclei minimally not seen; nuclei minimally enlarged, crowded with
enlarged; crowded with finely granular chromatin finely granular chromatin with micronucleoli;
and micronucleoli; myoepithelial cells present myoepithelial cells present within tissue fragments
within tissue fragments
Apocrine Cells Infrequent Frequent honeycomb sheets and with or without

papillary configuration
Stromal Tissue Loose fibrovascular stroma frequent Loose fibrovascular stroma frequent
Fragments
Naked Bipolar Nuclei Present Present
Background Foamy macrophages rare; calcific debris unusual Foamy macrophages frequent; calcific debris
frequent
(Fig. 16.45B) occurring during pregnancy and lactation COLLAGENOUS SPHERULOSIS

(Table 16.16). Although uncommon, breast cancer occurs
Collagenous spherulosis is a benign breast lesion, often
as the most common malignancy during pregnancy, next
seen as an incidental finding in association with intraduc-
to cervical cancer, with an estimated incidence of three
tal papilloma, sclerosing adenosis, or radial scar. The cyto-
per 10,000 pregnancies. Breast cancer in pregnancy is as-
histologic pattern is characterized by acellular eosinophilic
sociated with a poorer prognosis.
fibrillar spherules surrounded by proliferating, bland duc-
tal epithelial and myoepithelial cells (e-Figs. 16.26A to C).
The globules stain positive with PAS diastase resistant.
MISCELLANEOUS LESIONS The differential diagnoses include adenoid cystic carci-
noma and intraductal carcinoma (cribriform type).
GRANULAR CELL TUMOR
BREAST ASPIRATES WITH MUCOID
Granular cell tumor is a rare neoplasm of the breast occur-
BACKGROUND
ring in women who are 21 to 75 years of age. It is occa-
sionally seen in men. ER or PR expression has not been Some breast lesions may yield aspirates with mucoid mate-
reported in granular cell tumors. Cytohistologic presenta- rial, with the most common being mucinous or colloid car-
tion is the same as that described in soft tissue tumors cinoma. Other lesions include mucocele-like tumors and
(e-Figs. 16.25A and B; see Chapter 24). fibroadenomas with myxoid degeneration (Table 16.17).
TABLE 16.15 DIFFERENTIAL DIAGNOSES OF BREAST LESIONS WITH SMALL CELL PATTERN IN FINE NEEDLE
ASPIRATIONS: CYTOPATHOLOGIC FEATURES
Cellular Fibroadenoma
Well-Differentiated (with Predominant or Proliferative
Ductal Carcinoma Exclusive Epithelial Breast Disease
(In Situ & Invasive) Tubular Carcinoma Lobular Carcinoma Component) Ductal Hyperplasia
Cellularity Variable, often high Variable, often low Often low, rarely high Variable, often high Variable
Presentation Loosely cohesive groups Mostly syncytial tissue Cells mostly isolated, small Varying-sized tissue Varying-sized tissue
and small syncytial tissue fragments with small to groups of two or more cells fragments with or without fragments; small to
fragments with and without large elongated tubular or in short chains; rarely in branching; monolayered large with branching;
acinar or cribriform structures with sharp syncytial tissue fragments to syncytial with crowding monolayered with
pattern; single cells ⫹/⫺ angulation; few loosely with no architectural and overlapping of honeycomb pattern
cohesive groups; single cells patterns nuclei; myoepithelial cells to syncytial type with
infrequent noticeable within the tissue crowding and overlapping
fragments; loose aggregates of nuclei; myoepithelial cells
and single epithelial cells may be present within tissue
infrequent fragments; loose aggregates;
single cells infrequent
Epithelial Cells Small, uniform, round to Small, monomorphic; high Small, minimally Small cuboidal to round; Small cuboidal to round;
cuboidal; well-defined cell N/C ratios pleomorphic; high N/C minimal pleomorphism; minimal pleomorphism;
borders; high N/C ratios ratios high N/C ratios high N/C ratios
Nucleus Round to oval, smooth to Round to oval, uniform Round to oval, smooth to Round to oval, minimally Round to oval, minimally
slightly irregular nuclear smooth nuclear membrane; slightly irregular nuclear pleomorphic, smooth pleomorphic, smooth
membrane; finely granular evenly dispersed, fine to membrane; fine to coarsely nuclear membrane; finely nuclear membrane; finely
evenly dispersed chromatin; coarsely granular chromatin; granular chromatin; granular, evenly dispersed granular chromatin;
parachromatin clearing micronucleoli ⫹/⫺ prominent macronucleolus; chromatin; micronucleoli micronucleoli ⫹/⫺
⫹/⫺; micronucleoli ⫹/⫺ nuclear molding frequent
Cytoplasm Scant Scant Scant, secretory vacuole Scant Scant

indenting the nucleus ⫹/⫺
Background
Bipolar Cells ⫺ ⫹/⫺ Not present ⫹/⫺ ⫹/⫺
Stromal Tissue ⫺ ⫹/⫺ ⫹/⫺ ⫹/⫺ ⫹/⫺

Fragments
Apocrine Cells ⫺ ⫹/⫺ ⫹/⫺ ⫹/⫺ ⫹/⫺
Calcific Debris ⫺ ⫹/⫺ Not present Not present ⫹/⫺

Differential Diagnoses of Well-Differentiated (Low-Grade) Adenocarcinoma, NOS with a Small Cell Pattern
(See Figs. 16.40 to 16.44)
All the entities depicted here in Figures 16.40 to 16.44—low-grade invasive adenocarcinoma, NOS, tubular carcinoma, lobular
carcinoma, duct hyperplasia in fi broadenoma and proliferative breast disease with marked hyperplasia—exhibit common cytologic
parameters including cellular aspirates; syncytial architecture; poorly defined cell borders; scant cytoplasm; crowded and overlapped,
mildly enlarged nuclei with granular chromatin and with or without micronucleoli; a clean background; and a lack of single cells in
the background (Table 16.15). The cytologic differentiation of these lesions from each other is not possible.
A B
Figs. 16.40A and B. Well-differentiated duct carcinoma, NOS in situ/invasive. The syncytial tissue fragments of duct epi-
thelium are syncytial with a cribriform pattern. The component nuclei are minimally enlarged with coarsely granular chro-
matin, and scant cytoplasm. Some nuclei contain nucleoli. Note that there are no discrete cells. The background is clean.
A B
Figs. 16.41A and B. Tubular carcinoma. The syncytial tissue fragment of the duct epithelium demonstrates an acinar
and tubular pattern. The component cells contain uniform, small round nuclei with uniformly distributed coarsely
granular chromatin with occasional nucleoli. There are no single cells. The background is clean.
Fig. 16.42. Lobular carcinoma. This syncytial tissue fragment of

uniform, small cells with poorly defined cell borders and indiscern-
ible cytoplasm shows no architectural pattern. The nuclear chroma-
tin is granular and deep-staining.
722
A B
Figs. 16.43A and B. Fibroadenoma with duct hyperplasia. The tissue fragments of duct epithelium are syncytial with
acinar pattern. The nuclei are uniform with finely granular chromatin and contain micronucleoli. There are no single
cells. No stromal tissue or bipolar cells were present. The excisional biopsy showed a fibroadenoma.
A B
Figs. 16.44A and B. Proliferative breast disease with marked ductal hyperplasia. The syncytial tissue fragments in
this aspirate show a cribriform pattern. The nuclei are minimally enlarged, slightly pleomorphic and contain granular
chromatin. A suspicious diagnosis was not confirmed on biopsy which revealed marked duct epithelial hyperplasia.
A B
Figs. 16.45A and B. A: FNA breast mass in a lactating woman. The aspirate is cellular, consisting of medium-sized
epithelial cells present mostly in loose aggregates. Their cell borders are poorly defined. The enlarged nuclei contain
granular chromatin and prominent nucleoli. A suspicious diagnosis was not confirmed on biopsy which revealed a
fibroadenoma with lactating changes. B: FNA of a duct carcinoma, NOS in a lactating woman for comparison. The
malignant cells are in syncytial tissue fragments with crowding and overlapping. Note the cytologic overlap and the
difficulties in distinguishing them.
TABLE 16.16 DIFFERENTIATING FEATURES BETWEEN ADENOCARCINOMA

AND PREGNANCY LACTATION CHANGES
Pregnancy/Lactation Changes (Lactating Adenoma, Tubular,

Adenocarcinoma Adenoma or Fibroadenoma with Lactating Change)
Cellularity Variable, generally high cellularity Highly cellular
Presentation Cells isolated, in loosely cohesive groups Cells isolated, in tissue fragments or as entire breast lobules
and in syncytial tissue fragments with/ with normal architecture and myoepithelial cells at the
without acinar pattern periphery
Cells Size variable, uniform to pleomorphic; Small to slight enlargement, uniform, high N/C ratios; poorly
high N/C ratios; cell borders well to defined cell borders
poorly defined
Nucleus Pleomorphic in size, large round with Round, smooth nuclear membrane; finely granular chromatin;
smooth to irregular nuclear membrane; prominent central macronucleolus or small pyknotic nuclei
finely to coarsely granular chromatin;
parachromatin clearing; micro/
macronucleoli; mitoses ⫹/⫺
Cytoplasm Variable, generally scant Bubbly vacuolated to granular, frayed cytoplasmic borders
Background Clean to necrotic Proteinaceous fluid; myoepithelial cells or naked bipolar nuclei
TABLE 16.17 DIFFERENTIAL DIAGNOSES OF BREAST ASPIRATES WITH

MUCOID/MYXOID BACKGROUND
Fibroadenoma with Aspirate yields, fluid; cellularity low; few tissue fragments with honeycomb pattern; single epithelial
Mucoid Degeneration cells not present; nuclear atypia minimal; naked bipolar may be present; nuclei ⫹/⫺; stroma thick
and fibrillar
Mucocele-Like Tumor Aspirate yields fluid (multiloculated cyst); low cellularity, rare groups of bland duct epithelial cells;
naked bipolar nuclei absent; stroma abundant mucoid and stringy
Colloid or Mucinous Solid lesion; variable cellularity; malignant cells, isolated, in loosely cohesive groups or in syncytial
Carcinoma tissue fragments; malignant criteria ⫹; naked bipolar nuclei absent; mucoid stringy stroma with a
washed out appearance, often traversed by capillaries
TABLE 16.18 CYTOPATHOLOGIC FEATURES OF PAGET’S DISEASE OF THE BREAST

IN SCRAPINGS OF NIPPLE AND AREOLA
Presentation Cells isolated, in loosely cohesive groups or in syncytial tissue fragments, often obscured by cellular
and inflammatory debris
Cells Round, medium to large; cell borders well to poorly defined
Nucleus Variable in size, round to oval; high N/C ratio; nuclear membrane smooth to irregular; finely granular
chromatin; prominent nucleoli; molding of one nucleus by another with crescent-shaped appearance
Cytoplasm Variable, pale to dense, vacuolated (mucin stain ⫹)
Background Proteinaceous fluid, inflammatory and cellular debris

Fig. 16.46. Scrapings of areola with an oozing, eczematous lesion

in a 52-year-old woman. The smear demonstrates discrete, large
pleomorphic malignant cells. The background shows necrosis. The
biopsy confirmed Paget’s disease of the breast and underlying duct
adenocarcinoma.
Extensive myxoid degeneration in fibroadenoma may lead the involved nipple and areola does provide useful infor-
to a false-positive diagnosis of mucinous carcinoma. Con- mation. The malignant cells are easily detectable but are
versely, abundant mucoid material with sparse cellularity generally sparse (Table 16.18; Fig. 16.46). The differen-
may cause a false-negative diagnosis. tial diagnosis involves infl ammatory conditions such as
subareolar abscess with fistula and, rarely, herpetic ulcers,
as well as malignancies such as malignant melanoma.
MUCOCELE-LIKE TUMOR
The latter react positively to Melan-A, S100 protein, and
These are extremely uncommon lesions that grossly mimic HMB-45.
mucinous or colloid carcinoma. The lesions are multicystic.
The aspirates contain abundant mucinous material with
NIPPLE DISCHARGE
very few small groups of epithelial cells with bland nuclei.
Nipple discharge in a nonpregnant or a nonlactating
woman is an abnormal fi nding that has a multitude
METASTATIC TUMORS
of causes, with the most common being duct ectasia.
The involvement of the breast by metastatic neoplasms is The incidence of both benign and malignant neoplasia
an unusual occurrence, accounting for roughly 1 to 5% of increases with unilateral bloody discharge and the pres-
breast malignancies. A primary tumor is seen in the major- ence of a mass, particularly in older patients. The over-
ity of patients with metastatic disease. However, on rare all incidence of an abnormal nipple discharge is 3% in
occasions, it may be the initial presentation. Metastatic patients with malignancy. Cytological examination of the
tumors tend to grow rapidly and are usually not calcified. smears prepared from nipple discharge can provide valu-
The most common extramammary malignancies to able information that often aids in patient management.
metastasize to the breasts are ovarian and lung cancers, The smears are generally paucicellular, and the cellular
malignant melanomas, malignant lymphomas, and sarco- material tends to air dry, resulting in poor cellular detail.
mas. Prostate carcinoma is the common metastatic breast The common diagnostic problems entail differentiating
tumor in men. nonneoplastic lesions from neoplastic ones and papillary
lesions from duct adenocarcinomas.
The cytopathologic features of nipple discharges in
SCRAPINGS OF THE NIPPLE AND AREOLA
various pathologic entities are listed in Table 16.19 and
Cytologic evaluation of scrapings of the nipple and areola illustrated in e-Figures 16.27 to 16.30 and in Figures
in the diagnosis of Paget’s disease of the breast is seldom 16.47 to 16.53.
undertaken. The diagnosis is generally made by a biopsy
or following surgery (lumpectomy or mastectomy). Pag-
GYNECOMASTIA
et’s disease of the nipple appears as an eczematous, weep-
ing, crusting, or ulcerated lesion or presents as a retrac- Gynecomastia or enlargement of the male breast may be
tion of the nipple. The changes in the skin result from unilateral or bilateral and frequently occurs at puberty
an intraepithelial spread of malignant cells (Paget’s cells) and in older individuals. It usually presents as a palpable
from an underlying intraductal carcinoma with or with- subareolar mass, distinct from the adjacent adipose tissue,
out an associated invasive component. or as a diffuse enlargement. Histologically, gynecomas-
Although the ulceration of the skin causes a dirty, in- tia is characterized by stromal and ductal proliferation.
flammatory background with a proteinaceous fluid often Cytologically, the aspirates of gynecomastia demonstrate
obscuring the malignant cells, cytologic examination of features that closely resemble that of a fibroadenoma
TABLE 16.19 DIFFERENTIAL DIAGNOSES OF ABNORMAL NIPPLE DISCHARGE
Inflammatory Cystic Change Papillary Lesion

Mastitis/Subareolar Abscess Duct Ectasia & Stasis (Papilloma/Papillary Carcinoma) Duct Adenocarcinoma
Side Unilateral/bilateral Unilateral/bilateral Unilateral Unilateral
Gross Characteristics Sticky or purulent Clear, turbid to greenish Clear, serous, serosanguineous to Serous, serosanguineous,
of the Discharge sanguineous sanguineous, milky or purulent
Cellularity Acellular to paucicellular Variable Variable Variable
Composition of Cells
Foam Cells (Altered ⫹ Present in large numbers ⫹/⫺ ⫹/⫺

Duct Cells)
Porcine Cells Not present ⫹/⫺ ⫹/⫺ Generally not present
Characteristics of Cells if present; are few with Benign duct epithelial cells, small Small to large syncytial tissue Malignant cells-isolated; in loosely
Duct Epithelial Cells or without reactive nuclear with scant cytoplasm, high N/C fragments of duct epithelial cohesive groups or in syncytial
atypia; normal appearing in tight ratio; small groups of tightly cells, with or without complex tissue fragments with smooth
grouping packed cells; nuclear diameter branching; smooth external external contours; nuclei enlarged,
6–7 ␮m; compact chromatin contour; epithelial cells variable in pleomorphic, irregular nuclear
size; small to moderate increase; membranes, coarse chromatin;
cytoplasm variable, scant to parachromatin clearing; micro/
modest; pale to vacuolated, nuclei macronucleoli; cytoplasm variable,
mildly increased in size, granular generally scant; single cells with
chromatin; micronucleoli ⫹/⫺ cytoplasmic vacuoles
Psammoma Bodies Absent Absent ⫹/⫺ ⫹/⫺
Background
Inflammatory ⫹/⫺; neutrophilic keratin and Inflammation absent Inflammation absent Inflammation absent
multinucleated foreign body-type
giant cells in subareolar abscess
Cellular Debris ⫹ ⫹/⫺ Not present ⫹
Anucleated Cells ⫹ ⫹ Not present Not present
Calcific Debris Not present Not present ⫹/⫺ ⫹/⫺
Proteinaceous Fluid Not present ⫹/⫺ ⫹/⫺ ⫹/⫺
Blood (Fresh/Old) Not present Not present ⫹/⫺ ⫹/⫺

Nipple Secretions (See Figs. 16.47 to 16.53)
Fig. 16.47. Smear of an abnormal nipple discharge showing syncy- Fig. 16.48. Smear of an abnormal nipple discharge, consisting of
tial tissue fragments of duct epithelium with branching and anasto- a syncytial tissue fragment of duct epithelium with mildly enlarged
mosis. Their nuclei are mildly enlarged and uniform. The cytologic and pleomorphic nuclei. Note the cytoplasmic vacuoles. Surgical bi-
interpretation was papillary neoplasm, probably benign. Surgical opsy confirmed a cystic intraductal papilloma.
biopsy confirmed an intraductal papilloma.
Fig. 16.49. Smear of an abnormal nipple discharge. These syncytial Fig. 16.50. Smear of an abnormal nipple discharge. These syncytial
branching tissue fragments are slender, consisting of mildly enlarged branching tissue fragments are slender, consisting of moderately en-
duct epithelial cells containing uniform nuclei. The background is larged nuclei with coarsely granular chromatin. The background is
clean. Surgical biopsy confirmed an intraductal papilloma. clean. Surgical biopsy confirmed an intraductal papilloma.
A B
Figs. 16.51A and B. A: Smear of an abnormal, unilateral, bloody nipple discharge in an older woman showing
syncytial tissue fragments of malignant cells with psammoma bodies. Note the necrotic debris in the background.
Duct adenocarcinoma was diagnosed on biopsy. B: Smear of an abnormal bloody nipple discharge showing clearly
malignant cells in a syncytial tissue fragment, confirmed on biopsy.
727
Fig. 16.52. Smear of an abnormal nipple discharge exhibiting poorly

preserved malignant cells. Note the necrosis in the background.
A B
Figs. 16.53A to C. Comparison of cytologic features of (A) benign

duct epithelium, (B) intraductal papilloma, and (C) invasive duct
carcinoma in nipple secretions. Note that the small cell and small
nuclear size favor benign cells, often seen with fibrocystic change.
There is gradual nuclear enlargement from benign to papilloma to
C adenocarcinoma. The background is necrotic in carcinomas.
(Table 16.20; e-Figs. 16.32 and 16.34). Florid epithelial adenocarcinoma, NOS, in females (Figs. 16.54 and
proliferation with nuclear atypia may mimic neoplasia. 16.55). Some may be associated with nipple discharge.
Metastatic tumors occur with equal frequency as pri-
mary cancers. They may present as unilateral enlarge-
CARCINOMA OF THE MALE BREAST
ment, which is clinically indistinguishable from primary
The primary carcinoma arising in the male breast neoplasms. Chest wall masses may masquerade as breast
shows the same cytohistopathologic spectrum as lesions.
Fig. 16.54. FNA of breast mass in an elderly male. The cellular as- Fig. 16.55. FNA of a breast mass in a male, showing malignant cells
pirate shows malignant cells, discrete, loosely cohesive and in syncy- consistent with adenocarcinoma, NOS.
tial tissue fragments, consistent with adenocarcinoma, NOS.
TABLE 16.20 CYTOPATHOLOGIC FEATURES OF GYNECOMASTIA
Presentation Biphasic pattern with an admixture of epithelial and stromal components; mimics the cytologic pattern of
fibroadenoma
Epithelial Cells Mostly in loosely cohesive groups or in small tissue fragments either monolayered with honeycomb pattern
or syncytial with crowding and overlapping of nuclei; nuclei, uniform to mildly pleomorphic, round to oval;
smooth nuclear membrane; finely granular chromatin with or without micronucleoli; high N/C ratios
Stromal Tissue Varying-sized tissue fragments of loose fibrous stroma

Fragments
Background Tall columnar cells with bipolar processes isolated or at the periphery of epithelial tissue fragments;
nuclei finely granular evenly dispersed chromatin; naked bipolar nuclei ⫹/⫺; apocrine metaplasia ⫹/⫺;
histiocytes ⫹/⫺
TABLE 16.21 GUIDELINES FOR AN UNEQUIVOCAL DIAGNOSES OF BREAST CANCERa
● The aspirate must be cellular with malignant cells present on more than one slide.
● Single malignant cells must be present in addition to tissue fragments and loosely cohesive groups.
● Malignant diagnosis should not be made in the presence of marked acute inflammatory reaction with neutrophilic debris
obscuring details.
● Malignant diagnosis must not be made when the aspirate consists of small epithelial cells.
● The diagnosis of malignancy must be made with extreme caution when clinical and mammographic data do not support the
cytologic diagnosis.
a
These guidelines are followed in the author’s laboratory.
TABLE 16.22 REPORTING SYSTEM FOR BREAST ASPIRATESa
Unsatisfactory (due to) Scant cellularity

Air-drying, poor fixation
Thick bloody smears
Inflammation obscuring the cellular material
Benign No evidence of malignancy

May represent features of fibroadenoma
Atypical/Indeterminate Cellular material not diagnostic.

May represent changes of proliferative breast disease with or
without atypia
May represent atypia in the background of cystic change
May represent features of a duct papilloma
Suspicious for Malignancy Cellular findings suspicious for malignancy; specimen poorly
cellular or insufficient criteria for unequivocal diagnosis of
carcinoma
Malignant Cellular features diagnostic of malignancy

a
National Cancer Institute Fine Needle Aspiration of Breast Workshop Subcommittee. The uniform approach to breast
fine needle aspiration biopsy. Diagn Cytopathol 1997;16:295–311.
SUGGESTED READINGS
Ali SZ, Parwani AV. Breast Cytopathology. New York: Springer, Levine PH, Weisman J, Yang GC. Aspiration cytology of cystic car-
2007. cinoma of the breast. Diagn Cytopathol 2003;28:39–44.
Dooley WC. Ductal lavage, nipple aspiration, and ductoscopy for National Cancer Institute Fine Needle Aspiration of Breast Work-
breast cancer diagnosis. Curr Oncol Rep 2003;1:63–65. shop Subcommittee. The uniform approach to breast fine nee-
Dupont WD, Page DL. Risk factors for breast cancer in dle aspiration biopsy. Diagn Cytopathol 1997;16:295–311.
women with proliferative breast disease. N Engl J Med O’Malley FP, Pinder SE. Breast pathology. In: Goldblum JR, ed.
1985;312:146–151. Foundations in Diagnostic Pathology. Philadelphia: Churchill
Gangane N, Joshi D, Anshu, et al. Cytological diagnosis of col- Livingstone, 2006.
lagenous spherulosis breast associated with fibroadenoma: Siddiqui MT, Zakowski MF, Ashfaq R, Ali SZ. Breast masses in
report of a case with review of literature. Diagn Cytopathol males: Multi-institutional experience on fine needle aspiration.
2007;35:366–369. Diagn Cytopathol 2002;26:87–91.
Gangiarella J, Waisman J, Simsir A. Cytologic findings with Silverman J, Masood S, Ducatman BS, et al. Can FNA biopsy sepa-
histologic correlation in 43 cases of mammary intraductal rate atypical hyperplasia, carcinoma in situ, and invasive carci-
adenocarcinoma diagnosed by aspiration biopsy. Acta Cytol noma of the breast? Cytomorphologic criteria and limitations
2003;47:965–972. in diagnosis. Diagn Cytopathol 1993;9:713–728.
Jayaram G, Elsayed EM, Yacob RB. Papillary breast lesions diag- Simsir A, Weisman J, Cangiarella J. Fibroadenomas with atypia:
nosed on cytology. Profile of 65 cases. Acta Cytol 2007;51:3–8. Causes of under- and over-diagnosis by aspiration biopsy.
Johnson TL, Kini SR. Cytologic and clinicopathologic features Diagn Cytopathol 2001;25:278–284.
of abnormal nipple secretions in 255 cases. Diagn Cytopathol Tavassoli FA, Devlee P. Pathology and Genetics. Tumors of the
1991;7:17–22. Breast and Female Genital Tract. WHO Health Organization
Johnson TL, Kini SR. Metaplastic breast carcinoma: A cyto- Classification of Tumors. Lyon, France: IARC Press, 2003.
histologic and clinical study of 10 cases. Diagn Cytopathol Unal E, Firat A, Gunes P, et al. Apocrine carcinoma of the breast:
1996;14(3):226–232. Clinical, radiologic, and pathologic correlation. Breast J
Johnson TL, Kini SR. The significance of atypical apocrine 2007;13:617–618.
cells in fine needle aspirates of the breast. Diagn Cytopathol Xie HB, Salhadar A, Haara A, et al. How stereotactic core-needle
1989;5:248–254. biopsy affected breast fine needle aspiration utilization: An
Krishnamurthy S, Sneige N, Thompson PA, et al. Nipple aspirate 11 year institutional review. Diagn Cytopathol
fluid cytology in breast carcinoma. Cancer 2003;99:97–104. 2004;31:106–110.
17 MEDIASTINUM
Anatomically, the mediastinum is defined as a space between onstrating invasive characteristics, which can be dem-
the two pleural cavities with its boundaries formed superi- onstrated only upon thorough histologic examination.
orly by the thoracic inlet, inferiorly by the diaphragm, ante- ● Differentiation of the thymoma with a dual cell popu-
riorly by the sternum, and posteriorly by the spinal column. lation consisting of lymphocytes and epithelial cells
The mediastinum is subdivided arbitrarily into superior from germ cell tumors (germinoma) and Hodgkin
and inferior compartments by an imaginary line extend- lymphoma.
ing from the manubrium sterni to the fourth thoracic ver- ● Differentiation of lymphocyte predominant thymoma
tebrae. The inferior mediastinum is again subdivided into from lesions with a lymphocytic predominant pat-
anterior, middle, and posterior compartments. Besides the tern, such as reactive lymphoid processes, malignant
major anatomic structures such as the pericardial cavity lymphoma, and lymphocyte predominant Hodgkin
containing the heart, major blood vessels, trachea, and lymphoma.
major bronchi and esophagus, the mediastinum contains ● Differentiation of spindle cell thymoma from other
the thymus, lymph nodes, soft tissues, and nerve trunks. All spindle cell tumors such as spindle cell carcinoid,
the aforementioned structures may be involved by diverse malignant melanoma, or sarcomatoid carcinoma, and
pathologic processes. FNA biopsy performed to identify a mesenchymal tumors.
neoplastic process is done under radiologic guidance via a ● Differentiation of primary thymic carcinoma from
transthoracic route or transbronchially via flexible bron- metastatic carcinomas.
choscopy. Fine needle biopsies of thymic or mediastinal ● Differentiation of thymic carcinoid from other neuroen-
masses is not a very popular diagnostic technique and is not docrine carcinomas, malignant lymphoma, and poorly
widely practiced. The cytologic documentation is sparse. differentiated carcinomas.
Primary neoplasms involving the mediastinum arise ● Differentiation of malignant lymphomas from other
from divergent sources and can be grouped into five small round cell tumors such as neuroblastoma in the
broad categories: 1) thymus derived tumors; 2) malignant pediatric age group.
lymphomas that are thymus derived or involving the me- ● Ensuring adequacy of samplings with extensive sclero-
diastinal lymph nodes, either primarily or secondarily; sis in large B-cell lymphomas and nodular sclerosing
3) germ cell tumors; 4) neurogenic tumors; and 5) miscel- Hodgkin lymphoma, which results in diagnostic dif-
laneous (Table 17.1). These tumors have a predilection for ficulties and produces false-negative interpretations.
certain sites in the mediastinum. Hence, knowledge of the
anatomic location is very often helpful in the diagnostic
process. The mediastinum is also frequently involved by NORMAL THYMUS
metastatic malignancy. Although heterogenous in origin,
many primary mediastinal neoplasms share morphologic
The thymus, situated in the anterior mediastinum, is a
similarities and are also similar to secondary malignan-
bilobed organ. Each lobe is divided into several lobules
cies. Accurate diagnosis in many instances requires per-
by fibrous tissue septae. The lobules consist of cortex—
tinent clinical data, radiographic findings, immunohis-
mainly composed of lymphocytes with scattered epithelial
tochemical stains, and ultrastructural studies.
cells—and medulla consisting of small groups of epithelial
cells, sparse lymphocytes, and more histiocytes. The epi-
thelial cells in the medulla have a spindle shape. Squamous
DIAGNOSTIC CHALLENGES
differentiation and pearl formation within these groups is
referred to as Hassall’s corpuscles. The single epithelial
● Benign thymomas cannot be differentiated from malig- cells present within the cortex are different from the med-
nant thymomas from cytologic specimens since both can ullary epithelial cells. The former possess long cytoplasmic
have identical cytohistologic features. The diagnostic processes surrounding the lymphocytes. They resemble
criteria for malignancy are strictly dependant on dem- histiocytes and demonstrate no squamous differentiation.
731
TABLE 17.1 LESIONS OF THE THYMUS AND Over the years, several different classifications of thy-
MEDIASTINUM mic neoplasms have been proposed and utilized. Some are
simple while others are more complex, and some reflect
Disease Entity Location the biologic behavior of these neoplasms. Discussions on
Anterior and superior the subject are beyond the scope of this chapter.
Thymus Epithelial Derived Tumors
Thymoma/Invasive (malignant) mediastinum The most recent WHO classification of the thymo-
thymoma mas, based on the proportion of epithelial cells and lym-
Thymic carcinoma phocytes, has grouped thymomas into two major catego-
Neuroendocrine tumors ries: Type A and Type B. Type A is exclusively composed
of spindle epithelial cells with absent or sparse lympho-
Lymphoproliferative Disorders Anterior and middle cytes. Type B is further subdivided into three groups ac-
Hodgkin lymphoma cording to the extent of the nonneoplastic lymphocytic
Non-Hodgkin lymphoma, large infiltrate and the proportion of neoplastic epithelial cells
B-Cell type and their degree of atypia. These groups include 1) B1,
T-Cell lymphoma which is richest in lymphocytes with sparse epithelial
cells; 2) B2 with predominant lymphocytes but fewer
Germ Cell Tumors Anterior than B1 and more epithelial cells than B1; and 3) B3,
which is richest in epithelial cells. Thymomas consisting
Mesenchymal Tumors Posterior of both spindle and polygonal epithelial cell components
Neurogenic Tumors are designated as AB.
Ultrastructurally, thymoma cells typically show in-
Miscellaneous Superior creased numbers of junctional complexes and bundles of
Thyroid tonofi laments forming a characteristic garland-like pat-
Parathyroid tern around the nucleus.
WHO Type A Thymoma (Spindle Cell Thymoma). Spin-

dle cell thymoma or WHO Type A thymoma is a benign
PRIMARY NEOPLASMS OF THE THYMUS tumor, almost exclusively composed of spindle epithelial
cells, comprising 4 to 19% of all thymomas.
Tumors of the thymus comprise neoplasms that are Grossly, spindle cell thymomas are bulky with an aver-
assumed to arise from or differentiate toward thymic cel- age size of 10.5 centimeters. They are well-circumscribed
lular components including thymic epithelial tumors (thy- and encapsulated with vague, indistinct lobulations.
moma, thymic carcinomas and thymic neuroendocrine Their microscopic pattern is dominated by the presence
carcinomas), germ cell tumors, lymphoid and hematopoi- of spindle epithelial cells with sparse or no lymphocytes.
etic neoplasms, and mesenchymal tumors. The spindle cells are arranged either haphazardly in a dif-
fuse fashion or in fascicles forming a storiform pattern
(Fig. 17.1).
EPITHELIAL-DERIVED THYMIC NEOPLASMS
The cytologic pattern of spindle cell thymoma paral-
lels its histology (Table 17.2; Figs. 17.2 and 17.3). The
Thymoma
aspirates are usually very cellular, consisting of a large
Thymomas derived from the epithelial component of the population of elongated to short plump spindle epithe-
thymus are the most common neoplasms of the anterior lial cells; they present as isolated, in groups, or in fas-
superior mediastinum, accounting for 20% of all medi- cicles. The latter are often thick with poor cellular detail.
astinal lesions. Thymomas can occur at any age but are The spindle cells usually have well-defined cell borders
more common in the fifth and sixth decades of life. There and variable, pale cytoplasm containing finely granular
is equal sex incidence or a slight female predominance. chromatin and inconspicuous nucleoli. The background
Thirty percent of thymomas are associated with para- is clean with no mitotic activity or necrosis. Lymphocytes
neoplastic syndromes, such as myasthenia gravis, red cell are inconspicuous.
aplasia, acquired hypogammaglobulinemia, thyroiditis, and The immunoprofi le includes positive reactivity to
lupus erythematosus. Thymomas generally present with CD20 and AE1 defi ned acidic cytokeratin and negative
symptoms that are related to a large mediastinal mass or reactivity to AE1 defined basic cytokeratin and CK20.
paraneoplastic conditions, or they are detected incidentally. The differential diagnosis of spindle cell thymoma in-
Thymomas can be benign, encapsulated tumors, or cludes other spindle cell neoplasms involving the thymus
they can demonstrate invasive features. Both show identi- and the mediastinum (Table 17.3). The differentiating
cal histology except for the invasive characteristics. Their features are listed in Table 17.4 and illustrated in Figures
malignant potential is variable. 17.4 to 17.8.
Chapter 17: Mediastinum 733
TABLE 17.2 CYTOPATHOLOGIC FEATURES OF SPINDLE CELL THYMOMA
Cellularity Variable, usually cellular
Presentation Varying-sized, but many tissue fragments of spindle epithelial cells, often in fascicles or whorls or syncytia;
loosely dispersed cells; tissue fragments of connective tissue stroma ⫹Ⲑ⫺
Cells Medium-sized, oval to short spindle shape; poorly defined cell borders; N/C ratios variable;
Nucleus Uniform pattern; central; round, oval to oblong; occasionally convoluted; thin nuclear membranes; finely
granular evenly dispersed chromatin; nucleoli inconspicuous; no mitotic activity
Cytoplasm Scant to modest; pale; occasionally dense
Background Clean; absent or insignificant number of lymphocytes; no necrosis
Immunoprofile Cytokeratin positive
Differential Spindle cell carcinoid tumor

Diagnoses Medullary thyroid carcinoma
Malignant melanoma
Peripheral nerve sheath tumors
Solitary fibrous tumor
Sarcomatous carcinoma
Fig. 17.1. Histologic section of a spindle cell thymoma showing a

diffuse growth pattern formed by sheets of spindle cells with bland
nuclei. Lymphocytes are not recognized in the background (H&E).
A B
Figs. 17.2A and B. A: Low-power view of an overwhelmingly cellular aspirate. The tissue fragments are large, trabe-
cular and interdigitating. The background shows discrete and groups of cells (4⫻). B: Higher magnification showing
short plump cells mixed with few lymphocytes. The cells have oblong nuclei with bland chromatin.
A B
Figs. 17.3A and B. FNA of a spindle cell thymoma showing bundles of plump spindle cells with poorly defined cell
borders. The nuclear chromatin is finely granular, uniformly distributed.
TABLE 17.3 DIFFERENTIAL DIAGNOSES OF SPINDLE CELL THYMOMA CYTOPATHOLOGIC FEATURES

Spindle Cell Thymoma Short plump to elongated spindle cells in groups or in fascicles; poorly defined 17.2 to
cytoplasm with scant variable pale cytoplasm; finely granular, uniformly distributed 17.3
chromatin; clean background; no necrosis
Spindle Cell Carcinoid Tumor Spindle cells, pleomorphic in size, delicate unipolar processes; eccentric nuclei; salt 17.4
& pepper chromatin; intranuclear inclusions ⫹/⫺
Medullary Thyroid Spindle cells, pleomorphic in size, delicate unipolar processes; eccentric nuclei; salt 24.48
Carcinoma & pepper chromatin; intranuclear inclusions ⫹/⫺
Small Cell Carcinoma with a Short spindle cells, elongated nuclei, with scant, indiscernible cytoplasm; deep- 17.6
Spindle Cell Pattern staining nuclei with compact chromatin with nuclear molding; karyorrhexis ⫹;
mitoses ⫹; stretch artifacts ⫹
Sarcomatoid Carcinoma Cellular; malignant cells isolated, in loosely cohesive groups or in tissue fragments; 17.5
very pleomorphic, round, oval to elongated nuclei with smooth to irregular nuclear
membrane; coarsely granular chromatin; prominent nucleoli; variable pale, to dense
cytoplasm; mitoses ⫹; necrosis ⫹
Peripheral Nerve Sheath Variable cellularity; tissue fragments with single cells; fibrillar matrix; nuclear 17.7
Tumor palisading; Verocay bodies; cells elongated; comma-shaped nuclei (⫹/⫺); scant,
delicate cytoplasm; degenerative changes ⫹/⫺
Solitary Fibrous Tumor Very cellular; large tissue fragments, enclosing arcade spaces; closed packed, short, e-Figs.
delicate, spindle-shaped cells; round to ovoid nuclei; short cytoplasmic processes; 7.43A to D
tumor cells attached to the capillaries; mast cells; background clean
Malignant Melanoma Variable cellularity; cells dispersed, in aggregates; spindle-shaped cells of various sizes; 11.16B
cytoplasmic processes; unipolar and bipolar; well-defined cell borders; nuclei eccentric
to central; smooth to irregular cell borders; fine to coarsely granular chromatin;
parachromatin clearing; prominent micro/macronucleoli; intranuclear cytoplasmic
inclusions; cytoplasm variable; melanin pigment ⫹/⫺; background; necrosis ⫹/⫺
Soft Tissue Sarcomas Spindle cell pattern; please refer to Chapter 24, Table 24.5 for specific 17.8
cytopathologic features of various spindle cell neoplasms
TABLE 17.4 CYTOPATHOLOGIC FEATURES OF LYMPHOCYTE PREDOMINANT THYMOMAS

WHO TYPES B1 AND B2
WHO Type B1 WHO Type B2

Cellularity Hypercellular Hypercellular
Presentation Predominantly diffuse lymphocytic population, Predominantly diffuse lymphocytic population,

isolated epithelial cells, difficult to identify epithelial cells more in numbers and clearly
recognizable; present in aggregates or in
syncytial tissue fragments; lymphoid cells
either at the perimeter of the epithelial cells or
intimately incorporated in the tissue fragments;
no architectural patterns to the epithelial tissue
fragments
Cells Epithelial cells less visible and in very small Medium-sized, oval to short spindle shape; poorly
numbers; medium-sized, oval to short spindle defined cell borders; N/C ratios variable
shape; poorly defined cell borders; N/C ratios
variable
Nucleus Uniform pattern; central; round, oval to oblong; Uniform pattern; central; round, oval to oblong;
occasionally convoluted; thin nuclear membranes; occasionally convoluted; thin nuclear membranes;
finely granular evenly dispersed chromatin; finely granular evenly dispersed chromatin;
nucleoli inconspicuous; no mitotic activity nucleoli inconspicuous; no mitotic activity
Cytoplasm Scant to modest; pale, occasionally dense Scant to modest; pale; occasionally dense
Background Clean; no necrosis Clean; no necrosis
Immunoprofile Epithelial cells reactive to cytokeratins; Epithelial cells reactive to cytokeratins

lymphocytes to TdT
Differential Diagnoses Reactive lymphoid proliferation Reactive lymphoid proliferation

Lymphocyte predominant Hodgkin lymphoma Hodgkin lymphoma
Non-Hodgkin lymphoma, small cell type Non-Hodgkin large B-cell lymphoma
Small cell carcinoma Germinoma
Carcinoid tumors
Differential Diagnoses of Spindle Cell Thymoma (See Figs. 17.4 to 17.8)
Fig. 17.4. FNA of a carcinoid tumor with a spindle cell pattern. Fig. 17.5. FNA metastatic squamous carcinoma with a spindle cell
Note the typical salt & pepper chromatin of the nuclei. pattern (sarcomatous squamous carcinoma).
Fig. 17.6. FNA of a metastatic small cell carcinoma (neuroendocrine Fig. 17.7. FNA of a mediastinal schwannoma. Note the sparse cel-
carcinoma) to the mediastinum exhibiting a spindle cell pattern. lularity formed by haphazardly placed spindle cells in a fibrillar–
collagenous stroma.
Fig. 17.8. FNA of metastatic malignant fibrous histiocytoma.

The cells are malignant, pleomorphic and predominantly spindle-
shaped.
WHO Type B1 Thymoma. The Type B1 thymoma, also clinch the diagnosis. The pattern is best seen in histologic
referred to as lymphocyte predominant or cortical thy- material, and cell blocks, if available, will be extremely
moma, comprises 6 to 17% of all thymomas. They are useful. The diagnosis of B1 thymoma depends on finding
slightly more common in females. the epithelial cells.
Grossly, lymphocyte predominant B1 thymomas are The immunoprofi le includes positive reactivity to
large and bulky with an average size of 10 centimeters. They CK7, CK14, and CD19. TdT is positive because of the
are well-defined and encapsulated with a thick fibrotic cap- large numbers of immature nonneoplastic immature
sule and are lobulated. Histologically, lymphocyte predom- T-lymphocytes.
inant B1 thymomas are characterized by expanded areas The differential diagnoses include the lesions that
resembling normal thymic cortex, predominantly consist- yield aspirates with an exclusive lymphoid cell population
ing of nonneoplastic immature T-lymphocytes (Fig. 17.9) (Tables 17.6 and 17.7; see Figs. 17.15 to 17.17).
and very few epithelial cells. The presence of tingible body
histiocytes may give a starry-sky appearance. WHO Type B2 Thymoma. Type B2 lymphocyte predom-
The aspirates are usually hypercellular, dominated inant thymomas possess a low lymphocytic component
by an overwhelming population of small nonneoplastic and a greater epithelial component than Type B1 thymo-
lymphoid cells (Table 17.5; Figs. 17.10 to 17.12). The mas and comprise 30% of all thymomas.
epithelial cells are few, obscured by a diffuse population Grossly, B2 thymomas are bulky with an average size
of lymphoid cells and are very diffi cult to identify. Im- of 6 centimeters, presenting prominent lobulations. Mi-
munostains for cytokeratin are required to highlight the croscopically, the tumor shows a bimorphic pattern with
neoplastic epithelial cells, which present a most charac- a significant proportion of epithelial cells. They are present
teristic network of arborizing epithelial cell processes, to either as discrete or as clustered, ovoid cells containing
TABLE 17.5 DIFFERENTIAL DIAGNOSES OF LYMPHOCYTE-PREDOMINANT THYMOMAS WHO

TYPE B1 AND B2: CYTOPATHOLOGIC FEATURES
Cytopathologic Features See Fig(s).

Thymoma Large population of mature lymphoid cells obscuring neoplastic epithelial 17.10 to
Lymphocyte cells, occurring singly, in groups or in tissue fragments; poorly defined cell 17.14
Predominant borders, pale cytoplasm, and bland nuclei; CK⫹
WHO B1 & B2
Hodgkin lymphoma Cellularity sparse; mature lymphoid cells, plasma cells, eosinophil; few 17.20
Lymphocyte typical Reed-Sternberg cells, Hodgkin cells, lacunar cells, or popcorn cells;
Predominant CK⫺; CD20⫹; CD45⫹
Malignant lymphoma Cellularity sparse in primary mediastinal type with sclerosis; monomorphic 17.16 to
Non-Hodgkin type, population of immature lymphoid cells; large cell lymphomas (large cleaved 17.19
Large cell type or large noncleaved and immunoblastic); T or B cell type; CK⫺; CD19⫹;
CD20⫹
Malignant lymphoma Highly cellular aspirate, monomorphic immature lymphoid cells; 12 ␮m in 14.1
Lymphoblastic diameter; convoluted nucleus, stippled chromatin, inconspicuous nucleoli;
cytoplasm scant; mitoses may be numerous; CK⫺; TdT⫹; CD34⫹
Germinoma Cellularity variable; large round cells with well-defined cell borders, scant 17.22
cytoplasm, large round nucleus with finely granular chromatin and
prominent single macronucleolus; epithelioid cells ⫹/⫺; CK⫺; PLAP⫹;
CD117/c-kit⫹
Reactive hyperplasia Polymorphic lymphoid cell population with germinal center cells and 17.15
of lymph nodes or thymus tingible body macrophage; CK⫺; polyclonal
Metastatic small cell See Table 17.7 17.21

carcinoma
Thymic carcinoid tumor See Table 17.7 17.30
Lymphocyte Predominant Thymoma (See Figs. 17.9 to 17.14)
Fig. 17.9. Histologic section of a lymphocyte predominant thymo-

ma, B1 type, showing diffuse population of mature lymphoid cells.
Epithelial cells are difficult to identify and can be highlighted only
by immunostain with cytokeratin (H&E).
A B
Figs. 17.10A and B. FNA of lymphocyte predominant thymoma type B1. A: Low power view showing a large
lymphoid population (Romanowsky). B: Higher magnification showing a rare epithelial cell in the background of
mature lymphocytes (Romanowsky).
Fig. 17.11. FNA of lymphocyte predominant thymoma type B1 Fig. 17.12. FNA of lymphocyte predominant thymoma. Another
depicting mostly mature lymphocytes and scattered epithelial cells example of a surgically proven thymoma. The epithelial cells are
that blend with the lymphocytes. extremely difficult to visualize.
TABLE 17.6 CYTOPATHOLOGIC FEATURES OF EPITHELIAL PREDOMINANT THYMOMA WHO TYPE B3

(WELL-DIFFERENTIATED THYMIC CARCINOMA, ATYPICAL THYMOMA)
Cellularity Variable, usually hypercellular
Presentation Large syncytial tissue fragments of epithelial cells without any architectural patterns in the background of
variable numbers of lymphocytes (usually scant); dispersed pattern infrequent
Cells Medium to large, well to poorly defined cell borders; N/C ratios variable; may appear squamoid
Nucleus Moderately enlarged, round, oval to oblong with smooth nuclear membranes; finely granular chromatin; nucleoli ⫹
Cytoplasm Variable, usually modest amount; pale, can be dense
Background No necrosis; tissue fragments of stromal tissue ⫹Ⲑ⫺
Immunoprofile Positive reactivity to cytokeratins
Differential Metastatic poorly differentiated adenocarcinoma

Diagnoses Metastatic poorly differentiated squamous carcinoma
Hodgkin lymphoma
Non-Hodgkin lymphoma
Germ cell tumors
738
TABLE 17.7 DIFFERENTIAL DIAGNOSES OF THYMIC CARCINOID
Thymic Poorly Malignant

Carcinoid Adenocarcinoma # Differentiated Melanoma
NEC Grades Malignant Small Cell Small Cell Squamous with Small
I & II Lymphoma Carcinoma Pattern Carcinoma Cell Pattern
Presentation Neoplastic cells Discrete Cells isolated, Neoplastic cells Cells isolated, in Cells mostly
isolated, in monomorphic in loosely isolated, in loosely cohesive isolated,
loosely cohesive cells cohesive loosely cohesive groups, or in cohesive
groups and in groups or in groups, and in syncytial tissue groups
syncytial tissue syncytial tissue syncytial tissue fragments with or tissue
fragments fragments fragments with marked crowding fragments very
without any or without acinar and overlapping; rare
architectural pattern no architectural
patterns pattern
Cells Small, round; Small, round; Small, round Small, round to Small, round to Round, well-
N/C ratio 1:1; high N/C ratio; to oval; high cuboidal; N/C cuboidal; high defined cell
cell borders cell borders well- N/C ratio; cell ratio high; cell N/C ratio; cell borders
poorly defined defined borders poorly borders poorly borders well- to
defined defined poorly defined
Nucleus Round to oval; Round with Round to Round, Round, Round,

no molding; clefts, grooves, oval; irregular eccentric; nuclear central; nuclear eccentric;
salt & pepper convolutions; nuclear membrane membrane smooth
type chromatin; coarsely granular membrane smooth to smooth to nuclear
nucleoli to stippled molding; irregular; irregular; membrane;
inconspicuous; chromatin; coarsely finely granular chromatin fine to fine to coarsely
mitoses ⫹Ⲑ⫺ micronucleoli; granular chromatin; coarsely granular; granular
mitoses frequent chromatin; micronucleoli or no molding; chromatin;
nucleoli macronucleoli; nucleoli present; prominent
inconspicuous; mitoses ⫹Ⲑ⫺ mitoses ⫹ macronucleoli
mitoses ⫹
Cytoplasm Scant, pale Scant, pale Indiscernible Scant, pale, Scant, pale to Scant,
cytoplasmic dense brownish
vacuoles ⫹Ⲑ⫺ discoloration,
rudimentary
cytoplasmic
tailing
Background Necrosis ⫹Ⲑ⫺ Lymphoglandular Strings of Clean Clean to necrotic Clean

bodies nuclear
material;
necrosis;
nuclear debris
Immunoprofile NSE ⫹; LCA ⫹, specific Cytokeratin CEA ⫹; CEA ⫹; S100 protein ⫹;

chromogranin ⫹; lymphoma ⫹Ⲑ⫺; TTF-1 ⫹; cytokeratin ⫹; cytokeratin ⫹ HMB ⫹;
synaptophysin ⫹; markers neuroendocrine EMA HMB-45 ⫹;
cytokeratin ⫹ markers Melan-A
(mart-1) ⫹
vesicular nuclei and conspicuous nucleoli (Fig. 17.13). consisting of aggregates and syncytial tissue fragments of
There are abundant lymphocytes in the background. epithelial cells in the background of diffusely present non-
The cytologic recognition of this lymphocyte predom- neoplastic lymphoid cells (Table 17.5; Fig. 17.14). The ep-
inant thymoma is high because of the more conspicuous ithelial aggregates or tissue fragments may be sharply de-
presentation of epithelial cells. The FNAs are very cellular, marcated from the surrounding heavy lymphoid cells or
may be intimately mixed with or be permeated by them. brous septae (Fig. 17.23A). There is a paucity of lymphocytes.
The epithelial cells vary widely in size and shape and can Some neoplastic cells exhibit a squamoid appearance.
be round or oval to spindle-shaped. Their cytoplasm is The cytologic features of epithelial predominant Type
variable. The nuclei contain finely granular chromatin B3 thymomas are not well-documented since this type is
and nucleoli. The nuclei may be uniform or may demon- rare. The FNAs are usually cellular, consisting of large syn-
strate a variable degree of atypia. Proliferative activity is cytial tissue fragments of neoplastic epithelial cells without
not appreciated. The background is usually clean. any architectural pattern (Figs. 17.23A to F). These cells
Immunoprofile: The epithelial cells of thymoma react are medium-sized with poorly defined cell borders and
positively to CK19, CK5/6, and CK7. variable, pale, eosinophilic to cyanophilic, and sometimes,
Differential diagnoses of lymphocyte predominant dense cytoplasm. Their nuclei are round to oval, large,
Type B2 thymomas include entities that show a dual cell roughly three times the size of surrounding lymphocytes,
population (Table 17.5; Figs. 17.15 to 17.22) consisting and have granular chromatin. Sometimes, there may be a
of epithelial neoplastic cells and lymphoid cells. spindle cell component. Nuclear atypia is variable.
WHO Type B3 Thymoma. The Type B3 thymoma is Immunoprofile. The cells of epithelial predominant thy-
an epithelial predominant thymoma and is also referred momas react positively to cytokeratins (CK19, CK5/6,
to as atypical thymoma or well-differentiated thymic CK7, CK10, and CK8) as well as to AE1/3 and Leu7.
carcinoma. EMA may show focal positive reactivity.
Grossly, epithelial predominant thymomas are not en- Differential diagnoses of Type B3 or epithelial pre-
capsulated and show a vague infiltrative pattern with exten- dominant thymomas include primary thymic carcino-
sion into fat or adjacent organs. Histologically, the tumor ma (squamous carcinoma) and metastatic carcinomas
shows lobules of neoplastic epithelial cells separated by fi- (Table 17.6).
Fig. 17.13. Histologic section of a lymphocyte predominant thy-

moma, B2 type, with clearly visible groups of epithelial cells in the
background of lymphocytes (H&E).
A B
Figs. 17.14A to B. FNA of lymphocyte predominant thymoma, B2 type. A: Epithelial cells in syncytial tissue frag-
ment, surrounded by lymphocytes (Romanowsky). B: Same case stained by Papanicolaou, depicting epithelial cells
surrounded by mature lymphocytes. (continued)
C D
Figs. 17.14C to E. (continued) C: Smear from this case stained for

cytokeratin, to highlight the epithelial cells. D: Thymoma showing
an admixture of epithelial and lymphoid cells. E: A different field
from same case. The epithelial cells can be clearly identified from
the lymphoid cells. E
Differential Diagnoses of Lymphocyte Predominant Thymoma (See Figs. 17.15 to 17.24)
Fig. 17.15. FNA of reactive lymph node showing a polymorphic Fig. 17.16. FNA of malignant non-Hodgkin lymphoma depicting
lymphoid cell population. monomorphic immature lymphoid cells.
mas is based on their histologic pattern (e.g., squamous

Thymic Carcinomas
carcinoma, lymphoepithelioma-like, sarcomatoid, basa-
Thymic carcinomas are very rare but pose a significant loid, clear cell carcinoma, mucoepidermoid, and undif-
diagnostic dilemma since they resemble other types of car- ferentiated carcinomas). Cytologically and histologically,
cinomas (Fig. 17.24). The classification of thymic carcino- thymic carcinomas cannot be differentiated from other
Fig. 17.17. FNA of malignant non-Hodgkin lymphoma, small cell Fig. 17.18. FNA of malignant non-Hodgkin lymphoma, primary
type. mediastinal, with sclerosis. The lymphoma cells are pleomorphic in
size; some are large with convoluted nuclear membranes.
Fig. 17.19. FNA of malignant non-Hodgkin lymphoma. Another Fig. 17.20. FNA of Hodgkin lymphoma. The Hodgkin cells are few
example of a primary mediastinal lymphoma. (arrows) and difficult to visualize, requiring a careful search.
Fig. 17.21. FNA of metastatic small cell (neuroendocrine) carcino- Fig. 17.22. FNA of mediastinal seminoma. The medium-sized
ma. The nuclear molding, stretch artifacts and karyorrhexis are the round cells with scant cytoplasm, high N/C ratios, and prominent
clues to correct diagnosis. macronucleolus with lymphocytes in the background are diagnostic
features of seminoma.
A B
C D
E F
Figs. 17.23A to F. A: Histologic section of an epithelial predominant thymoma showing large islands of epithelial
cells with lymphocytes bordering the epithelial cells. B, C, D, E, F: FNA of this case showing syncytial tissue fragments
of epithelial cells with poorly defined cell borders and variable amount of cytoplasm. Their cell borders are poorly
defined. The nuclei are round to oval and mildly pleomorphic. This thymoma was widely invasive.
malignant neoplasms with similar histomorphology (Figs.

17.25 to 17.30). These include metastatic carcinomas, Neuroendocrine Carcinomas
sarcomas, germ cell tumors, and malignant lymphomas. The epithelial neuroendocrine tumors of the thymus
Accurate diagnosis often requires ancillary studies. comprise typical and atypical carcinoid tumors, as well
as large and small cell carcinomas. The histologic cri-
Immunoprofile. The cells of thymic carcinomas react teria used are identical to those used in the lung. In
positively to CD5, CD70, and CD117. line with the nomenclature of neuroendocrine tumors
Fig. 17.24. FNA of a thymic carcinoma showing a poorly differen-

tiated malignant tumor. There was no history of primary tumor. The
diagnosis of a primary thymic carcinoma is usually by exclusion
and sometimes may require ultrastructural studies.
Differential Diagnoses of Thymic Carcinoma (See Figs. 17.25 to 17.31)
Fig. 17.25. FNA of a poorly differentiated metastatic carcinoma

involving the mediastinum.
Fig. 17.26. FNA of a metastatic poorly differentiated carcinoma to Fig. 17.27. FNA Hodgkin lymphoma. These large bizarre Hodg-
the mediastinum. kin cells may be misinterpreted as poorly differentiated carcinoma
cells.
A B
Figs. 17.28A and B. FNA Primary mediastinal malignant non-Hodgkin lymphoma. Note the tight aggregate of
pleomorphic and large lymphoma cells, characteristic of primary mediastinal lymphomas.
A B
Figs. 17.29A and B. FNA of an embryonal carcinoma arising in the Fig. 17.30. FNA of a primary thymic carcinoid tumor.
mediastinum.
Fig. 17.31. FNA of a mediastinal mass in a child, depicting a small

blue cell tumor, consistent with a neuroblastoma.
occurring in other sites of the body (see Chapter 10), Primary thymic carcinoids are rare, accounting for
thymic carcinoids are termed as well-differentiated only 2.5% of primary thymic tumors. They are often a
neuroendocrine carcinomas, and atypical carcinoids part of MEN 1 syndrome and may be associated with
are termed as moderately differentiated carcinomas. Cushing’s syndrome. Their cytohistologic presentation
Thymic neuroendocrine tumors are biologically more is similar to carcinoid tumors occurring elsewhere in the
aggressive. body (Table 17.7; Fig. 17.30).
The differential diagnosis of thymic carcinoid tumors Because of the sclerotic stroma, the aspirates of medi-
include neoplasms that consist of small cells, as listed in astinal Hodgkin lymphoma are often poorly cellular. Since
Table 17.7. Neuroblastoma must be considered in the pe- the diagnostic Reed–Sternberg cells generally constitute a
diatric age group (Fig. 17.31). minority of the cell population of Hodgkin lymphomas,
their absence in the aspirated samples is not uncommon,
often compromising the accuracy of the diagnosis. With
MALIGNANT LYMPHOMAS OF THE lymphocyte predominance and rare or absent Reed–
MEDIASTINUM AND THYMUS Sternberg/Hodgkin cells, the aspirate may be mistaken for
either a reactive process or a small cell lymphoma. Hodg-
kin cells, with very atypical nuclei, may mimic a poorly
A broad range of lymphomas and hematopoietic neo- differentiated carcinoma—either a metastatic one or a pri-
plasms can occur in the thymus but the following types mary thymic carcinoma. The combination of lymphoid
account for the majority of cases: cells and a few Hodgkin cells may be mistaken for a germ
● Nodular sclerosis Hodgkin lymphoma cell tumor such as seminoma. Few mononuclear Hodgkin
● Mediastinal large B-Cell lymphoma cells can be mistaken for a non-Hodgkin lymphoma.
● T-Lymphoblastic lymphoma
NON-HODGKIN LARGE B-CELL LYMPHOMA
HODGKIN LYMPHOMA Malignant non-Hodgkin lymphomas involve the medi-
Hodgkin lymphoma is the most common type of mediastinum, either primarily or secondarily, with the latter
astinal lymphoma in adults and is of B-cell lineage; it may being more frequent. Secondary mediastinal involvement
occur either in the thymus or in the mediastinal lymph is reported in 15 to 50% of non-Hodgkin lymphomas else-
nodes. Grossly, these tumors are encapsulated and lob- where in the body. Primary mediastinal large cell lymphoma
ulated, resembling thymomas. Almost all mediastinal of the B-cell lineage is a distinctive form of lymphoma
Hodgkin lymphomas are of the nodular sclerosing type occurring in the anterior mediastinum, accounting for 2 to
with large fibrous bands extending from the capsule into 3% of non-Hodgkin lymphomas. It is of rare occurrence
the neoplasm. The neoplastic cells are generally lacunar with a predilection for occurring in female patients in their
Reed–Sternberg cells that are characterized by their large 30s. The patients may present with symptoms of superior
size and large, multilobated nuclei, as well as their abun- venacaval obstruction and pleural/pericardial effusion.
dant, pale, eosinophilic cytoplasm. The typical forms These tumors form bulky intrathoracic masses with an
with mirror image nuclei containing macronucleoli are invasion of the adjacent structures. The morphology is
rare. Aspirates of nodular sclerosing Hodgkin disease are characterized by large noncleaved and cleaved cells con-
generally paucicellular; the characteristic Reed–Sternberg taining multilobated nuclei and immunoblasts (Figs. 17.16
cells are rather diffi cult to identify. Differentiation from to 17.19, and 17.28). A prominent feature of primary
thymoma may be extremely diffi cult (Figs. 17.20 and mediastinal lymphoma is marked interstitial sclerosis.
17.27). The background is infl ammatory with a mixed
infiltrate including plasma cells and eosinophils. Immunoprofile
The malignant lymphoma cells demonstrate crisp cell
Immunoprofile membrane reactivity for CD19, CD20, and CD22 and
Hodgkin lymphoma cells react positively to CD15, CD30, negative reactivity to CD79, PAX-5, CD15, and CD21.
and keratin and react negatively to LCA, PLAP, S100 pro- Differential diagnoses of non-Hodgkin lymphoma
tein, and CD45. include reactive lymph nodes (including Castleman’s dis-
Diagnostic difficulties are encountered mostly due to ease), thymic hyperplasia, Hodgkin lymphoma, lympho-
inadequate aspirates—a likely occurrence due to marked cyte predominant thymoma, neuroendocrine carcinomas
sclerosis. A sparse number of Reed–Sternberg/Hodgkin (carcinoid tumors and small cell carcinomas), metastatic
cells in the aspirate may lead to a diagnosis of either a re- small cell carcinoma, and basaloid squamous carcinoma.
active process or a small cell lymphoma. The differential In the pediatric age group, considerations must be given
diagnosis of Hodgkin lymphoma includes to neuroblastoma and PNET.
● Non-Hodgkin lymphoma
T-LYMPHOBLASTIC LYMPHOMA
● Metastatic poorly differentiated adeno/squamous cell
carcinomas Lymphoblastic lymphoma is the most common anterior
● Thymic carcinoma mediastinal tumor for children; it occurs in the thymus
● Lymphocyte predominant Type B thymoma gland, predominantly in males. Most develop into leuke-
● Reactive lymphadenitis mias and are the T-cell type. The neoplasm is nonencap-
● Seminoma sulated, lacks lobulations, and presents a diffuse growth
pattern, widely infiltrating into perithymic fat. The lym-

phoma cells are small at roughly 12 nanometers in diameter GERM CELL TUMORS OF THE THYMUS
with a convoluted nucleus containing stippled chromatin AND MEDIASTINUM
and inconspicuous nucleoli. Mitotic activity may be brisk.
Necrosis is frequent. The lymphoma cells react positively to Next to the gonads, the mediastinum is the most common
TdT (see Chapter 14). site for extragonadal germ cell tumors, accounting for 2 to
6% of all mediastinal tumors. These include germinomas,
Differential Diagnoses embryonal carcinomas, yolk sac tumors, and teratomas. Of
these various types of germ cell tumors, germinomas are
The differential diagnoses of non-Hodgkin lymphoma encountered more often than others. Germ cell tumors may
include thymic hyperplasia, Castleman’s disease, lym- contain more than one histologic type. With discrete neo-
phocyte-predominant thymoma, and germ cell tumors. plastic cells in the background of a lymphoid cell popula-
However, with this type being common in children, other tion (Figs. 17.22 and 17.32), aspirates of mediastinal germi-
diagnostic considerations are less likely. nomas must be differentiated from neoplasms that present
Other non-Hodgkin lymphomas such as MALT lym- a similar dimorphic cell population (e.g., thymoma, Hodg-
phomas, anaplastic large cell lymphoma, and small non- kin, and non-Hodgkin lymphoma) (Table 17.3; Figs. 17.9
cleaved cell lymphomas are very uncommon in the medi- to 17.15). Cytologically, embryonal carcinomas (Fig.
astinum and thymus and will not be further discussed. 17.33) or yolk sac tumors (Fig. 17.34) are very difficult to
Germ Cell Tumors (See Figs. 17.32 to 17.34)
Figs. 17.32A and B. FNA of a metastatic seminoma to the mediastinum. The seminoma cells are immunoreactive to
CD117 (c-kit) and PLAP and are nonreactive to cytokeratin.
Fig. 17.33. FNA of an embryonal carcinoma in the mediastinum. Fig. 17.34. FNA of a large mediastinal mass in a child consistent
Note that this poorly differentiated malignant neoplasm will require with yolk sac tumor. The cells of the yolk sac tumor react positively
ancillary testing for proper identification. The cells of embryonal to ␣-fetoprotein and keratin and are negative to PLAP.
carcinoma react positively to keratin and CD30.
differentiate from thymic carcinomas or metastatic poorly the testes, and malignant melanoma and soft tissue sarco-
differentiated carcinomas (see Chapters 22 and 25). mas. Well-differentiated carcinomas are easy to recognize
from known primaries. Poorly differentiated carcinomas
may create diagnostic diffi culties, particularly with an
unknown primary. Small cell carcinoma is the most com-
MESENCHYMAL TUMORS
mon malignant neoplasm to metastasize to the mediasti-
nal lymph node. The differentiation between small cell
Mesenchymal tumors include neurogenic tumors, solitary carcinoma and thymic carcinoid or between thymic car-
fi brous tumors, and very infrequently, rhabdomyosarco- cinoma and metastatic poorly differentiated carcinoma
mas and synovial sarcomas. are diagnostic challenges. In children, neuroblastoma is
a consideration with small cell malignancy and must be
differentiated from malignant lymphoma.
NEUROGENIC TUMORS
MISCELLANEOUS
Neurogenic neoplasms account for 20% of mediastinal
tumors, equaling the frequency of thymoma; they pri-
marily involve the posterior compartment of the medi- Primary neoplasms in the miscellaneous category include
astinum. They can be grouped into two major categories: those involving the thyroid and parathyroid glands.
nerve sheath tumors (Fig. 17.7) and tumors arising from Their cytopathologic features are described in detail in
neuroectoderm such as neuroblastoma, ganglioneuroblas- Chapter 13.
toma, or ganglioneuroma and PNET. These are discussed
in Chapters 24 and 25.
CYSTS OF THE MEDIASTINUM
Twenty percent of all mediastinal lesions are primary
cysts and include bronchogenic cysts, esophageal cysts,
The mediastinum is very frequently involved by meta- gastroenteric cysts, thymic cysts, pericardial cysts, pan-
static malignancy. The common primary sites are the creatic pseudocysts, and meningocele. Most of these
lung, the breast, and the stomach. Other sources include represent developmental abnormalities and are not true
the thyroid, the head and neck, the kidney, the prostate, neoplasms.
SUGGESTED READINGS
Chhieng DC, Rose D, Ludwig ME, et al. Cytology of thymomas. Singh HK, Silverman JF, Powers CN, et al. Diagnostic pitfalls in
Emphasis on morphology and correlation with histologic sub- fine-needle aspiration biopsy of the mediastinum. Diagn Cyto-
types. Cancer (Cancer Cytology) 2000;90:24–32. pathol 1997;17:121–126.
Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia: Travis WP, Brumbilla E, Muller-Hermelink HK, et al. Tumors of
Churchill Livingstone, 2006. the Lung, Pleura, Thymus and Heart. Lyon, France: IARC Press,
Moran CA. Primary neuroendocrine carcinoma of the mediasti- 2004.
num: Review of current criteria for histopathologic diagnosis Wakley PE. Cytopathology and histopathology of the mediasti-
and classification. Semin Diagn Pathol 2005;22:223–229. num: Epithelial, lymphoproliferative and germ cell neoplasms.
Siagel DD, Powers CN, Melaragno MJ, et al. Spindle-cell lesions Ann Diagn Pathol 2002;6:30–43.
of the mediastinum: Diagnosis by fine-needle aspiration biopsy. Wakley PE. Cytopathology of thymic epithelial neoplasms. Semin
Diagn Cytopathol 1997;17:167–176. Diagn Pathol 2005;22:213–222.
18 LIVER
Aspiration biopsy is a valuable diagnostic procedure for lobule contains a central vein from which radiate liver cell
evaluating mass lesions of the liver. Performed under the plates that are separated by sinusoids lined by endothe-
radiologic guidance of computed tomography or ultra- lial cells and Kupffer cells. The periphery of the lobule
sound, it provides high diagnostic accuracy with minimal is bordered by delicate fi brovascular connective tissue
complications or morbidity. However, this procedure is of containing a portal triad consisting of tributaries of the
limited or of no value in evaluating medical liver diseases. hepatic artery, portal vein, and bile duct. Bile canaliculi
In the last decade or so, FNAs of the liver have become are present in between the hepatocytes and drain into the
less traditional in major medical centers since clinicians bile ducts.
have shown a preference for tissue biopsy. It is a miscon-
ception that needle biopsy is better than FNA since it pro-
cures more tissue. More is not always better. Core biopsies
PIGMENTS IN HEPATOCYTES
may not always provide the appropriate diagnostic tissue
while a concurrently performed FNA biopsy may do so.
An adequate FNA and a well-prepared cell block can pro- The presence of various kinds of pigments is a fre-
vide sufficient tissue for immunochemical tests. Both FNA quent occurrence in hepatocytes. Lipofuscin is a golden
and needle core biopsies are complementary. brown, granular pigment that is typically distributed
Indications for a percutaneous FNA biopsy of the around the nucleus and is considered a “wear and tear”
liver include pigment.
Hemosiderin is a hemoglobin-derived brown–black
● Confi rmation of the clinical diagnosis of hepatocellu-
refractile pigment seen in patients with hemolytic ane-
lar carcinoma.
mia or congestive heart failure or in recipients of multiple
● Confirmation of metastatic disease in cases with known
blood transfusions. Excess hemosiderin is also present in
malignancy for staging.
the congenital disorder of hemochromatosis (e-Fig. 18.3).
● Diagnosis of mass lesions with an unknown primary
The presence of hemosiderin can be easily confirmed by a
source.
positive Prussian blue reaction.
Diagnostic problems in aspiration cytopathology of Bile pigment varies in texture, color, size, and the den-
the liver include sity of the granules. The cytoplasm may be dusted with a
greenish tinge or may contain green to greenish-yellow
● Differentiation of reactive/regenerative hepatocytes
coarse granules or large droplets. The latter are some-
from hepatocellular carcinoma.
times seen in bile canaliculi.
● Differentiation between cirrhosis, focal nodular hyper-
plasia, hepatocellular adenoma, and hepatocellular
carcinoma.
● Differentiation between hepatocellular carcinoma and NONNEOPLASTIC LESIONS
other malignancies. OF THE LIVER
REACTIVE/REGENERATIVE CHANGES
NORMAL COMPONENTS IN FINE NEEDLE
Reactive or regenerative hepatocytes are often encoun-
ASPIRATES OF LIVER
tered in aspirates from cirrhotic livers, or livers harboring
metastatic tumors. These cells display considerable pleo-
The normal cellular constituents in a liver aspirate include morphism in size with frequent binucleate and trinucleate
hepatocytes, bile duct epithelium, endothelial cells, and forms. The nuclei vary in size. Although the N/C ratio
very rarely, Kupffer cells (Table 18.1; e-Figs. 18.1 and is altered, it is never as high as that seen in hepatocel-
18.2). The liver is composed of multiple lobules. Each lular carcinoma. The nuclear chromatin can be extremely
749
TABLE 18.1 NORMAL COMPONENTS OF A LIVER ASPIRATE
Hepatocytes Bile Duct Epithelium Endothelial Cells Kupffer Cells

Presentation Cells isolated or in Cells mostly in tissue fragments Present infrequently as Only rarely present
monolayered tissue as strips with palisading of single cells either as single
fragments, with trabecular nuclei and with luminal border, cells or attached to
pattern or as large sheets or monolayered sheets with a tissue fragments of
honeycomb arrangement hepatocytes
Cells Large, polygonal with Small cuboidal to columnar; Spindle or oblong cells; Small, round cells; low
well-defined cell borders; ill-defined cell borders; high poorly defined cell N/C ratio
low N/C ratio N/C ratio borders
Nucleus Small, round, central Uniform, small, round, Elongated with blunt Kidney-shaped with
location; binucleation eccentric location; smooth edges; smooth nuclear smooth nuclear
frequent; smooth nuclear nuclear membrane; granular membrane; finely membrane; compact
membrane; evenly to compact chromatin; granular chromatin; one chromatin
distributed, finely granular nucleoli ⫹/⫺; no intranuclear or more micronucleoli
chromatin, prominent cytoplasmic inclusions
nucleolus; intranuclear
cytoplasmic inclusions
Cytoplasm Abundant granular to Scant, pale Scant, pale to clear Moderate, pale to dense
vacuolated, speckled
with brownish lipofuscin
pigment; may contain bile
pigment and hemosiderin
coarse or smudgy. Nucleoli may be prominent and intra- showing cellular, infl ammatory debris and degenerating
nuclear cytoplasmic inclusions are not uncommon in hepatocytes.
reactive hepatocytes.
HEPATIC CYSTS
FATTY CHANGE
Hepatic cysts can be either congenital or acquired. The
Fatty change—a nonspecifi c but common fi nding in liver congenital cysts may be solitary or multiple, small to large,
disorders—can be focal or diffuse and can produce images and may be associated with cysts of the kidney and in
on CT scans mimicking metastatic disease. Hepatocytes the lung. These cysts are lined by cuboidal to low colum-
with fatty change show multiple small to single large vac- nar epithelium and contain clear fluid. Aspiration biopsy
uoles, giving either a bubbly or a signet-ring appearance will yield clear fluid and may contain benign columnar to
(e-Fig. 18.4). cuboidal epithelium.
INFLAMMATORY CONDITIONS HYDATID CYSTS

The use of FNA biopsy in inflammatory conditions of Hydatid cysts are caused by the larvae of the dog tape-
the liver is limited, particularly when the disease process worm Echinococcus granulosus. These are multilocular;
is diffuse. FNA biopsy is performed only when the lesion their walls are composed of an external acellular hyaline
is nodular and a malignancy must be ruled out. Infec- layer and an inner germinative layer, both of which are
tious granulomas such as those caused by mycobacteria studded with daughter cysts. The latter contains scoleces
may be encountered and can be identified cytologically with diagnostic hooklets. The aspirated fluid contains
(e-Fig. 18.5). degenerated cysts called Brood’s capsules, which are
often referred to as hydatid sand, and consists of scoleces,
hooklets, and calcified debris (e-Fig. 18.6).
HEPATIC ABSCESS
Clinical suspicion of a hydatid cyst is a contraindica-
Hepatic abscesses are bacterial or parasitic (amebic) in tion for aspiration biopsy because of the possible anaphy-
origin. Aspiration biopsy yields necrotic purulent material lactic reaction.
Chapter 18: Liver 751
CIRRHOSIS fi broconnective tissue containing bile ducts and inflam-

matory infiltrate.
Cirrhosis is a chronic disorder of the liver caused by mul-
FNA biopsy will yield normal-appearing hepatocytes
tiple etiologic factors and is characterized by a variable
and bile duct epithelial cells (Figs. 18.1A and B). The dif-
degree of fi brosis and regenerative nodules that range in
ferential diagnoses include hepatocellular adenoma and
size with considerable architectural distortion. Cirrhosis
hepatocellular carcinoma (see Table 18.3).
requires a histologic examination for the diagnosis. The
nodules of cirrhosis may be biopsied when the mass lesion
is suspected of malignancy.
PRIMARY HEPATIC NEOPLASMS
Cytopathologic Features of Cirrhosis
The aspirates show variable cellularity, with liver cells HEMANGIOMAS
forming varying-sized trabeculae. Nuclear pleomorphism
Hemangiomas are the most common benign tumors of
and atypia range from minimal to marked, mimicking
the liver. Generally asymptomatic, they are identified as
hepatocellular carcinoma. A helpful feature is the pres-
incidental findings when the patients are being examined
ence of bile duct epithelium in cirrhosis. Also, the tissue
for a suspicion of cancer. Although a typical pattern in
fragments of hepatocytes are often irregular with jagged
sonography includes solitary, homogenous hyperechoic
margins and lack transgressing capillaries and an endothe-
lesions with a diameter of less than 3 centimeters, atypi-
lial envelope. Fragments of fibrotic stroma and lymphoid
cal sonographic patterns are difficult to differentiate from
cells may accompany aspirates of cirrhosis.
primary or secondary malignancy. An FNA biopsy is per-
formed under such circumstances.
FOCAL NODULAR HYPERPLASIA The aspiration biopsy yields mostly blood and bland
tissue fragments of fibrous tissue and endothelial cells and
Focal nodular hyperplasia is a tumor-like condition of the
spindle cells of stromal origin. There are no specific cyto-
liver of unknown etiology and pathogenesis. Some con-
logic findings for hemangiomas.
sider it a hamartomatous process.
The lesion is generally solitary and, on CT scan, ap-
pears as a well-delineated mass lesion with a central area HEPATOCELLULAR ADENOMA
of low attenuation corresponding to the central fibrotic
Hepatocellular adenomas are benign neoplasms aris-
scar seen in the surgically resected specimen. These lesions
ing from hepatocytes. The development of these tumors
are generally an incidental finding.
is related to a prolonged use of oral contraceptives for
Grossly, the nodules could be large with a central scar
more than five years. Hepatocellular adenomas are large,
harboring a large feeding vessel. The cut surface, although
sharply demarcated, completely or partially encapsulated,
well-demarcated, is nonencapsulated with a lobular ap-
and consist of morphologically normal or enlarged hepa-
pearance. Histologically, focal nodular hyperplasia shows
tocytes. The cytoplasm may be clear, reflecting glycogen
lobules of benign hepatocytes with minimal atypia and
or fat content. Hepatocellular adenomas are generally
associated Kupffer cells that are separated by bands of
A B
Figs. 18.1A and B. FNA of focal nodular hyperplasia. A: The aspirate is very cellular, consisting of tissue fragments
with a trabecular pattern (low power). B: Higher magnification showing very uniform round to polygonal hepatocytes
with well-defined cell borders and small central nuclei. The cytoplasm is pale to vacuolated. Bile duct epithelium was
present in other fields. The diagnosis of focal nodular hyperplasia cannot be made from cytologic specimens.
A B
Figs. 18.2A and B. FNA of hepatocellular adenoma. A: Low power showing branching trabeculae of hepatocytes.
B: Higher magnification shows the trabeculae are thin. The nuclei of the hepatocytes are uniform and lack targetoid
macronucleoli. No bile ducts were present in the aspirate.
solitary and large at sizes of up to 10 centimeters; how- orange to red with areas of necrosis. Several morphologic
ever, multiple adenomas have also been described. Degen- patterns of HCC are described, characterized by variable
erative changes with necrosis, hemorrhage, and rupture growth patterns and degrees of differentiation such as
may be seen. Another key feature described is the pres- well-differentiated, moderately differentiated, and poorly
ence of haphazardly distributed arteries and thin-walled differentiated. The most common growth pattern is tra-
veins. becular. The trabeculae of malignant hepatocytes may be
narrow (microtrabecular, 3 cells thick or more) or broad
Cytopathologic Features of Hepatocellular Adenoma (macrotrabecular) and are enveloped by an endothelial
lining. Necrosis in macrotrabeculae will form gland-
Aspiration biopsy of hepatocellular adenoma yields a cel- like spaces simulating an adenocarcinoma. An acinar or
lular aspirate containing benign-appearing hepatocytes pseudoglandular pattern occurs with a bile canaliculus
with a microtrabecular pattern and endothelial lining (see forming a lumen plugged with bile. HCC can have a solid
Table 18.3; Figs. 18.2A and B). The tumor cells show min- or papillary pattern. The stroma is generally scant but
imal nuclear atypia and may contain prominent nucleoli. may be abundant in sclerosing fibrolamellar types. The
Bile duct epithelium is conspicuously absent, unlike in malignant hepatocytes may be large and polygonal in
focal nodular hyperplasia. well-differentiated carcinoma but small with a high N/C
Differential diagnoses include focal nodular hyper- ratio in poorly differentiated types. The latter may contain
plasia and well-differentiated hepatocellular carcinoma spindle, giant, and clear cells. The cytoplasm of HCC cells
(see Table 18.3). may be scant or abundant and granular or vacuolated due
to fatty change. It may contain bile, inclusions such as
alcoholic hyaline, and eosinophilic inclusion bodies sur-
HEPATOCELLULAR CARCINOMA
rounded by a clear halo. The microscopic appearance of
Hepatocellular carcinomas (HCC) are rare in the United HCC is variable not only from one tumor to another but
States, with an incidence of one per 10,000 of general within the same tumor as well. Such a diverse pattern
population but make up 80% of primary hepatic malig- is also presented in cellular material obtained by FNA
nancy. It is the most common and fatal malignant neo- biopsy.
plasm in the Orient and parts of South Africa. Hepato-
cellular carcinomas usually arise in the background of a Cytopathologic Features
diseased liver (e.g., cirrhosis), chronic active hepatitis B
The cytopathologic features of hepatocellular carci-
and C, hemochromatosis, chronic cholestatic conditions,
noma, in most instances, are very characteristic, allow-
exposure to toxins such as Thorotrast and vinyl chloride,
ing easy recognition (Table 18.2; Figs. 18.3 to 18.13).
vascular diseases such as Budd–Chiari syndrome, glyco-
The aspirates are generally very cellular, characterized
gen storage disease, and certain parasitic diseases.
by branching and anastomosing trabeculae of varying
thickness (Fig. 18.3). The aspirates also contain syncy-
tial tissue fragments without any architectural configu-
Grossly, HCC may be solitary, massive, diffuse, or multi- rations. These trabeculae and the syncytial tissue frag-
centric with a variegated appearance from bright yellow– ments are traversed by streaming capillaries, which are
TABLE 18.2 CYTOPATHOLOGIC FEATURES OF HEPATOCELLULAR CARCINOMA
Cellularity Generally marked (low in sclerosing type or fibrolamellar type)
Presentation Neoplastic cells isolated, in loosely cohesive groups, or in tissue fragments with various architectural configurations
Architecture Syncytial arrangement with any architectural pattern; microtrabecular (up to 5 cells thick) or macrotrabecular
of the Tissue with branching; acinar or pseudoacinar pattern; smooth outline of tissue fragments invested by endothelial
Fragments cells; sinusoidal capillaries and proliferating endothelial cells traversing the tissue fragments
Cells Variable size, small, large, to giant forms, round to polygonal, rare spindle forms; cell borders sharp, well-
defined in well-differentiated tumors, indistinct in poorly differentiated HCC; high N/C ratios
Nucleus Single, binucleation, or multinucleation, central or eccentric round, oval, to irregular with considerable
variation in size; fine to coarsely granular chromatin with excessive clearing of parachromatin; single/multiple
macronucleoli and/or micronucleoli, or prominent central cherry-red macronucleolus with targetoid pattern;
intranuclear cytoplasmic inclusions
Cytoplasm Variable, scant in poorly differentiated tumors, abundant in well-differentiated tumors; clear, pale, delicate, to
dense or granular; bile, eosinophilic hyaline bodies surrounded by clear halos or alcoholic hyaline (eosinophilic
granular material)
Background Large numbers of bare neoplastic cell nuclei; benign hepatocytes may be present
Immunoprofile Positive reactivity to Hep Par-1; low molecular weight keratin; ␣-fetoprotein (AFP) ⫹/⫺; canalicular pattern
with polyclonal CEA and CD10
Differential Well-differentiated hepatocellular carcinoma

Diagnoses Reactive hepatocytes
Focal nodular hyperplasia
Hepatocellular adenoma
Poorly differentiated hepatocellular carcinoma
Poorly differentiated adenocarcinoma/squamous carcinoma
Renal cell carcinoma
Neuroendocrine tumors (pheochromocytoma/carcinoid tumors)
Malignant melanoma
Adrenal cortical carcinoma
easily recognized because of the spindly endothelial lin- cytoplasm, the cell membranes disrupt easily with bare
ing (Fig. 18.4). The tissue fragments are also enveloped nuclei in the background (Fig. 18.13). Rarely, hepatocel-
by endothelial cells—a diagnostic feature imparting a lular carcinomas may contain multinucleated malignant
smooth, rounded contour (Fig. 18.5C). The neoplastic giant cells (Fig. 18.9). Poorly differentiated hepatocellu-
cells are usually large and round to polygonal with well lar carcinomas show a solid growth pattern with marked
to poorly defined cell borders. Variation in their size is nuclear atypia.
frequent. Their cytoplasm is abundant, granular to dense, Certain key features allow an accurate diagnosis
and sometimes clear. The nuclei are pleomorphic and of hepatocellular carcinoma (Fig. 18.9). These features
variable in size with smooth to irregular nuclear mem- include malignant polygonal cells with large central nu-
branes. The N/C ratios vary, depending on the amount clei arranged in nests and trabeculae being enveloped
of cytoplasm. The chromatin is granular with excessive by endothelial cells or capillaries traversing through
parachromatin clearing. Multiple micronucleoli and the tissue fragments of neoplastic cells and the presence
targetoid macronucleoli (Figs. 18.6 and 18.7) are charac- of bile.
teristic of hepatocellular carcinomas. Intranuclear inclu- Morphologic variants include the fibrolamellar type,
sions are frequent (Fig. 18.8). Binucleation is commonly which is characterized by marginal cellularity due to fibrous
present. The cytoplasm may contain eosinophilic inclu- stroma. The cells are discrete to loosely cohesive, large, and
sions (Fig. 18.10) and may demonstrate bile (Figs. 18.11 polygonal with abundant granular cytoplasm (Figs. 18.14
and 18.12). The background can be variable. With clear and 18.15), and they stain strongly with CK7.
Cytopathologic Features of Hepatocellular Carcinoma (See Figs. 18.3 to 18.15)
A B
Figs. 18.3A to C. FNA of hepatocellular carcinoma. A: Low power

showing a very cellular aspirate with anastomosing broad trabe-
culae. Endothelial envelope can be appreciated even at low power
(arrows). B: Higher magnification of the trabeculae being enveloped
by endothelial lining (arrows). C: Syncytial tissue fragments and tra-
C beculae with an envelope of endothelial cells (arrows).
A B
Figs. 18.4A to B. FNA of hepatocellular carcinoma. A: Low power showing a very cellular aspirate with syncytial tis-
sue fragments with branching and anastomosing. Capillaries can be seen traversing through the tissue fragments even
at this power (arrows). B: The tissue fragment of large malignant hepatocytes. Note the large nuclei and prominent
nucleoli. A capillary with endothelial lining is visible along the tissue fragment (arrows). (continued)
Figs. 18.4C. (continued) C: A characteristic pattern of hepatocel-

lular carcinoma with large round to polygonal cells containing ma-
lignant nuclei and targetoid macronucleoli. Note the endothelial cell
C lining of the capillary (arrow).
A B
C D
Figs. 18.5A to D. FNA of hepatocellular carcinoma. A: Syncytial tissue fragment of malignant hepatocytes with
marked crowding and overlapping of large nuclei containing very prominent macronucleoli. B: A broad trabeculae
with smooth external contour and covering of endothelial cells (arrow). Note the intracytoplasmic bile (arrow heads).
C: Different field depicting loosely cohesive malignant hepatocytes with poorly defined cell borders. Their nuclei are
large and pleomorphic in size with excessive parachromatin clearing, giving the nucleus an empty look. The macronu-
cleoli are very striking. The nuclear membranes are irregular. D: Diffuse staining of the cytoplasm by ␣-fetoprotein.
Fig. 18.6. FNA of hepatocellular carcinoma. Pleomorphic malig- Fig. 18.7. FNA of hepatocellular carcinoma. Pleomorphic ma-
nant hepatocytes. Note the targetoid macronucleoli (arrows) and a lignant hepatocytes with abundant granular cytoplasm. There is
capillary (arrow head). extreme variation in size and shape of the cells. Their cell borders
are well-defined with variable cytoplasm from scant to abundant.
The nuclei likewise vary in size. Note the multiple micro and
macronucleoli.
Fig. 18.8. FNA of hepatocellular carcinoma. The malignant hepa-

tocytes are loosely cohesive and much smaller in size. The cell bor-
ders are well-defined. Their cytoplasm is pale and vacuolated. The
nuclei are large and an occasional one shows intranuclear inclusion
(arrow).
A B
Figs. 18.9A and B. FNA of a hepatocellular carcinoma with multinucleated giant cells. A: Low power. B: Higher
magnification
Fig. 18.10. This hepatocellular carcinoma consists of small round Fig. 18.11. The cells of this hepatocellular carcinoma are medium-
cells with poorly defined cell borders and scant cytoplasm. Nuclei sized, present a pseudoacinar pattern. Some cells contain bile in the
contain prominent nucleoli. cytoplasm (arrows).
Fig. 18.12. FNA hepatocellular carcinoma. The malignant cells are

medium to large-sized with well-defined cytoplasm and contain
variable, granular cytoplasm. The nuclei are pleomorphic in size
with finely granular chromatin and prominent nucleoli.
A B
Figs. 18.13A to B. FNA of a hepatocellular carcinoma. A: Low power view of a cellular aspirate presenting
a dispersed cell pattern. B, C: Higher magnification showing mostly stripped nuclei that exhibit prominent
macronucleoli. (continued)
Fig. 18.14. FNA of a histologically confirmed fibrolamellar variant Figs. 18.15. FNA of a hepatocellular carcinoma, fibrolamellar
of hepatocellular carcinoma. variant.
Immunoprofile HCC (Figs. 18.16 and 18.17). A well-differentiated hepa-

tocellular carcinoma must also be differentiated from
The cells of hepatocellular carcinoma are strongly immu-
focal nodular hyperplasia and hepatocellular adenoma
noreactive to Hep Par-1 (hepatocyte paraffin-1) with high
(Table 18.3; Figs. 18.1 and 18.2). The poorly differenti-
specifi city. Their reactivity to ␣-fetoprotein is not very
ated hepatocellular carcinomas (Table 18.4; Fig. 18.18)
consistent. Other diagnostically useful antibodies are
present morphologic overlap with poorly differentiated
polyclonal CEA, CD10, and CD34.
metastatic carcinomas originating from the pancreas (Fig.
18.19), the lung (Fig. 18.20), neuroendocrine tumors (Fig.
18.21), malignant melanomas (Fig. 18.22), Hürthle cell
carcinoma of the thyroid (Fig. 18.23A), and adrenal corti-
DIAGNOSTIC DIFFICULTIES AND cal carcinoma (Fig. 18.23B). HCCs with clear cytoplasm
DIFFERENTIAL DIAGNOSES are considerably diffi cult to differentiate from renal cell
carcinomas (Fig. 18.24). Occasionally, poorly differenti-
The diagnostic diffi culties result from several factors. ated urothelial carcinomas present similar diagnostic dif-
The adequacy of the specimen is of prime importance. ficulties (Fig. 18.25).
Although the aspirates of hepatocellular carcinomas tend
to be adequately cellular, those with fibrosis or the fibrola-
CHOLANGIOCARCINOMA
mellar variant may be paucicellular, precluding a definite
diagnosis. Also, the aspirate can be very bloody, obscuring Cholangiocarcinomas (a term that refers to intrahepatic
the cellular material. Reactive/regenerating hepatocytes bile duct carcinoma) are malignant neoplasms of the
with variable nuclear atypia may present considerable dif- intrahepatic bile duct epithelium and comprise 8.2%
fi culties in differentiating them from well-differentiated of all primary hepatic malignancies. Histologically and
TABLE 18.3 DIFFERENTIAL DIAGNOSES OF WELL-DIFFERENTIATED HEPATOCELLULAR CARCINOMA
Focal Nodular Hepatocellular Hepatocellular Carcinoma,

Reactive Hepatocytes Hyperplasia Adenoma Well-Differentiated
Cellularity Generally high Generally high Generally high Generally high
Presentation Cells isolated, in loosely Cells isolated, in loose Cells isolated, in Cells isolated, in loosely cohesive
cohesive groups and in aggregates or in tissue aggregates or in groups or in tissue fragments
tissue fragments fragments tissue fragments
Architecture Thin trabeculae; Varying-sized, Syncytial Syncytial arrangement—micro

of the Tissue monolayered sheets monolayered sheets arrangement with or macrotrabecular, or three-
Fragments with jagged edges; lack with irregular jagged microtrabecular or dimensional tissue fragments
endothelial envelope or edges; lack endothelial three-dimensional enveloped by endothelial cells; acinar
transversing capillaries envelope or transversing pattern, large or pseudoacinar pattern; transversing
capillaries branching fragments capillaries and endothelial cells
within tissue fragments
Cells Variable in size; well- Uniformly benign, Size approach that of Variable in size, large polygonal;
defined cell borders; N/C normal-sized; well- normal hepatocytes, well-defined cell borders; high N/C
ratio variable but low defined cell borders; low uniform; N/C ratio ratio
N/C ratio low
Nucleus Variable in size, round, Uniform, normal- Round, small,

range of normal to very sized, smooth nuclear uniform, smooth
atypical with transition membranes; finely nuclear membranes;
forms; chromatin finely granular chromatin; lack nucleoli ⫹/⫺
granular to compact and prominent nucleoli
smudgy; nucleoli ⫹/⫺
Cytoplasm Abundant, granular, Abundant granular, may Abundant, pale Abundant, granular, pale to dense,
vacuolated lipofuscin, be vacuolated; bile ⫹/⫺ due to increased vacuolated; bile ⫹/⫺
hemosiderin pigment; glycogen content;
bile ⫹/⫺ bile ⫹/⫺
Background Variable numbers of bile Variable numbers of bile Lack bile duct Lack bile duct epithelium; stripped
duct epithelial; large duct epithelium epithelium; nuclei with malignant features
numbers in cirrhosis stripped nuclei
with benign
features
Necrosis absent Necrosis absent Necrosis frequent Necrosis ⫹/⫺
Differential Diagnoses of Hepatocellular Carcinoma (See Figs. 18.16 and 18.17)
A B
Figs. 18.16A to B. A, B: Reactive hepatocytes can be very pleomorphic and show mild to severe nuclear atypia. They
lack the typical nuclear morphology of hepatocellular carcinoma. (continued)
759
Figs. 18.16C. (continued) C: Compare this hepatocellular carci-

C noma with the reactive hepatocytes.
Fig. 18.17. Loosely cohesive and discrete reactive hepatocytes from

reactive/regenerative nodules, as confirmed by core needle biopsy.
Differential Diagnoses of Poorly Differentiated Hepatocellular Carcinomas (See Figs. 18.18 to 18.25)
A B
Figs. 18.18A and B. Hepatocellular carcinoma. A: Low power showing anastomosing trabeculae. B: Higher
magnification. The cells are medium-sized round to polygonal with well-defined cell borders, abundant, granular to
dense cytoplasm. The nuclei are central to eccentric and show prominent macronucleoli and intranuclear inclusions.
TABLE 18.4 DIFFERENTIAL DIAGNOSES OF POORLY DIFFERENTIATED HEPATOCELLULAR CARCINOMA
Poorly Differentiated Poorly Differentiated Poorly Differentiated Neuroendocrine

Hepatocellular Carcinoma Adenocarcinoma Squamous Carcinoma Malignant Melanoma Renal Cell Carcinoma Tumor
Cellularity Highly cellular Highly cellular Highly cellular Highly cellular Highly cellular Highly cellular
Presentation Malignant cells isolated, Malignant cells isolated, Malignant cells Malignant cells, most Malignant cells isolated, Malignant cells
in loosely cohesive groups, in loosely cohesive isolated, in loosely isolated or in loosely in loosely cohesive isolated, in loosely
or in syncytial tissue groups or in syncytial cohesive groups, or cohesive groups; tissue groups, or in syncytial cohesive groups, or
fragments, smooth outline tissue fragments with or in syncytial tissue fragments not present tissue fragment in syncytial tissue
enveloped by endothelial without acinar pattern; fragments without any with anastomosis; fragments
cells, transversing no endothelial envelope; architectural pattern; monolayered, or
capillaries ⫹/⫺ transversing capillaries transversing capillaries with crowding and
rare ⫹/⫺; no endothelial overlapping; trabecular
envelope or occasionally papillary
Cells Round, cuboidal to Pleomorphic in size, Pleomorphic in size, Pleomorphic in size, round, Pleomorphic, round Small, slightly
polygonal, giant forms round, cuboidal, giant round, cuboidal to to polygonal with giant to polygonal; poorly pleomorphic with
⫹/⫺; well to poorly defined forms ⫹/⫺; poorly polygonal; well- forms; well-defined cell defined cell borders; occasional giant
cell borders; high N/C defined cell borders; high defined cell borders; borders; high N/C ratios N/C ratios moderately forms; well to poorly
ratios N/C ratios high N/C ratios increased defined cell borders;
N/C ratios high
Nucleus Pleomorphic in size, round Pleomorphic in size, Pleomorphic in size, Pleomorphic in Round, central, Round, central,
to irregular, finely granular round central to eccentric, round, central location, size, binucleation to mild variation in mild variation in
chromatin with excessive multinucleation, smooth nuclear membrane multinucleation, central to size, smooth nuclear size, smooth nuclear
parachromatin clearing, to irregular nuclear smooth to irregular; eccentric smooth to irregular membranes; finely membrane; salt
multiple nucleoli with membranes; finely parachromatin nuclear membranes; fine to granular chromatin, & pepper type
large targetoid forms; granular chromatin, clearing, multiple coarsely granular chromatin, multiple micronucleoli chromatin granules;
intranuclear cytoplasmic parachromatin clearing, micronucleoli and/ parachromatin clearing, or micronucleus; micronucleoli;
inclusions multiple micronucleoli; or macronucleoli; multiple micronucleoli; intranuclear cytoplasmic no intranuclear
intranuclear cytoplasmic intranuclear intranuclear cytoplasmic inclusions ⫹/⫺ cytoplasmic
inclusions cytoplasmic inclusions inclusions inclusions
Cytoplasm Variable pale, vacuolated, Variable, scant to Variable, pale to Variable, pale to dense, Variable, pale, granular, Scant, pale
granular to dense, hyaline abundant, pale to dense; dense; endoplasm/ cytoplasmic fading; dusting vacuolated; cytoplasmic
globules or alcoholic cytoplasmic (secretory) ectoplasm; individual of cytoplasm with brown glycogen and lipid ⫹/⫺;
hyaline; bile ⫹/⫺; mucin ⫺ vacuoles ⫹/⫺; mucin cell keratinization discoloration; melanin mucin ⫺
stain ⫹/⫺ ⫹/⫺; mucin stain ⫺ pigment ⫹/⫺; mucin stain ⫺
Background Bare nuclei Necrosis ⫹/⫺ Necrosis ⫹/⫺ Necrosis ⫹/⫺ Rare nuclei, bloody Bare nuclei, bloody
to necrotic
Immunoprofile Hep Par-1 ⫹ ␣-fetoprotein Cytokeratin ⫹; Cytokeratin ⫹ CEA ⫹ HMB-45 ⫹ S100 protein ⫹ Cytokeratin ⫹ CEA ⫺ Chromogranin
⫹/⫺; ␣-antitrypsin ⫹/⫺; polyclonal CEA ⫹ EMA p-63 ⫹ Melan-A vimentin ⫹ low ⫹ NSE ⫹
polyclonal CEA ⫹ for ⫹ BerEP4 ⫹ molecular weight synaptophysin ⫹
bile duct canaliculi; keratin ⫹ RCC antibody CEA ⫹ Cytokeratin
low molecular weight ⫹ CD10 ⫹ ⫹ TTF-1 CD20 ⫺
cytokeratin ⫹ EMA ⫹
CD10 ⫹ canalicular pattern
A B
Figs. 18.19A and B. FNA of a liver mass A: Low power showing a cellular aspirate with branching tissue fragments.
B: Higher magnification depicting a pleomorphic malignant cell population. With morphology reminiscent of hepato-
cellular carcinoma, this lesion was subsequently proven to be metastatic pancreatic adenocarcinoma.
A B
Figs. 18.20A and B. FNA of a liver mass. A: Low power showing a cellular aspirate with branching syncytial tissue
fragments of malignant cells. Note the capillaries traversing the trabeculae. The pattern is highly suggestive of hepa-
tocellular carcinoma. B: Higher magnification showing pleomorphic malignant cells with small, to giant forms. Their
shapes vary from round, polygonal to spindle shape and the cytoplasm is dense and abundant. This was confirmed as
metastatic poorly differentiated squamous carcinoma of the lung.
A B
Figs. 18.21A and B. FNA of a liver metastasis of intestinal neuroendocrine carcinoma (carcinoid). A: Low power
view showing a cellular aspirate consisting of tissue fragments of small cells B: Higher magnification showing a
dispersed cell pattern sometimes seen in hepatocellular carcinomas.
A B
Figs. 18.22A and B. A: Metastatic malignant melanoma. The melanoma cells are large, polygonal with abundant
cytoplasm. In the absence of melanin pigment differentiation between melanoma cells and hepatocellular carcinoma
can be difficult without immunostains. B: Note the morphologic similarity to hepatocellular carcinoma.
A B
Figs. 18.23A and B. A: Metastatic Hürthle cell carcinoma of the thyroid. Without a known history of thyroid cancer,
the cytomorphology of this tumor can be mistaken for a hepatocellular carcinoma. B: Adrenal cortical carcinoma
with large pleomorphic malignant cells.
A B
Figs. 18.24A and B. A: Metastatic renal cell carcinoma with large polygonal cells and abundant cytoplasm can be
misinterpreted as liver cell carcinoma. B: FNA of a liver cell carcinoma showing morphologic overlap with renal cell
carcinoma.
cytologically, cholangiocarcinomas present conventional Grossly, the tumor foci may be small and diffuse or large
patterns of an adenocarcinoma and cannot be differenti- and hemorrhagic. Several growth patterns have been de-
ated from a metastatic adenocarcinoma on morphologic scribed including sinusoidal, cavernous, nodulopapillary,
grounds alone (Figs. 18.26A and B). Cholangiocarcino- and solid spindle cell.
mas are a diagnosis of exclusion. The aspirates show varying numbers of spindle to
epithelioid cells with considerable nuclear pleomorphism,
including bizarre forms. The cells of hemangioendothe-
ANGIOSARCOMA/
lioma typically stain with CD31, CD34, and factor VIII.
HEMANGIOENDOTHELIOSARCOMA
The differential diagnosis includes spindle cell lesions in
Primary sarcomas of the liver are rare, but among them, liver aspirates (Figs. 18.27A and B).
angiosarcoma is the most common, occurring in older
men and associated with exposure to a variety of chemi-
HEPATOBLASTOMA
cal toxins such as Thorotrast, vinyl chloride, and arsenic,
and radiation. Hepatoblastoma is a malignant tumor of embryonic or
Patients with angiosarcoma present with hepato- fetal hepatocytes that often contains mesenchymal ele-
megaly, ascites, jaundice, and thrombocytopenia. Filling ments and occurs prior to three years of age. For detailed
defects are common, thus mimicking a metastatic disease. information, please refer to Chapter 25.
A B
Figs. 18.25A and B. Metastatic transitional cell carcinoma. Urothelial carcinomas that metastasize in distant organs
are usually poorly differentiated and consist of markedly pleomorphic malignant cells. A primary source of urothelial
carcinoma cannot be determined from their cytology, without a clinical documentation.
Primary Cholangiocarcinoma (See Fig. 18.26)
A B
Figs. 18.26A and B. FNA cholangiocarcinoma. Both images depict features of a conventional adenocarcinoma.
Cholangiocarcinomas present no specific diagnostic features that would allow their differentiation from other
adenocarcinomas.
METASTATIC MALIGNANCY One of the difficult areas in aspiration cytology is the

identifi cation of metastatic lesions from an unknown or
The liver is the most common site in the abdomen to be
occult primary. In fact, in 12 to 20% of the patients with
involved by metastatic cancers of both epithelial and non-
symptoms of metastatic disease, the primary site is un-
epithelial types. The secondary neoplasms in the liver out-
known. While evaluating an aspirate from such a case,
number the primary malignancies. Most metastases are
the first step is to identify the malignant cells and then to
bloodborne, spread via the portal vein from abdominal
categorize them as adeno, squamous, small cell, malig-
organs or via the hepatic artery from extra-abdominal
nant melanoma, lymphoma, neuroendocrine, or sarcoma.
organs. Tumors of the stomach, the pancreas, the gall
Architectural patterns and functional differentiation of-
bladder, and extrahepatic bile ducts may involve the liver
ten provide clues to the primary site. Histochemical and
by direct extension. Hepatic metastases can be single or
immunocytohistochemical stains are often required.
multiple, with the latter pattern being more frequent.
The majority of metastatic malignancies are easily
identified from cytological specimens, particularly with a
METASTATIC ADENOCARCINOMAS
known primary site (Figs. 18.28 to 18.37). Comparison
with the original histologic material is very helpful and Adenocarcinomas are the most common malignant tumors
should always be made. to metastasize to the liver. They frequently originate from
Hemangioendotheliosarcoma (See Fig. 18.27)
A B
Figs. 18.27A and B. Hemangioendothelial sarcoma. The malignant cells are few, scattered, and can be easily
overlooked (arrows).
Metastatic Malignancy to the Liver (See Figs. 18.28 to 18.37)
Fig. 18.28. Metastatic adenocarcinoma from breast. Fig. 18.29. Metastatic adenocarcinoma of the prostate.
Fig. 18.30. Metastatic adenocarcinoma of the colon. Fig. 18.31. Metastatic keratinizing squamous carcinoma.
Fig. 18.32. Metastatic adenocarcinoma of the pancreas. Fig. 18.33. Metastatic neuroendocrine carcinoma, high-grade (small
cell carcinoma).
Fig. 18.34. FNA of a liver mass showing a small cell carcinoma. No Fig. 18.35. Metastatic gastric neuroendocrine carcinoma (atypical
primary tumor was identified. This could be a primary small cell carcinoid tumor).
carcinoma of the liver.
Fig. 18.36. Metastatic Hodgkin lymphoma. Fig. 18.37. Metastatic leiomyosarcoma of the stomach.
the lung (24.8%); the gastrointestinal tract, particularly the cherry–red macronucleoli; and intranuclear cytoplasmic
colon (15.7%); the stomach (6%); the pancreas (10.9%); inclusions are very difficult to differentiate from HCCs
the breast (10%); and the prostate (rare). Many of these without resorting to immunostains such as S100 protein,
present typical morphologic features. For example, colonic HMB-45, and Melan-A (Fig. 18.22A).
adenocarcinomas have elongated cells with cigar-shaped
nuclei with a picket fence pattern, large papillary fronds, RENAL CELL CARCINOMA
mucinous background, and necrosis (Fig. 18.30). Small
signet-ring malignant cells suggest gastric primary. Most Renal cell carcinoma with large, round to polygonal cells
metastatic adenocarcinomas present a conventional cyto- containing clear or granular cytoplasm resembles HCC.
morphologic pattern and syncytial tissue fragments with Both may show round, central nuclei with prominent
or without an acinar pattern and variably sized nuclei. targetoid macronucleoli (Fig. 18.24A).
Cells derived from prostatic or breast adenocarcinomas Adrenal cortical carcinoma also presents a morpho-
(Fig. 18.28) are small to medium-sized with prominent logic overlap with cells of HCC. The cells of adrenal cor-
macronucleoli. The diagnosis of metastatic prostatic ade- tical carcinoma are large and polygonal, have abundant
nocarcinoma (Fig. 18.29) should be supported by immu- cytoplasm, and pleomorphic irregular nuclei with macro-
nostain with a prostatic-specific antigen. nucleoli (Fig. 18.23B).
NEUROENDOCRINE TUMORS
SQUAMOUS CARCINOMAS
Neuroendocrine tumors of all grades, particularly from
Metastatic squamous carcinomas to the liver originate the gastrointestinal tract, the pancreas, and the lung fre-
from the bronchus, the larynx, the esophagus, the cer- quently metastasize to the liver (Figs. 18.33 to 18.35). Pri-
vix, or the vagina. A well-differentiated carcinoma with mary neuroendocrine carcinoma of the liver is extremely
keratinization (Fig. 18.31) is easily identifi ed for type. A rare (Fig. 18.34). The characteristic morphology of all
poorly differentiated squamous carcinoma that shows no neuroendocrine neoplasms allows easy recognition. Occa-
functional differentiation shares some morphologic fea- sionally, HCCs with bare nuclei may present morphologic
tures with poorly differentiated HCC. Cytologic differ- similarity (Fig. 18.21). The liver is also a frequent site for
entiation may be extremely difficult, particularly with an neoplasms such as neuroblastomas in the pediatric age
occult primary (Figs. 18.20A and B). group. Immunocytochemical studies with neuroendocrine
markers are helpful. Several different types of neoplasms
MALIGNANT MELANOMA present with a small cell pattern mimicking neuroendo-
crine tumors. These include neuroendocrine carcinomas,
Patients with malignant melanoma frequently harbor malignant lymphoma, malignant melanoma, and adeno-
metastatic lesions in the liver. Malignant melanomas are carcinomas with small cell pattern.
known to make their appearance several years after the
initial diagnosis has been made. In some instances, a his-
METASTATIC MALIGNANCY FROM
tory of melanoma is not available. The presence of melanin
OTHER SOURCES
pigment in the malignant cells allows accurate recognition.
Amelanotic lesions composed of large polygonal cells with Urothelial (transitional cell) carcinomas that metastasize
abundant cytoplasm; large, round nuclei with prominent are usually of high grade, presenting a very pleomorphic
cellular pattern and consisting of small to large, round Leiomyosarcomas

or polygonal to spindle cells, which are referred to as
Leiomyosarcomas originating in the gastrointestinal tract
cercariform cells (Figs. 18.25A and 18.25B). The nuclei
or the female genital tract frequently metastasize to the liver,
are pleomorphic with prominent nucleoli. Neoplasms
usually in the form of multiple, bulky nodules. The aspi-
of the thyroid that involve the liver include anaplastic,
rate shows spindle-shaped cells—occurring as isolated and
medullary, and Hürthle cell carcinomas (Fig. 18.23A).
in fascicles—containing cigar-shaped nuclei (Fig. 18.37).
Their incidence is extremely low.
Round to polygonal cells are seen in epithelioid forms. The
differential diagnosis is primary angiosarcoma. The diag-
MALIGNANT LYMPHOMA, nosis may be confirmed by positive immunoreactivity to
NON-HODGKIN TYPE AND HODGKIN vimentin and desmin and muscle-specific actin. The gas-
LYMPHOMA trointestinal stromal tumors may be difficult to separate
Malignant non-Hodgkin lymphoma and Hodgkin lym- from leiomyosarcoma without staining for CD117/c-kit.
phoma (Fig. 18.36) are known to involve the liver
secondarily. DIFFERENTIAL DIAGNOSES OF SPINDLE CELL
LESIONS IN THE LIVER
METASTATIC SARCOMAS
Spindle cell lesions are rare in liver aspirates, with the
Common soft tissue sarcomas that metastasize to the liver common ones being leiomyosarcomas and gastrointesti-
include GIST, leiomyosarcomas from the gastrointestinal nal stromal tumors, comprising 5% of metastatic lesions.
tract and the female genital tract, and rarely, soft tissue The diagnostic possibilities include hemangioma, granu-
sarcomas such as malignant fi brous histiocytomas and lomatous lesions, primary angiosarcoma, metastatic sar-
synovial sarcomas. comas, and fibrolamellar HCC.
SUGGESTED READINGS
Boucher LD, Swanson PE, Stanley MW, et al. Cytology of Kunz G Jr, Chung J, Ali SZ. Hepatocellular carcinoma-fibrolamel-
angiosarcoma. Findings in fourteen fine needle aspiration lar variant: Cytopathology of an unusual case. Diagn Cyto-
biopsy specimens and one pleural fluid specimen. Am J Clin pathol 2002;26:257–261.
Pathol 2000;114:210–219. Lau SK, Prakask S, Gellar SK, et al. Comparative histochemical
Centeno B. Pathology of liver metastases. Cancer Control 2006; profile of hepatocellular carcinoma, cholangiocarcinoma
13:13–26. and metastatic adenocarcinoma. Hum Pathol 2002;33:
Chhieng DC. Fine needle aspiration biopsy of liver–an update. 1175–1181.
World J Surg Oncol 2004;2:5. Rader AE, Avery A, Wait CL, et al. Fine needle aspiration biopsy
De Las Casas LE, Gokden M, Baker SJ, et al. Malignant melanoma diagnosis of gastrointestinal stromal tumors using morphology,
metastatic to the liver. A cytomorphologic comparative study to immunochemistry, and mutational analysis of c-kit. Cancer
identify reproducible criteria by fine needle aspiration biopsy. 2001;93:269–275.
Acta Cytol 2004;48:32–38. Saad RS, Luckaseviv TM, Naga CM, et al. Diagnostic value of Hep
Goodman ZD. Neoplasms of the liver. Mod Pathol 2007;20:S49–S60. Par-1, pCEA, CD10, and CD34 expression in separating hepa-
Guy CD, Yuan S, Ballo MS. Spindle cell lesions of the liver: tocellular carcinoma and metastatic carcinoma in fine needle
Diagnosis by fine needle aspiration biopsy. Diagn Cytopathol aspiration cytology. Diagn Cytopathol 2004;30:1–6.
2001;25:94–100.
19 PANCREAS (EXFOLIATIVE
AND ASPIRATION)
The specimens for the cytologic diagnosis of pancreatic It is often associated with fl orid ductal hyperplasia
lesions are usually obtained via FNA biopsies performed with or without nuclear atypia and is extremely dif-
under radiologic guidance. Specimens are also obtained fi cult to differentiate cytologically from well-differen-
by brushing the pancreatic duct or the bile duct and aspi- tiated ductal adenocarcinoma.
rating the duct contents via endoscopic retrograde cho- ● Ductal adenocarcinomas with a small cell pattern
langiopancreatography (ERCP) (Table 19.1). The most often exhibit morphologic similarities to neuroendo-
common indication for the cytologic examination of vari- crine tumors, solid pseudopapillary tumors, acinar cell
ous types of specimens is the discovery of a mass lesion of carcinomas, and malignant lymphomas.
the pancreas. It is primarily aimed at confirming the clini- ● Acinar cell carcinomas bear a strong resemblance to
cal and/or radiologic diagnosis of a pancreatic adenocar- benign acinar tissue. Cytologic differentiation between
cinoma as well as other types of malignant or potentially the two may be very challenging.
malignant lesions such as acinar cell carcinoma, solid ● Cystic lesions comprise a wide group of different
pseudopapillary tumors (SPT), neuroendocrine carcino- diagnostic entities and include nonneoplastic and
mas, cystic neoplasms, and metastatic malignancy. benign as well as malignant lesions. Since their treat-
With advances in technology, several modalities are ment modalities are different, they must be accurately
available for obtaining cytologic specimens (Table 19.1); identified.
each has its merits and drawbacks with considerable varia- ● FNA biopsy performed under EUS is a technically dif-
tions in sensitivity and specificity. Endoscopic ultrasound ficult procedure requiring special training and skills for
guided biopsies (EUS) have lately been very popular because producing adequate specimens. Adequacy and proper
they are safe and practical with a reported diagnostic speci- sampling is, thus, operator-dependant.
ficity of 100% and sensitivity of 80%. Their use is on the ● Likewise, satisfactory interpretation requires experi-
rise, and they have almost completely replaced CT-guided enced cytopathologists to avoid the diagnostic pitfalls.
transabdominal biopsies in major medical centers. An ad- ● Differentiation of Intraductal Papillary Mucinous
ditional advantage of the EUS-guided procedure is the flex- Neoplasms (IPMN) from mucinous cystic neoplasm
ibility to perform biopsies of the gastrointestinal stromal (MCN) is practically impossible from cytologic sam-
lesions and of peripancreatic, periesophageal, and retroperi- ples. This is because the fi nal diagnosis of the latter
toneal lesions. Organs such as the liver, the adrenal glands, entity requires the presence of ovarian stroma, which
and the kidneys can also be sampled for staging purposes. can only be identifi ed from a surgically excised speci-
The use of exfoliative cytology utilizing the specimens men. Also, IPMNs communicate with the ductal
obtained by endoscopic retrograde cholangiopancreatog- system.
raphy (ERCP) is limited. The pancreatic lesions are not al- ● Since the aspiration biopsy needle is targeted via the
ways visualized. The specimens obtained by brushings are stomach or the duodenum in EUS-guided biopsies, the
often poorly cellular, and excess bile may obscure the cel- normal gastric or duodenal epithelium may be seen in
lular details. ERCP-obtained specimens are less sensitive. significant amounts and are often extremely difficult to
Diagnostic problems in the cytopathology (aspiration differentiate from low-grade lesions. Excess gastroin-
and exfoliative) of pancreatic lesions may be encountered testinal mucus may also be a diagnostic issue in cases
in many settings. Considerations must be given to the of mucinous lesions.
following: ● Mesothelial tissue fragments aspirated using a transab-
dominal approach can cause difficulties in the diagnosis
● Neoplasms arising in the pancreas may originate from of well-differentiated adenocarcinoma.
heterogenous sources but show morphologic overlap ● Some lesions are inherently hypo or acellular (e.g., cystic
(Table 19.2). or desmoplastic lesions).
● Chronic pancreatitis with fi brosis mimics malignancy ● A team approach with radiologists, gastroenterolo-
clinically, radiologically, and grossly (intraoperatively). gists, and cytopathologists is highly desirable.
769
TABLE 19.1 TYPES OF SPECIMENS FOR THE TABLE 19.2 SOURCE OF VARIOUS NEOPLASMS OF
CYTOLOGIC DIAGNOSIS OF PANCREATIC THE PANCREAS
LESIONS
Source Tumor Type
● Endoscopic ultrasound-guided (EUS) fine needle
aspiration biopsy of the pancreatic mass and peri- Exocrine cells
pancreatic lesions.
● Transabdominal percutaneous fine needle aspiration Duct Epithelial Cells Duct adenocarcinomas
biopsy under CT guidance. Benign and malignant cystic
● Intraoperative FNA. neoplasms
● Endoscopic brushings/washings of pancreatic duct,
ampulla and common bile duct and aspiration of the Acinar Cells Acinar cell carcinoma
duct contents via endoscopic retrograde pancreato-
cholangiography (ERCP). Uncertain Solid pseudopapillary tumor
Neuroendocrine Cells Neuroendocrine tumors

Pancreatoblastoma
TABLE 19.3 CHARACTERISTICS OF NORMAL COMPONENTS OF THE PANCREAS
Acinar Cells Ductal Cells Islet Cellsa

Presentation Mostly in varying-sized tissue Rarely isolated, in groups or in Normal islet cells are
fragments with acinar pattern; rarely tissue fragments with honeycomb rarely seen in aspirates
isolat ed; lobular pattern may be arrangement of cells; or strips with
evident palisading nuclei
Cells Small, triangular Cuboidal to tall columnar Round to oval
Cell Borders Well-defined Well-defined Poorly defined
Nucleus Round, oval, monomorphic Round, oval, monomorphic Round, oval,

monomorphic or mildly
pleomorphic
Nuclear Chromatin Granular to compact Finely granular Coarsely granular
Nucleolus Present Present Inconspicuous
Cytoplasm Abundant, granular Scant to moderate, pale to vacuolated Variable; clear to granular
a
Islet cell morphology from scrapings of a normal pancreas.
From Hidvegi D. Liver and Pancreas. Guide to Clinical Aspiration Biopsy. New York: Igaku-Shoin, 1988.
(Figs. 19.2C) while those obtained via the transabdominal

NORMAL COMPONENTS route contain mesothelium (Table 19.4).
The normal components of the pancreas in the cytologic

material obtained by needle biopsy or endoscopic brushings/
DUCT ADENOCARCINOMA
washings of the pancreatic–bile ducts include acinar tissue
OF THE PANCREAS
and duct epithelial cells. No basal/myoepithelial cells are
present in the pancreatic ducts. Islet cells are rarely identi-
fied, if at all. Their cytologic presentation is listed in Table Pancreatic adenocarcinomas are uncommon, comprising
19.3 and illustrated in Figures 19.1A and B and 19.2A 3% of all malignancies; yet, they are the fourth leading
and B. Some cytologic samples, particularly those obtained cause of cancer in the United States. They are slightly
via EUS, contain normal gastric and duodenal epithelium more common in males, occurring in the seventh to eighth
Chapter 19: Pancreas (Exfoliative and Aspiration) 771
A B
Figs. 19.1A and B. FNA pancreas. Normal pancreatic acinar tissue. A: Note the intact lobule composed of acini
(low power). B: Higher magnification showing intact acini composed of triangular cells with granular cytoplasm and
uniform small nuclei.
A B
Figs. 19.2A to C. A: Pancreatic duct brushings via ERCP, showing

tissue fragments of normal epithelial lining composed of cuboidal
to columnar cells. B: A tissue fragment of normal gastric mucosa in
EUS guided biopsy. C: A tissue fragment of normal duodenal mu-
C cosa in EUS guided biopsy.
TABLE 19.4 FREQUENT CONTAMINANTS IN CYTOLOGIC SPECIMENS OBTAINED

FOR THE EVALUATION OF PANCREATIC LESIONS
Contaminant
Technical Procedure (Cell Type) Cytopathologic Features
Percutaneous Transabdominal Mesothelial cells Varying-sized tissue fragments of mesothelial cells with a honeycomb
FNA Biopsy arrangement, two-dimensional, monolayered, with well-defined cell
borders; larger tissue fragments fold upon themselves and may appear
syncytial; nuclei round to oval, with smooth, crisp nuclear membrane;
finely granular uniformly distributed chromatin; micronucleoli ⫹Ⲑ⫺,
nuclear groves frequent; moderate, pale cytoplasm
Percutaneous Transabdominal Hepatocytes Large polygonal cells, singly or in sheets; abundant dense cytoplasm;
FNA Biopsy low N/C ratios; small round nucleus with prominent nucleolus
Endoscopic Ultrasound Guided Intestinal mucosa Large monolayered, two-dimensional tissue fragments with
for the Lesions of Head of the honeycomb arrangement, intermixed with goblet cells, appearing as
Pancreas (Transduodenal) punched out holes; uniform, round to oval, evenly spaced nuclei; pale,
moderate cytoplasm; single cells ⫹Ⲑ⫺; thin mucus
Endoscopic Ultrasound Guided Gastric mucosa Varying-sized two-dimensional monolayered tissue fragments with
for the Lesions of Body and Tail honeycomb arrangement; pale cytoplasm with well-defined cell
of the Pancreas (Transgastric) borders; uniform nuclei with evenly distributed chromatin; no goblet
cells; luminal brush border; tissue fragments often smaller than
intestinal; pale, moderate cytoplasm; associated with mucin
Endoscopic Retrograde None

Cholangiopancreatography
(ERCP)
decades of life. Over 90% of pancreatic cancers are ade- variants of adenocarcinomas include adenosquamous,
nocarcinomas of the duct epithelial origin. The present- mucinous noncystic, hepatoid, medullary, signet-ring, and
ing symptoms depend on the location of the tumor. Those undifferentiated with and without associated osteoclast-
arising in the head of the pancreas (over 70%) present type giant cells.
with symptoms such as obstructive jaundice early on
while those arising in the body or the tail are diagnosed
late in the disease since they remain asymptomatic for a
long time. Adenocarcinomas of the pancreas metastasize The cytologic features of duct adenocarcinomas (Table
locally to the lymph nodes, adjacent organs, and at dis- 19.5) correspond to the histologic grade (Figs. 19.3 to
tant sites. Ascites is frequent. Pancreatic adenocarcinomas 19.14). With adequate specimens, most duct carcinomas
offer a dismal prognosis with a 5-year survival rate of less are accurately identifi ed. The malignant cells are present
than 4%. as isolated, in loose aggregates, and in syncytial tissue
fragments with or without an acinar (glandular) pattern.
Papillary confi gurations are occasionally seen. The aspi-
rates may exhibit monolayered syncytial tissue fragments
Pancreatic adenocarcinomas are infi ltrative tumors rang- of large malignant cells with abundant cytoplasm and
ing in size from 3 centimeters to very large ones. The cut pleomorphic nuclei with altered polarity and are referred
section is fi rm, stellate, poorly defined, white—yellow, to as “drunken honeycombs” (Fig. 19.9). Variation in
and usually solid. Areas of degeneration, necrosis, hemor- nuclear size within a tissue fragment is an important
rhage, and cystic change may be present. diagnostic feature. Malignant cells are pleomorphic in
Histologically, duct adenocarcinomas present a wide size, ranging from small or medium to large with giant
spectrum from conventional morphology characterized forms. Their nuclei can be uniformly small and bland in
by a glandular pattern to many morphologic variants. The well-differentiated adenocarcinomas to markedly pleo-
differentiation ranges from well- to poorly differentiated morphic and overtly malignant in poorly differentiated
ones with anaplastic forms. They can be cystic, or they ones. In syncytial tissue fragments of malignant cells, vari-
may demonstrate intense desmoplasia. The morphologic ation in the nuclear size from small to four times as large
TABLE 19.5 CYTOPATHOLOGIC FEATURES OF PANCREATIC DUCT ADENOCARCINOMA
Cellularity Variable; scant in desmoplastic tumors; hypercellular in poorly differentiated carcinomas
Presentation Cells isolated, in loosely cohesive groups, or in syncytial tissue fragments with and without acinar pattern;
occasionally papillary
Cells Size variable; small, medium to large to pleomorphic giant forms; N/C ratios variable
Nucleus Round to oval, central to eccentric; nuclear membrane smooth to irregular; chromatin finely to coarsely
granular with parachromatin clearing; hypochromic pattern characteristic; single to multiple micro/
macronucleoli; bi-multinucleation ⫹Ⲑ⫺; mitoses ⫹Ⲑ⫺
Cytoplasm Scant to abundant; pale to dense; vacuolated; signet-ring pattern ⫹Ⲑ⫺; squamous differentiation in poorly
differentiated carcinomas
Background Clean to necrotic; mucin ⫹Ⲑ⫺; osteoclast-type giant cells in some poorly differentiated carcinomas
Immunoprofile Positive reactivity to cytokeratin 7, 8, 18, 19; CA19.9; CEA
Differential Normal acinar tissue

Diagnoses Mesothelial tissue fragments (in transabdominal aspirates)
Gastric and intestinal epithelium in EUS-guided biopsies
Chronic pancreatitis with duct hyperplasia
Atypical bile duct epithelium in ERCP specimens
Neuroendocrine tumor
Acinar cell carcinoma
Solid pseudopapillary tumor (SPT)
Spectrum of Cytopathologic Features of Pancreatic Adenocarcinomas in FNA Specimens (See Figs. 19.3 to 19.14)
Fig. 19.3. A syncytial tissue fragment of adenocarcinoma cells with Fig. 19.4. The adenocarcinoma cells are small to medium-sized.
marked crowding and overlapping of enlarged nuclei. Note the hy- Note the presence of macronucleoli.
pochromatic nuclei, a feature quite typical of pancreatic adenocar-
cinomas.
Fig. 19.5. The malignant cells contain large cytoplasmic vacuoles. Fig. 19.6. A syncytial tissue fragment of adenocarcinoma cells. The
nuclei are large, pleomorphic, containing coarsely granular chroma-
tin with parachromatin clearing, and nucleoli. Their cytoplasm is
pale to dense and vacuolated.
Fig. 19.7. These syncytial tissue fragments of adenocarcinoma cells Fig. 19.8. A syncytial tissue fragment of adenocarcinoma with
show luminal borders of neoplastic glandular spaces. The component abundant mucin production.
nuclei are large, pleomorphic and contain coarsely granular chromatin
and nucleoli. The cytoplasm is abundant, foamy, vacuolated to dense.
Fig. 19.9. A syncytial but monolayered tissue fragment of adenocar- Fig. 19.10. A poorly differentiated adenocarcinoma showing large
cinoma with abundant mucin production. Note that the cell borders pleomorphic malignant cells with giant forms, present discretely.
are well-defined but the nuclear polarity is altered. This architecture
is sometimes referred to as “drunken honeycomb.”
Fig. 19.11. A poorly differentiated adenocarcinoma showing a dis-
persed pattern formed by small pleomorphic malignant cells with
some giant forms. The cytoplasm is scant but occasionally shows
mucin vacuoles.
A B
Figs. 19.12A to C. Adenocarcinoma with squamous differentiation.

A: Low power view of an aspirate from pancreatic mass showing
large tissue fragments of malignant squamous cells. B: Higher mag-
nification showing pleomorphic malignant squamous cells. C: Tis-
sue fragments of large polygonal malignant squamous cells with
C abundant cytoplasm.
Fig. 19.13. A poorly differentiated adenocarcinoma with medium-

sized, pleomorphic malignant cells with a dispersed pattern. Note
the necrosis in the background.
775
A B
Figs. 19.14A and B. FNA of a poorly differentiated adenocarcinoma with osteoclast-type giant cells. A: Low power show-
ing a cellular aspirate. Multinucleated giant cells are conspicuously present in large numbers. B: Higher magnification.
is referred to as the “four to one” rule and is considered issue in the identification of well-differentiated adenocarci-
a feature in favor of malignancy. The chromatin may be nomas (Table 19.4). Also, tissue fragments of mesothelium,
fi nely granular and powdery, appearing hypochromic to which were aspirated while performing a transabdominal
coarsely granular. In fact, hypochromasia is quite charac- percutaneous biopsy, may fold upon themselves and ap-
teristic (Fig. 19.3). Nucleoli can be single or multiple and pear syncytial, causing diagnostic pitfalls. Normal acinar
of micro and/or macro type. Mitoses may be prominent tissue in excessive amounts can mimic a well-differentiated
in poorly differentiated carcinomas. The malignant cells adenocarcinoma (Fig. 19.20).
contain variable cytoplasm that is pale to dense or vacu- Chronic pancreatitis with fl orid ductal hyperplasia
olated. The background may show necrosis. may yield an overwhelmingly cellular specimen with nu-
The morphologic variants exhibit characteristic fea- merous tissue fragments of duct epithelium, sometimes
tures such as squamous differentiation in adenosquamous with mild nuclear atypia (Figs. 19.15A to C). The hyper-
carcinomas (Figs. 19.12A to C), excessive mucin production cellularity coupled with nuclear atypia may result in both
in colloid carcinomas, and anaplastic forms with or without false-positive and false-negative diagnoses.
osteoclast-type giant cells (Figs. 19.10, 19.13, and 19.14). The cytologic presentation of a well-differentiated
duct adenocarcinoma may be remarkably bland, resulting
in diagnostic problems. The tissue fragments of neoplas-
IMMUNOPROFILE
tic epithelium are syncytial but monolayered with altered
Pancreatic adenocarcinoma cells react positively to epithelial polarity, slight overlap, and well- to poorly defined cell
membrane antigen (EMA), cytokeratins (AE1/AE3), CK7, borders with variable cytoplasm, which has finely gran-
Cam 5.2, and polyclonal carcinoembryonic antigen (CEA). ular to powdery chromatin and micronucleoli (see Figs.
19.16 to 19.19). Irregularities of the nuclear membranes
provide subtle clues in favor of malignancy. The N/C ra-
tios of the neoplastic cells are increased but only mildly.
Nuclear enlargement with mild pleomorphism may also
Diagnostic diffi culties in the cytologic diagnosis of pan- be seen in duct hyperplasias; however, nuclear polarity is
creatic adenocarcinomas depend upon the method of maintained.
procurement of the samples (FNA biopsy or brushings/ Other areas of concern are adenocarcinomas that
washings of the pancreatic/bile duct), the adequacy of are composed of small-sized cells, adenocarcinomas with
the specimen, and the presence and number of normal excessive mucin production, and those with cystic de-
contaminant cells. Diagnostic difficulties also result from generation. Neoplasms consisting of small-sized cells in-
cystic degeneration and overlapping cytologic features clude duct adenocarcinomas, acinar cell carcinoma, solid
between benign lesions and well-differentiated carcino- pseudopapillary neoplasms, neuroendocrine tumors, and
mas as well as between various malignancies. malignant lymphomas (see Table 19.11). With cystic de-
The differential diagnostic entities are listed in Table generation, the differential diagnoses include other cystic
19.6 (also see Table 19.11). Their cytologic features are lesions such as pseudocysts and benign and malignant
illustrated in Figures 19.15 to 19.20. cystic neoplasms (see Table 19.14).
Contaminants of normal gastroduodenal epithelia in Metastatic malignancies in the peripancreatic areas
EUS-guided aspiration biopsies can be a major diagnostic clinically and radiologically simulate primary pancreatic
TABLE 19.6 CYTOPATHOLOGIC FEATURES DIFFERENTIATING DUCTAL HYPERPLASIA FROM

WELL-DIFFERENTIATED DUCT ADENOCARCINOMA AND MESOTHELIUM
Pancreatic Duct
Duct Hyperplasia Chronic Pancreatitis Adenocarcinoma Mesothelial Tissue Fragments
Cellularity Variable; scant with marked fibrosis; Variable, scant in Variable
cellular in cases associated with duct desmoplastic tumor;
hyperplasia generally cellular
Presentation Varying-sized tissue fragments of duct Cells rarely isolated or in In tissue fragments; monolayered
epithelial cells; monolayered with loosely cohesive groups; with honeycomb pattern is
honeycomb pattern; goblet cells ⫹Ⲑ⫺; predominantly in tissue characteristic; infolding of edges
single cells rare to absent; acinar tissue fragments; monolayered may render appearance of syncytial
usually scant to absent; large fragments with syncytial arrangement arrangement
of fibrovascular connective tissue (nuclei with altered polarity,
crowding and overlapping);
acinar pattern ⫹Ⲑ⫺
Cells Cuboidal duct epithelial cells; uniform; Cuboidal, variably enlarged Cuboidal to polygonal with well-
normal to slightly enlarged; well-defined but only mildly, well to defined cell borders
cell borders poorly defined cell borders
Nucleus Round, oval, normal-sized; smooth Round to oval, enlarged; Round, oval to kidney-shaped;
nuclear membranes; finely granular irregular nuclear membrane, uniform; N/C ratio normal; crisp
evenly dispersed chromatin; finely granular chromatin; nuclear membrane; nuclear groove
micronucleoli ⫹Ⲑ⫺; uniform; minimal micronucleoli frequent; finely granular evenly
atypia dispersed chromatin; micronucleoli
Cytoplasm Variable, pale to vacuolated Variable, scant to moderate, Moderate amount, pale
pale or vacuolated
Background Stromal cells with atypical nuclei; Clear to inflammatory Clean

clean to inflammatory; mucin may be
abundant; calcific debris ⫹Ⲑ⫺
Immunoprofile CEA ⫹; keratin ⫹; EMA ⫹ CEA ⫹; keratin ⫹; EMA ⫹ CEA ⫺; keratin ⫹
Differential Diagnoses of Adenocarcinoma (See Figs. 19.15 to 19.20)
A B
Figs. 19.15A to B. Chronic pancreatitis with duct epithelial hyperplasia. A: Pancreatic duct brushings showing a large
number of epithelial tissue fragments (low power). B: Medium power showing honeycomb arrangement of cells with
uniform nuclei. (continued)
C
Figs. 19.15C. (continued) C: Higher magnification to highlight the Fig. 19.16. FNA of a pancreatic mass. Note that this epithelial tis-
uniform nuclei with finely granular, evenly dispersed chromatin. sue fragment shows a partial glandular architecture as seen by the
luminal border (arrows). The cells along the border have large nu-
clei with granular chromatin, micronucleoli and excessive parach-
romatin clearing. The cells forming the syncytial tissue fragment are
small with round uniform nuclei. A definite diagnosis of malignancy
is difficult in this case.
Fig. 19.17. A poorly cellular aspirate of a pancreatic mass. This Fig. 19.18. FNA of a pancreatic mass proven to be an adenocar-
fi eld shows a large tissue fragment of hyperplastic duct epithelium cinoma. This tissue fragment is syncytial with a glandular pattern
and aggregates of few malignant cells (arrows). Note the contrast as noted by luminal borders (arrow). The nuclei are round, mostly
in morphology. However inadequate sample such as this may not uniform but some are considerably enlarged showing size variation
allow an unequivocal diagnosis of malignancy. and conform to rule of 4 to 1. Their polarity is altered. The malig-
nant criteria are very subtle.
Fig. 19.19. A tissue fragment of normal duct epithelium for com- Fig. 19.20. A tissue fragment of mesothelial cells obtained during
parison. a transabdominal approach may mimic a well-differentiated adeno-
carcinoma.
778
Acinar Cell Carcinoma (See Figs. 19.21 to 19.25)
Figs. 19.21A and B. An acinar cell carcinoma of the pancreas.

A: Low power. B: High power. The tumor demonstrates a diffuse
growth pattern with attempt at forming acini. The cells are large
with abundant granular cytoplasm and resemble normal acinar
A B
cells. The nuclei are pleomorphic with prominent nucleoli (H&E).
malignancy and are diffi cult to differentiate without an- this tumor becomes diffi cult (Table 19.7; Figs. 19.22 to
cillary testing. 19.23). The clues to recognition are the dissociated pat-
tern, granular nuclear chromatin, parachromatin clearing
with prominent nucleoli, and the stripped nuclei in the
ACINAR CELL CARCINOMA background. The normal acinar cells are cohesive with
compact nuclear chromatin and inconspicuous nucleoli.
Acinar cell carcinomas are distinctive but uncommon
malignant neoplasms derived from acinar cells, account- IMMUNOPROFILE
ing for 1 to 1.5% of all malignant tumors of the exocrine
Acinar carcinoma cells react positively to chymotrypsin,
pancreas. They occur at any age—with the median being
trypsin, lipase, and ␣-antitrypsin.
51 years—and have a slightly higher incidence in males.
Acinar cell carcinomas may present with jaundice, back
pain, and with distant metastasis. Acinar carcinomas are ULTRASTRUCTURE
rarely functional, secreting enzymes such as amylase,
Ultrastructurally, the cells of acinar cell carcinoma dem-
lipase, or trypsin, and resulting in distant foci of fat necro-
onstrate electron-dense zymogen granules of up to 250
sis and polyarthropathy. Acinar cell carcinomas metasta-
nanometers in diameter (Fig. 19.22C).
size widely and carry a poor prognosis.

Grossly, acinar carcinomas are unencapsulated, cir-
Acinar carcinomas are rarely encountered in routine
cumscribed, large (averaging 10 centimeters), gray to
practice. Also, their cytologic presentations are not widely
tan–red, and soft to firm with areas of necrosis. Histo-
documented. Large lobules of normal acinar tissue in
logically, these tumors demonstrate a solid growth pat-
aspirated specimens may cause diagnostic problems (Fig.
tern and remarkably reproduce the normal acinar cell
19.24) and may be interpreted as acinar cell carcinoma.
morphology. The neoplastic cells are round and short
However, diagnostic entities such as well-differenti-
columnar to triangular with basally located, round to
ated adenocarcinomas (Fig. 19.25), neuroendocrine car-
oval nuclei containing finely granular chromatin and
cinomas, and solid pseudopapillary tumors (SPT) must be
prominent nucleoli. Mitoses are sparse. The cell borders
considered in differential diagnoses (see Table 19.10).
are poorly defined. The cytoplasm is moderate, granu-
lar, and eosinophilic to purplish. The tumor cells are
arranged in nests, cords, or in an acinar pattern (Figs.
SOLID PSEUDOPAPILLARY TUMORS (SPT)
19.21A and B).
Solid pseudopapillary tumors (SPT) are a low-grade malig-

nant epithelial neoplasm, known by several synonyms:
The cytologic pattern of acinar cell carcinoma resembles solid cystic tumor, solid cystic papillary tumor, or papil-
the benign acinar cells so closely that the recognition of lary cystic tumor.
TABLE 19.7 CYTOPATHOLOGIC FEATURES OF ACINAR CELL CARCINOMA OF THE PANCREAS
Cellularity Highly cellular
Presentation Dissociated pattern characteristic; neoplastic cells isolated, in loosely cohesive groups and in syncytial
tissue fragments with and without acinar pattern; naked nuclei ⫹Ⲑ⫺
Cells Slightly larger than their normal counterpart and bear a strong resemblance; cuboidal to triangular with
poorly defined cell borders; high N/C ratios
Nucleus Round to oval; smooth nuclear membrane; finely granular chromatin with prominent nucleoli; mitoses ⫺
Cytoplasm Variable, granular
Background Usually clean
Immunoprofile Positive reactivity to chymotrypsin, trypsin, lipase and ␣-antitrypsin; negative reactivity to ␣-amylase
Ultrastructure Zymogen granules
Differential Diagnoses Benign pancreatic acinar tissue

Well-differentiated duct adenocarcinoma
Solid pseudopapillary tumor
Neuroendocrine tumor
A B
Figs. 19.22A to C. FNA biopsy of the carcinoma depicted in Fig-

ure 19.21. A, B: The cellular aspirate consisted of syncytial tissue
fragments of medium-sized cells with uniform nuclei and high N/C
ratios. Their cytoplasm is variable and granular. C: Electron micro-
C graph showing zymogen granules in the cytoplasm.
A B
Figs. 19.23A and B. FNA of another case of acinar cell carcinoma showing several syncytial tissue fragments of malig-
nant cells. Note the strong resemblance to the normal acinar tissue. However, the ARCHITECTURE is haphazard.
Fig. 19.24. Normal acinar tissue for comparison. Fig. 19.25. A well-differentiated adenocarcinoma exhibiting mor-
phologic similarity to acinar cell carcinoma.
Solid pseudopapillary tumors occur primarily in ous delicate capillary-sized blood vessels. There is no
women in their 20s, with the age range being 7 to 79 gland formation. With degenerative changes and necro-
years; the median age is 29 years. Most patients present sis, the viable tumor cells line the capillaries, producing
with nonspecific symptoms related to an intra-abdominal a pseudopapillary pattern (Fig. 19.26). Their nuclei are
mass such as abdominal pain, nausea, and vomiting, but aligned away from the capillaries, resulting in a band of
they may be incidentally detected. The radiologic findings cytoplasm along the capillaries. The cytoplasm of the
can be highly suggestive of this neoplasm and consist of neoplastic cells may be clear, pale, foamy, vacuolated,
a well-circumscribed mass with cystic and solid compo- or sometimes contain eosinophilic hyaline globules of
nents with foci of calcifications. The SPTs frequently oc- 1 to 20 nanometers. The nuclei are round to oval and
cur in the body or tail and are easily amenable to surgical uniform with finely stippled chromatin and longitudi-
excision. nal grooves. Areas of degenerative changes and hem-
orrhage with blood lakes may dominate the picture.
Hyaline globules are more frequently present in the
background.
Grossly, the tumors are often very large with an average
diameter of 10.5 centimeters and are encapsulated. The
cut surface reveals soft, white–gray to yellow solid with
irregular cystic areas containing friable, necrotic mate- The aspirates of SPT are generally very cellular, composed
rial and areas of recent and old hemorrhage. Micro- of a large population of medium-sized cells that are isolated,
scopically, the solid areas contain sheets of relatively in loosely cohesive groups, and in syncytial tissue fragments
uniform, round to polygonal cells mixed with numer- with branching, many exhibiting a pseudopapillary pattern
Solid Pseudopapillary Tumor (See Figs. 19.26 to 19.29)
Fig. 19.26. Histologic section of a solid pseudopapillary tumor

showing a pseudopapillary pattern. The papillary cores demonstrate
capillaries with myxoid stroma along the exterior. The lining cells
are uniform with nuclei polarized towards the periphery (H&E).
(Table 19.8; Figs. 19.27 to 19.29). The latter are charac- ules. The hyaline globules are confi rmed to represent
terized by central capillaries with neoplastic cells lining ␣1-antitrypsin. A minority of SPT tumors show small
the exterior with their nuclei away from the capillaries, neurosecretory granules.
leaving a band of cytoplasm along the capillaries (Fig.
19.28B). The stroma surrounding the capillaries may be DIAGNOSTIC DIFFICULTIES AND
hyaline or myxoid. The neoplastic cells are medium-sized, DIFFERENTIAL DIAGNOSES
uniform, round to cuboidal with well to poorly defined
The SPTs are very uncommon neoplasms but present a
cell borders. Their nuclei are round to oval with smooth
characteristic and easily recognizable cytologic pattern
nuclear membranes. The chromatin is finely granular and
provided the aspirate is adequate. Diagnostic difficulties
uniformly distributed. Micronucleoli may be present.
mostly stem from an inadequate aspirate, particularly in
Slight indentation of the nuclear membranes and grooving
cases of extensive hemorrhage and large cyst formation.
may be noted. Mitoses are rare. The cytoplasm is scant to
Diagnostic entities to be considered in differential diag-
moderate and pale and may demonstrate long cytoplasmic
noses include well-differentiated adenocarcinoma, acinar
processes. Another feature is the presence of metachro-
cell carcinoma, neuroendocrine tumors (Fig. 19.11) and
matically staining hyaline globules (Fig. 19.28D) that are
cystic lesions (see Table 19.14).
usually present in an extracellular location but may also
be seen within the cytoplasm. These globules are PAS posi-
tive and diastase resistant. The background often shows
PANCREATIC ENDOCRINE TUMORS (PET)
fresh and old hemorrhage with histiocytes that contain
hemosiderin pigment. Stripped nuclei may also be pres-
ent. The cytologic features of SPT are illustrated in Figures Pancreatic endocrine tumors (PET), also referred to as
19.27 to 19.29. pancreatic neuroendocrine tumors (PNT), are uncommon,
constituting 1 to 2% of all pancreatic neoplasms. Previ-
IMMUNOPROFILE ously reported as “islet cell tumor” because of the assump-
tion that they arise from the islets of Langerhansí, PET is
The cells of SPT strongly and diffusely react to vimentin,
now considered to rise from the multipotential epithelial
␣1-antitrypsin, ␣1-antichymotrypsin, ␤-catenin (nuclear
cells in pancreatic ductules. In keeping with the current ter-
staining), CD10, neuron-specific enolase, CD56, and pro-
minology of neuroendocrine tumors (see Chapter 10, Table
gesterone receptors but not to estrogen receptors. The
10.2), pancreatic endocrine tumors are classified as well-
SPT cells do not react to cytokeratins, CA19–9, and CEA
differentiated, moderately differentiated, and poorly differ-
and reactivity to neuroendocrine markers such as synap-
entiated endocrine carcinomas. They can be nonfunctioning
tophysin is variable.
or functioning with an elaboration of a number of different
hormones. Pancreatic endocrine tumors can occur sporadi-
ULTRASTRUCTURE
cally or as a part of hereditary syndromes such as MEN 1
Solid pseudopapillary tumors exhibit evidence of epithe- and von Hippel Lindau disease. The mean reported age is
lial differentiation. Large membrane bound granules are 58 years with a wide range of 12 to 78 years. Patients with
present; some have the morphology of zymogene gran- the hereditary syndromes are usually younger. Clinically,
the patients may be asymptomatic or may present symp- an indolent behavior, although they may metastasize to
toms related to the specific hormone production. distant organs several years after the initial diagnosis has
Radiographically, pancreatic endocrine neoplasms been made. The organs most frequently involved second-
can be detected as localized mass lesions. MRI can also arily are the liver, the lymph nodes, and the lungs. More
detect peripancreatic lymph node and liver involvement. than 90% of pancreatic endocrine tumors are benign and
Most of the pancreatic neuroendocrine tumors present cured by complete surgical removal.
TABLE 19.8 CYTOPATHOLOGIC FEATURES OF SOLID PSEUDOPAPILLARY TUMOR (SPT)

OF THE PANCREAS
Cellularity Variable, generally highly cellular
Presentation Neoplastic cells isolated, in loosely cohesive groups and in varying-sized syncytial tissue fragments with or
without branching; papillary pattern with complex branching may be striking; central capillaries enveloped by
hyaline or myxoid stroma and neoplastic cells with their nuclei polarized away from the capillaries
Cells Uniform, round to cuboidal with well to poorly defined cell borders
Nucleus Round to oval; indentation and grooving; smooth membranes; finely granular, uniformly distributed
chromatin; micronucleoli ⫹Ⲑ⫺
Cytoplasm Scant, mild to moderate; hyaline globules ⫹Ⲑ⫺
Background Lakes of blood; histiocytes with and without hemosiderin; varying-sized hyaline globules staining
metachromatically magenta in Romanowsky stained preparations and orange with Papanicolaou stain
Immunoprofile Diffuse and strong positive reactivity to vimentin, ␣1-antitrypsin, ␣1-antichymotrypsin, ␤-catenin, CD10,
neuron-specific enolase, CD56 and progesterone receptors; negative reactivity to estrogen receptors,
cytokeratins, CEA, CA19–9; reactivity to synaptophysin variable
Ultrastructure Epithelial differentiation; large membrane bound granules morphology of zymogene granules; hyaline globules
represent ␣1-antitrypsin; rare small neurosecretory granules
Differential Well-differentiated adenocarcinoma

Diagnoses Neuroendocrine tumor
Normal acinar tissue
A B
Figs. 19.27A to B. A: Low power view of the cellular aspirate from same case as Figure 19.26. Note the papillary
architecture, quite evident at this power. B: Higher magnification showing syncytial tissue fragment of uniform
monomorphic cells with round, pale nuclei and scant cytoplasm. (continued)
C D
Figs. 19.27C to D. (continued) C: Another field from the same case demonstrating a papillary frond. The lining cells
have uniform nuclei. D: Same case with a syncytial tissue fragment of uniform round cells.
A B
C D
Figs. 19.28A to D. Another example of a solid pseudopapillary tumor. A: Medium power view showing a cellular
aspirate with a papillary tissue fragment with branching. The lining cells are small with round monomorphic nuclei.
The stromal core contains myxoid tissue. The cytologic pattern mimics the perithelial cell distribution seen in
neuroendocrine tumors. B: Higher magnification of a frond, covered by multilayers of uniform, small round cells.
C: Higher magnification of another field showing a dispersed cell pattern with discrete, round, plasmacytoid and
short spindle cells with monomorphic round nuclei, strongly mimicking the cytologic presentation of neuroendocrine
tumor. D: A different field from the same case. Note the single extracellular hyaline globule (arrow).
A B
Figs. 19.29A to C. A: FNA of a solid pseudopapillary tumor with

a very cellular aspirate showing several papillary tissue fragments
with complex branching. Note the large population of dispersed
cells in the background. B: Medium power view showing small
round uniform cells lining the capillaries. C: This dispersed pattern
C strongly resembles the neuroendocrine tumor.
GROSS AND MICROSCOPIC FEATURES elongated. The cytoplasm is variable—usually scant—

and pale, clear, or eosinophilic. The nuclei are uniform
Grossly, pancreatic endocrine tumors are well-demarcated
with characteristic salt & pepper chromatin. The nucle-
and may or may not be encapsulated; they can occur any-
oli may be present or inconspicuous. Mitoses are rare
where in the pancreas. The cut surface may be soft and
in well-differentiated tumors. Poorly differentiated PETs
red to yellow–tan and hemorrhagic or gray and firm with
exhibit a pattern similar to that of a small cell neuroen-
fibrosis, or it may be cystic.
docrine carcinoma.
Microscopically, most pancreatic neuroendocrine
tumors fall into the well-differentiated category (Fig.
19.30). The poorly differentiated neoplasms such as
small cell carcinomas or large cell neuroendocrine car-
cinomas are uncommon. The histomorphology of the The cytologic presentation of the neuroendocrine neopla-
well-differentiated neuroendocrine tumor is very char- sia is, however, very characteristic, providing helpful clues
acteristic and similar to that of intestinal and other to the diagnosis (Table 19.9; Figs. 19.31 to 19.39). The
low-grade endocrine tumors such as carcinoid tumors. neoplastic cells are small to medium-sized and are uni-
Several architectural patterns are recognized: 1) trabe- form and monomorphic or may demonstrate pleomor-
cular (gyriform); 2) acinar (rosette-like, perivascular, phism. They present themselves as isolated and in loosely
glandular, alveolar, or duct-like); and 3) solid (medul- cohesive groups, forming a dispersed cell pattern, or pres-
lary or diffuse). The sheets or nests of neoplastic cells ent in syncytial tissue fragments. The latter may present
may be separated by strands of fibrous tissue or closely a trabecular pattern, insulae, or rosettes or may form no
packed with intervening delicate, thin, vascular stroma. architectural configuration.
Frequently, the neoplastic cells are arranged around the The neoplastic cells are round or cuboidal to plasma-
blood vessels or spaces containing eosinophilic material. cytoid with central or eccentric nuclei. The plasmacytoid
The tumor cells are generally uniform in size and shape, pattern has been interpreted as extramedullary plasma-
round, oval (plasmacytoid), cuboidal, polygonal, or cytoma. Spindle and large giant forms are occasionally
Pancreatic Neuroendocrine Tumor (See Figs. 19.30 to 19.39)
A B
Figs. 19.30A and B. Histologic sections of a pancreatic neuroendocrine tumor. A: The neoplasm shows large nests
of uniform cells bordered by delicate fibrovascular septae, Medium power. B: Higher magnification shows the
neoplastic cells to be medium-sized, uniform with eccentric nuclei, granular chromatin and appreciable granular
cytoplasm (H&E).
TABLE 19.9 CYTOPATHOLOGIC FEATURES OF PANCREATIC NEUROENDOCRINE TUMORS
Presentation Cells discrete, in loosely cohesive groups or in syncytial tissue fragments; dispersed cell pattern
frequent; tissue fragments may be trabecular, form well-defined-nests (insulae) or acinar pattern; solid
cell groups may be traversed by branching blood vessels; cells attached to the blood vessels
Cells Small to medium-sized with occasional large forms; round to cuboidal to plasmacytoid, sometimes
polygonal and rarely triangular or spindle-shaped; usually a monomorphic pattern; cell borders
poorly defined with high N/C ratios
Nucleus Central to eccentric; round to oval; smooth nuclear membranes; salt & pepper chromatin;
micronucleoli ⫹Ⲑ⫺; molding, mitotic activity and karyorrhexis are not the features of well-
differentiated neoplasms
Cytoplasm Variable; insignificant to scant; pale to granular; abundant and eosinophilic in oncocytic variant
Background Usually clean; necrotic in high-grade lesions or with cystic change; hemorrhagic ⫹Ⲑ⫺
Histochemistry Positive reactivity with silver stains
Immunoprofile Positive reactivity with pan-neuroendocrine markers; specific peptide markers depending on tumor
type
Differential Diagnoses Well-differentiated duct adenocarcinoma

Solid pseudopapillary tumor
Other neuroendocrine tumors
Malignant lymphoma
Serous microcystic adenoma (rare)
Normal acinar tissue
A B
Figs. 19.31A to C. FNA from the same case showing marked cel-
lularity. A, B: The neoplastic cells are discrete, in loosely cohesive
groups and in syncytial tissue fragment without any architectural
pattern. The nuclei are larger with high N/C ratios. Nucleoli are
prominent. C: This syncytial tissue fragment shows uniform cells
C with nuclei containing salt & pepper chromatin.
lar location. Mitotic activity or necrosis is usually not

present. The cell block preparations are extremely useful
in the diagnostic evaluation since they allow ancillary
testing.
The other less frequent neuroendocrine carcinomas
include atypical carcinoid tumors (Fig. 19.36), large cell
neuroendocrine carcinomas, small cell carcinomas (Figs.
19.37 to 19.39), and rarely, paraganglioma.
IMMUNOPROFILE
The neoplastic cells are reactive to neuroendocrine mark-
ers, cytokeratins, TTF-1, and specific markers to the pep-
tide production in functioning tumors.
Fig. 19.32. FNA of a pancreatic neuroendocrine tumor demonstrat-
ing a very pleomorphic cell pattern. ULTRASTRUCTURE
Ultrastructurally, the pancreatic neuroendocrine tumors
demonstrate dense-core neurosecretory granules, ranging
present. The nuclear membranes are smooth and crisp.
from 80 to 300 nanometers in diameter and with a ten-
The chromatin is characteristic of the neuroendocrine
dency to cluster around Golgi complexes.
family of tumors and are uniformly and coarsely granu-
lar, presenting a salt & pepper pattern. Nucleoli are not
consistently present. The cytoplasm is variable, scant to
moderate, and pale to eosinophilic in the oncocytic vari-
ant. A capillary network may be prominent in the back- With an adequate aspirate, the cytologic diagnosis from
ground, and neoplastic cells may be seen in a perivascu- a cell population composed of small uniform cells with
A B
Figs. 19.33A and B. A: A different example of pancreatic neuroendocrine tumor showing a dispersed cell pattern of
plasmacytoid cells with occasional giant nucleus (Papanicolaou). B: Same aspirate (Romanowsky).
Fig. 19.34. FNA of a pancreatic neuroendocrine tumor. The neo- Fig. 19.35. FNA of a poorly differentiated neuroendocrine carci-
plastic cells are small, but pleomorphic with scant cytoplasm, high noma. This pattern must be differentiated from a poorly differenti-
N/C ratios. Malignant lymphoma may present a similar pattern. ated carcinoma.
Fig. 19.36. FNA of a poorly differentiated neuroendocrine carci- Fig. 19.37. FNA of a small cell carcinoma (neuroendocrine carcino-
noma with a strong resemblance to adenocarcinoma cells. ma, grade III). Note the small cell size, scant cytoplasm with poorly
defined cell borders, high N/C ratios and nuclear molding. There is
karyorrhexis in the background.
Fig. 19.38. A different example of poorly differentiated neuroen-

docrine carcinoma.
A B
Figs. 19.39A and B. FNA of a poorly differentiated neuroendocrine carcinoma of the pancreas.
a typical salt & pepper type nuclear chromatin is clearly lial and stromal components. The epithelial component
apparent. However, diagnostic difficulties may be encoun- is represented by syncytial tissue fragments with varied
tered with inadequate specimens containing small cells or differentiation such as acinar, squamous, and neuroendo-
with necrosis and cystic change. The differential diag- crine, or they may be primitive. The stromal component
nostic entities include small cell lesions of the pancreas shows atypical primitive spindle cells with or without het-
(Tables 19.10 and 19.11; Figs. 19.40 to 19.45). A pancre- erologous elements.
atic endocrine carcinoma with extensive cystic degenera-
tion must be differentiated from other cystic lesions of the
pancreas (see Table 19.13).
CYSTIC LESIONS OF THE PANCREAS
Pancreatic cystic lesions can be nonneoplastic or neoplas-

PANCREATOBLASTOMA
tic (Table 19.12). The latter are less common, comprising
less than 20% of all cystic lesions. The majority of these
Pancreatoblastomas are exceedingly rare neoplasms seen cysts represent pseudocysts. With advances in imaging
primarily in children under the age of 10 but are also technologies and endoscopy, cystic lesions of the pancreas
reported in adults. They are slightly more common in are being discovered more frequently.
males. Patients usually present with an abdominal mass EUS-guided fi ne needle biopsy is a new emerging
and may or may not be symptomatic. subspecialty in gastrointestinal medicine. Coupled with
The cytologic features include variably cellular as- highly advanced radiographic technology, the cystic
pirates with a biphasic cell pattern consisting of epithe- lesions—small or large—are being detected with increasing
TABLE 19.10 DIFFERENTIAL DIAGNOSES OF PANCREATIC NEUROENDOCRINE TUMORS
Diagnostic Entity Cytopathologic Features Ancillary Tests

Pancreatic Cellular aspirate, uniform, small to medium-sized, round, Neuroendocrine markers
Neuroendocrine Tumor plasmacytoid cells; dispersed pattern common; cells isolated, positive; specific hormonal
in groups and in syncytial tissue fragments; rarely pseudopapillary or marker for a given tumor;
acinar patterns; perithelial location of neoplastic cells; well to poorly EM ⫺; neurosecretory
defined cell borders; high N/C ratios; scant cytoplasm; salt & pepper granules
chromatin; inconspicuous nucleoli
Well-Differentiated Variable cellularity; cells loosely cohesive and in syncytial Keratin ⫹; neuroendocrine
Pancreatic tissue fragments with and without acinar pattern; cells small with markers ⫺
Adenocarcinoma with a scant cytoplasm and poorly defined cell borders; nuclei crowded
Small Cell Pattern and overlapped; minimally pleomorphic; nuclear membrane
irregularities ⫹Ⲑ⫺; finely granular chromatin; parachromatin clearing;
micronucleoli ⫹; mitoses ⫹Ⲑ⫺
Normal Acinar Tissue Lobules of acinar tissue, uniform cells with small nuclei; low N/C
ratios
Acinar Cell Carcinoma Cellular aspirate; cells, discrete, in groups and in syncytia PAS diastase resistant;
with acinar pattern; strong resemblance to the normal counterpart; diffusely positive for
cells triangular with abundant granular cytoplasm; nuclei round keratin, lipases ⫹ (trypsin,
with smooth nuclear membrane, finely granular chromatin with ␣-antitrypsin, amylase); EM
prominent nucleoli; no mitotic activity; variable, clear to granular ⫺; zymogene granules
cytoplasm
Solid Papillary Tumor Aspirates usually cellular; tissue fragments of small to Positive reactivity to; vimentin
(SPT) medium-sized round cells with syncytial and papillary architecture, ⫹, NSE, ␣-antitrypsin,
uniform, bland nuclei with evenly dispersed chromatin, micronucleoli; ␣-antichymotrypsin,
grooves ⫹Ⲑ⫺; no molding; no necrosis; scant cytoplasm; hyaline CAM5.2⫺focally ⫹,
globules ⫹Ⲑ⫺; background debris ⫹Ⲑ⫺, hemorrhage, evidence for chromogranin and
cystic change-histiocytes synaptophysin variable
positivity
Malignant Lymphoma Usually cellular aspirate with a dispersed pattern; cells discrete with Keratin ⫺; neuroendocrine
rare tissue fragment. Small to medium-sized; poorly defined markers ⫺; LCA ⫹, CD
cell borders; high N/C ratios, nuclei round; nuclear membrane ⫹; monoclonal light chain
irregularities ⫹Ⲑ⫺; parachromatin clearing; nucleoli single large one restriction
to multiple small ones; mitoses ⫹; no nuclear molding; karyorrhexis;
stretch artifacts ⫹Ⲑ⫺
Serous Microcystic Uniform, medium-sized cells, round to cuboidal, scant pale Glycogen; PAS ⫹, diastase
Adenoma cytoplasm, loosely cohesive groups sensitive
Paraganglioma Cellular aspirate; monomorphic to pleomorphic cell pattern; cells S100 protein ⫹
small, round, oval, plasmacytoid to medium to large with occasional
giant forms; polygonal to spindle shapes; nuclei round, oval, oblong
to spindle-shaped, salt & pepper chromatin; variable cytoplasm with
or without unipolar processes
TABLE 19.11 DIFFERENTIAL DIAGNOSES OF PANCREATIC DUCT ADENOCARCINOMA

WITH A SMALL CELL PATTERN
Pancreatic Duct Acinar Cell Neuroendocrine Solid Pseudopapillary Malignant

Adenocarcinoma Carcinoma Tumor Tumor (SPT) Lymphoma
Cellularity Variable, scant Highly cellular Highly cellular Highly cellular Variable
in desmoplastic
tumor; generally
cellular
Presentation Cells isolated, in Cells isolated, in Cells isolated, in Dissociated pattern, Dispersed
loosely cohesive loosely cohesive loosely cohesive cells in aggregate or pattern
groups or in groups or in groups or in syncytial in papillary tissue
syncytial tissue syncytial tissue tissue fragments; solid fragments, some in
fragments with fragments with groups, traversed by loosely cohesive groups
or without acinar pattern; thin capillaries; cells
acinar pattern; dissociated pattern attached to the wall of
occasionally characteristic the vessels palisading
papillary along intact capillaries
Cells Small to medium Strong resemblance Small to medium- Small to medium-sized Small, uniform
to normal sized round, oval bland, monomorphic
counterpart; slight to polygonal rarely
enlargement; poorly triangular to fusiform;
defined cell borders occasional giant forms;
cell borders poorly
defined
Nuclei Round to oval, Nuclei round to oval, Eccentric, round Round to oval, Round, nuclear
enlarged; high slightly enlarged to oval, granular finely granular membranes;
N/C ratio; compared to normal salt & pepper type chromatin; smooth crisp, smooth,
irregular nuclear counterpart; finely chromatin; nucleoli nuclear membranes; granular
membrane, fine to granular chromatin; prominent; nuclear micronucleoli, nuclear chromatin;
coarsely granular prominent nucleoli, molding in poorly grooves, N/C ratios high nucleoli ⫹;
chromatin; micro/ smooth nuclear differentiated mitoses
macronucleoli membranes, N/C neuroendocrine frequent;
ratios high carcinoma karyorrhexis ⫹
Cytoplasm Variable, scant to Granular, variable Scant Generally scant; PAS Scant
moderate, pale, but scant ⫹ diastase resistant
vacuolated or granules; hyaline
dense globules ⫹Ⲑ⫺; vacuoles
⫹Ⲑ⫺
Background Clear to Naked nuclei Necrosis, karyorrhexis Hemorrhagic, cellular Clean, no mucin
inflammatory; frequent ⫹Ⲑ⫺ necrosis; histiocytes,
mucin ⫹Ⲑ⫺; multinucleated foreign-
cellular necrosis body-type giant cells
Immunoprofile CEA ⫹; CEA ⫺; CEA ⫺; cytokeratin ⫹; Vimentin ⫹; alpha-1- CK ⫺; LCA ⫹;

cytokeratin ⫹; chymotrypsin ⫹; EMA ⫺; NSE ⫹; antitrypsin ⫹; CD10 CD19 ⫹,
EMA ⫹; CD56 ⫺; trypsin ⫹; ␣-amylase chromogranin ⫹; ⫹; neuron specific CD20 ⫹
NEC markers ⫺ ⫹; lipase ⫹ synaptophysin ⫹; enolase ⫹; progesterone
somatostatin ⫹; specific receptors⫹; CEA ⫺;
peptide ⫹ CD56 ⫹ cytokeratin ⫹/⫺
Differential Diagnoses of Pancreatic Neuroendocrine Tumors (See Figs. 19.40 to 19.45)
A B
Figs. 19.40A and B. Adenocarcinoma of the pancreas with a small cell pattern. Note the presence of prominent
nucleoli.
Fig. 19.41. Lobules of normal acini with infolding of the tissue

fragments may appear syncytial. This well-preserved pattern with
uniform nuclei may be misinterpreted not only as acinar cell car-
cinoma but also as well-differentiated adenocarcinoma and a neu-
roendocrine tumor.
A B
Figs. 19.42A and B. FNA of an acinar cell carcinoma. The uniformity of the neoplastic cell nuclei require consider-
ation of neuroendocrine tumor in the differential diagnosis, the chromatin is not salt & pepper type. The architectural
pattern mimics an adenocarcinoma. (continued)
C D
Figs. 19.42C and D. (continued) The aspirate consists of round to cuboidal small to medium-sized cells in syncytial
tissue fragments with no architectural configurations. Their cytoplasm is moderate and eosinophilic. The nuclei are
uniform.
Fig. 19.43. FNA of a solid pseudopapillary tumor. The dispersed

pattern of pleomorphic cells, uniform nuclei and cytoplasmic tailing
strongly resembles a neuroendocrine tumor.
A B
Figs. 19.44A and B. FNA of a periduodenal/pancreatic mass. The cellular aspirate shows discrete, loosely cohesive
and syncytial tissue fragments of pleomorphic cells, with predominant round cell pattern. A minor proportion of the
cells are larger with abundant granular cytoplasm. Note the occasional racket-shaped giant cell with eccentric
nucleus. The immunostains were positive for S100 protein confirming the presence of sustentacular cells and the
diagnosis of paraganglioma.
Fig. 19.45. Malignant lymphoma. FNA biopsy of peripancreatic/

pancreatic mass showing discrete round cells with high N/C ratios.
The cytoplasm is scant. The nuclear borders are smooth to irregular.
The differential diagnoses included poorly differentiated adenocar-
cinoma and malignant lymphoma. The latter was confirmed by flow
cytometric evaluation.
TABLE 19.12 CYSTIC LESIONS OF THE PANCREAS crine tumors, as well as solid pseudopapillary tumors.
Table 19.13 lists the differential diagnostic entities of
Nonneoplastic
various cystic lesions.
Pseudocyst
Congenital cysts
PSEUDOCYST OF THE PANCREAS
Retention cysts
Lymphoepithelial cysts As the name implies, pseudocysts are not true cysts
since they lack an epithelial lining. They are the most
Infectious cysts common cystic lesions, accounting for at least 60%.
The etiologic factors include acute pancreatitis or
Neoplastic recurrent bouts of chronic pancreatitis, blunt or opera-
Mucinous neoplasms tive trauma, chronic alcohol abuse, and rarely, biliary
tract diseases such as possible reflux into the pancre-
Mucinous cystic neoplasms atic duct. Clinical presentation may simulate pancre-
atic carcinoma.
Intraductal papillary mucinous neoplasm The pathogenesis of a pseudocyst involves the leak-
age of pancreatic juice into the parenchyma. The diges-
Serous microcystic adenoma tive enzymes such as lipase, amylase, and trypsin cause
necrosis and chemical peritonitis. The local inflammatory
Solid pseudopapillary neoplasm response, along with an outpouring of fluid, walls off the
irritants, forming a unilocular cyst that can attain a large
Acinar cell carcinoma size. The fl uid from these cysts varies in volume up to
several liters. The fluid may be clear and straw-colored in
Duct adenocarcinoma with cystic degeneration long-standing cysts while brown or frankly hemorrhagic
in recent cysts. High levels of amylase and lipase in these
Neuroendocrine tumor with cystic degeneration fluids are diagnostic.

frequency. Some are benign and left without any surgi- Grossly, pancreatic pseudocysts demonstrate great varia-
cal intervention while others are surgically curable. Some tion in size from 3 to 10 centimeters in diameter. The
have unknown malignant potential. A preoperative diag- external surfaces are shaggy in cases of recent acute pan-
nosis, although challenging, is extremely useful in plan- creatitis, while smooth with longer duration. Pseudo-
ning treatment modality. The differential diagnoses of cysts are unilocular. Their lining is smooth in longstand-
cystic neoplasms also include cystic degeneration in ading cysts (Fig.19.46A) to shaggy in recently developed
enocarcinomas, acinar cell carcinomas, and neuroendo- cysts.
TABLE 19.13 CYSTIC LESIONS OF THE PANCREAS
Intraductal
Papillary Ductal Neuroendocrine
Serous Mucinous Solid Pseudo- Adenocarcinoma Tumor (NET)
Cystadenoma Neoplasm Mucinous Cystic Papillary Tumor with Cystic with Cystic
Pseudocyst (Microcystic) (IPMN) Neoplasms (MCN) (SPT) Degeneration Degeneration
General Features
Incidence Up to 80% of all 38.5% of cystic 30% of cystic 10% of cystic neoplasms 20% of cystic 4% of cystic 1% of cystic
cystic lesions neoplasms neoplasms neoplasms neoplasms neoplasms
Gender Prevalence More common in 1:2 1.5:1 Almost exclusively seen in 1:9.5 M⬎W M⫽W
M:F males perimenopausal women
Age Adults 5th decade 6th to 7th decade 5th decade 4th decade 7th to 8th decade 5th to 6th decade
Clinical Presentation Alcohol-related May be Often detected Often detected incidentally Vague symptoms; Abdominal pain, Symptomatic
pancreatitis 59– asymptomatic incidentally enlarging jaundice, wt loss with functioning
75%; gall stones; or nonspecific abdominal tumor; associated
hyperlipidemia; symptoms; often mass; some are with syndromes or
trauma; post an incidental asymptomatic asymptomatic
surgery; acute finding; abdominal
episodes of pain
pancreatitis
Imaging Unilocular; lack Microcystic with Macrocystic; Unilocular; macrocystic; Rarely Mass lesion; Mass lesion;
solid/mural a honeycomb communication no communication with macrocystic; infiltrating; circumscribed
nodules; features pattern; with the main the ductal system cysts with solid common bile duct
of pancreatitis; Intramural pancreatic component or pancreatic duct
atrophy; calcifications; duct and large obstruction
calcification central stellate branches.
scar; lobulated
outline
Location Outside the Body, tail Anywhere in the Tail Body, tail Anywhere; more Functioning
pancreas pancreas; more common in the neuroendocrine
common in head head tumors (NET)
with cystic
degeneration
more frequent
in head or tail;
nonfunctioning
ones in the body
(continued)
Intraductal
Gross & Microscopic Unilocular; Most frequently a Cystic dilatation Spherical neoplasm with Usually large, Variably sized; Variably sized;
Pathology surrounded by a single tumor, well- of pancreatic a smooth external surface round, 8–20 cm; infiltrative tumor functioning
densely fibrotic circumscribed, ducts; intraductal and fibrous capsule; size lobulated with up to 10 cm, tumors tend to be
wall; associated bosselated, round, proliferation 2–35 cm calcification areas of necrosis, average of 3 small; may reach
changes of 1–30 cm; cyst of neoplastic ⫹/⫺; Uni- to multilocular hemorrhagic cm; firm, poorly large size up to
acute/chronic contents clear; mucin- producing containing thick mucus cystic spaces (solid defined lesion; 10 cm with cystic
pancreatitis; lining multiple micro epithelium with or material; lining smooth, growth pattern white-yellow, degeneration;
smooth/shaggy cystic, with a without papillary glistening with and with necrosis foci of necrosis microscopically
calcification ⫹/⫺ honeycomb architecture; without small papillary and forming varying-sized cysts; show a typical
Granulation tissue pattern, microcysts varying degrees excrescences; mural pseudopapillary microscopically, neuroendocrine
lining the cyst bordered of nuclear atypia; nodules ⫹/⫺; characterized pattern); infiltrating tumor; growth pattern
by delicate papillae with three by two distinct histological Monomorphic; well to poorly and cellular/
fibrovascular distinct patterns: components; epithelial small to medium- differentiated; nuclear
septae lining 1) intestinal type layer of mucin-secreting sized cells; scant mucin production morphology
of flattened to 2) pancreatobiliary epithelium and ovarian eosinophilic to in well-
cuboidal cells 3) gastric type stroma (not identified clear cytoplasm; differentiated
with or without 4) oncocytic in cytologic specimens); PAS-diastase carcinoma ⫹/⫺
stratification; lined by tall columnar resistant, extra
bland nuclei; pale mucin-producing and intracellular
to clear glycogen- epithelium; with basally hyaline globules;
rich cytoplasm; located nuclei abundant, nuclei round
PAS ⫹; diastase intracytoplasmic apical to oval with
sensitive mucin; flat sheets or finely granular
papillae; gastric foveolar chromatin
differentiation ⫹/⫺; goblet
cells ⫹/⫺; nuclei bland
to varying degrees of
atypia; may show invasive
component in histologic
sections
Cyst Fluid Analysis
Gross Turbid, bloody Clear to Thick mucoid Thick mucoid Hemorrhagic ⫺ Clear to turbid or
to clear, amber sanguineous hemorrhage
colored
CEA ⬍5 mg/ml ⬍5 mg/ml ⬎800 mg/ml ⬎800 mg/ml ⫺ ⫺ ⫺
Amylase ⬎250 μ/l ⬍250 ␮/l ⫺ ⫺ ⫺ ⫺ ⫺
Cellularity No epithelial cells Low cellularity; Variable Variable Variable; usually Variable, often low Variable; often
may be acellular high local
Presentation Fluid clear, straw Fluid clear; Thick, viscous Fluid viscous; cells isolated Semisolid aspirate; Fluid turbid to Fluid turbid to
colored brown, monolayered mucin; cells in loosely cohesive groups dispersed cell hemorrhagic; hemorrhagic; cells
turbid or frankly sheets of isolated, in groups or in syncytial tissue pattern, loose malignant cells, isolated, in loosely
hemorrhagic; epithelial cells and in tissue fragments with or without aggregates or isolated, in cohesive groups or
dependant on the with honeycomb fragments; often papillary architecture syncytial tissue loosely cohesive in syncytial tissue
duration of the arrangement; embedded in the fragments with groups and in fragments
cyst occasional mucin; honeycomb papillary pattern syncytial tissue
papillary group; pattern to with or without fragments with
small aggregates syncytial branching or without acinar
or nests, isolated arrangements pattern; obscured
cells with or without by cellular and
papillary inflammatory
architecture debris or with
mucin ⫹/⫺
Neoplastic Cells NA Small, uniform, Small to medium- Small to medium-sized, Monomorphic, Pleomorphic in Cells small,
cuboidal; well- sized; round to round to columnar; small to medium- size, small to large, uniform, round
defined cell columnar; well well to poorly defined sized; poorly round, cuboidal to cuboidal;
borders; low N/C to poorly defined cell borders; N/C ratios defined cell to polygonal; poorly defined cell
ratios cell borders; N/C variable; goblet cells ⫹ borders; round, poorly defined cell borders; high N/C
ratios variable; high N/C ratios borders; high N/C ratios; occasional
goblet cells ⫹/⫺ ratios large forms
(continued)
Intraductal
Nuclei NA Small round, Uniform to Pleomorphism in Uniform, round Pleomorphic in Uniform,

smooth nuclear pleomorphic size ⫹/⫺; round to to oval; central size; round to round to oval;
membranes; in size; bland, oval, basally located to eccentric; oval, smooth to smooth nuclear
finely granular, benign appearing or eccentric, nuclear smooth nuclear irregular nuclear membranes,
evenly dispersed to atypical; membrane smooth to membranes; membranes; fine to salt & pepper;
chromatin; nuclei ⫹/⫺; irregular; finely granular longitudinal coarsely granular type chromatin;
nucleoli micronucleoli ⫹/⫺ chromatin; micronucleoli grooves; finely chromatin with nucleoli
inconspicuous granular, evenly parachromatin prominent; no
dispersed clearing; micro/ molding; mitosis
chromatin; macronucleoli uncommon
micronucleoli ⫹ mitoses ⫹/⫺;
nuclear
hypochromasia ⫹/−
Cytoplasm NA Pale to clear Appreciable; Variable, large cytoplasmic Scant; eosinophilic Variable, pale, Scant
modest amounts vacuolated vacuoles hyaline globule vacuolated to
⫹/⫺ dense
Background Acute and/ Clean, mucin Abundant thick Abundant mucin Necrosis Cellular and Necrosis;
or chronic absent mucin hemorrhage; inflammatory karyorrhexis in
inflammatory cells, psammoma bodies debris, high-grade tumors
foamy histiocytes, ⫹/⫺; histiocytic macrophages,
multinucleated giant cells ⫹/⫺; mucin ⫹/⫺
histiocytic giant calcific debris
cells; stromal cells ⫹/⫺; extracellular
with pleomorphic hyaline globules of
shapes, variable- varying size
sized nuclei
with prominent
nucleoli; fat
necrosis;
cellular and
necrotic debris,
hemorrhage
Ancillary Studies
Histochemistry
Alcian Hue NA ⫺ ⫹ ⫹ ⫹ diastase ⫹ –

resistant
PAS NA PAS ⫹ diastase ⫹ –

sensitive
Immunoprofile
Cytokeratin N/A ⫹ ⫹ ⫹ Occasionally ⫹ ⫹ ⫹
CEA N/A ⫺ ⫹ ⫹ ⫺ ⫹ –
CA19.9 N/A ⫺ ⫺ ⫹ ⫺ ⫺ –
Vimentin N/A ⫺ ⫺ ⫺ ⫹ ⫺ –
Neuron Specific N/A ⫺ ⫺ ⫺ ⫹ ⫺ ⫹

Enolase (NSE)
Synaptophysin N/A ⫺ ⫺ ⫺ ⫹/⫺ weak ⫺ ⫹
Chromogranin N/A ⫺ ⫺ ⫺ ⫺ ⫺ ⫹
␤-Catenin N/A ⫺ ⫺ ⫺ ⫹ ⫺ –
␣-Antitrypsin N/A ⫺ ⫺ ⫺ ⫺ ⫺ –
␣-Antichymotrypsin N/A ⫺ ⫺ ⫺ ⫹ ⫺ –
Progesterone N/A ⫺ ⫺ ⫺ ⫹ ⫺ –
Receptors
CD10 N/A ⫺ ⫺ ⫺ ⫹ ⫺ –
CD56 N/A ⫺ ⫺ ⫺ ⫹ ⫺ ⫹
Pseudocyst of the Pancreas (See Figs. 19.46 to 19.49)
A B
Figs. 19.46A and B. A: Gross photograph of a large pancreatic pseudocyst, with a smooth internal lining. B: Histologic
section of the cyst demonstrating a fibrous wall lined by granulation tissue, H&E.
cytological examination, pseudocysts can be accurately

diagnosed. Diagnostic problems may result from the pres-
ence of atypical nonepithelial lining cells originating from
the granulation tissue.
Other benign nonneoplastic cysts listed in Table 19.12
are uncommon and will not be discussed further.
CYSTIC NEOPLASMS OF THE PANCREAS
Cystic neoplasms of the pancreas are less common, com-

prising 10% of all the neoplasms. They form a heterog-
Fig. 19.47. Cyst contents of a pseudocyst with acute pancreatitis, enous group of lesions that are often detected as inciden-
showing cellular debris and fat necrosis. tal findings. They present nonspecific clinical features but
behave differently, have widely different malignant poten-
tial, and are treated differently.
Histologically, pseudocysts are lined by granulation
tissue, lacking an epithelial lining (Fig. 19.46B).
MICROCYSTIC SEROUS CYSTADENOMA

Cytologically, the fl uid aspirated from a pseudocyst Microcystic serous cystadenoma is a benign epithelial
shows variable numbers of acute and chronic inflamma- neoplasm composed of uniform, cuboidal, glycogen-rich
tory cells, histiocytes, histiocytic giant cells, and cellular/ cells that form numerous cysts containing serous fluid.
necrotic debris. Exuberant granulation tissue from the Microcystic serous cystadenomas are rare, accounting
wall may exfoliate fi broblasts containing atypical nuclei, for 1 to 2% of all exocrine pancreatic neoplasms. They
causing interpretative difficulties (Table 19.13; Figs. 19.47 occur more frequently in women, with the female:male
to 19.49). ratio being 7:3 and a mean age of 65 at the time of
diagnosis.
Serous cystadenomas may present as a large ab-
dominal mass but are often detected as incidental find-
ings. The presenting symptoms may be nonspecific.
In the right clinical setting with the imaging data, gross The radiographic findings are very characteristic. The
appearance of the cyst and its contents, fluid analysis, and CT shows a well-defined mass with microcystic spaces
A B
C D
Figs. 19.48 A to D. A: Contents of the cyst depicted in Figure 19.45, containing a large number of histiocytes. Note
the scattered atypical cells (arrows) (medium power). B, C, D: Higher magnification to show these atypical cells to be
discrete, extremely pleomorphic with irregular nuclei containing macronucleoli and may cause diagnostic difficulties.
The histologic section revealed atypical stromal cells from the granulation tissue.
A B
Figs. 19.49A to B. Contents of another pseudocyst showing stromal cells with bizarre nuclei, containing macronucleoli.
These cells cause a potential diagnostic pitfall. (continued)

separated by delicate septae. The center of the lesion
often has a central stellate scar, which may present the Grossly, serous cystadenomas tend to be large—up to
sunburst appearance of microcalcifications. The major- 30 centimeters in diameter—with a bosselated surface.
ity of serous cystadenomas are present in the body or The cut section shows innumerable small, thin-walled
tail of the pancreas. cysts presenting a honeycomb appearance and bordered
Serous Cystadenoma (See Figs. 19.50 to 19.53)
Fig. 19.50. Histologic section of a serous cystadenoma showing Fig. 19.51. Pancreatic cyst aspirate showing a tissue fragment of
cysts bordered by fibrous tissue septae and lined by flattened epi- uniform cuboidal cells with round nuclei, containing finely granular
thelium (H&E). chromatin. The cyst was proven to be a serous cystadenoma.
by delicate fi brovascular septae. The cysts are filled with

clear straw-colored fl uid. A central stellate scar with or MUCINOUS NEOPLASMS
without calcifi cation is characteristic. Histologically, the
microcysts are lined by a single layer of flattened or uni- The mucinous neoplasms of the pancreas include intra-
form glycogen-rich cuboidal cells (Fig. 19.50). ductal papillary mucinous neoplasms (IPMN) and muci-
nous cystic neoplasms (MCN).
INTRADUCTAL PAPILLARY MUCINOUS
The aspirated fluid is clear and thin but may be sanguinous.
NEOPLASMS (IPMN)
The cellularity is often low to acellular. The smears contain
small, monolayered tissue fragments of uniform, cuboidal IPMNs are mucin-producing neoplasms that arise in
cells forming a honeycomb pattern. Their cytoplasm is the pancreatic ducts and account for 1 to 3% of exo-
scant and pale to finely vacuolated. The nuclei are uni- crine pancreatic neoplasms. They are found in a broad
form and round with finely granular chromatin and incon- age range, with the median age being 60 and are slightly
spicuous nucleoli. The background is usually clean, and more common in males. With newer imaging techniques,
no mucin is present (Table 19.13; Figs. 19.51 to 19.53). the IPMNs are being detected with increasing frequency
The cytologic diagnosis is usually made with ease. Rarely, in the last few years. The patients present with nonspe-
however, a cellular aspirate with monomorphic nuclei may cific clinical symptoms. Very often, these lesions are iden-
mimic a neuroendocrine tumor (Fig. 19.53). tified incidentally. The radiographic appearance is very
characteristic with the dilatation of the pancreatic duct

and its branches. The endoscopic findings of thick mucin
extruding from the ampulla is considered a diagnostic Grossly, the main pancreatic duct and its branches
finding of IPMN. These lesions are frequently located in show considerable dilatation and are filled with thick
the head. mucin. Microscopically, the lining epithelium of the
A B
Figs. 19.52A to C. Cyst aspirate from a histologically confirmed

serous cystadenoma. The cyst fluid was poorly cellular, containing
rare monolayered tissue fragments of cuboidal cells with pale to
clear cytoplasm and uniform round nuclei. The background is clean
C and lacks mucus.
A B
Figs. 19.53A to B. A, B: The pancreatic cyst aspirate is moderately cellular consisting of small uniform cells loosely
cohesive and in small monolayered tissue fragments. The cell borders are poorly defined and the cells contain scant
pale to clear cytoplasm. The nuclei are uniform. This aspirate was interpreted as possible neuroendocrine tumor. A
second opinion was requested by the clinician. The cytopathology consultant interpreted the lesion as mucinous
neoplasm due to the background present in Figure 19.53B. (continued)
Figs. 19.53C. (continued) C: Surgical excision confirmed a serous

C cystadenoma (H&E).
Intraductal Papillary Mucinous Neoplasm (IPMN) (See Figs. 19.54 to 19.59)
A B
C D
Figs. 19.54A to D. Histologic spectrum of IPMN. A: low power view depicting markedly dilated pancreatic duct
lined by hyperplastic epithelium. B: Different case exhibiting several dilated spaces. C: A hyperplastic lining
epithelium of gastric foveolar type. D: Pancreatobiliary type epithelium with nuclear atypia.
dilated ducts is of the mucin-producing type with vary- cells with prominent nucleoli; 3) gastric foveolar type;
ing degrees of atypia. It may be a single cell thick or and 4) oncocytic (Figs. 19.54A to D). The epithelium
present a papillary growth pattern and is of four types: can be bland and benign-appearing or may demonstrate
1) intestinal, which is morphologically similar to that of varying degrees of atypia with features of carcinoma in
colonic villous adenoma; 2) pancreatobiliary, in which situ (CIS). Foci of invasion have been noted in 30% of
the papillae are more complex and lined by cuboidal the tumors.
TABLE 19.14 CYTOPATHOLOGIC FEATURES OF INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM

(IPMN) AND MUCINOUS CYSTIC NEOPLASMS (MCN)
Intraductal Papillary Mucinous Neoplasm (IPMN) Mucinous Cystic Neoplasms (MCN)

Cellularity Variable, from paucicellular to hypercellular Variable, from paucicellular to hypercellular
Presentation Predominantly in tissue fragments, varying in sizes and Predominantly in tissue fragments, varying in sizes
in architecture; monolayered sheets to syncytia; papillary and in architecture; monolayered sheets to syncytia;
pattern frequent with or without complex branching; papillary pattern infrequent; discohesive pattern of
discohesive pattern of single cells or loosely cohesive single cells or loosely cohesive groups of cells often
groups of cells often trapped within mucus; epithelial tissue trapped within mucus; epithelial tissue fragments
fragments may be enveloped by mucin; goblet cells ⫹Ⲑ⫺ may be enveloped by mucin; goblet cells ⫹Ⲑ⫺
Cells Medium-sized cuboidal to tall columnar; cell borders well Medium-sized cuboidal to tall columnar; cell
to poorly defined; N/C ratios dependent on the degree of borders well to poorly defined; N/C ratios
nuclear atypia dependent on degree of nuclear atypia
Nucleus Uniformly round, with smooth nuclear membranes and with Uniformly round with smooth nuclear membranes
bland chromatin in low-grade lesions; variably pleomorphic and with bland chromatin in low-grade lesions;
with crowding and overlapping in moderately dysplastic variably pleomorphic with crowding and
lesions to clearly malignant; micro to macronucleoli; mitoses overlapping in moderately dysplastic lesions to
may be seen in malignant lesions clearly malignant; micro to macronucleoli; mitoses
may be seen in malignant lesions
Cytoplasm Scant to moderate amount; mucinous or dense Scant to moderate amount; mucinous or dense
Background Abundant mucin; thick, tenacious and stringy offering Abundant mucin; thick, tenacious and stringy
difficulties in aspirating and making smears; mucin can be of offering difficulties in aspirating and making
thin consistency smears; mucin can be of thin consistency; necrotic
debris, inflammatory cells and histiocytes ⫹Ⲑ⫺
bland epithelium to an overwhelmingly cellular one. In

low-grade neoplasms, the epithelium can be monolayered
and composed of mucin-producing columnar cells con-
taining uniform nuclei with fi nely granular chromatin.
The mucin may be in the form of thin wisps or it can
be abundant and very thick, making the smearing very
difficult. This thick mucus stains metachromatically bright
magenta in Romanowsky-stained preparations. The aspi-
rate in moderate to high-grade IPMNs shows syncytial
tissue fragments of cuboidal to columnar epithelium with
and without a papillary pattern. Their nuclei are enlarged,
crowded, and overlapped and contain granular chromatin
and nucleoli. Goblet cells may be identified singly, some-
times within the mucus and in tissue fragments.
Fig. 19.55. Aspirate from a case of IPMN showing a large amount
of thick mucus. No epithelial cells are present.
Cytologic recognition of IPMN presents multiple chal-
lenges: 1) the neoplastic cells may be very bland and benign-
The aspirates of IPMN are variably cellular. The range of appearing, not lending themselves to be differentiated from
cytopathologic presentation is extremely wide and greatly the gastric or duodenal contaminants—a very frustrating
depends on the degree of proliferation of the lining epi- experience for the cytopathologists indeed; 2) the gastric or
thelium, its type, and grades of atypia (Tables 19.13 and duodenal mucus may be present in large amounts, dominat-
19.14; Figs. 19.55 to 19.59). The cellularity may be very ing the cellular sample; and 3) mucinous cystic neoplasm
low with a few tissue fragments of mucin-producing cannot be differentiated cytologically from IPMNs.
A B
Figs. 19.56A to C. A: Low power showing a cellular aspirate con-

sisting of several tissue fragments of mucin-rich epithelium, evident
even at this magnification (arrows) B, C: Higher magnification
C showing the bland, mucin-rich epithelium.
A B
Figs. 19.57A to C. A: Aspirate of a cystic lesion of the pancreas

with poor cellularity. Note the aggregates of goblet cells. B: Differ-
ent field showing a syncytial tissue fragment of benign appearing
bland cuboidal cells and a strip of goblet cells. C: Section of the
excised IPMN showing a dilated pancreatic duct lined by colonic
C type epithelium.
806
The gastric epithelium is usually present in tissue MUCINOUS CYSTIC NEOPLASMS

fragments and is composed of uniform, cuboidal cells
Mucinous cystic neoplasms (MCN) are composed of mucin-
with well-defined cell borders, presenting as a honey-
producing epithelium associated with ovarian-like stroma.
comb pattern. The luminal border may be apparent with
These tumors occur almost exclusively in perimenopausal
cells containing pale, foamy, mucinous epithelium. The
women with a mean age of 48. It is very uncommon, com-
duodenal epithelium is often seen in aspirates as large
prising 2 to 5% of exocrine pancreatic neoplasms. These
folded-over sheets of epithelium with interspersed gob-
tumors are usually located in the tail of the pancreas.
let cells.
A
B
Figs. 19.58A to B. FNA of an IPMN. A: Aggregates of discrete gob-

let cells suggest a mucinous neoplasm. B: Bland benign cuboidal
epithelium and goblet cells. C: This large tissue fragment of benign
cuboidal cells with a honeycomb pattern may represent the IPMN.
The cells at the periphery are disorganized with suggestion of being
mucin-producing type. This pattern cannot be differentiated from a
C gastric contaminant.
A B
Figs. 19.59A to B. FNA of an IPMN. A, B: The aspirate is overwhelmingly cellular consisting of several varying-sized
tissue fragments with mucin streaks in the background. Also note the tissue fragments of mucin-rich epithelium
(arrows). (continued)
C D
E F
Figs. 19.59C to F. (continued) C, D: Higher magnification demonstrating the syncytial arrangement of cells contain-
ing pleomorphic nuclei. Note the presence of goblet cells (G). This epithelium is moderately atypical. E: A syncytial
tissue fragment of mucin-rich epithelium with nuclear atypia. F: The cell block showing hyperplastic colonic type
epithelium (H&E).
Gross and Microscopic Features is not a diagnostic problem. Syncytial architecture should
raise the suspicion of a neoplasm. The aspirates often con-
Grossly, MCNs are composed of large multilocular cysts
tain variable numbers of goblet cells and thick mucin in the
ranging in size from one to several centimeters in diame-
background. Necrosis may be seen in the background.
ter. The locules have thick, fibrotic walls and do not com-
municate with the pancreatic duct system—an important
differentiating feature from IPMN. The wall of the cysts
may be smooth or may show small papillary excrescences.
The contents are thick and mucoid but may be watery. The diagnostic difficulties are the same as those described
Microscopically, MCNs resemble MCNs of the ovary for IPMN. The differential diagnosis includes other cystic
in that the cystic areas are surrounded by ovarian-like stro- lesions of the pancreas (Table 19.13).
ma and constitute a defining feature of this pancreatic tu-
mor. The lining epithelium may be of tall columnar mucin-
producing type or may be composed of cuboidal cells and MUCINOUS NONCYSTIC ADENOCARCINOMA
goblet cells. The nuclei may be bland to overtly malignant.
Mucinous noncystic adenocarcinoma, also known as col-
loid carcinoma, is a morphologic variant of pancreatic
duct adenocarcinoma (Fig. 19.62). It is characterized by
Cytological features (Tables 19.13 and 19.14; Figs. 19.60 mucin-producing neoplastic cells fl oating in large pools
and 19.61) include bland mucin-producing epithelium of extracellular mucin. The colloid component constitutes
that cannot be differentiated from the gastric/duodenal over 80% of the tumor. Mucinous noncystic adenocar-
contaminants to tissue fragments of epithelium with vary- cinoma is morphologically different from conventional
ing degrees of nuclear atypia. An overtly malignant lesion adenocarcinoma that shows mucin production.
Mucinous Cystic Neoplasm (See Figs. 19.60 to 19.62)
A B
C D
Figs. 19.60A to D. A: Sections of a mucinous cystic neoplasm showing a cyst with ovarian type stroma in the wall.
B: Higher magnification showing the lining of a single layer of mucinous epithelium (H&E). C, D: The aspirate
demonstrating tissue fragments of benign epithelium with vacuolated cytoplasm. A cytologic diagnosis of mucinous
cystic neoplasm cannot be made from this morphology.
A B
Figs. 19.61A and B. FNA of a pancreatic mass showing tissue fragments of malignant cells, embedded in abundant
thick mucin. A: Low power. B: Higher magnification. The component cells are clearly malignant. This pattern may
represent an IPMN, or a mucinous cystadenocarcinoma or a colloid carcinoma. Differentiation is not possible from
cytology.
either with no primary history or with a history in the

remote past.
MOLECULAR MARKERS
Currently, there are no definitive molecular assays used

for the clinical management of pancreaticobiliary carcino-
mas. However, mutations frequently associated with pan-
creatic and biliary carcinomas may be used to enhance the
diagnostic accuracy in a cytology specimen, discriminat-
ing reactive from malignant cells, or used when neoplas-
tic cells are limited in a brush cytology or FNA sample.
The false-negative rate will reduce if the lesional cells are
Fig. 19.62. FNA of a metastatic colonic adenocarcinoma to the
pancreas. microdissected to enrich tumor DNA. The increasing use
of EUS-guided FNA often leads to an increased diagnostic
challenge due to sample inadequacy.
DIAGNOSTIC DIFFICULTIES AND In the literature, mutations in codon 12 of the KRAS
DIFFERENTIAL DIAGNOSES OF gene and the loss of heterozygosity in frequently deleted
PANCREATIC CYSTIC LESIONS genes (e.g., Riz [retinoblastoma interacting zinc finger, lo-
cus: 1p36–1p34], VHL [von Hippel-Lindau gene, locus
3p26–3p25], APC [adenomatous polyposis coli gene,
Lately, there has been a sizable increase in the number
locus: 5q23–5q23], PTEN [phosphate and Ten sin ho-
of EUS-guided biopsies for identifying pancreatic cys-
mologue deleted on chromosome Ten], and TP53 [locus:
tic lesions. The majority of pancreatic cysts are pseudo-
17p13–17p13]) have been used to provide a definitive di-
cysts. However, it is very important to identify the cases
agnosis on cytology specimens since these mutations occur
that require surgical intervention. The cytologic diagno-
in high frequency (Khalid et al., 2004). A similar approach
sis should always be made with a complete knowledge
has been used in pancreatic cyst aspiration specimens to
of clinical data and radiologic findings. The cytologic
detect MCNs of the pancreas (Khalid et al., 2005).
interpretations are often a diagnostic challenge. The
There is an emerging “tsunami” of knowledge in
clinicopathologic and cytologic features are listed in
MicroRNA profiles of different epithelial malignancies
Table 19.13.
and their normal counterparts. One such publication by
Bloomston et al. describes MicroRNA expression patterns
to differentiate pancreatic adenocarcinoma from a normal
pancreas and chronic pancreatitis. Authors concluded that
pancreatic cancer may have a distinct miRNA expression
Secondary malignancy involving the pancreas is pattern that may differentiate it from a normal pancreas
uncommon. The pancreas is either involved by a direct and chronic pancreatitis. The patterns may also reflect cor-
extension of malignancy from adjacent organs or by relation with short- and long-term survival. Szafranska et
a hematogenous spread from distant organs, such as al. also published their data on a miRNA analysis of pan-
the lungs, the kidney, the breast, and the colorectum, creatic FNA biopsy samples that may help in the pathologic
and by melanoma. Metastatic lesions are not frequently evaluation of suspicious cases and may provide a new strat-
biopsied unless the lesions present as solitary nodules egy for improving the diagnosis of pancreatic diseases.
SUGGESTED READINGS
Adsay NV. Cystic lesions of the pancreas. Mod Pathol 2007;20: Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al.
S71–S93. Diagnosis of pancreatic cystic neoplasms: a report of the
Belsley NA, Pittman MB, Lauwers GY, et al. Serous cystadenoma cooperative pancreatic cyst study. Gastroenterology 2004;
of the pancreas. Limitations and pitfalls of endoscopic ultra- 126:1330–1336.
sound guided fine-needle aspiration biopsy. Cancer (Cancer Chhieng DC, Stelow EB. Pancreatic cytopathology. In: Rosenthal DL,
Cytopathol) 2008;114:102–110. ed. Essentials in Cytopathology Series. New York: Springer, 2007.
Bloomston M, Frankel WL, Petrocca F, et al. MicroRNA expression Deshpande V. Cystic pancreatic endocrine tumor. A variant
patterns to differentiate pancreatic adenocarcinoma from normal commonly confused with cystic adenocarcinoma. Cancer
pancreas and chronic pancreatitis. JAMA 2007;297:1901–1908. 2007;111:47–53.
Hruban RH, Bishop Pittman M, Klimstra DS. Tumors of the Pan- Nagle JA, Wilbur DC, Pitman MB. Cytomorphology of gastric
creas. Washington DC: Armed Forces Institute of Pathology, and duodenal epithelium and reactivity to B72.3: A baseline
Fourth series, Fascicle 6, 2007. for comparison to pancreatic lesions aspiration by EUS FNAB.
Khalid A, McGrath KM, Zahid M, et al. The role of pancreatic Diagn Cytopathol 2005;33:351–386.
cyst fluid molecular analysis in predicting cyst pathology. Clin Stelow EB, Stanley MW, Bardales RH, et al. Intraductal papil-
Gastroenterol Hepatol 2005;3:967–973. lary mucinous neoplasm of the pancreas. The findings and
Khalid A, Pal R, Sasatomi E, et al. Use of microsatellite marker limitations of cytologic samples obtained by endoscopic
loss of heterozygosity in accurate diagnosis of pancreati- ultrasound-guided fine-needle aspiration. Am J Clin Pathol
cobiliary malignancy from brush cytology samples. Gut 2003;120:398–404.
2004;53:1860–1865. Szafranska AE, Doleshal M, Edmunds HS, et al. Analysis
Layfield LJ, Cramer H. Fine needle aspiration cytology of intraduc- of microRNAs in pancreatic fine-needle aspirates can
tal papillary mucinous tumors; a retrospective analysis. Diagn classify benign and malignant tissues. Clin Chem
Cytopathol 2005;32:16–20. 2008;54:16–24.
20 KIDNEY
Mariza d
de Peralta-Venturina
l • Sudha
dh R. Kini
FNA biopsy of the kidney is a useful technique in the diag-

nosis and management of a subset of solid or cystic renal CYTOLOGY OF NORMAL KIDNEY
lesions. This technique is used in the following instances:
● For cystic lesions as a therapeutic procedure.
The normal components of renal parenchyma (e.g., glom-
● For cystic lesions with radiographic or clinical suspi-
eruli and tubules), are only rarely encountered in FNAs.
cion of malignancy. The glomerulus appears as a well-defined lobulated mass
● In advanced malignancy for a morphologic diagnosis
of tangled capillaries with endothelial cells, which may
prior to radiation or chemotherapy. superfi cially resemble the papillae of papillary renal cell
● To confirm a metastatic malignancy.
carcinoma. The proximal tubular cells consist of sheets
● To confi rm a malignant diagnosis in a patient who is
of varying-sized cuboidal cells with well-defined cell
not a surgical candidate. borders, abundant eosinophilic cytoplasm, and centrally
● To confirm a recurrence at the site of nephrectomy for
placed round nuclei with compact chromatin (e-Fig. 20.1).
renal carcinoma. These cells may resemble the cells of renal oncocytoma
● To diagnose lesions when partial nephrectomy might
or chromophobe renal cell carcinoma. The distal tubular
be the preferred choice for neoplasms such as oncocy- cells are smaller cells with scant clear to slightly granular
toma, chromophobe carcinoma, and angiomyolipoma. cytoplasm with small, round nuclei, which may contain
micronucleoli. In contrast to hypercellular aspirates from
Diagnostic problems in the aspiration cytology of the neoplastic renal tumors, inadvertent sampling of normal
kidney include elements is often seen in sparsely cellular aspirates.
● Differentiation of cystic renal cell carcinomas (RCC)
with poor cellularity from benign renal cysts and
benign cystic neoplasms such as cystic nephroma. CYSTIC LESIONS OF THE KIDNEY
● Differentiation of renal cell carcinoma (RCC) of the
clear cell type from normal adrenal cortical cells, adre- Nonneoplastic cysts of the kidney are either congenital or
nocortical hyperplasia, or adenoma. acquired. Multiple congenital cysts are seen in polycystic
● Differentiation of renal oncocytoma from renal cell disease of the kidney. Most cysts are acquired, clinically
carcinomas with granular cytoplasm (conventional silent, and identifi ed as incidental fi ndings as 85% of all
and chromophobe types). renal masses are cysts. Acquired cysts are common in peo-
● Differentiation of renal cortical papillary adenoma ple over the age of 50 and may attain a large size. Cystic
from renal cell carcinoma, particularly the papillary lesions are classified based on radiologic appearance using
subtype. the 4-category Bosniak system (Category 1: benign; 2, 3:
● Differentiation of normal renal tubular cells from low- indeterminate; and 4: highly suspicious for renal cell car-
grade renal cell carcinoma. cinoma). Tumors in categories 2 and 3 are often selected
● Differentiation of renal cell carcinoma from inflamma- for FNA. Cytologically, the cyst fluid may be acellular or
tory lesions. may show variable numbers of histiocytes, multinucle-
● Differentiation of hepatocytes from renal cell ated histiocytic giant cells, and rare benign tubular cells
carcinoma. (e-Fig. 20.2). In some cases, rare epithelial cells will show
● Differentiation of poorly differentiated or high-grade either nuclear or cytoplasmic atypia. Despite the presence
renal cell carcinoma from metastatic poorly differenti- of rare atypical cells, these cases should not be signed out
ated carcinomas. as positive since the changes may be seen in reactive cyst
● Differentiation of low-grade urothelial carcinoma of lining cells. Patients with both acquired and congenital
renal pelvis/ureters from benign urothelium. cystic disease are at increased risk of renal cell carci-
● Differentiation of high-grade urothelial carcinoma noma, which is often multifocal and often of the papillary
from poorly differentiated renal cell carcinoma. type, although recently, tumors with hybrid features of
812
Chapter 20: Kidney 813
papillary and clear cell features have been seen in patients a central scar in approximately one-third of cases. It may
with end-stage kidney disease. show recent hemorrhage in up to 20% of cases but necro-
FNAs of cystic renal masses have a relatively low sen- sis, cystic degeneration, or extension into perinephric fat
sitivity leading to false-negative results due to the scant is rarely seen. These tumors may be multifocal or bilateral
cellularity. Despite negative cytologic findings, a comment in up to 13% of cases.
stating that a cystic renal cell carcinoma is not completely Histologically, oncocytomas are composed of large po-
excluded is advisable. lygonal cells arranged in nests and tubules. The cells have
An important differential diagnosis includes a type of deeply eosinophilic abundant granular cytoplasm, small
clear cell renal cell carcinoma (RCC) that is a multilocular bland-appearing nuclei and centrally located nucleoli.
cystic RCC and which, by definition, should not contain ex- Degenerative atypia consisting of marked size variation
pansile nodules of clear cells. It is composed entirely of cysts and hyperchromatic nuclei without prominent nucleoli or
and septa. This type of tumor is uncommon and accounts mitoses may be seen in oncocytoma. The cytologic pattern
for 1 to 5% of all RCCs and is, by definition, of Fuhrman is characteristic (Table 20.1; e-Figs. 20.4 to 20.6). Differ-
nuclear grade 1. ential diagnoses of oncocytoma include normal proximal
tubular cells, conventional RCC with granular cytoplasm,
CYSTIC NEPHROMA (MULTILOCULAR CYST) chromophobe RCC, and normal hepatocytes. Differentia-
tion from the eosinophilic variant of chromophobe carci-
Cystic nephroma, or multilocular cyst of the kidney, is a rare noma may be difficult on the basis of cytology (see Table
benign neoplasm occurring in childhood and middle-aged 20.7; Fig. 20.28). Oncocytoma and chromophobe RCC
adults, usually females. Cystic nephromas are solitary, uni- show an overlapping immunohistochemical profile (both
lateral, and encapsulated, involving the upper pole of the kid- are positive for c-kit and Ksp-cadherin and are negative
ney. Histologically, they are multiloculated with no commu-
nication between the loculi and calyces or pelvis. Although
cystic, the lesion often appears solid radiographically. The TABLE 20.1 CYTOPATHOLOGIC FEATURES OF
loculi are lined by a single layer of epithelium with or with- RENAL ONCOCYTOMA
out nuclear atypia and have a hobnail pattern. The stroma Cellularity Highly cellular
in between the loculi is fibrous. The adjacent parenchyma
is normal. Cytologically, the cells may show small papillary Presentation Cells isolated, in loosely cohesive groups,
clusters of atypical epithelial cells and may be misinterpreted or monolayered sheets
as carcinoma (e-Figs. 20.3A to D; see Table 20.6).
Cells Large, round to polygonal with well-
defined cell borders; low N/C ratios
BENIGN NEOPLASMS OF THE KIDNEY
Nucleus Round, binucleation frequent, uniform,
small in size; smooth nuclear membrane;
METANEPHRIC ADENOMA finely granular evenly dispersed chromatin,
prominent macronucleoli; no mitotic
Metanephric adenoma typically occurs in women in the activity
fi fth decade of life and is histologically composed of
tubules and short papillae lined by small uniform cells Cytoplasm Abundant granular; may stain deep
with scant cytoplasm. Cytologically, the cells show a eosinophilic or cyanophilic with
superfi cial resemblance to Wilms’ tumor but are often a Papanicolaou stain
low nuclear grade, resembling low-grade papillary RCC
(e-Figs. 20.4A to C). Psammoma bodies may occasionally Background Clean, no necrosis
be seen. Immunohistochemically, the cells are immunore-
active with WT1, CD57, and S100 protein but are CK7 Immunoprofile Positive: c-kit, PAX2
and AMACR negative (in contrast to papillary RCC). Negative: vimentin; typical renal cell
carcinoma markers, CK7
RENAL ONCOCYTOMA Ultrastructure Large numbers of mitochondria showing

Oncocytomas are benign neoplasms that are believed to lamellar or focally stacked cristae; rare
microvesicles
arise from the intercalated cells of renal collecting tubules
and comprise 5 to 7% of all resected renal tumors. They
Cytogenetics May show loss of sex chromosome and
occur more frequently in males and have a median age
chromosome 1; structural rearrangements
of 62. Generally asymptomatic, they are discovered as an involving chromosome 11q12–13; partial
incidental fi nding. Grossly, oncocytomas are uniformly or complete loss of chromosome 14
tan to mahogany brown and are well-circumscribed with
for vimentin and typical markers for conventional/clear adipose tissue are rarely aspirated since it can be diagnosed
cell RCC [CD10, RCC]). Because of the cytologic similari- reliably with radiologic studies. Most cases that undergo
ties between these two tumors, most people advocate sign- FNA have a scant fat component. The predominant cellular
ing these cases as “oncocytic neoplasm” based on FNA. elements in these aspirates are the smooth muscle elements,
which can demonstrate some degree of atypia. The epithe-
lioid variant of angiomyolipoma may be mistaken for renal
RENAL ANGIOMYOLIPOMA
cell carcinoma, particularly the sarcomatoid type. Positive
Renal angiomyolipoma is an uncommon benign neoplasm, staining for HMB-45 and Melan-A and negative staining
comprising 0.7 to 2% of all renal neoplasms. Fifty percent for cytokeratin supports the diagnosis of angiomyolipoma
of angiomyolipomas are associated with the hereditary in a renal neoplasm with spindled and epithelioid areas.
disorder called tuberous sclerosis complex. These tumors
may be symptomatic with flank pain and can be detected
XANTHOGRANULOMATOUS PYELONEPHRITIS
radiologically. Angiomyolipomas are more frequent in
females in the fourth decade of life. Grossly, these intra- A variant of chronic pyelonephritis, xanthogranuloma-
renal tumors are lobular and yellow. Histologically, the tous pyelonephritis may mimic RCC radiographically and
tumor is composed of blood vessels, mature adipose tis- clinically. It may be focal or diffuse. Histologically, it is
sue, and smooth muscle in varying proportions. The blood characterized by extensive accumulation of foamy mac-
vessels are unusually thick, and the smooth muscle cells rophages with other infl ammatory cells. The aspirate is
are arranged radially. Immature smooth muscle fibers composed of foamy histiocytes and multinucleated giant
may predominate. Adipose tissue may be associated with cells in a necrotic dirty background (see Figs. 20.25A and
hemorrhagic necrosis and giant cell reaction. B). The epithelioid histiocytes may resemble the cells of
Aspiration biopsy shows adipose tissue and smooth RCC. However, these cells will stain positive for CD68
muscle fibers, occasionally with atypical nuclei. The vascu- and CD163 and are negative for cytokeratin.
lar component is more apparent in cell block preparations
(Table 20.2; e-Figs. 20.7A to C). Tumors with abundant
RENAL MALAKOPLAKIA
TABLE 20.2 CYTOPATHOLOGIC FEATURES OF Malakoplakia is a distinctive form of chronic inflam-

ANGIOMYOLIPOMA mation and involves the kidney as a single lesion or as
multiple mass lesions, simulating renal cell carcinoma.
Cellularity Variable, moderate to sparse It is usually associated with urinary tract infection or
severe immunosuppression. Histologically, the lesion is
Presentation Polymorphic cell pattern; admixture of composed of a large population of macrophages with
mature adipose tissue, blood vessels, abundant granular cytoplasm. The characteristic features
smooth muscle, and fibrous tissue, adipose include the presence of Michales–Güttman bodies, which
tissue; in variable proportions are 2 to 5 nanometers in diameter and are round, concen-
tric, multilayered, and basophilic calcospherites within
Cells Spindle cells isolated or in fascicles, with and outside the cytoplasm.
cigar-shaped nuclei containing finely
granular chromatin, poorly defined cell
borders and pale cytoplasm; immature RENAL CORTICAL (PAPILLARY) ADENOMA
smooth muscle cells appear round with
high N/C ratios; nuclear atypia /; Papillary adenoma is currently defi ned as a small lesion
epithelioid forms /; occasional giant that is always less than 0.5 centimeters with papillary or
cell resembling ganglion cell tubular architecture and is of low nuclear grade (e-Figs.
20.8A to D). These are often found incidentally and are
Blood Vessels Thick walled (seen particularly in cell too small to be aspirated. It resembles type 1 papillary
block preparations) renal cell carcinoma morphologically and immunohis-
tochemically (positive staining with EMA, low molecular
Adipose Tissue Normal appearing weight cytokeratin, and p504s).
Immunoprofile Positive—smooth muscle markers, desmin,

smooth muscle actin; melanocytic
markers (e.g., HMB-45, Melan-A) RENAL CELL CARCINOMA (RCC)
Negative—S100
Background Collagenous matrix /; macrophages

RCCs account for 3% of adult malignancies. Annu-
/; bare spindle-shaped nuclei ally, approximately 36,000 new cases are diagnosed in
the United States with more than 10,000 deaths. The
tumors are more frequent in males with a male:female Typing errors can occur with chromophobe type car-
ratio of 1.6:1, and they occur mainly in adults with a cinoma and renal oncocytomas. The chromophobe type
median age of 55. Renal cell carcinomas remain silent RCC and the clear cell type with a predominant granular
and grow to a large size before being discovered. Some component may be difficult to differentiate from oncocy-
present initially at the metastatic site. Up to 40% of tomas (Table 20.7; Figs. 20.21 and 20.22) and may show
patients do not have genitourinary symptoms at the overlapping immunohistochemical staining character-
initial diagnosis, and the classic triad of flank pain, istics. Histiocytes may also pose diagnostic problems in
hematuria, and flank mass is seen in less than 15% of differentiating chromophobe RCC and oncocytoma (Figs.
cases. 20.20 to 20.22).
The majority of renal cell carcinomas are of the clear The poorly differentiated RCCs are, at times, difficult
cell type (60–70%) followed by papillary RCC (10–15%) to recognize from high-grade urothelial carcinoma and
and chromophobe RCC (5%). Less common histologic metastatic neoplasms. The spindle cell pattern of a sarco-
subtypes are the collecting duct carcinoma including matoid RCC, although not very frequent, overlaps with
medullary carcinoma, unclassifi ed RCC and recently de- cells of sarcomatoid urothelial carcinoma, metastatic soft
scribed entities including translocations carcinoma (asso- tissue sarcomas, and angiomyolipoma (see Table 20.8).
ciated with Xp11 translocation and particularly seen in
pediatric patients), mucinous tubular and spindle cell tu-
mor, tubulocystic carcinoma, and acquired cystic disease
MALIGNANT LYMPHOMA
associated renal cell carcinoma. The reader is advised to
refer to the literature for more information on these un-
usual and recently described tumors. Since sarcomatoid Malignant lymphoma of the kidney occurs in four clinical
type has been found to arise in any of the types of renal forms: secondary, primary, post-transplant lymphoprolif-
cell carcinoma mentioned above, it is not recognized as erative disorder, and intravascular lymphoma. The kid-
a morphologic variant (see Fig. 20.13). Certain specific ney is frequently involved in post-transplant disorders.
genetic changes have been found in different morphologic Fine needle biopsy is infrequently utilized for diagnostic
variants and may have prognostic implications. Histologic purposes.
nuclear grading of RCC uses the 4-tier nuclear grading by
Fuhrman, which depends on the size and pleomorphism
of the nuclei and the prominence of the nucleoli. There
is a good histologic and cytologic correlation using this PRIMARY CARCINOMA OF THE RENAL
grading scheme. PELVIS AND URETERS
The clinicopathologic features and cytomorphology
of the commonly encountered renal cell carcinomas— Carcinomas of the renal pelvis and ureters are uncom-
clear cell type, chromophobe type, and papillary type— mon, accounting for less than 5% of all urothelial tumors.
are listed in Tables 20.3 and 20.4 and are illustrated in They occur at all ages, most commonly in males aged 50
Figures 20.1 to 20.18. to 70 and are frequently associated with similar lesions at
other sites lined by urothelium.
Carcinomas can involve any part of the upper collect-
DIAGNOSTIC DIFFICULTIES
ing system with the majority being the urothelial cell type.
Most renal cell carcinomas are identifi ed without much The exophytic tumors appear as translucent light tan to
diffi culty from FNAs. Diagnostic problems are encoun- pink, soft, friable, cauliflower-like masses projecting into
tered in several situations (Table 20.5; Figs. 20.19 to the lumen of the calyces and pelvis. Invasive tumors form a
20.29). Scant cellularity, particularly in cases of cystic firm gray—white, dense, poorly demarcated mass that ex-
RCCs or carcinomas with extensive necrosis (see Figs. tends into the perihilar region and may form a retroperito-
20.26 to 20.29), may result in a false-negative diagnosis. neal mass. Their cytologic diagnosis is provided either on
Cystic carcinomas must also be differentiated from benign brushings or on fine needle biopsies. The pattern depends
cystic lesions such as a benign cyst or a renal abscess on the histologic grade (Table 20.9; Figs. 20.30 to 20.34).
(Table 20.6; Figs. 20.26, 20.27, and 20.29). RCCs may Low-grade urothelial cell carcinomas are considerably dif-
be overcalled when normal tubular cells are mistaken for ficult to differentiate from benign urothelium (Fig. 20.35).
low-grade RCCs, particularly in poorly cellular aspirates High-grade carcinomas consist of very pleomorphic cells
(Figs. 20.23A and B). Large histiocytes from xanthogran- varying in size and shape and often containing bizarre nu-
ulomatous pyelonephritis (Figs. 20.25A and B), on occa- clei. Squamous and glandular differentiation may be pres-
sion, are mistaken for RCC. The adrenal cortical cells or ent. Metastatic urothelial cell carcinomas exhibit consid-
cells of adrenal cortical hyperplasia/adenoma (Fig. 20.22) erable pleomorphism in cell size and shape. Discohesive
may mimic RCC. Inadvertently, biopsied hepatocytes may cells, many with cytoplasmic processes (cercariform cells),
be mistaken for RCC. are characteristic of urothelial cell carcinoma.
TABLE 20.3 RENAL CELL CARCINOMAS (RCC), MORPHOLOGIC VARIANTS,

CLINICOPATHOLOGIC FEATURES
Clear Cell RCC Chromophobe Type Papillary
Incidence (% of Renal 70–75% 5% 10–15%

Cell Carcinomas)
Gross Variably sized, could be large Variably sized, well- Variably sized; well-
and bulky, variegated cut circumscribed; cut surface circumscribed, eccentrically
surface; bright yellow-red, fleshy bulging pale gray to mahogany situated in renal cortex; cut
with cystic areas brown; lack hemorrhage or surface gray to golden yellow;
necrosis hemorrhage, necrosis /
Histopathology Large round to polygonal cells Well-defined cell borders, Fibrovascular stalks in single
forming alveoli or pseudoacinar abundant cytoplasm; intimate layer; tubular pattern /; lipid
pattern separated by delicate mixture of large cells with laden macrophages in the stalk;
vascular stroma; pseudoacini pale transparent cytoplasm tumor necrosis /; cholesterol
filled with serous fluid, blood and smaller cells with brightly crystals; nuclei small, bland
or hemosiderin containing acidophilic cytoplasm, the latter chromatin pattern; nuclear
macrophages; solid areas in cells may be present along enlargement, hyperchromasia
poorly differentiated tumors; cells the vascular septae; nuclei and anaplasia are distinctly
with well to poorly defined cell monomorphic with coarsely unusual; psammomatous
borders, abundant clear cytoplasm granular chromatin, minimally calcification; 2 morphologic
(glycogen lipid); round central pleomorphic nucleoli /; variants: Type 1—small cells
nucleus with finely granular narrow zone of dense cytoplasm with low nuclear grade and scant
chromatin; micronucleoli/ at the periphery accentuating cell cytoplasm; Type 2—larger cells
macronucleoli; necrosis / borders; weakly PAS with higher nuclear grade
Immunohistochemistry Positive: vimentin; CD10; RCC Positive: c-kit, Ksp-cadherin; Positive: vimentin; AMACR;
Ma; PAX2 CK7 CD10;
Negative: CK7; AMACR; c-kit; Negative: Vimentin, AMACR; RCC Ma; CK7
Ksp-cadherin CD10; RCC Ma; PAX2 Negative: c-kit
Genetic Facts Loss of genetic material in 3p; Monosomy of multiple Trisomy of 7 and 17 and loss of
50% show somatic mutations in chromosomes (1, 2, 6, 10, 13, Y chromosome
Von Hippel-Lindau (VHL) genes 17, and 21); hypodiploidy
Genes Involved in VHL gene (3p25-26) Birt-Hogg-Dube syndrome MET oncogene (7q31) in
Hereditary Forms hereditary papillary real
carcinoma (HPRC)
Ultrastructure Microvilli and abundant Numerous microvesicles Luminal microvilli and variable
glycogen numbers of mitochondria with
lamellar cristae; contain little or
no glycogen or microvesicles
Proposed Cell of Proximal convoluted tubular Intercalated cells of the Proximal convoluted tubular
Origin cells collecting duct system cells
RENAL NEOPLASMS IN INFANCY NEOPLASMS METASTATIC

AND CHILDHOOD TO THE KIDNEYS
Several types of tumors are known to arise in the kidney Metastasis to the kidney is extremely uncommon to
during infancy and childhood, of which nephroblastoma present as the initial manifestation of the malignancy.
(Wilms’ tumor) is the most frequent. See Chapter 25 for The lung is the most common primary site. A study by
details. Tabatabai and Staerkel suggested that the presence of
TABLE 20.4 RENAL CELL CARCINOMAS, MORPHOLOGIC VARIANTS, CYTOPATHOLOGIC FEATURES
Clear Cell RCC Chromophobe Type Papillary

Cellularity Variable, generally high; low with High cellularity High cellularity
cystic degeneration
Presentation Cells isolated, in loosely cohesive Cells isolated, in loosely cohesive Large papillary tissue fragments
groups, or in syncytial tissue groups, or in syncytial tissue with or without branching
fragments, with or without acinar fragments with architectural and with or without central
pattern, or monolayered patterns fibrovascular cores; cells isolated,
in loosely cohesive groups, and
in syncytial tissue fragments with
smooth external contours; thin
delicate fibrovascular cores in
Type 1 and dense and fibrous
fibrovascular cores in Type 2
Cells Large round to polygonal; well to Two cell types: Two morphologic variants:
poorly defined cell borders; low 1) large polygonal with abundant Type 1—small epithelial cells with
N/C ratios almost transparent and slightly low nuclear grade with minimal
flocculent cytoplasm, often pale cytoplasm;
plant-like cell membrane Type 2—larger cells with higher
(chromophobe cell) often nuclear grade and abundant
adjacent to vascular channels; eosinophilic cytoplasm
2) smaller cells with less
cytoplasm but granular
and eosinophilic (resembles
oncocytoma cells)
Nucleus Central location, variably sized, Hyperchromatic with irregular Type 1: Small round to ovoid
round with smooth nuclear wrinkled nuclear contours; nuclei with inconspicuous
membrane; chromatin finely binucleation common; perinuclear nucleoli;
granular with micronucleoli in halos seen often in more Type 2: Large and spherical nuclei
low-grade; granular chromatin eosinophilic cells with prominent nucleoli and
with prominent macronucleoli in varying degrees of nuclear
high-grade pseudostratification
Cytoplasm Abundant, clear; may have cells Abundant, pale to clear, flocculent Type 1: Minimal pale to clear
with granular cytoplasm often in cytoplasm (chromophobe cell); cytoplasm
high-grade tumors; eosinophilic peripheral condensation (plant-like Type 2: Abundant typically
globules in the cytoplasm cell membrane); smaller cells have eosinophilic cytoplasm
occasionally present; lipid present less cytoplasm which is eosinophilic
and granular; lipid absent
Psammoma Bodies Not present Not present Variably present (10%)
Background Often Less often Often

Hemorrhagic / Not present /
Necrosis Frequent Not present /
Bare Nuclei / Not present Often positive within the papillary
Foamy histiocytes cores or within sheets of tumor
With or Without cells in Type 1; seen in areas of
Hemosiderin necrosis in Type 2 rather than
within papillae
Differential Benign cyst, cystic nephroma; Oncocytoma; clear cell RCC Clear cell RCC with papillary
Diagnoses adrenal cortical cell; hyperplasia with predominant granular cell architecture
or adenoma; renal cortical component
cells; renal cell carcinoma
chromophobe type; oncocytoma
Cytopathologic Features of Renal Cell Carcinoma (RCC) and Its Morphologic Variants (See Figs. 20.1 to 20.18)
Fig. 20.1. FNA renal cell carcinoma, clear cell type. The malignant Fig. 20.2. FNA renal cell carcinoma, clear cell type. The malignant
cells are large, round to polygonal with abundant pale cytoplasm cells are large, round to polygonal with abundant pale cytoplasm
and low N/C ratios. The nuclei are central, round with uniformly dis- and low N/C ratios. The nuclei are central, round with uniformly dis-
tributed finely granular chromatin. Nucleoli are readily appreciated. tributed finely granular chromatin. Nucleoli are readily appreciated.
Fig. 20.3. FNA renal cell carcinoma, clear cell type. Showing a syn-
cytial tissue fragment composed of large, round to polygonal cells
with abundant pale cytoplasm and low N/C ratios. Their cell bor-
ders are well-defined. The nuclei are central, round with uniformly
distributed finely granular chromatin.
A B
Figs. 20.4A and B. FNA renal cell carcinoma. A: The aspirate is very cellular, consisting of several syncytial tissue
fragments of malignant cells with eosinophilic granular cytoplasm (medium power). B: Higher magnification showing
malignant cells with variable granular, eosinophilic cytoplasm and low N/C ratios. The nuclei are round, pleomorphic
in size with uniformly distributed finely granular chromatin and contain micronucleoli.
A B
Figs. 20.5A and B. FNA renal cell carcinoma. The malignant cells are large, round to polygonal with abundant pale
cytoplasm containing eosinophilic globules (arrows). The globules are also present in the background (arrow head).
The nuclei are round, minimally pleomorphic. The N/C ratios are low. The nuclear chromatin is finely granular
chromatin.
Fig. 20.6. FNA renal cell carcinoma. The renal cell carcinoma cells
have poorly defined cell borders. The nuclei are small and uniform.
Note many bare nuclei in the background.
A B
Figs. 20.7A and B. FNA renal cell carcinoma. A: Markedly cellular aspirate consisting of syncytial tissue fragments of
cells (low power). B: Higher magnification showing loosely cohesive cells and syncytial tissue fragments of malignant
cells, pleomorphic in size. Their cytoplasm is variable. The nuclei are mildly pleomorphic with coarsely granular
chromatin.
Fig. 20.8. FNA renal cell carcinoma, high-grade. The malignant Fig. 20.9. FNA renal cell carcinoma, high-grade. The malignant
cells are medium-sized arranged in a syncytial tissue fragment. Their cells are pleomorphic in size and shape containing pleomorphic nu-
cytoplasm is scant with high N/C ratios. The nuclear chromatin is clei with coarsely granular chromatin and nucleoli.
coarsely granular.
Fig. 20.10. FNA renal cell carcinoma, high-grade. The malignant Fig. 20.11. FNA renal cell carcinoma, high-grade. The malignant
cells are pleomorphic in size and shape containing pleomorphic nu- cells are very large, containing pleomorphic nuclei with coarsely
clei with coarsely granular chromatin and nucleoli. The N/C ratios granular chromatin and macronucleoli.
are very high. The cytoplasm is granular and eosinophilic.
Fig. 20.12. FNA renal cell carcinoma, sarcomatoid type. The malig-
nant cells are pleomorphic with spindle forms.
A B
Figs. 20.13A to C. FNA renal cell carcinoma, papillary type.

A: The aspirate is very cellular consisting of branching papillary
tissue fragments (low power). B: Higher magnification showing
papillary fronds covered by medium-sized cells with high N/C
C ratios. Their cytoplasm is scant. C: Same case (Romanowsky).
A B
Figs. 20.14A to C. FNA renal cell carcinoma, papillary type. A: The

aspirate is very cellular consisting of several large tissue fragments
with branching and three-dimensional spherules. B, C: Higher mag-
nification showing syncytial arrangement of medium-sized cells
C containing uniform nuclei.
821
A B
Figs. 20.15A and B. FNA renal cell carcinoma, papillary type. A: The aspirate is very cellular consisting of branching
papillary tissue fragments (low power). B: Higher magnification showing small cells with high N/C ratios. Their
cytoplasm is scant. Note the psammoma bodies.
A B
Figs. 20.16A to C. FNA renal cell carcinoma, chromophobe type.

A: The cellular aspirate consists of large population of cells, iso-
lated, in loosely cohesive groups and in syncytial tissue fragments
(medium power). B: Higher magnification shows large, round to po-
lygonal cells variable pale eosinophilic cytoplasm and low N/C ra-
tios. The nuclei are round with uniform, finely granular chromatin.
C: Different field showing discrete very large, round to polygonal
cells with binucleation. The nuclei are central to eccentric with low
N/C ratios. The nuclei appear bland. The cytoplasm is abundant
C and granular.
A B
Figs. 20.17A and B. FNA renal cell carcinoma, chromophobe type. A: The neoplastic cells are in syncytial tissue
fragment with pale eosinophilic cytoplasm. The nuclei have bland chromatin. B: Different field presenting the typical
morphology with large round to polygonal cells.
A B
Figs. 20.18A and B. FNA renal cell carcinoma, chromophobe type. The cellular aspirate presents a large population
of pleomorphic round to polygonal cells containing eosinophilic cytoplasm and bland nuclei. Note the strong
morphologic resemblance to oncocytoma.
Differential Diagnoses of Renal Cell Carcinoma, (See Figs. 20.19 to 20.29)
Fig. 20.19. Histiocytes. A large number of histiocytes from a renal Fig. 20.20. Oncocytoma. The cells of oncocytoma are easy to mis-
cyst bearing a strong resemblance to both oncocytoma as well as interpret as renal cell carcinoma, chromophobe type.
renal cell carcinoma, chromophobe type.
TABLE 20.5 DIFFERENTIAL DIAGNOSES OF RENAL CELL CARCINOMA, LOW-GRADE
Helpful Features
Normal Renal Tubular Mostly in monolayered sheets as small cells with abundant pale to clear Scant cellularity
Cells cytoplasm or as bare nuclei; low N/C ratios; small round nuclei with finely
granular chromatin; inconspicuous nucleoli
Renal Cell Carcinoma, Cells in monolayered tissue fragments, in loosely cohesive groups, and isolated; Low molecular weight
Clear Cell Type, well to poorly defined cell borders; abundant pale, lacy to clear cytoplasm; Cytokeratin ;
Low-Grade uniform small, round nuclei, some crowding and overlapping; finely granular vimentin RCC Ma ;
chromatin; nucleoli / CD 10; PAX2
Histiocytes from Cells in monolayered tissue fragments, in loosely cohesive groups, and isolated; Cytokeratin ;
Renal Abscess or well to poorly defined cell borders; abundant pale, lacy to clear cytoplasm; CD68 or CD163
Xanthogranulomatous uniform small, round nuclei, some crowding and overlapping; finely granular
Pyelonephritis chromatin; nucleoli /
Adrenal Cortical Individually dispersed cells or in tissue fragments; poorly defined cell borders; Cytokeratin ;
Cells or Cortical low N/C ratios; small centrally placed nuclei; nucleoli inconspicuous, crowded, vimentin ;
Hyperplasia/ and overlapped; stripped nuclei; pale, lacy, bubbly cytoplasm Inhibin ;
Adenoma Melan-A
Hepatocytes Cells mostly in trabeculae, sheets, or isolated; polygonal well-defined cell Cytokeratin ;
borders; low N/C ratios; abundant granular cytoplasm with or without vimentin ;
lipofuscin pigment Hep Par-1
TABLE 20.6 DIFFERENTIAL DIAGNOSES OF CYSTIC LESIONS OF THE KIDNEY
Simple (Nonneoplastic) Multilocular Renal Cyst

Renal Cyst (Cystic Nephroma) Cystic Renal Cell Carcinoma
Cellularity Acellular to low Variable but low Variable
Presentation Predominantly histiocytes with Syncytial tissue fragments of Cells isolated, in loosely cohesive
rare group or tissue fragment of epithelial cells, single cells groups, or in syncytial tissue fragments
benign renal tubular cells infrequent
Cells Benign tubular epithelial cells, Medium to large, pleomorphic; Large, round to polygonal; low N/C
round to cuboidal; well-defined high N/C ratio ratio
cell borders; low N/C ratio
Nucleus Small, round, smooth nuclear Pleomorphic in size; smooth to Small, round, smooth nuclear
membrane; finely granular, evenly irregular nuclear membrane; membrane; finely granular chromatin;
dispersed chromatin; nucleoli granular chromatin; prominent nucleoli prominent
inconspicuous nucleoli
Cytoplasm Moderate, pale to slightly granular Moderate, pale to slightly granular Abundant; clear
Background Variable numbers of histiocytes Clean, no necrosis; inflammatory Variable numbers of foamy
with pale to foamy cytoplasm; cells / macrophages with or without
multinucleated histiocytic giant hemosiderin; mixed inflammatory cells;
cells; occasional spindle-shaped blood /; necrosis /
stromal cells
Fig. 20.21. Renal cell carcinoma, granular cell type. These cells may Fig. 20.22. Adrenal cortical cells with abundant, granular to dense
also be typed as chromophobe carcinoma or an oncocytoma. cytoplasm and bland nuclei may be diagnosed as renal cell carci-
noma or an oncocytoma.
A B
Figs. 20.23A and B. Renal tubular cells forming tubules mimic renal cell carcinoma.
A B
Figs. 20.24A and B. Renal cell carcinoma in fine needle aspirate. Note the similarity to normal renal proximal
tubular cells.
A B
Figs. 20.25A and B. Xanthogranulomatous pyelonephritis. A: These large numbers of macrophages with abundant
foamy cytoplasm mimic clear cell carcinoma. B: The presence of multinucleated foreign-body type giant cells should
provide a clue.
Fig. 20.26. Necrotic carcinoma. Extensive necrotic and cellular de-

bris can obscure the malignant cells resulting in a missed diagnosis.
A B
Figs. 20.27A and B. Another example of a necrotic renal cell carcinoma. The malignant cells are difficult to identify
as they are obscured by inflammatory debris.
A B
C D
Figs. 20.28A to D. Cystic papillary carcinoma. The aspiration biopsy yielded clear fluid. The cellularity was low,
represented by small cells forming syncytial tissue fragments with a cartwheel pattern, reminiscent of cystic papillary
thyroid carcinoma.
Fig. 20.29. Oncocytoma with small cell size are easily misinterpreted
as renal cell carcinoma.
a heterogeneous cell population, hemosiderin deposit, antibodies. Distinction between renal metastases from
small cytoplasmic vacuoles, and low N/C ratio favors urothelial carcinoma of the renal pelvis or ureter can be
primary conventional RCC rather than metastasis. difficult, and immunohistochemistry may not be help-
Immunohistochemical staining for CD10, RCC Ma, ful as urothelial carcinoma immunostaining may over-
and PAX2 favors renal primary although other nonre- lap with metastatic squamous cell carcinoma from any
nal tumors may rarely show positive staining with these organ site.
TABLE 20.7 DIFFERENTIAL DIAGNOSES OF RENAL TUMORS PREDOMINANTLY COMPOSED

OF GRANULAR EOSINOPHILIC CELLS
Diagnostic Clues/
Renal Oncocytoma Cells mostly in trabeculae, sheets, or isolated; polygonal Histochemistry: Hale’s colloidal iron stain
well-defined cell borders; low N/C ratios; abundant may be focally , but never diffusely
granular cytoplasm with or without lipofuscin pigment; compared with chromophobe RCC
no glycogen; no lipid Immunohistochemistry
Positive: c-kit; Ksp-cadherin; CK7,
Negative: Vimentin; typical RCC markers
(RCC Ma, CD10)
Cytogenetics: May show loss of chromosome
1, sex chromosome or chromosome 14
Chromophobe Renal Cells isolated, in aggregates, or in tissue fragments; Histochemistry: Hale’s colloidal iron–always
Cell Carcinoma size variable, generally large, round to polygonal; well- diffuse, stain (bluish-green)
defined accentuated cell borders; low N/C ratios; nucleus Immunohistochemistry
variable in size, round to oval, central to eccentric; Positive: c-kit; Ksp-cadherin; CK7
smooth nuclear membrane; granular to compact Negative: Vimentin typical RCC markers
chromatin; nucleolus inconspicuous; mitoses /; (RCC Ma, CD10, PAX2)
abundant granular cytoplasm; some may have lacy to Cytogenetics: Hypodiploid (loss of entire
clear cytoplasm with peripheral condensation; necrosis; chromosomes)
no glycogen; no lipid
Clear Cell Carcinoma Cells isolated, in aggregates, or in syncytial tissue Histochemistry: Oil-red-O ; Hale’s
with a Predominant fragments, variable in size, round to polygonal; well to colloidal iron stain , occasionally some
Granular Cell poorly defined cell borders; moderately increased N/C granular staining
Component ratios; nucleus variable in size, pleomorphic, round Immunohistochemistry
to oval; smooth nuclear membranes; fine to coarsely Positive: Vimentin; CD10;
granular chromatin; nucleoli may be prominent; mitoses RCC Ma; PAX2
/; moderate to abundant granular cytoplasm; Negative: Ksp-cadherin, c-kit, CK7
background necrosis /; lipid ; glycogen Cytogenetics: Loss of 3p
TABLE 20.8 DIFFERENTIAL DIAGNOSES OF SPINDLE CELLS IN ADULT RENAL/PERIRENAL NEOPLASMS
Sarcomatoid Renal Sarcomatoid

Angiomyolipoma Cell Carcinoma Urothelial Carcinoma Soft Tissue Sarcomas
Spindle Cells Usually low nuclear Variable nuclear grade Often high nuclear Variable; often
grade resembling smooth but often high nuclear grade high nuclear grade,
muscle; may show atypia grade most common
(degenerative type) leiomyosarcoma
Non-Spindled Mature adipose tissue Typical epithelioid Typical urothelial Often not present
Component and thick-walled vessels RCC, most commonly carcinoma
clear cell RCC
Immunohistochemistry
Cytokeratin Negative Positive Positive Negative
Vimentin Positive Positive May be positive Positive
Smooth Muscle Actin Positive May be positive May be positive May be positive
Other Positive
Markers: HMB 45; CD10, PAX2 p63, 34BE12, Desmin (if
Melan-A RCC Ma, thrombomodulin leiomyosarcoma)
TABLE 20.9 CYTOPATHOLOGIC FEATURES OF UROTHELIAL CARCINOMA OF RENAL PELVIS AND

URETERS IN FINE NEEDLE ASPIRATES
Cellularity Generally high
Presentation Dissociated pattern characteristic; cells mostly isolated or in loosely cohesive groups; syncytial tissue
fragments infrequent
Cells Variable morphology; small to large, round, polygonal, elongated to columnar (transitional), pyramidal,
spindle, racket-shaped to giant forms; high N/C ratios
Nucleus Central to eccentric, at broad end of transitional forms; variable size, round to oval, smooth to irregular
nuclear membrane; fine to coarsely granular chromatin, parachromatin clearing /; micronucleoli/
macronucleoli
Cytoplasm Variable, pale eosinophilic to cyanophilic; vacuoles /; cytoplasmic tails; squamous or glandular
differentiation /
Immunoprofile Positive for high molecular weight cytokeratin such as 34BE12; p63 and CK5/6, CK7, CK20, CD10,
Uroplakin; negative for RCC Ma and PAX2
Carcinoma of the Renal Pelvis (See Figs. 20.30 to 20.35)
Fig. 20.30. Urothelial carcinoma of the renal pelvis. The malignant Fig. 20.31. Papillary urothelial carcinoma of the renal pelvis.
cells are pleomorphic, elongated to short spindle cells with high N/C
ratios.
Fig. 20.32. Metastatic poorly differentiated urothelial carcinoma to

the inguinal lymph node.
A B
Figs. 20.33A and B. Metastatic poorly differentiated urothelial carcinoma to the lung.
A B
Figs. 20.34A and B. Metastatic poorly differentiated urothelial carcinoma to the liver.
A B
Figs. 20.35A and B. Hyperplastic urothelium lining the renal pelvis misinterpreted as urothelial carcinoma.
formed for documentation of the type of tumor. FNAs

FUTURE OF RENAL MASS NEEDLE
of pediatric renal tumors have not been popular since
ASPIRATION
it upstages cases of Wilms’ tumor, but this thinking has
changed recently. However, pediatric renal tumors show
With the advent of renal tumor ablation by a variety of overlapping features and generally show small, round cell
methods such as chemical, heat, or radiofrequency, an tumor characteristics, making cytologic categorization of
FNA of renal masses prior to the procedure is often per- pediatric renal tumor quite challenging.
SUGGESTED READINGS
Bosniak MA. Difficulties in classifying cystic lesions of the kidney. Murphy WM, Grignon DJ, Pearlman EJ. Tumors of the kidney,
Urol Radiol 1991;1391–1393. bladder and related urinary structures. AFIP Atlas of Tumor
Cheng L, Zhang S, MacLennan GT, et al. Molecular and cytoge- Pathology, Series 4. Washington, DC: American Registry of
netic insights into the pathogenesis, classification, differential Pathology, 2004.
diagnosis, and prognosis of renal epithelial neoplasms. Hum Renshaw AA. Fine needle aspiration biopsy of the kidney. In:
Pathol 2009;40:10–29. Bostwick DG, Cheng L, eds. Urologic Surgical Pathology.
Domanski HA. Cytologic features of angiomyolipoma: Philadelphia: Mosby Elsevier, 2008;196–213.
Cytologic-histologic study of 10 cases. Diagn Cytopathol Tabatabai ZL, Staerkel GA. Distinguishing primary and metastatic
2002;27:161–166. conventional renal cell carcinoma from other malignant neo-
Lopez-Beltran A, Carrasco JC, Cheng L, et al. 2009 update on the plasms in fine-needle aspiration biopsy specimens. Arch Pathol
classification of renal epithelial tumors in adults. Int J Urol Lab Med 2005;129:1017–1021.
2009;16:432–443.
MacClennan GT, Cheng L. Neoplasms of the kidney. In: Bostwick
DG, Cheng L, eds. Urologic Surgical Pathology. Philadelphia:
Mosby Elsevier, 2008;78–171.
21 ADRENAL GLANDS AND
RETROPERITONEUM
The increasing use of modern imaging techniques has melanoma, renal cell carcinoma, and hepatocellular
contributed a great deal to the detection of adrenal gland carcinoma.
lesions that may be as small as 1 centimeter or several ● Adrenal glands are a common site for neuroblastomas.
times larger. Many are incidental findings. FNA biopsy
performed under radiologic guidance is extremely useful
in identifying various types of lesions affecting the adre-
nal glands. Primary adrenal gland neoplasms are very
infrequent. The most common indication for adrenal NORMAL HISTOLOGY AND CYTOLOGY
gland biopsy is to detect a metastatic lesion for staging OF THE ADRENAL GLANDS
a malignancy. The use of FNA biopsy of adrenal gland
lesions peaked in the 70s and 80s and gradually declined.
The adrenal glands have a dual embryologic origin. The
Lately, FNA biopsies of adrenal masses are being per-
mesoderm-derived cortex and the ectoderm or neural
formed during EUS-guided biopsies of pancreatic and
crest-derived medulla differ both functionally as well as
peripancreatic lesions.
cytohistologically.
Diagnostic considerations in adrenal gland aspiration
The adrenal cortex consists of three zones. The two
biopsy should be given to the following:
peripheral zones—the zona fasciculata and the zona
● Fine needle biopsies are primarily performed to iden- glomerulosa—are composed of lipid-rich, large, polygo-
tify a metastatic process. Its use in the primary diagno- nal cells with small nuclei (Figs. 21.1A and B, 21.2A and
sis of adrenal neoplasms is very limited. B). The zona reticularis consists of smaller lipid-poor cells
● Suspected cases of pheochromocytomas are contra- with granular cytoplasm (Figs. 21.3A and B).
indications. In cytologic preparations, adrenal cortical cells
● Since the adrenal gland has a dual embryologic origin, are seen either isolated or in aggregates. Their borders
neoplasms arising from the cortex are different from are poorly defined, frayed, and due to the clearing of
those that originate in the medulla. the lipid-rich cytoplasm during cytopreparation, appear
● Adrenal cortical cells with abundant granular cyto- as naked nuclei. The latter are small, round with com-
plasm and well-defi ned cell borders strongly resemble pact chromatin, and may be mistaken for metastatic
hepatocytes and renal adenocarcinoma cells. small cell undifferentiated carcinoma (Table 21.1; Figs.
● Adrenal cortical cells with clear lipid-rich cytoplasm 21.1 and 21.2C) or a malignant lymphoma. The cells of
frequently present themselves as stripped nuclei due to zona reticularis are round; small with well-defined cell
the dissolution of the cytoplasm during cytoprepara- borders; and have a centrally located small, round nu-
tions and can be mistaken for small cell undifferenti- cleus and abundant granular to dense cytoplasm, which
ated carcinoma. sometimes contains lipofuscin pigment. Because of their
● Hyperplastic cortical nodules, cortical adenoma, and a granular cytoplasm, the cells of zona reticularis resemble
well-differentiated adrenal cortical carcinoma cannot hepatocytes (Fig. 21.3).
be generally distinguished based on cytology. The adrenal medulla is composed of pleomorphic cells
● Poorly differentiated adrenal cortical carcinomas of the neuroendocrine type. They are polygonal, fusiform,
are difficult to distinguish from poorly differenti- or ovoid with well-defi ned cell borders and have granu-
ated metastatic malignancy (particularly with an lar cytoplasm. The nuclei are eccentric, small, round, and
occult primary), pheochromocytomas, malignant uniform containing granular chromatin.
832
Chapter 21: Adrenal Glands and Retroperitoneum 833
A B
Figs. 21.1A and B. Normal adrenal cortical cells. A: The cells are stripped off of the cytoplasm and are present as
crowded, overlapped bare, small, round nuclei with compact chromatin. B: Better preserved cortical cells, medium-
sized, cuboidal to polygonal with well to poorly defined cell borders. Their nuclei are small, round, uniform with
compact chromatin. The cytoplasm is pale.
A B
Figs. 21.2A to C. A: Aggregate of markedly crowded and over-

lapped stripped small round nuclei with compact chromatin can
mimic a metastatic small cell carcinoma. B: Another field from the
same smear, showing cuboidal to polygonal adrenal cortical cells
containing nuclei with morphology similar to that seen in Figure
21.2A. C: FNA of an adrenal aspirate showing a metastatic small
cell carcinoma. Note that the nuclei are slightly larger and display
C molding (arrows).
A B
Figs. 21.3A and B. FNA of a histologically confirmed adrenal cortical adenoma. The medium-sized, round to
polygonal cells arranged in syncytial tissue fragments with a trabecular pattern. Their cell borders are well-defined.
Note the dense and abundant cytoplasm. These cells with dense cytoplasm resemble hepatocytes.
TABLE 21.1 DIFFERENTIATING FEATURES BETWEEN NORMAL ADRENAL CORTICAL CELLS AND
SMALL CELL (NEUROENDOCRINE) CARCINOMA
Normal Adrenal Cortical Cells Metastatic Small Cell Carcinoma

Cellularity Generally low Generally marked
Presentation Cells mostly isolated, in aggregates, or in Cells isolated or in syncytial tissue fragments with
honeycomb sheets; naked nuclei frequent no architectural patterns
Cells Medium-sized to large; poorly defined cell borders; Small cells; cytoplasmic borders flush with the
low N/C ratios nuclei; high N/C ratios
Nucleus Small, round; smooth nuclear membranes; compact Round, oval to oblong; smooth to irregular nuclear
chromatin; nuclei overlapped but no molding; no membranes; coarsely granular to compact deep
mitoses staining chromatin; nuclear molding ⫹; mitoses ⫹
Cytoplasm Variable when cell borders are intact; clear to Scant, indiscernible
vacuolated to dense
Background Clean; no necrosis Necrosis; karyorrhexis
Immunoprofile Nonreactive to neuroendocrine markers and TTF-1 Reactive to neuroendocrine markers and TTF-1
4 centimeters in size. Rarely, they are functional, causing

LESIONS OF THE ADRENAL CORTEX syndromes such as primary hyperaldosteronism, Cush-
ing’s syndrome, and still more rarely, virilism.
The aspiration biopsies of both cortical nodules and a
ADRENAL CORTICAL HYPERPLASIA
cortical adenoma yield a hypercellular aspirate with large
AND ADENOMA
tissue fragments of benign cortical cells (Fig. 21.4). Dif-
Adrenal cortical hyperplasia is almost always bilateral ferentiation of an adenoma from a hyperplastic cortical
and can be either diffuse and/or nodular. The cortical nodule is not possible based on cytology alone. Adrenal
nodules range from microscopic ones to large nodules cortical adenoma may rarely exhibit a markedly atypical
that are detected by imaging techniques. They are usually pattern with pleomorphic cells containing bizarre nuclei
detected as an incidental finding. (Figs. 21.5A and B). The occasional bizarre cells do not
Adrenal cortical adenomas are solitary lesions that reflect malignancy. Diagnosis of malignancy is made only
are generally nonfunctioning, silent tumors of less than in the presence of invasive features.
Fig. 21.4. FNA of an enlarged adrenal cortical nodule. The aspirate

is very cellular, consisting of loosely cohesive small round cells with
poorly defined cell borders and small nuclei with compact chroma-
tin. The cells resemble normal cortical cells. The lesion may repre-
sent either hyperplastic cortex or an adenoma.
A B
Figs. 21.5A and B. Scrape preparation of an adrenal cortical adenoma. A: showing a strikingly pleomorphic cell
population (low power). B: Higher magnification. The neoplastic cells are large with bizarre giant forms with large
pleomorphic nuclei containing compact chromatin. The cortical cells in the background are polygonal with dense
cytoplasm.
patterns, characterized by very broad interdigitating tra-

ADRENAL CORTICAL CARCINOMA
beculae that are several layers thick or slender trabecu-
Primary adrenal cortical carcinomas are exceedingly rare, lae that are oriented parallel or serpiginous. Perithelial
with the incidence being one in 2,000,000 of the general orientation or a diffuse growth pattern, nesting, or an
population. They can occur at any age with a bimodal alveolar growth pattern may also be encountered. The
peak in incidence in the first and fifth decades of life with carcinomas demonstrate varying degrees of differen-
a slight preponderance in females. Clinically, adrenal cor- tiation, ranging from bland and well-differentiated to
tical carcinomas present with abdominal or flank fullness poorly differentiated neoplasms with marked pleomor-
or mass. They may be functional. Adrenal cortical carci- phism, numerous mitoses, and necrosis. The neoplastic
nomas are very aggressive tumors that metastasize widely cells may be lipid-depleted and contain dense eosino-
and are fatal. philic cytoplasm or may have vacuolated lipid-rich
cytoplasm. The nuclei are usually eccentric; they can be
small, round, and bland-appearing to extremely pleo-
morphic with bizarre giant forms.
Adrenal cortical carcinomas can attain a size up to or
larger than 20 centimeters and weigh over 1000 grams
when discovered. They are bulky and lobulated with soft
bulging nodules, appearing yellow–orange to tan with The cytologic features of adrenal cortical carcinoma are
areas of hemorrhage and necrosis. Histologically, adre- variable, dependent on histologic differentiation (Table 21.2;
nal cortical carcinomas present a wide range of growth Figs. 21.6 to 21.8). The aspirates are usually very cellular
TABLE 21.2 CYTOPATHOLOGIC FEATURES OF ADRENAL CORTICAL CARCINOMA
Cellularity Generally highly cellular
Presentation Cells isolated with a dispersed pattern or in loosely cohesive groups or in syncytial tissue fragments with
no architectural patterns
Cells Size variable; uniform, medium-sized to large and pleomorphic; round, plasmacytoid, cuboidal to polygonal
and occasionally spindle-shaped; cell borders well to poorly defined; cytoplasmic processes absent
Nucleus Size variable; uniform to markedly pleomorphic with bizarre forms; central to often eccentric; single to
multiple nuclei; nuclear membranes smooth to irregular; chromatin finely granular and evenly dispersed
to coarsely granular and chunky with parachromatin clearing; single/multiple micro-macronucleoli;
intranuclear inclusions frequent; mitoses ⫹Ⲑ⫺
Cytoplasm Variable; scant to abundant; clear, vacuolated, granular to dense
Background Clean to necrotic; stripped nuclei; arborizing blood vessels
Immunoprofile Variable positive reactivity (up to or ⬎50%) with pancytokeratins, vimentin, calretinin, inhibin,
synaptophysin; do not react with chromogranin, TTF-1
Ultrastructure Whorls of smooth endoplasmic reticulum
Adjunct Lab Studies Levels of hydroxycorticosteroids may be increased
Differential Diagnoses Adrenal cortical hyperplasia/cortical adenoma

Pheochromocytoma
Renal cell carcinoma
Metastatic poorly differentiated carcinomas (adeno/squamous)
Malignant melanoma
Malignant lymphoma
Adrenal Cortical Carcinoma (See Figs. 21.6 to 21.8)
A B
Figs. 21.6A to C. FNA of an adrenal cortical carcinoma. A: Cellular aspirate with a dispersed pattern. The cells are round to polygonal
and pleomorphic in size. The N/C ratios are high. Note the prominent macronucleoli. B, C: Higher magnification. The malignant cells
are large, loosely cohesive, and plasmacytoid. The cell borders are well-defined. The variable cytoplasm is dense. The nuclear chromatin
is very coarse. (continued)
A B
Figs. 21.7A to C. FNA Adrenal cortical carcinoma. A: Low power

view of a very cellular aspirate showing broad, interconnecting tra-
beculae. B, C: Higher magnification showing large polygonal cells
with well-defined cell borders and abundant granular cytoplasm.
C The nuclei are eccentric containing coarsely granular chromatin.
with neoplastic cells occurring singly, in loosely cohesive brisk. The cytoplasm of the malignant cells is variable from
groups, or in syncytial tissue fragments with or without a modest to abundant and pale to dense. Stripped nuclei and
trabecular pattern. The cells vary in size from medium to necrosis is often present in the background.
large and are polygonal with frequent giant forms. Occa-
sionally, spindle cells may also be present. Their nuclei are
Immunoprofile
round and uniform in well-differentiated carcinomas to large
and irregular. The chromatin ranges from bland to finely The adrenal cortical carcinoma cells react variably to
granular to irregularly clumped and has excessive parachro- pancytokeratin, calretinin, inhibin, vimentin, and synap-
matin. Nucleoli are very prominent. Mitotic activity can be tophysin and react negatively to chromogranin.
A B
Figs. 21.8A to B. FNA of an adrenal cortical carcinoma. The malignant cells are variable in size, small round to
bizarre multinucleated giant forms (arrows). Their cell borders are poorly defined with variable cytoplasm. The nuclei
are pleomorphic in size with granular chromatin and parachromatin clearing. Nucleoli are prominent. Also note the
intranuclear inclusions (arrows). Stripped nuclei are present in the background.
Diagnostic Difficulties diagnostic possibilities for the pheochromocytomas dif-

and Differential Diagnoses fer from paragangliomas that occur at extra-adrenal
sites. Hence, pheochromocytomas are discussed sepa-
There are no specific cytologic features for adrenal corti-
rately from paragangliomas.
cal carcinomas. Likewise, there are no specific markers.
The cytohistologic patterns of adrenocortical carcinomas
overlap with several different neoplasms and include
PHEOCHROMOCYTOMA
adrenal cortical adenoma, pheochromocytoma, renal cell
carcinoma, malignant melanoma, hepatocellular carci- Pheochromocytomas, also referred to as adrenal para-
noma, and a poorly differentiated squamous carcinoma gangliomas, are neoplasms arising from the neuroendo-
or adenocarcinoma (see Table 21.6). A well-differentiated crine cells of the adrenal medulla. Pheochromocytomas
adrenal cortical carcinoma closely resembles an adrenal are rare. Ninety percent are sporadic, while 10% are
cortical adenoma and cannot be differentiated on a cyto- familial. The familial cases may be associated with MEN
logic basis (Table 21.3). IIA, particularly IIB, von Recklinghausen’s disease or
von Hippel–Lindau disease. Pheochromocytomas occur
over a broad age range from infancy to old age with
a peak in the fifth decade of life. There is no gender
TUMORS OF THE ADRENAL MEDULLA predilection.
AND EXTRA-ADRENAL PARAGANGLIA Common presenting symptoms are mostly related to
the abnormal secretion of epi- and norepinephrine and
Pheochromocytomas and paragangliomas are derived include headache, palpitations diaphoresis, flushing of the
from morphologically and cytochemically similar cells skin, anxiety, nausea, and constipation. The less common
of neural crest origin. These cells are widely distrib- symptoms include dyspnea, chest pain, visual disturbances,
uted in the body and are referred to as paraganglia. The abdominal pain, fatigue, and paresthesias. The triad of
cells of paraganglia resemble ganglion cells except that headaches, palpitations, and sweating are particularly
they lack axons and dendrites. For physiological and predictive of a diagnosis of pheochromocytoma. Hyper-
pathologic purposes, the paraganglia—existing in close tension with or without tachycardia is the key physical
proximity to either sympathetic or parasympathetic finding. Roughly 10 to 15% of patients have a palpable
nerve trunks—are broadly divided into two groups. abdominal mass. The majority of patients harboring
The prototype of sympathetic paraganglia is the adre- pheochromocytomas are symptomatic due to increased
nal medulla, while the one for parasympathetic para- production of catecholamines causing paroxysmal hy-
ganglia is the carotid body. The morphologic structure pertension, sweating, and palpitations. Increased plasma
of pheochromocytomas of the adrenal gland and the levels of vanillylmandelic acid (VMA) and catecholamines
paragangliomas that occur at multiple sites throughout are present in roughly 90% of cases. The biologic behav-
the body are similar. The term “pheochromocytoma,” ior of pheochromocytomas is unpredictable. The tumor
however, is strictly applied to the tumor of the adre- may show extensive local spread or may metastasize to
nal medulla. The clinical characteristics and differential the distant organs.
TABLE 21.3 DIFFERENTIATING FEATURES BETWEEN ADRENAL CORTICAL NODULES/ADENOMA

AND ADRENAL CORTICAL CARCINOMA
Adrenal Cortical Hyperplasia/Adenoma Adrenal Cortical Carcinoma

Cellularity Very cellular Very cellular
Presentation Cells isolated with a dispersed pattern or in loosely Cells isolated with a dispersed pattern or in loosely
cohesive groups or in syncytial tissue fragments cohesive groups or in syncytial tissue fragments with no
with no architectural patterns architectural patterns
Cells Medium-sized to large; cell borders poorly defined; Size variable; uniform, medium-sized to large and
often frayed with stripped nuclei that may pile up pleomorphic; round, plasmacytoid, cuboidal to
in tight aggregates; low N/C ratios polygonal and occasionally spindle-shaped; cell borders
well- to poorly defined; cytoplasmic processes absent
Nucleus Round, generally uniform; occasionally very Size variable; uniform to markedly pleomorphic with
pleomorphic with bizarre giant forms; nuclear bizarre forms; central to often eccentric; single to
membranes smooth; chromatin finely granular; multiple nuclei; nuclear membranes smooth to irregular;
nucleoli inconspicuous chromatin finely granular and evenly dispersed to
coarsely granular and chunky with parachromatin
clearing; single/multiple micro-macronucleoli;
intranuclear inclusions frequent; mitoses ⫹Ⲑ⫺
Cytoplasm Scant to abundant; vacuolated to granular or dense Variable; scant to abundant; clear, vacuolated, granular
to dense
Background Clean; no necrosis Clean to necrotic; stripped nuclei; arborizing blood

vessels
Immunoprofile Same Same
Ultrastructure Same Same
Adjunct Lab Levels of hydroxycorticosteroids may be increased Levels of hydroxycorticosteroids may be increased
Studies
Radiologic Findings Histologically, pheochromocytomas demonstrate var-

ious growth patterns such as trabecular, alveolar or nesting
On CT scans, pheochromocytomas appear as well-demar-
(Zel Bellen), and diffuse. Pseudoacinar or spindle cell pat-
cated and circumscribed nonhomogeneous tumors. The
terns are occasionally observed. The tumors are very vascu-
lack of homogeneity is due to hemorrhage, necrosis, and
lar with a prominent meshwork of delicate capillaries sur-
cystic degeneration. The 131I-MIBG scan using a radio-
rounding groups of neoplastic cells. Most are encapsulated.
active material that is taken up by neuroendocrine tumors
is diagnostically useful.
The cytologic features of pheochromocytoma vary widely
Sporadic pheochromocytomas are usually single, uni- from case to case (Table 21.4; Figs. 21.9 to 21.12). The
lateral tumors that are 3 to 5 centimeters in diameter. common pattern is composed of large polygonal cells
Multiple and bilateral tumors are common in a hereditary with finely granular, abundant, eosinophilic to slightly
setting. The cut surface is gray to pink–tan or red with basophilic cytoplasm and low N/C ratios. The nuclei are
areas of recent hemorrhage. Areas of old hemorrhage, central to eccentric and round to ovoid with stippled
fibrosis and cystic degeneration, and necrosis are frequent chromatin and small nucleoli. The nuclear pleomorphism
in large neoplasms. The tumor takes on a deep mahogany may be striking with the presence of giant forms with
color after exposure to air. After immersion in a dichro- pyknosis. Intranuclear inclusions may also be present.
mate solution, the tumor turns deep brown as a result of The tumor cells may exhibit a wide range of size and
the oxidation of the catecholamines. shapes from small and round to polygonal, spindle, or
TABLE 21.4 CYTOPATHOLOGIC FEATURES OF PHEOCHROMOCYTOMA/PARAGANGLIOMA
Cellularity Variable; scant to cellular
Presentation Cells discrete with a dispersed pattern and/or, in loosely cohesive groups and in syncytial tissue fragments as
nests, trabeculae, occasionally rosettes
Cells Size and shapes variable; monomorphic to extremely pleomorphic; small to giant forms; round, oval,
plasmacytoid, polygonal to spindle shapes, strap cells; cell borders poorly defined; N/C ratios variable
Nucleus Variable in size; central to eccentric; bi-to multinucleation; round to oblong; smooth nuclear membranes;
occasionally convoluted; granular chromatin; nucleoli prominent in aggressive tumors; intranuclear inclusions
⫹Ⲑ⫺; mitoses ⫹Ⲑ⫺
Cytoplasm Variable, scant indiscernible to abundant; pale, dense to granular to vacuolated; cytoplasmic processes,
generally unipolar; melanin pigment ⫹Ⲑ⫺
Background Bare nuclei frequent; bloody
Immunoprofile Positive reactivity to neuroendocrine markers; S100 positivity for sustentacular cells; TTF-1 negative
Pheochromocytoma and Paraganglioma (See Figs. 21.9 to 21.12)
Fig. 21.9. Scrape preparation of a pheochromocytoma. The neo-

plastic cells are medium-sized, round with scant cytoplasm and nu-
clei with a typical “salt & pepper” chromatin pattern.
A B
Figs. 21.10A and B. Scrape preparation of a pheochromocytoma. A: Uniformly small cells with scant cytoplasm,
poorly defined cell borders and round nuclei with evenly distributed chromatin. Note the occasional spindle cell
(arrow). B: A different example of pheochromocytoma in a scrape preparation. The neoplastic cells are pleomorphic
in size with occasional bizarre multinucleated and multilobated nuclei.
840
A B
C D
Figs. 21.11A to E. FNA of pheochromocytoma. A, B, C: The neo-

plastic cells are extremely pleomorphic in size with giant forms,
poorly defined cell borders. Note the finely granular nuclear chroma-
tin and prominent macronucleoli (H&E). D: Papanicolaou stained
preparation. Note the morphologic similarity to medullary thyroid
carcinoma. E: Same aspirate (Romanowsky). (Courtesy of Mithra
E Baliga, M.D., University of Mississippi, Jackson, Mississippi.)
triangular to strap-like cells. Their cytoplasm is, likewise, neuroendocrine markers demonstrate positive reactivity.
variable. Some cells appear ganglion-like. Their cytoplasm S100 protein antibody stains the supporting sustentacular
may contain eosinophilic, PAS-positive, diastase-resistant cells.
globules. Degenerative changes are frequent as seen in Ultrastructure: The diagnostic feature is the presence
areas of old and new hemorrhage. Stromal amyloid has of membrane-bound neurosecretory granules ranging
been reported in 70% of cases. The cells of pheochromo- from 150 to 250 nanometers.
cytoma possess argyrophilic granules that can be demon- Malignancy in pheochromocytomas is diagnosed only
strated by Grimelius and Churukian–Schenk stains. in the presence of metastases. The reported incidence is 14
Immunochemistry: The most useful antibody is chro- to 50%. Several features are associated with malignancy;
mogranin for staining neuroendocrine cells. Several other however, there is no single criterion. Large size, being
coarsely nodular or multinodular, having tumor conflu- TABLE 21.5 DIFFERENTIAL DIAGNOSES
ent necrosis, mitoses, extensive local invasion, dopamine OF PARAGANGLIOMAS AND
secretion, small cells with high N/C ratios, the monotony PHEOCHROMOCYTOMASa
of cytologic features, and having a spindle cell pattern are
all associated with malignancy. Epithelial malignancies
Diagnostic Difficulties Endocrine tumors

Pancreatic exocrine tumors
Given the location and an adequate aspirate, the cytologic
features of pheochromocytomas usually lend themselves Follicular carcinoma of the thyroid
to the correct identifi cation of the tumor. Being a very
vascular neoplasm, the aspirates may be bloody, obscur- Adrenal cortical adenoma/carcinoma
ing the cellular details and may result in unsatisfactory
samples and a false-negative diagnosis. Because of the Sex cord stromal tumors
morphologic overlap, several neoplasms in the vicinity of
the adrenal gland must be considered in the differential Neuroendocrine tumors
diagnosis. These include adrenal cortical carcinoma, renal
cell carcinoma, hepatocellular carcinoma, metastatic Pituitary
poorly differentiated carcinomas, malignant melanoma,
Parathyroid
and malignant lymphomas of the large cell type (Tables
21.5 and 21.6; see Figs. 21.18 to 21.22). Appropriate
Pancreas
immunostains are required for correct identification.
Medullary carcinoma of the thyroid
EXTRA-ADRENAL SYMPATHETIC
PARAGANGLIOMA Peripheral primitive neuroendocrine tumor
Extra-adrenal paragangliomas are encountered throughout
Esthesioneuroblastoma
the body. Those associated with the sympathetic nervous
system can occur anywhere from the upper neck to the Soft tissue tumors
pelvic floor. More than 90% occur in the retroperitoneum,
and 30 to 50% of these are in the vicinity of the organs of Synovial sarcoma
Zuckerkandl. Approximately 25 to 27% of the tumors are
functional. Nonfunctional tumors may present with spinal Alveolar soft part sarcoma
compression and pain or as incidental findings. Despite
their general similarities, extra-adrenal paragangliomas in Mesenchymal chondrosarcoma
different locations vary somewhat in terms of age distri-
bution, gender predilection, the likelihood of multicentric- Epithelioid leiomyosarcoma
ity, and the potential to metastasize. Extra-adrenal sympa-
thetic paragangliomas are more likely to be malignant as Neurogenic tumors
compared to their intra-adrenal counterparts.
Intra-abdominal paragangliomas occur at all ages but Angiosarcoma
are common in the third to the fi fth decades with male
preponderance reported in some series. Approximately Glomus tumor
30 to 40% of retroperitoneal paragangliomas are reported
to metastasize. Malignant melanoma
Intrathoracic paravertebral paragangliomas are
Meningioma
usually located in the mid-thoracic region and may
present with catecholamine-related symptoms. Cervical a
Note that this exhaustive and comprehensive list of differential diagnostic
paravertebral paragangliomas are rare. Paragangliomas entities for pheochromocytomas and paragangliomas does not apply
uniformly to all cases. The differential diagnosis greatly depends on the
of the cauda equina are very uncommon and are usually location and morphologic patterns, varying from case to case.
located in the filum terminale. The tumors are mostly
intradural; they occur slightly more frequently in males
and may be associated with low back pain, neurologic
deficiencies, and incontinence. Paragangliomas of the
cauda equina region are generally egg-shaped or sau-
sage-shaped, encapsulated, dark red tumors attached to
TABLE 21.6 DIFFERENTIAL DIAGNOSES OF PHEOCHROMOCYTOMA
Metastatic Poorly Metastatic

Adrenal Cortical Differentiated Carcinoma Metastatic Renal Malignant Pheochromocytoma/
Carcinoma Adeno/Squamous Cell Carcinoma Melanoma Paraganglioma Hepatocellular Carcinoma
Cellularity Cellular Cellular Cellular Cellular Variable Usually cellular
Presentation Cells mostly isolated, Cells isolated, in loosely Cells isolated, in Cells mostly isolated Cells isolated, in Cell discrete, in loosely cohesive
in loosely cohesive cohesive groups or in loosely cohesive or in loosely loose aggregates or groups and in syncytial tissue
groups or in syncytial syncytial tissue fragments groups or in syncytial cohesive groups; in syncytial tissue fragments, predominantly a
tissue fragments with no with or without acinar tissue fragments; tissue fragments fragments without trabecular pattern with smooth
architectural patterns pattern monolayered, unlikely any architectural contours, pseudoacinar pattern;
papillary or without patterns cell nests and trabeculae with
any architectural endothelial envelop; capillaries
pattern transgress through the tissue
fragments
Cells Uniform to markedly Variable in size, round to Variable in size, Variable in size and Monomorphic to Variable in size, but usually
pleomorphic, round, polygonal; well to poorly round to polygonal; shape, round to pleomorphic cell large, polygonal with well to
plasmacytoid, cuboidal defined cell borders; high poorly defined cell polygonal to giant population; small, poorly defined cell borders; N/C
to polygonal; cytoplasmic N/C ratios borders; N/C ratios forms; well-defined large to giant forms, ratios variable
processes rare; N/C ratios mildly increased cell borders; high oval, polyhedral,
mildly increased in well- N/C ratios myoid, spindle
differentiated tumor, shapes; cell borders
markedly increased in well-defined; N/C
poorly differentiated types ratios high
Nucleus Variable size, round, Round, central to Round, central Round, central to Uniform, round Central; binucleation frequent;
oval to elongated; eccentric, pleomorphic in location, smooth eccentric, bi- to to oblong, egg- size variable; round with
multinucleation ⫹/⫺; size; smooth to irregular nuclear membranes; multinucleation shaped; eccentric bi- smooth to irregular nuclear
central or eccentric nuclear membranes; finely granular frequent; nuclear multinucleation; salt membranes, chromatin granular
smooth to irregular fine to coarsely granular chromatin; micro membranes smooth, & pepper chromatin, with excessive parachromatin
nuclear membranes, chromatin, parachromatin to prominent irregular; fine to micro/macronucleoli; clearing; single; large targetoid
very coarsely clearing; micro/ macronucleoli coarsely granular intranuclear macronucleus to multiple
granular to chunky macronucleoli chromatin; multiple inclusions ⫹/⫺, giant micronucleoli; pseudoinclusions
chromatin; prominent micro/macronucleoli; nuclei with clumped ⫹/⫺; multinucleated tumor
macronucleoli; intranuclear chromatin ⫹/⫺ giant cells on rare occasions
intranuclear cytoplasmic cytoplasmic
inclusions ⫹/⫺ inclusions
(continued)
Metastatic Poorly Metastatic

Adrenal Cortical Differentiated Carcinoma Metastatic Renal Malignant Pheochromocytoma/
Carcinoma Adeno/Squamous Cell Carcinoma Melanoma Paraganglioma Hepatocellular Carcinoma
Cytoplasm Variable, moderate Variable, scant to Variable, moderate Variable, scant to Variable, scant to Variable usually dense, granular
to abundant, clean, abundant, pale to dense, to abundant, pale to abundant, pale, abundant, pale bile ⫹/⫺ inclusions bare
vacuolated, granular to secretory vacuoles ⫹/⫺; granular; glycogen ⫹ granular to dense; granular to dense; nuclei ⫹/⫺
dense; glycogen absent glycogen ⫹; mucin ⫹/⫺ cytoplasmic cytoplasmic processes
tailing ⫹/⫺
Background Bloody; necrosis Necrosis ⫹/⫺ Bloody; necrosis ⫹/⫺ ⫺ Bloody, bare nuclei
Immunoprofile Vimentin ⫹ Vimentin ⫺ Vimentin ⫹ S100 protein ⫹ Vimentin ⫺ Hep Par-1 ⫹

Epithelial markers ⫺ Epithelial markers ⫹ Epithelial markers ⫺ HMB-45 ⫹ Epithelial markers ⫺ Alpha fetoprotein ⫹
Lewis blood group Lewis blood group Melan-A ⫹ Lewis blood group polyclonal CEA ⫹
antigen ⫺ antigen ⫹; keratin antigen ⫺
Calretinin ⫹ ⫹, CD10 ⫹ Neuroendocrine
Inhibin ⫹ markers ⫹; S100
protein ⫹
Cytokeratins ⫹
Ultrastructure Whorls of smooth Adenocarcinoma-surface Microvilli, copious Melanosomes Electron dense Bile canaliculi
endoplasmic reticulum; microvilli; intracytoplasmic cytoplasmic membranes bound,
lipid vacuoles lumina; secretory granules; glycogen; lipid secretory granules
intercellular findings; vacuoles
irregularly distributed
intermediate; filaments
squamous carcinoma –
tonofilaments and
desmosomes
Adjunct Elevated levels of 17 NA NA NA Elevated plasma Elevated serum, alpha

Studies ketosteroids in urine/ and urinary levels of fetoprotein ⫹/⫺
serum catecholamines and
vanillylmandelic acid
the filum terminale or a nerve root. The size varies from 21.13 to 21.16) are similar to those described for pheochro-
2 to 4 centimeters and can be easily shelled out. mocytomas. Likewise, their immunoprofile and ultrastruc-
ture are also similar (see section on pheochromocytoma).
EXTRA-ADRENAL PARASYMPATHETIC
PARAGANGLIOMAS DIAGNOSTIC DIFFICULTIES AND
Jugular and tympanic paraganglia are the most common DIFFERENTIAL DIAGNOSES OF
sites of origin of parasympathetic paragangliomas in most EXTRA-ADRENAL PARAGANGLIOMAS
published series (57–81% of tumors), followed by carotid The differential diagnosis of paragangliomas depends not
body (8–36%), vagal (4–13%), and aortic (4–10%). only on the location of the tumor but also on the cytohis-
In contrast to adrenal and extra-adrenal sympathetic tologic patterns and covers a wide spectrum of diagnostic
paragangliomas, which cause catecholamine-related entities (Tables 21.5 and 21.6). The diagnostic process is,
symptoms in a majority of cases, only about 1% of para- at times, very challenging. The cervical paragangliomas
sympathetic paragangliomas are clinically functional. are already discussed in Chapter 12—Head and Neck.
The differential diagnoses of abdominal or retro-
Gross, Microscopic,
peritoneal paragangliomas include a wide range of diag-
and Cytologic Features
nostic entities, emphasizing the fact that paragangliomas
The tumors are usually solitary but may be multiple. Their not only overlap with other neuroendocrine tumors but
gross, histologic, and cytologic appearances (Table 21.4; Figs. also with a host of epithelial and mesenchymal tumors.
Fig. 21.12. FNA of a pheochromocytoma demonstrating a very

pleomorphic cell pattern consisting of small to large, round, plasma-
cytoid to triangular and spindle forms with cytoplasmic processes, a
pattern very similar to medullary thyroid carcinoma.
Extra-Adrenal Paraganglioma (See Figs. 21.13 to 21.17)
A B
Figs. 21.13A and B. FNA of cervical paraganglioma. The neoplastic cells are small, arranged in a syncytial tissue
fragment with no architectural pattern. The cytoplasm is scant with high N/C ratios. A diagnosis of paraganglioma
is difficult from this cytomorphology without immunostains.
Fig. 21.14. FNA of cervical paraganglioma. This cellular aspirate
shows very pleomorphic cells ranging from small round to spindle
cells with cytoplasmic processes. The nuclei are round with compact
chromatin.
A B
Figs. 21.15A and B. FNA paraganglioma involving cauda equine. The neoplastic cells are discrete and loosely cohe-
sive, mostly small round, plasmacytoid to spindle-shaped, with cytoplasmic processes. Their cytoplasm is scant.
A B
Figs. 21.16A to C. A: FNA retroperitoneal paraganglioma. This cel-

lular aspirate with a pleomorphic cell pattern resembles that of a
medullary thyroid carcinoma. B: FNA of a peripancreatic paragan-
glioma. The aspiration biopsy was performed via EUS for clinically
and radiologically suspected pancreatic carcinoma. The medium-
sized neoplastic cells are discrete, loosely cohesive and in syncytial
tissue fragments. Their nuclei present a typical salt & pepper chro-
matin. C: FNA of a lytic bone lesion involving the vertebrae. The
patient had a history of retroperitoneal paraganglioma. The malig-
nant cells are large, forming syncytial tissue fragments, and appear
epithelioid. Without the clinical history, these malignant cells will be
C interpreted as poorly differentiated epithelial malignancy.
Paragangliomas involving the cauda equina include sev- METASTASES TO THE ADRENAL GLAND
eral diverse tumors in differential diagnoses including
Adrenal glands are the fourth most common site of met-
ependymoma and chondrosarcoma.
astatic cancer. The frequent sources are the lung, Kidney,
the breast, malignant melanomas, the colon, and the rec-
tum. The metastatic involvement may be bilateral and
PRIMITIVE extensive. With a known primary site, cytologic recogni-
NEUROECTODERMAL TUMORS tion of metastatic lesions is usually straightforward. A
poorly differentiated malignancy often causes diagnos-
tic difficulties, particularly with an occult primary (Figs.
NEUROBLASTOMA
21.18 to 21.22).
Neuroblastoma is one of the common childhood malig-
nancies and frequently originates in the adrenal gland. It
is described in detail in Chapter 25.
MISCELLANEOUS
GANGLIONEUROBLASTOMA
ADRENAL CYSTS
Ganglioneuroblastomas are differentiating neuroblasto-
mas consisting of neuroblastic cells and ganglionic cells Adrenal cysts are a rare occurrence and may attain a
in variable proportions. large size. Most are pseudocysts resulting from old hem-
orrhage. Rarely, they may be lined by endothelial cells.
A cystic degeneration of a neoplasm should be consid-
GANGLIONEUROMA ered in the differential diagnosis of adrenal cysts. The
Ganglioneuromas are benign lesions of the ganglionic aspirated fluid may be clear, turbid, or hemorrhagic
cells. They are usually seen in the posterior mediastinum and is either acellular or contains hemosiderin laden
and occasionally in adrenals. They occur predominantly macrophages.
in adults, in contrast to neuroblastomas. Cytohistologi-
cally, ganglioneuromas are composed of mature ganglion
ADRENAL AND EXTRA-ADRENAL
cells and often occur in groups in the background of pro-
MYELOLIPOMA
liferating nerves and fibrous tissue (Figs. 21.17A and B).
Myelolipomas are rare, benign tumors or tumor-like
lesions of uncertain pathogenesis, consisting of mature adi-
PERIPHERAL NEUROECTODERMAL
pose tissue and hematopoietic elements. The majority of
TUMORS (PNET)
myelolipomas are located in the adrenal gland, are asymp-
Peripheral neuroectodermal tumor (PNET) is a primitive tomatic, and are discovered incidentally by either CT scan
neuroblastic tumor occurring outside the autonomic ner- or magnetic resonance imaging (MRI) that is performed
vous system. PNET can occur at any age and involves for another unrelated clinical indication. Extra-adrenal
the extremities, the trunk, the retroperitoneum, and the myelolipomas are extremely rare and may be symptom-
pelvis. PNET is discussed in Chapter 25. atic. They have been described in various locations such
A B
Figs. 21.17A and B. FNA adrenal ganglioneuroma. The large ganglion cells are characteristic.
Differential Diagnoses of Pheochromocytoma/Paraganglioma (See Figs. 21.18 to 21.23)
Fig. 21.18. FNA of metastatic renal cell carcinoma to the adrenal Fig. 21.19. FNA of metastatic esophageal poorly differentiated
gland. The large polygonal cells of renal cell carcinoma with dense carcinoma.
granular cytoplasm may be mistaken for pheochromocytoma or ad-
renal cortical carcinoma.
Fig. 21.20. FNA of malignant melanoma. The malignant melanoma Fig. 21.21. FNA of pancreatic poorly differentiated adenocarcinoma
cells are known to mimic a wide range of neoplasms. These plasma- resembling pheochromocytoma.
cytoid cells strongly resemble a neuroendocrine tumor.
Fig. 21.22. FNA of a poorly differentiated hepatocellular carci-

noma. The morphologic overlap with pheochromocytoma/paragan-
glioma is clearly apparent.
TABLE 21.7 DIFFERENTIAL DIAGNOSES OF ADRENAL/EXTRA-ADRENAL MYELOLIPOMA
Diagnostic Entity Cytologic Features Diagnostic Clues Ancillary Tests See Fig(s).
Adrenal/Extra-Adrenal Erythroid, myeloid, and platelet Precursors of all three cell lines in the 21.23A and B
Myelolipoma precursors; megakaryoblasts with dense background of adipocytes
cytoplasm and large hyperchromatic
nucleus with smudgy chromatin;
megakaryocytes with multilobulated
nucleus containing smudgy chromatin;
background contains adipocytes, stromal
tissue fragments
Extramedullary Erythroid, myeloid, and platelet Erythroid precursors predominate, 6.21

Hematopoiesis precursors; megakaryoblasts with dense lack adipocytes and stromal tissue
cytoplasm and large hyperchromatic fragments
nucleus with smudgy chromatin;
megakaryocytes with multilobulated
nucleus containing smudgy chromatin
Hodgkin Lymphoma Reed–Sternberg cells with mirror Lack hematopoietic precursors and 21.27
image nuclei containing prominent adipocytes
macronucleoli; Reed–Sternberg variants
with multilobulated nuclei; mononuclear
Hodgkin cells; mixed lymphoid cell
population; eosinophils and plasma cells
Poorly Differentiated Pleomorphic giant tumor cells; Lack hematopoietic precursors; 21.25
Carcinoma with Giant mononucleated or multinucleated; immunostains with positive reactivity
Tumor Cells malignant nuclear features; mitoses to epithelial markers
frequent; background shows necrosis
Soft Tissue Sarcoma Pleomorphic cell population; Lack hematopoietic precursors; 21.28
mononucleated or multinucleated tumor certain specific features—vacuoles
giant cells with malignant features; in lipoblasts may be present;
mitoses frequent; background shows immunostains with vimentin ⫹,
necrosis ⫹/⫺ epithelial markers ⫺
Angiomyolipoma Polymorphic cell population with Lack hematopoietic elements; 21.29

tissue fragments of smooth muscles, presence of smooth muscle; thick
fibroadipose tissue; very infrequently walled blood vessels, particularly
atypical and multinucleated stromal cells identified in cell block
Malignant Melanoma Pleomorphic malignant cell population; Lack hematopoietic elements; 21.26
giant forms with mononucleate immunostains with positive reactivity
to multinucleate forms; malignant to S100 protein and HMB-45
characteristics; intranuclear cytoplasmic
inclusions ⫹; mitoses ⫹
Anaplastic Large cell Pleomorphic malignant cell population Lack hematopoietic elements; 14.17
Lymphoma with large multinucleated cells with immunostains with positive reactivity
wreath-like nuclear arrangement or to Ki-1 (CD30) and EMA
Reed-Sternberg-like malignant cells
as the presacral region, mediastinum, perirenal, hepatic, maturation (Fig. 21.23). Because of megakaryoblasts and
gastric, and paravertebral areas. Extra-adrenal myeloli- megakaryocytes, these lesions may be misinterpreted as
pomas are generally solitary, well-circumscribed, and soft any of several different types of lesions containing multi-
yellow to red. Cytohistologically, they show adipose tis- nucleated giant cells, both neoplastic and nonneoplastic
sue with foci of hematopoietic cells in various stages of (Table 21.7; Figs. 21.24 to 21.29).
A B
Figs. 21.23A and B. FNA of an adrenal myelolipoma. A, B: The aspirate contained numerous megakaryoblasts and
megakaryocytes along with precursors of erythroid and myeloid cells.
Differential Diagnoses of Adrenal Myelolipoma (See Figs. 21.24 to 21.29)
Fig. 21.24. Metastatic giant cell carcinoma of the lung presenting a Fig. 21.25. Metastatic poorly differentiated carcinoma of pancreas
pattern similar to adrenal myelolipoma. with bizarre tumor giant cells.
Fig. 21.26. Malignant melanoma can present as giant cell malignancy. Fig. 21.27. Hodgkin lymphoma with large Hodgkin cells.
Fig. 21.28. Malignant fibrous histiocytoma with very pleomorphic Fig. 21.29. FNA of an angiomyolipoma of the kidney. This tumor
malignant cells presenting giant forms. may contain multinucleated foreign-body type giant cells in the
background of mixed inflammatory cells. The presence of spindle
cells may be a clue.
static carcinomas, whose common primary sites are the

RETROPERITONEUM ovary, the colon, the stomach, and the breast.
Primary retroperitoneal malignancy is very rare.
The retroperitoneum is a potential space extending antero- The majority are soft tissue sarcomas of which liposar-
posteriorly from the posterior layer of the parietal peri- comas are the most common, followed by leiomyosar-
toneum to the muscles of the posterior abdominal wall. comas and malignant fibrous histiocytomas. Malignant
It extends superiorly from the diaphragm through to the lymphomas; germ cell tumors; and neural tumors such
pelvic peritoneal attachments, inferiorly encompassing as ganglioneuromas, ganglioneuroblastomas, neuroblas-
the lumbar and iliac regions. Besides the major abdominal toma, paragangliomas, and nerve sheath tumors account
organs such as the kidney, the adrenals, and the pancreas, for the rest. Benign neoplasms such as angiomyolipo-
the retroperitoneal space contains major blood vessels, mas, myelolipomas, leiomyomas, or lipomas have been
nerve trunks and plexuses, lymphatics, lymph nodes, and encountered. Nonneoplastic processes include idiopathic
fibroadipose tissue. retroperitoneal fibrosis.
The majority (85–95%) of the tumors involving the The cytopathologic features of many of the neo-
retroperitoneal space are metastatic and include malig- plasms stated above are described in various chapters in
nant lymphomas, sarcomas, germ cell tumors, and meta- this atlas.
SUGGESTED READINGS
Ellison DA, Parham DM. Tumors of the autonomic nervous sys- Nervous System Tumors. New York: Churchill Livingstone,
tem. Am J Clin Pathol 2001;115(Suppl 1):S45–S55. 2002;240–242.
Gong Y, DeFrias DV, Nayar R. Pitfalls in fine needle aspiration Luck E. Tumors of the Adrenal Glands and Extra-Adrenal Para-
cytology of extra-adrenal paraganglioma. A report of two ganglia. Washington, DC: AFIP, 2007.
cases. Acta Cytol 2003;47:1082–1086. Ren R, Guo M, Sneige N, et al. Fine needle aspiration of adrenal
Ironside JW, Moss TH, Louis DN, Lowe JS, Weller RO. Neuronal cortical carcinoma. Cytologic spectrum and diagnostic chal-
and mixed neuronal-glial tumors. In: Diagnostic Pathology of lenges. Am J Clin Pathol 2006;126:389–398.
22 GONADS (OVARIES AND TESTES)
Follicular cysts are usually more than 3 centimeters in

OVARIES diameter, unilocular, lined internally by granulosa cells
and externally by theca interna cells. The cyst fluid is usu-
The use of FNA biopsy in the management of ovarian ally clear.
lesions has remained a controversial issue. The reluc- The cytologic features in aspirated fluids from fol-
tance mainly stems from the fear of possible spillage of licular cysts are characteristic (Table 22.2; Figs. 22.1 to
the contents and local spread of a malignant lesion as 22.3). The cellularity is variable from scant to mark-
well as the inability to differentiate borderline lesions edly cellular, consisting of small, round, uniform cells
from malignant ones on a cytologic basis. Also, the that present either in a dispersed pattern or in syncy-
diverse morphology of ovarian lesions may not allow tial tissue fragments without any architectural patterns.
specific typing. One notable problem is the low sensitiv- The cells possess poorly defined cell borders, scant to
ity of the procedure in terms of cytologic diagnosis due indiscernible cytoplasm, and high N/C ratios. Their
to inadequate samples. However, the technique has been nuclei are round with smooth nuclear membranes and
successfully used by some in select cases of unilocular coarsely granular chromatin with inconspicuous nucle-
cysts that have benign features (lacking septae or solid oli. The normal granulose cells may mimic Call–Exner
areas) on ultrasonography, laparoscopy, or laparotomy. bodies. Enlarged granulosa cells with increased pale
FNA biopsy has been helpful for both diagnostic and
therapeutic purposes. TABLE 22.1 CYSTIC LESIONS OF THE OVARIES
This section will focus on the differential diagnoses of
cystic ovarian lesions since solid lesions (by ultrasound/ Nonneoplastic, Nonepithelial
CT scan) are not routinely subjected to an FNA biopsy Follicular
procedure. However, the fi ne needle biopsy procedure is
utilized in cases of recurrent or metastatic lesions. Corpus luteal cyst
Cystic ovarian masses encompass a broad group of Nonneoplastic, Epithelial
cystic lesion including nonneoplastic cysts and benign
and malignant cystic neoplasms (Table 22.1). They origi- Surface epithelial inclusion cyst
nate from different sources. For example, they may arise Endometriotic cysts
from noncelomic epithelium (e.g., follicular cysts, corpus
luteum cysts, and granulosa cell tumor) or from celomic Neoplastic, Nonepithelial
epithelium (e.g., surface epithelial inclusion cysts and en- Granulosa cell tumor
dometriotic cysts), serous and mucinous neoplasms, and
dermoid cysts (cystic teratoma) arising from the totipo- Neoplastic, Epithelial
tential cells. The cytologic features of all cystic lesions of Benign
the ovaries are described in Table 22.2.
Serous cystadenoma
Mucinous cystadenoma
NONEPITHELIAL BENIGN CYSTS AND
NEOPLASMS Malignant
Serous cystadenocarcinoma
Follicular Cysts
Follicular cysts are derived from the germinal follicles Mucinous cystadenocarcinoma
of the ovaries and usually occur during the reproductive Neoplasm of Totipotential Cells
years. These are mostly incidental findings but may pres-
Cystic mature teratoma or dermoid cyst
ent with symptoms due to increased estrogen activity.
852
TABLE 22.2 DIFFERENTIAL DIAGNOSES OF CYSTIC OVARIAN LESIONS: CYTOPATHOLOGIC FEATURES
Germinal
Inclusion
Follicular Cystic Cyst Serous Cysta- Mucinous
Cyst with Teratoma Paratubal/ denocarcinoma Mucinous Carcinoma
and without Corpus Luteal Granulosa Cell Endometriotic Dermoid Parovarian/ Serous Borderline/ Cystade- Borderline/
Luteinization Cyst Tumor Cyst Cyst Simple Cystadenoma Malignant noma Malignant
Aspirate Clear Clear to bloody Clear to bloody Bloody, chocolate Yellow, cheesy Clear Clear Clear to turbid Thick, stringy May be thick
colored and stringy
Cellularity Variable, may Variable Variable Variable Variable Generally Generally low Highly cellular Variable Variable
be marked paucicellular
Presentation Dissociated Dispersed Isolated, in loosely Bicellular; Polymorphic Cells isolated Isolated or in Isolated in Cells in Cells in loosely
pattern pattern cohesive groups and endometrioid cell types in small to small tissue loosely cohesive stripes or in cohesive
frequent; cells in syncytial tissue glandular and derived from large tissue fragments with groups or in honeycomb groups,
isolated and/ fragments; Call– stromal cells one to more fragments with honeycomb syncytial tissue sheets syncytial tissue
or in tight Exnera bodies germinal layers or without to syncytial fragments with fragments
aggregates; honeycomb arrangement; solid, acinar or with papillary
Call–Exnera pattern; may papillary papillary pattern configuration
bodies rare resemble pattern ⫹/⫺ with or without
mesothelium branching
Cells Small to Medium to large Small, monomorphic Endometrial Squamous to Small, round Small cuboidal Pleomorphic in Tall columnar, Columnar,
medium-sized round with poorly glandular cells- glandular or to oval; well- to columnar; size; small round well-defined wall to poorly
(luteinized); defined cell borders; small, round to specialized defined cell well to poorly to large; N/C cell borders; defined cell
poorly defined high N/C ratios cuboidal; poorly type borders; cilia defined cell ratio high: signet- low N/C ratios borders; N/C
cell borders; defined cell ⫹/⫺ borders ring forms ratio higher
high N/C borders; high than benign
ratios N/C ratio counterpart
Nucleus Round to oval; Round oval Round to oval; Round to oval; Round to oval; Round to Round to oval; Pleomorphic in Round to oval Pleomorphic
smooth nuclear to polygonal; smooth nuclear smooth nuclear smooth nuclear oval; smooth smooth nuclear size, considerable uniform, basal in size; nuclear
membrane; eccentric membrane; finely membrane; membrane; nuclear membrane; variation location in membrane
granular evenly nucleus; granular chromatin evenly bland membrane, evenly dependent on the strips; smooth smooth to
dispersed smooth nuclear with parachromatin dispersed, chromatin evenly dispersed, grade; nuclear nuclear irregular;
chromatin; membrane; clearing; finely granular dispersed finely granular membrane membrane, granular
micronucleoli finely granular, micronucleoli chromatin; chromatin; smooth to uniformly chromatin with
⫹/⫺; mitoses evenly dispersed prominent; nuclear micronucleoli micronucleoli irregular; granular dispersed, parachromatin
frequently chromatin; grooves ⫹/⫺ ⫹/⫺ chromatin with finely granular clearing;
present; prominent parachromatin to compact micronucleoli
grooves ⫹/⫺; nucleolus clearing, single or chromatin;
nuclear atypia multiple; micro/ nucleoli ⫹/⫺
⫹/⫺ macronucleoli
(continued)
Germinal
Inclusion
Follicular Cystic Cyst Serous Cysta- Mucinous
Cyst with Teratoma Paratubal/ denocarcinoma Mucinous Carcinoma
and without Corpus Luteal Granulosa Cell Endometriotic Dermoid Parovarian/ Serous Borderline/ Cystade- Borderline/
Luteinization Cyst Tumor Cyst Cyst Simple Cystadenoma Malignant noma Malignant
Cytoplasm Scant to Scant Scant Variable, Scant, pale Scant, pale Scant to Abundant pale Abundant pale
granulosa depending on vacuolated to vacuolated to vacuolated
cells; modest cell type cytoplasm
amount of
granular
to foamy
cytoplasm in
luteinized cells
Background Bloody ⫹/⫺ Bloody Blood ⫹/⫺ Fresh or Keratin debris; Amorphous Histiocytes, Necrotic debris; Histiocytes, Bloody;
⫹/⫺hemosiderin old blood; multinucleated debris inflammation psammoma multinucleated abundant
containing histiocytes with foreign-body ⫹/⫺; few bodies ⫹/⫺ foreign-body thick mucin;
macrophages; or without type giant cells; inflammatory type giant histiocytes
foreign- hemosiderin; anucleated cells and cells; strings of
body type round with squames histiocytes mucin
multinucleated central to
giant cells; eccentric bland
stromal cells ⫹/⫺ nucleoli
Confirmatory High Estridol ⫺ Immunocytochemical ⫺ ⫺ ⫺ Epithelial Levels of Epithelial Levels of

Tests levels stain for CEA ⫺; markers ⫹ CA125↑; markers ⫹ CA125↑;
EM ⫺; keratin ⫺; epithelial epithelial
vimentin ⫺; LCA ⫺ markers ⫹ markers ⫹
a
Call–Exner bodies: radially arranged granulosa cells around a space or cavity filled with pale to dense acellular material.
Chapter 22: Gonads (Ovaries and Testes) 855
A B
Figs. 22.1A to C. Follicular cyst aspirate. A: low power view show-

ing marked cellularity. The cells are present in tissue fragments as
well as dispersed. B: Higher magnification showing the granulosa
cells to be small, uniform forming pseudofollicular pattern. C: Some
of the cells are larger containing moderate amount of pale cyto-
C plasm suggesting luteinization.
Figs. 22.2A and B. A, B: Follicular cyst aspirate. The cells are small,
forming tight syncytia. The cell borders are poorly defined with in-
A B significant cytoplasm and high N/C ratios. The nuclear chromatin
coarsely granular to compact.
cytoplasm indicate a luteinizing process. Large follicular The differential diagnoses of follicular cysts include
cysts, sometimes occurring during pregnancy and post- surface epithelial inclusion cysts, granulose cell tumor,
partum, have presented considerable cytologic atypia. and serous neoplasms.
Also, on occasion, increased cellularity and high mitotic
rate may pose potential diagnostic problems and be
Corpus Luteal Cysts
misinterpreted as malignant (Fig. 22.2). The cytomor-
phology of cellular follicular cysts overlaps with that Corpus luteal cysts occur in younger women. They are
of granulosa cell tumors and, cytologically, cannot be solitary, unilocular, and thin-walled. The recent corpus
differentiated from the latter (see Figs. 22.6, 22.8A and luteal cyst is hemorrhagic and characterized by fresh
C, 22.9A and B). blood and granulation tissue while the older ones are
A B
Figs. 22.3A and B. A: Follicular cyst aspirate showing marked cellularity with very large tissue fragments of granu-
lose cells (low power). B: Higher magnification showing slight nuclear enlargement. This pattern cannot be differenti-
ated from that of a granulose cell tumor.
A B
Figs. 22.4A and B. Corpus luteum cyst aspirate. A: Note the hypercellularity with cells mostly discrete and in loosely
cohesive groups (low power). B: Higher magnification showing large round cells with abundant cytoplasm.
convoluted and yellow with clear fluid. The lining is com- cell tumors demonstrate various growth patterns: solid
posed of large polyhedral luteinized cells with abundant diffuse, trabecular, micro-/macrofollicular, and insular.
granular cytoplasm and a small nucleus with a prominent The neoplastic cells tend to be small and uniform with
nucleolus (Table 22.2; Fig. 22.4). scant cytoplasm and nuclei containing finely granular
chromatin and nuclear grooves. The hallmark of granu-
Granulosa Cell Tumors lose cell tumors is the presence of Call–Exner bodies,
particularly seen with a microfollicular pattern. The
Granulosa cell tumors are the most common amongst the
Call–Exner bodies are characterized by microscopic
sex cord–stromal tumors of the ovaries; however, they
spaces containing deeply eosinophilic basal lamina
are very infrequent, comprising 1 to 3% of all ovarian
material bordered by small, uniform, neoplastic granu-
malignancies. They can occur at any age but are com-
lose cells.
mon in peri- and postmenopausal women and are often
associated with estrogenic manifestations. The tumors are
mostly unilateral. Cytopathologic Features. The cytologic samples of gran-
ulosa cell tumors may represent aspirated ovarian cyst
Gross and Microscopic Features. Grossly, the tumors fl uid, peritoneal/pelvic washings, or aspiration biopsy
may attain a large size of up to 12 centimeters and are specimens; the latter is usually performed to confirm a
either solid or solid cystic. Their cut surface shows a recurrent or a metastatic process (Table 22.3). The cellu-
yellow–white tumor, and the cystic areas, when present, larity of the specimens is variable and can be overwhelm-
may be filled with clear fluid. Histologically, granulose ing. The cells are usually small and uniform, occurring
TABLE 22.3 CYTOPATHOLOGIC FEATURES OF GRANULOSA CELL TUMORS (SEE FIGS. 22.5 TO 22.10)
Presentation Cells isolated, in loosely cohesive groups and in syncytial tissue fragments; dispersed pattern frequent;
Call–Exner bodies ⫹/⫺
Cells Small, round to cuboidal, well to poorly defined cell borders; high N/C ratios; central nuclei
Nucleus Round to oval; uniform; longitudinal groove resulting in coffee-bean shape; chromatin finely to coarsely
granular with parachromatin clearing; micronucleoli ⫹; pleomorphism may be seen in high-grade tumors
Cytoplasm Very scant, indiscernible
Background Clean
Immunoprofile Positive reactivity to Inhibin, calretinin, vimentin
Differential Follicular cyst

Diagnoses Surface epithelial inclusion cysts
Endometriosis
Endosalpingiosis
Serous cystadenoma
Ovarian serous cystadenocarcinoma, borderline tumor
Primary peritoneal serous cystadenocarcinoma, borderline
A B
Figs. 22.5A and B. A: FNA of a granulosa cell tumor, showing granulosa cells and Call–Exner bodies. B: Different
example of a granulosa cell tumor. This fine needle aspirate of an ovarian cyst depicts a characteristic cytologic pat-
tern of GCT. The tumor cells are in syncytia, slightly larger than their normal counterparts, round with poorly defined
cell borders. The nuclei are round with sharp nuclear membranes with marginated chromatin. Note the micronucleoli,
finely granular chromatin, and nuclear grooves.
discrete, in aggregates, or in syncytial tissue fragments spaces in Call–Exner bodies stains either eosinophilic or
without any architectural patterns or in trabeculae and, cyanophilic with a Papanicolaou stain (Table 22.3; Figs.
infrequently, with Call–Exner bodies. The cells of granu- 22.5 to 22.10).
lose cell tumor tend to be somewhat larger than those The immunoprofile of granulosa cells include positive
seen in follicular cysts. The cell borders are ill-defined reactivity to inhibin, calretinin, and vimentin. The reactiv-
with very high N/C ratios. Their nuclei are round to oval ity to keratin, WT-1, S100, CD10, CD56, smooth muscle
with frequent longitudinal grooves referred to as a “coffee actin, and EMA is variable.
bean” pattern. The chromatin is fine to coarsely granular The differential diagnoses include follicular cysts,
with micronucleoli. The presence of Call–Exner bodies is adenocarcinoma—either primary ovarian or metastatic—
diagnostic. The central, dense, acellular material filling the and neuroendocrine tumors.
A B
Figs. 22.6A and B. A: Peritoneal fluid from a patient with a history of granulosa cell tumor, now having local recurrence. B: Peritoneal washings from
another patient with a history of granulosa cell tumor. Note the Call–Exner bodies and scattered granulosa cell tumor cells in the background.
Fig. 22.7. Ovarian cyst aspirate showing granulosa cell tumor with
multiple Call–Exner bodies.
A B
Figs. 22.8A to C. FNA granulosa cell tumor. A: Moderately cellular

aspirate consisting of small cells, slightly larger than normal fol-
licular cells, loosely cohesive and in syncytial tissue fragments, with
poorly defined cell borders, nuclei with pale finely granular chro-
matin. B: Note the dispersed cell pattern. The nuclear chromatin is
pale compared to the normal follicular cells. The nuclear grooves
are readily seen and micronucleoli are prominent. C: Different field
from the same case showing a syncytial tissue fragment composed
C of smaller cells with nuclei containing coarsely granular chromatin.
A B
Figs. 22.9A and B. Patient with a history of granulosa cell tumor. A: Peritoneal fluid. The smear showing syncytial
tissue fragment of closely packed small round cells with suggestion of Call–Exner bodies. B: FNA of the recurrent
abdominal tumor syncytial tissue fragments and loosely cohesive small round cells with uniform nuclei, containing
granular chromatin. The neoplastic cells demonstrate micronucleoli and nuclear grooves.
A B
Figs. 22.10A and B. Peritoneal fluid from a patient with a history of granulosa cell tumor. This recurrent tumor
shows syncytial tissue fragments of small to medium-sized, round neoplastic cells with poorly defined cell borders,
coarsely granular chromatin and mild pleomorphism.
that have lost their connection with the surface. These are
Endometriotic Cysts
frequently encountered in clinical practice. They are small
Endometriotic cysts mainly occur during the reproductive in size and measure up to 1 centimeter.
years. Chronic pelvic pain is a frequent symptom. The cyst The cysts are typically lined by a single layer of colum-
fluid may be grossly bloody or the contents may be choco- nar epithelium, usually of the serous or tubal type. Psammo-
late-colored, representing old blood. The histologic diagno- ma bodies may be present. These cysts are indistinguishable
sis is based on finding endometrial tissue, glandular and/or from paratubal or paraovarian cysts and are often called
stromal. The identification of stromal cells in an aspirated simple cysts (Table 22.2; Fig. 22.12). The aspirated cyst
specimen may be difficult. Very often the fluid may contain fluid is often acellular to poorly cellular with small round to
only histiocytes (Table 22.2; Fig. 22.11). The peritoneal/ cuboidal cells either dispersed or forming honeycomb sheets.
pelvic washings may show evidence of endometriosis. They have scant, pale cytoplasm with uniform, round nuclei
containing pale chromatin. Cilia are sometimes noted.
SURFACE EPITHELIAL CYSTS
AND EPITHELIAL NEOPLASMS NEOPLASMS OF THE OVARIAN
SURFACE EPITHELIUM
Surface Epithelial Inclusion Cysts
The surface epithelial malignant neoplasms are histologi-
Surface epithelial inclusion cysts are believed to arise from cally classified into serous, mucinous, endometrioid, clear
cortical invaginations of the ovarian surface epithelium cell, transitional, undifferentiated, and miscellaneous types.
Fig. 22.11. Endometriotic cyst, showing an endometrial gland with

closely packed endometrial glandular cells.
A B
Figs. 22.12A and B. Surface epithelial inclusion cyst. The fluid from these cysts is generally clear and paucicellular.
The cells are larger than the follicular cells and are present mostly in monolayered tissue fragments. Their cell borders
are well to poorly defined and the cytoplasm is visible but pale and scant. The nuclei are round, uniform with evenly
dispersed finely granular chromatin.
Since an aspiration biopsy of the possible malignant lining consists of a single layer of cuboidal epithelium or
ovarian lesions is not routinely performed and the cytol- columnar tubal type with uniform, round to oval nuclei
ogy is of limited use in their primary diagnosis, this chap- containing compact chromatin (Table 22.2; Fig. 22.13).
ter will only mention their salient features. The cellularity is generally low. The cytologic presenta-
tion is very similar to that of a surface inclusion cyst.
OVARIAN TUMORS WITH SEROUS SURFACE
Malignant Serous Tumors (Serous Adenocarcinoma
EPITHELIAL TUMORS
of Low Malignant Potential and Serous
Tumors with serous differentiation are characterized by Adenocarcinoma)
epithelial cells resembling fallopian tubal epithelium and
Malignant serous neoplasms include serous carcinomas of
are subdivided into three broad groups: serous cystade-
low malignant potential (LMP)—also referred to as bor-
noma, serous borderline tumor (tumor of low malignant
derline tumors—and serous adenocarcinomas. The bor-
potential), and serous carcinoma.
derline tumors comprise 15% of all serous ovarian tumors
with 33 to 60% limited to one ovary. The serous border-
Serous Cystadenoma
line tumors are capable of extraovarian spread, recurrence,
Serous cystadenomas comprise 20% of all benign ovar- and death. The progression of the disease is slow and indo-
ian neoplasms, occurring mainly during the reproductive lent. Serous adenocarcinomas are more common and often
years. The cysts may be large or thin-walled and are usu- bilateral with the peak incidence between the fourth and
ally unilocular with clear fl uid content. The interior may sixth decades of life. They are highly aggressive and metas-
have intramural nodules or papillary excrescences. The tasize locally and to distant organs. They are often present
Fig. 22.13. FNA of a serous cystadenoma. The tissue fragment is

syncytial composed of slightly pleomorphic round to oval small
to medium-sized cells with crowding and overlapping and contain
scant cytoplasm.
A B
Figs. 22.14A to C. FNA of a serous cystadenocarcinoma, border-

line. A, B: The aspirate shows considerable necrotic and cellular
debris. The malignant cells are present discrete and in small tissue
fragments buried in the debris. C: The malignant cells are round
to cuboidal, medium-sized forming small syncytial tissue fragments
with an acinar pattern. Note the cytoplasmic vacuoles. The nuclei
C are mildly pleomorphic.
with ascites or pleural effusion and with positive cytology. Cytologic identification is generally easily achieved if
Serous carcinomas are multilocular with papillary growths and when aspirates are evaluated (Table 22.2; Figs. 22.14
springing from the wall; the growths are less abundant in to 22.16). However, the differentiation of tumors with
borderline tumors than in carcinomas. Histologically, the low malignant potential (borderline tumors) from the ma-
tumors may be well- to poorly differentiated with papillary, lignant ones is diffi cult, if not impossible, on a cytologic
acinar, or a solid pattern and varying degrees of nuclear aty- basis. The same diffi culty is encountered in the cytologic
pia as well as a frequent occurrence of psammoma bodies. evaluation of peritoneal fluids.
Fig. 22.15. FNA of a serous cystadenocarcinoma. The malignant

cells are arranged in syncytial tissue fragment with a branching tra-
becular pattern.
A B
Figs. 22.16A and B. FNA of serous cystadenocarcinoma. The malignant cells are forming syncytial tissue
fragments with an acinar pattern. Note the psammoma body in B.
Figs. 22.17A and B. FNA of a clear cell carcinoma of the ovary.

A B Some of the malignant cells have poorly defined cell borders and
abundant clear cytoplasm.
Immunoprofile. The serous adenocarcinoma cells react

Mucinous Cystadenoma
to CK7, EMA, WT1, Ber EP4, CA125, and CD15 and are
negative to CK20, and calretinin. Mucinous cystadenomas comprise 20% of benign ovar-
Clear cell carcinomas of the ovaries (Fig. 22.17) are ian neoplasms, occurring in the third through the fifth
rare. The aspiration biopsy reveals pleomorphic malig- decades of life. They may be asymptomatic or may be
nant cells with clear cytoplasm. associated with pelvic pain, abdominal or pelvic mass,
A B
Figs. 22.18A and B. A: FNA of a mucinous cystadenoma showing strips of mucin-producing epithelium (medium
power). B: a different field showing a syncytial tissue fragment of closely packed epithelial cells with some cells
showing cytoplasmic vacuoles. The nuclear chromatin is uniform. There are numerous histiocytes in the background.
and abdominal distention. Mucinous cystadenomas can NEUROENDOCRINE TUMORS

grow to be an enormous size of up to 50 centimeters. OF THE OVARIES
They are unilocular with a smooth glistening surface and
Ovarian neuroendocrine neoplasms include carcinoid
are lined by a single layer of tall columnar mucin-produc-
type tumors and small cell carcinomas. Primary ovarian
ing epithelium (Table 22.2; see Fig. 22.21). If an excision
carcinoids are rare, accounting for less than 1% of all
of the larger cyst becomes a technically difficult surgical
carcinoid tumors. They can occur at all ages. The most
procedure, its contents are emptied and submitted for
common clinical manifestation is the pelvic mass. Ovar-
cytologic evaluation. Grossly, the cyst contents are thick
ian carcinoid tumors are invariably unilateral. The major-
and mucinous. The cytologic features are characterized
ity occurs in association with mature cystic teratomas but
by tissue fragments and strips of benign mucin-producing
can also occur in pure form. Ovarian carcinoid tumors
epithelium. The background contains a large number of
are sometimes seen grossly as a solid nodule of tan or yel-
histiocytes and abundant mucin (Fig. 22.18).
lowish tissue adjacent to or protruding into a cyst or as a
mural thickening of the cyst wall.
Malignant Mucinous Tumors
Primary carcinoid tumors of the ovary have been
Malignant mucinous tumors include tumors with low divided into two major histologic types: insular (midg-
malignant potential and adenocarcinoma. The former ut derivation), which is the most common type and fre-
comprise 13% of all mucinous tumors and occur in quently a component of cystic teratoma, and trabecular
patients from age 9 to 70. Mucinous carcinomas com- (foregut or hindgut derived the uncommon type). Carci-
prise 6 to 10% of all primary malignant ovarian tumors noid syndrome is found only in association with insular
with 25% being bilateral. They occur most frequently type carcinoids. Histologically, the tumors present a typi-
during the fourth to sixth decades of life. These mucinous cal neuroendocrine growth pattern and immunoprofile
neoplasms are multilocular with cyst cavities containing (see Chapter 10). Small cell neuroendocrine carcinomas
thick stringy mucin and papillary excrescences growing of the ovaries are extremely rare.
from the wall. Histologically, the tumor is characterized The cytologic presentation of ovarian carcinoids is
by a papillary to solid growth pattern formed by mucin- not documented in the literature. A case of ovarian car-
producing epithelium, either of endocervical type or intes- cinoid tumor in association with a dermoid cyst that was
tinal type. The cytologic features are characterized by syn- identifi ed in peritoneal/pelvic washings is illustrated in
cytial tissue fragments of malignant epithelium with and Chapter 6, Figure 6.53.
without an acinar or papillary pattern. The malignant
cells are large with variable, vacuolated cytoplasm. There
is usually abundant mucin in the background (Table 22.2;
Figs. 22.19A to D).
TESTES
Immunoprofile. The cells of mucinous cystadenocarci- FNA biopsy of testicular masses is not a widely accepted
noma react positively to CK7, CK20, CEA, and CDX2 procedure for the diagnosis of testicular neoplasms,
and react negatively to CA125. although the technique is used successfully in Scandinavia.
A B
C D
Figs. 22.19A to D. FNA of a mucinous cystadenocarcinoma. A: Low power view showing a tissue fragment of cells
in the background of abundant mucin. B, C, D: Higher magnification showing syncytial arrangement with acinar pat-
tern and cytoplasmic mucin.
In the United States, FNA biopsy is predominantly used TABLE 22.4 CLASSIFICATION OF GERM
to confirm metastasis from testicular tumors or in identi- CELL TUMOR
fying extratesticular germ cell tumors.
The majority of testicular tumors (up to 95%) are Teratoma
of germ cell origin while stromal tumors account for the
remainder. Mature
Immature
GERM CELL TUMORS OF THE With malignant germ cell tumor component(s)
OVARIES AND TESTES
Germ cell tumors are derived from primitive germinal Germinoma
epithelium and more frequently involve the testes than
the ovaries (Table 22.4). They also occur in extragenital Embryonal cell carcinoma
sites such as the mediastinum, the retroperitoneum, the
sacrococcygeal region, and the pineal body. Testicular Endodermal sinus tumor (yolk sac tumor)
germ cell tumors are the most common neoplasms occur-
Choriocarcinoma
ring in men between the ages of 25 and 29. Although they
commonly present as testicular masses, they occasionally
Gonadoblastoma
remain occult and present at the metastatic site. Extragen-
ital germ cell tumors are also encountered in the pediatric Polyembryoma
age group and in adolescents.
Seminoma Cytologic Features. The aspirates are usually cellular,

consisting of a large population of discrete, medium-sized,
Seminoma is the most common germ cell tumor in males,
round cells with well- to poorly defined cell borders; scant
accounting for up to 70% of primary testicular tumors.
cytoplasm; and large, round nuclei with high N/C ratios
Gross and Microscopic Features. Grossly, these tumors are (Table 22.5; Figs. 22.20 and 22.21). The nuclear mem-
well-circumscribed with a fleshy cut surface. Histologically, branes are smooth, and the chromatin is finely granular.
seminomas consist of sheets and lobules of medium-sized A central prominent macronucleolus is very characteristic
round cells with central, large nuclei containing a prominent of seminomas. The neoplastic cells are intimately mixed
nucleolus. The cytoplasm is very scant. A lymphocytic infil- with lymphoid cells and epithelioid cells from the granu-
trate intimately mixed with the neoplastic cells and a granulomatous reaction. In Romanowsky-stained prepara-
lomatous reaction are characteristic features of seminomas. tions, the aspirates of seminomas present a characteristic
TABLE 22.5 CYTOPATHOLOGIC FEATURES OF SEMINOMA/DYSGERMINOMA
Cellularity Variable, generally marked
Presentation Neoplastic cells mostly isolated or in aggregates; epithelioid histiocytes mixed with lymphoid cells
Cells Round, well-defined cell borders, medium-sized; high N/C ratios
Nucleus Large round, crisp nuclear membrane, finely granular evenly dispersed chromatin; giant central nucleolus
Cytoplasm Scant to moderate, pale
Background Lymphocytes/epithelioid cells, (frothy appearance, ‘tigroid’ in Romanowsky stain); bare nuclei
Immunoprofile Cytokeratin ⫺; LCA ⫺; AFP ⫺; vimentin ⫺; PLAP ⫹; CD30 ⫺; CD117/c kit ⫹
Ultrastructure Glycogen granules primitive intercellular junctions
Differential Embryonal carcinoma

Diagnoses Endodermal sinus tumor (yolk sac tumor)
Immunoblastic lymphoma
Poorly differentiated adenocarcinoma
Malignant melanoma
Hodgkin lymphoma
Germ Cell Tumors (See Figs. 22.20 to 22.24)
A B
Figs. 22.20A to C. FNA of a testicular seminoma. A, B: The smear is cellular consisting of discrete round medium to
large round cells with poorly defined cell borders, large round nuclei and scant pale cytoplasm. The nuclear chroma-
tin is finely granular and the nucleoli are prominent. Lymphocytes are present in the background. (continued)
Figs. 22.20C. (continued) C: This image depicts the characteristic

frothy background seen in seminomas with Romanowsky stain, re-
C ferred to as “tigroid” background.
A B
Figs. 22.21A and B. FNA of a seminoma demonstrating discrete medium-sized round cells in the background of
lymphocytes. This cytologic presentation resembles that of a malignant large cell lymphoma.
background pattern referred to as “tigroid” (Fig. 22.20C). carcinoma (Fig. 22.22). The malignant cells have poorly
The fragile cell borders of the neoplastic cells rupture defi ned cell borders, unlike seminoma cells. Embryonal
easily, and their stripped nuclei may be present in the carcinomas may form abortive glands or papillary struc-
background. tures with areas of necrosis. The differential diagnosis
Seminomas may be associated with other types of includes an adenocarcinoma.
germ cell tumors (mixed germ cell tumors) and may pres-
ent diagnostic problems. Endodermal Sinus Tumor
Endodermal sinus tumor, also known as yolk sac tumor, is
Immunoprofile. Seminoma reacts positively to PLAP and
considered an “infantile” form of embryonal carcinoma.
CD117/c kit. They do not react to cytokeratin, LCA, AFP,
It is the most common germ cell tumor found in the pedi-
vimentin, and CD30.
atric age group, occurring either alone or in combination
The differential diagnoses of seminoma include ma-
with other germ cell tumors. In infants and newborns, the
lignant lymphoma, metastatic adenocarcinoma, malig-
sacrococcygeal area is most frequently involved while in
nant melanoma, and thymoma in the mediastinum (Table
adolescents it is the ovary. Other sites include the mediasti-
22.6; see also Chapter 17).
num, the retroperitoneum, the pineal area, and the vagina.
Testicular endodermal sinus tumors peak in infancy and
Embryonal Carcinoma
in adolescence. Grossly, endodermal sinus tumors are
Embryonal carcinoma is a highly malignant neoplasm soft and pale tan–yellow with areas of necrosis and cysts.
comprising 20% of all testicular tumors. Cytohistologi- Microscopically, they are characterized by several pat-
cally, embryonal carcinomas consist of masses of large terns, ranging from areas that are indistinguishable from
malignant cells with pleomorphic nuclei and prominent embryonal carcinoma to papillary pattern and net-like
nucleoli, resembling a poorly differentiated to anaplastic reticular pattern. Papillary projections are associated with
TABLE 22.6 DIFFERENTIAL DIAGNOSES OF SEMINOMA/DYSGERMINOMA

Seminoma/ Neoplastic cells mostly dispersed; medium-sized, uniform; poorly defined cell PLAP ⫹
Dysgerminoma borders with scant to moderate pale cytoplasm; large, round nucleus, smooth AFP ⫺
nuclear membrane; finely granular chromatin; prominent central macronucleoli; Cytokeratin ⫺
lymphocytes and epithelioid histiocytes may be present; bare nuclei with LCA ⫺
distorted forms frequent; tigroid background with Romanowsky stain CEA ⫺
CD117 (c kit) ⫹
Embryonal Carcinoma Neoplastic cell, very pleomorphic, isolated, in aggregates, or in syncytial tissue PLAP ⫹
fragments with or without papillary and acinar pattern; nuclei pleomorphic in AFP ⫹
size, may be irregular; coarsely granular chromatin; multiple prominent nucleoli; Cytokeratin ⫹
variable cytoplasm; necrosis LCA ⫺
CEA ⫺
Endodermal Sinus Neoplastic cells, isolated, in loose aggregates, and in syncytial tissue fragments PLAP ⫹/⫺
Tumor (Yolk Sac with papillary and/or acinar pattern; nuclei pleomorphic; fine to coarsely AFP ⫹
Tumor) granular chromatin; micronucleoli; variable cytoplasm; vacuolated or with Cytokeratin ⫹
eosinophilic hyaline bodies; mucoid material in the background LCA ⫺
CEA ⫺
Immunoblastic Dispersed medium-sized cells; monomorphic pattern; round nuclei; finely PLAP ⫺
Lymphoma granular chromatin; central nucleoli; moderate cytoplasm; mitoses ⫹; AFP ⫺
lymphoglandular bodies in Romanowsky stain; necrosis Cytokeratin ⫺
LCA ⫹
CEA ⫺
Poorly Differentiated Malignant cells isolated, in loosely cohesive groups and in syncytial tissue PLAP ⫺
Adenocarcinoma fragments; pleomorphic in size; high N/C ratio; regular to irregular nuclei; AFP ⫺
coarsely granular chromatin; multiple micronucleoli/ macronucleoli; variable Cytokeratin ⫹
cytoplasm with vacuoles ⫹/⫺; necrosis ⫹/⫺ LCA ⫺
CEA ⫹
Malignant Melanoma Malignant cells individually dispersed; round with central large nuclei; nuclear PLAP ⫺
membrane smooth to irregular; fine to coarsely granular chromatin; prominent AFP ⫺
single or multiple nucleoli; intranuclear cytoplasmic inclusions; cytoplasm Keratin ⫺
variable, pale to dense; cytoplasmic tailing ⫹/⫺ LCA ⫺
CEA ⫺
HMB-45 ⫹
Melan-A
Hodgkin Lymphoma Dual population of lymphocytes and typical Reed–Sternberg and Hodgkin cells; PLAP ⫺
no tigroid background AFP ⫺
Cytokeratin ⫺
LCA ⫺
CEA ⫺
CD15 ⫹
CD30 ⫹
characteristic perivascular sheaths of cells, referred to as

Teratomas
an endodermal sinus structure or Schiller–Duval bodies.
Most well-differentiated tumors contain intracellular and Teratomas are defined as neoplasms that originate in pluri-
extracellular hyaline droplets that are PAS positive, dia- potent cells composed of a wide variety of tissues; they are
stase resistant, and immunoreactive to ␣-fetoprotein. The foreign to the organ or anatomic site in which they arise
cytologic features are described in Chapter 25. with component tissues showing a lack of organization
A B
Figs. 22.22A and B. FNA of an embryonal carcinoma of the testis. The neoplastic cells are loosely cohesive and in
syncytial tissue fragments without any architectural pattern. They are large and contain clearly malignant nuclei and
scant cytoplasm. Immunostains are necessary to diagnose this case as embryonal carcinoma.
Fig. 22.23. FNA of an ovarian dermoid cyst (cystic teratoma). This

image shows squamous cells in the background of cellular and kera-
tin debris.
and various stages of maturation. The majority of neonatal external surface. The contents are thick, yellow, and
teratomas occur in the sacrococcygeal area. Other locations cheesy, often with hairs. Cytohistologically, the tumors
are the cervical area, the upper jaw, the nasopharynx, the may show structures derived from all primitive germ cell
intracranial cavity, the retroperitoneum, the mediastinum, layers, with the most frequent being the skin and adnexal
and the gonads. Teratoma comprises 4 to 9% of testicu- structures (Table 22.2; Fig. 22.23).
lar tumors. It can occur at any age but is frequent during Teratomas with a malignant germ cell component
the first three decades of life. Grossly, the neoplasms may may have one or more areas representing germinoma,
be solid, cystic, or multiple. Histologically, teratomas are embryonal carcinoma, endodermal sinus tumor, or cho-
subclassified as mature, immature, and malignant. The riocarcinoma. Their cytologic features are described and
mature type consists of well-differentiated structures such illustrated in Chapter 25.
as the brain, the skin with adnexal structures, the gastro-
intestinal and respiratory tracts, and the bone. The imma-
Choriocarcinoma
ture type consists of embryonic appearing neuroglial or
neuroepithelial elements resembling medulloblastoma or A highly malignant germ cell tumor, choriocarcinoma is
ependymoma, in addition to the mature elements. Cystic characterized by both malignant syncytiotrophoblasts
mature teratomas are referred to as “dermoid cysts.” and cytotrophoblasts. The tumor cells are large giant
Dermoid cysts constitute 5 to 25% of all ovarian forms with bizarre nuclei. The tumor is associated with
neoplasms; they are most common during the reproduc- high levels of chorionic gonadotrophin. The differential
tive years. Often an incidental finding, dermoid cysts may diagnoses in a metastatic site include anaplastic giant cell
present with abdominal pain and/or a mass. Up to 15% carcinoma and other poorly differentiated carcinomas or
are bilateral. Grossly, these vary in size and have a smooth sarcomas (Fig. 22.24).
Fig. 22.24. FNA of a choriocarcinoma showing bizarre malignant

cells.
SUGGESTED READINGS
Higgins RV, Matkins JF, Marroum MC. Comparison of fine needle Nucci MR, Oliva E. Gynecologic pathology. In: Goldblum JR, ed.
aspiration cytologic findings of ovarian cysts with ovarian his- Foundations in Pathology. Philadelphia: Churchill and Livings-
tologic findings. Am J Obstet Gynecol 1999;180:550–553. ton, 2009.
Martinez-Onsurbe P, Villaespesa AR, Anquela JMS. Aspiration
cytology of 147 adnexal cysts with histologic correlation. Acta
Cytol 2001;45:941–947.
23 CENTRAL NERVOUS SYSTEM*
Aditya Raghunathan
Adi h h • SSudha
dh R. Kini
i i
● The tendency of primary CNS tumors not to exfoliate

CEREBROSPINAL FLUID AND CRUSH
PREPARATIONS OF STEREOTACTIC in CSF decreases the utility in the diagnosis of space-
BIOPSIES OF THE CENTRAL NERVOUS occupying lesions of the brain.
● Scant cellularity.
SYSTEM LESIONS
● Diffi ulties
c in differentiating lymphocytic pleocy-
tosis from leukemia/lymphoma. The specimens are
Cytologic specimens for evaluating disease processes often insuffi cient for ancillary studies such as flow
involving the central nervous system include cytometry.
● Cerebrospinal fl uid obtained via lumbar puncture or ● Diffi culties in differentiating lymphocytes from small
aspirating ventricles via Burr holes. cell tumors such as medulloblastoma.
● Smears or crushed preparation of specimens obtained
intraoperatively as an open biopsy following craniotomy
or an aspiration biopsy via stereotactic CT-guided biopsy. NORMAL COMPONENTS
Examination of the cerebrospinal fl uid is useful in Normal cerebrospinal fl uid is paucicellular, containing
evaluating disease processes affecting the leptomeninges very few mature lymphocytes and macrophages. Ependy-
and the subarachnoid space. Aspiration biopsy is used for mal cells and choroid plexus cells are of rare occurrence.
the primary diagnosis of intracranial mass lesions. These last two are more likely to be seen in cerebrospinal
This chapter is divided into two sections: 1) cerebro- fl uid obtained by ventricular puncture. Ependymal and
spinal fluid and 2) aspiration cytology. choroid plexus cells appear as small to medium-sized
cuboidal to low columnar cells with pale cytoplasm.
CEREBROSPINAL FLUID Choroid plexus cells may be seen in tissue fragments
(e-Fig. 23.1). Ventricular fluids may contain parenchymal
Indications for the cytologic evaluation of cerebrospinal
cells such as neurons, astrocytes, and blood vessels.
fluid (CSF) are
● Confi rmation of metastatic malignancy with leptom-
eningeal involvement in cases of known malignancy. NONNEOPLASTIC PROCESSES
● To verify a suspected malignancy in the primary central Reactive, infl ammatory, or infectious processes involving
nervous system (CNS) or one that is metastatic with an the leptomeninges are often represented by lymphocytic
unknown primary. pleocytosis (see e-Fig. 23.3), which can sometimes be dif-
● In patients with lymphoid malignancies or leukemias. ferentiated from malignant lymphoma or leukemia cells
● To diagnose leptomeningeal involvement that can by their polymorphic cell composition that includes lym-
occur without clinical manifestations. phocytes with varying degrees of maturation along with
● To monitor the response to chemotherapy and radiation. macrophages. Neutrophilic cell infiltrate signifies an acute
Limitations and diagnostic problems in the cytologic infectious process. Intrathecal chemotherapy is an impor-
evaluation of CSF include the following: tant cause of lymphocytic response. Other causes include
viral and fungal infections. Among the latter, Cryptococ-
● The amount of CSF specimen obtained is generally of cus neoformans is the most common organism affecting
limited quantity. immunologically compromised patients. The organisms
● The cells deteriorate rapidly in the normal milieu of are identifi ed by yeast forms with budding and their
cerebrospinal fl uid. The specimen must be processed unstained capsule (e-Fig. 23.2). Caution must be exer-
immediately. Cytospin preparations generally provide cised not to over-diagnose water bubbles or red blood
great results. cells as Cryptococcus organisms. Tuberculous meningitis
*Note: All smear preparations are stained with hematoxylin and eosin is an important infectious process that is encountered fre-
unless otherwise specified. quently in underdeveloped countries.
870
Chapter 23: Central Nervous System 871
NEOPLASTIC PROCESSES The neoplastic cells are small with high N/C ratios and
scant, indiscernible cytoplasm with round nuclei, coarse-
Neoplastic processes involving the leptomeninges ly granular chromatin, and inconspicuous nucleoli. The
include systemic lymphoma/leukemia and meningeal cells are in syncytial tissue fragments—closely packed or
carcinomatosis (Figs. 23.1 to 23.3). Primary central ner- exhibiting rosette formation—in contrast to lymphoma/
vous system lymphoma may also present with meningeal leukemia cells, which are individually dispersed (Fig.
dissemination. Of the primary central nervous system 23.4). See the section on medulloblastoma for further
neoplasms, medulloblastoma is one of the most likely discussion.
tumors to exfoliate neoplastic cells into cerebrospinal
fluid (Fig. 23.4).
METASTATIC TUMORS IN CSF AND
MENINGEAL CARCINOMATOSIS
PRIMARY CNS TUMORS IN CSF
Meningeal involvement by carcinomas leads to the exfo-
Primary CNS tumors are often deep-seated and do not liation of neoplastic cells in cerebrospinal fluids (Figs.
exfoliate into cerebrospinal fluid. Neoplastic cells are 23.5 to 23.7). The most common tumors to metastasize
encountered in the cerebrospinal fluid only when there to the brain and the meninges are the lung in males and
is a direct extension with the involvement of ventricles. the breast in females followed by malignant melanoma
Medulloblastoma—a common primary malignant and the stomach. Occasionally, meningeal involvement is
brain tumor of childhood—often exfoliates into CSF. the first presentation of the malignancy.
A B
Figs. 23.1A and B. CSF. Acute myeloid leukemic cells in CSF. A: Papanicolaou stain. B: Romanowsky stain.
Fig. 23.2. CSF. Acute lymphoblastic leukemia. Fig. 23.3. CSF. Burkitt’s lymphoma.
A B
Figs. 23.4A and B. CSF. Medulloblastoma. A: Papanicolaou stain. B: Romanowsky stain.
Fig. 23.5. CSF. Metastatic breast adenocarcinoma cells. Fig. 23.6. CSF. Metastatic adenocarcinoma of lung.
A B
Figs. 23.7A and B. A: CSF. Metastatic small cell carcinoma of the lung. B: CSF. Metastatic malignant melanoma cells.
● Normal astrocytes are diffi cult to recognize and the

STEREOTACTIC CT-GUIDED BIOPSY
distinction between the various subtypes is not pos-
AND/OR INTRAOPERATIVE OPEN BIOPSY
sible with routine stains.
WITH CRUSH PREPARATIONS
● High cellularity and the normal appearance of cerebel-
lar cortical cells may be misinterpreted as neoplastic.
An aspiration biopsy of CNS lesions, performed under ● Differentiation between reactive gliosis and low-grade
stereotactic CT guidance, has become a routine proce- astrocytomas may be very difficult.
dure in the diagnosis of mass lesions. Advancement in ● Sampling errors may lead to over-diagnosis or under-
radiological techniques and neurosurgical procedures has diagnosis.
made access possible to practically every region of the ● Differentiation between glioblastoma multiforme and
CNS. Lesions in areas such as the suprasellar, the intra- metastatic poorly differentiated carcinoma may pose
ventricular, the brain stem, or the pineal regions, once considerable difficulties.
thought to be inaccessible, are now easily biopsied. The ● Differential diagnoses of neoplasms consisting of uni-
importance of this procedure can be appreciated in light form, small, round cells include several possibilities.
of the fact that approximately 22,000 cases of primary ● Accurate typing and grading of gliomas, particularly
malignant brain tumors were diagnosed in the United astrocytomas, may offer difficulties.
States in 2008 (www.cancer.org). The incidence of both
primary malignant and nonmalignant brain tumors in the
United States is approximately 16.5 per 100,000 annu- NORMAL COMPONENTS
ally. Worldwide, the age-standardized mortality for pri- A normal cerebral cortex characteristically produces smooth
mary malignant brain tumors is approximately two to smears with an even distribution of cells in a uniform, lightly
three per 100,000 population. Secondly, the incidence of eosinophilic, and finely fibrillar background (normal neuro-
brain tumors is high in children and adolescents, compile). All of the following cell types can be found in the cere-
pared to other types of solid neoplasms. Lastly, there has bral cortex, deep cerebral nuclei, or gray matter of the brain
been an increase in brain tumors in the elderly and in stem or spinal cord. Samples of white matter throughout
immunosuppressed patients. the CNS show exclusively glial cells without neurons. Nor-
mal gray matter also tends to contain more thin-walled ves-
TECHNIQUE OF SMEAR PREPARATION sels, represented in smears as slender structures composed
of uniform, spindle-shaped endothelial cells.
There are different ways of making smears from the
biopsy specimens, which depend on personal preferences. Neurons
The techniques are well-described and illustrated in the
CNS neurons in smears prepared from the crush tech-
literature. A proper smearing technique, thin smears,
nique tend to lose all or most of their cytoplasm and can
prompt fixation, and good staining are critical for micro-
only be recognized as large bare nuclei with a single, usu-
scopic evaluation. The common techniques include 1)
ally peripheral, nucleolus (Fig. 23.8). Purkinje cells of the
touch imprints, 2) squash or crush preparation, and 3)
cerebellar cortex are identified by their large triangular or
smear preparation (see Appendix).
flask-shaped body containing Nissl granules (Fig. 23.9).
The evaluation of the above-mentioned cytologic
preparations require the pathologist/neuropathologist to Astrocytes
be informed of clinical data, radiologic findings, and clini-
cal/operative findings. It also requires the following: In crush preparations, normal astrocytes are seen as oval
or round nuclei with very scant or no discernible cyto-
● Familiarity with the normal but complex anatomy and
plasm (Fig. 23.10). These nuclei are smaller than those
histology of certain brain regions such as the pineal, of neurons, containing a smooth nuclear membrane and
ventricular, and cerebellopontine area and the normal evenly dispersed finely granular chromatin with no nucle-
regional variations of the microscopic appearance. oli. The distinction between subtypes of astrocytes is not
● Knowledge of the large number of differential diagnos-
possible in smear preparations.
tic possibilities to be considered based on the location of
the tumor, patient’s age, and radiological appearance.
Oligodendrocytes
● Proper specimen triage and optimal cytopreparation.
Oligodendrocytes are the most common glial cells found
Some of the diagnostic problems in the cytologic
in smears, readily identifi ed by their small, uniformly
evaluation of the intraoperative smear preparations in-
round and dark nuclei with no nucleoli. Their cytoplasm
clude the following:
is indiscernible, but occasionally a perinuclear clear halo
● Appearance of CNS neurons is generally very different in can be identified (fried egg appearance). Oligodendroglial
crush preparations as compared to histologic sections. nuclei are smaller than astrocytic nuclei (Fig. 23.8).
A B
Figs. 23.8A to C. A: Smear of normal cerebral cortex. Note the even

neurophil background (low power). B, C: Neurons are recognized
by their bare nuclei with prominent nucleoli. The small bare nuclei
C represent oligodendrocytes.
A B
Figs. 23.9A and B. Smear of the normal cerebellum. The large Purkinje cells contrast with numerous small neurons.
Microglia Normal Cerebellar Cortex

Microglial cells are considered to be of monocyte/mac- The normal cerebellar cortex contains several types of neu-
rophage origin and in their resting state cannot be identi- rons that are unique to this organ. The Purkinje cells are the
fi ed in normal CNS smears. Microglial cells are readily most characteristic type (Figs. 23.9A and B). They appear
identifi ed as macrophages when activated in conditions as very large cells with a characteristic flask-shaped body;
such as infarcts, encephalitis, or abscess. a large central nucleus with prominent nucleoli; an apical;
A B
Figs. 23.10A to C. Gliosis. A, B: Reactive fibrillary astrocytes with

long slender processes admixed with round nuclei of the oligoden-
drocytes. C: Reactive plump astrocytes, with multiple cellular pro-
C cesses, imparting a “fuzzy” appearance.
A B
Figs. 23.11A and B. Low-grade astrocytoma. A: Low power view with characteristic uneven distribution. Compare
this with normal cerebral cortex. B: Higher magnification showing fibrillary neoplastic astrocytes with pointed
dark nuclei and slender processes.
an elaborate dendritic tree; and a single, thick basal axon. and display small round nuclei with dense chromatin and
Although these cells are not numerous, their presence in no nucleoli or visible cytoplasm. Thus, these small neurons
smears is evidence that the sample represents normal cer- may be mistaken by the inexperienced for lymphocytes or
ebellar cortex. Much more numerous, the small granular small primitive cells of medulloblastoma, pineal tumors,
neurons of the deep cerebellar cortex may be a source of or germ cell neoplasms. Correct identification is based on
diagnostic confusion (Fig. 23.9A). These very small neurons their very uniform appearance and their small size, much
are about the same size or slightly larger than a lymphocyte smaller than any neoplastic cells.
TABLE 23.1 DIFFERENTIATING FEATURES BETWEEN GLIOSIS & ASTROCYTOMA
Reactive Gliosis Astrocytoma

Cellularity Low Low
Presentation Evenly spaced astrocytes; poorly defined cell borders Uneven spacing, neoplastic astrocytes
often concentrated around blood vessels;
aggregation of slightly pleomorphic cells
Nucleus Central location, small round and uniform delicate finely Nuclei larger; irregular nuclear membrane;
granular chromatin; nucleoli not present; nuclear overlap or round ovoid, spindle shape to pointed
molding absent; smooth nuclear membrane triangular-shaped; coarsely granular
chromatin
Cytoplasm Generally scant; abundant in reactive astrocytes Cytoplasmic processes, densely staining,
(gemistocytes); cytoplasmic processes barely discernible longer, stouter; lack stellate symmetry;
but when present are multiple, short, arise from entire cell bipolar processes frequent
(stellate symmetry)
Background Normal granular background; inflammatory cells ⫹/⫺; Fibrillar; no macrophages; (Rosenthal
oligodendrocytes; normal capillary network; histiocytes fibers and eosinophilic bodies in pilocytic
(gitter cells) arborizing blood vessels not present astrocytes); numerous arborizing capillaries
Radiologic Features Variable depending on the underlying lesion Expanding lesion with mass effect,
nonenhancing
taken from the representative areas of low-grade gliomas,

GLIOSIS
the cellularity tends to be relatively low as compared to
Gliosis is a reactive proliferation of astrocytic cells that high-grade glial and nonglial neoplasms, but the neoplas-
can occur in a variety of disease processes. The distinction tic cells tend to form crowded aggregates around blood
between reactive nonneoplastic glial hyperplasia (gliosis) vessels, with fewer cells away from these structures. This
and a low-grade glioma is one of the most common and uneven, lumpy appearance of gliomas is very characteris-
diffi cult differential diagnostic problems encountered in tic, even at low magnification.
neuropathology practice. A very large number of nonneo- The cell morphology in reactive gliosis may con-
plastic conditions, such as infl ammatory (e.g., encepha- sist of fibrillary astrocytes with very small nuclei and
litis or cerebellitis), vascular (angiitis, small infarcts), or very scant cytoplasm but long, slender processes (Fig.
demyelinating (acute or chronic multiple sclerosis), may 23.10). In other instances, particularly when the lesion
produce clinical symptoms or radiologic manifestations is inflammatory—such as in plaques of acute multiple
that may be diffi cult to differentiate from a neoplasm, sclerosis or progressive multifocal leukoencephalopathy
particularly a low-grade astrocytoma. In some of these (PML)—reactive astrocytes display large irregular nuclei,
circumstances, a brain biopsy may be necessary to reach increased perinuclear cytoplasm, and abundant but rela-
a diagnosis. In other instances, many benign or malig- tively short processes, giving the cell a fuzzy appearance
nant brain lesions may induce a reactive glial hyperplasia, (Fig. 23.10C). When tissue necrosis is present, such as
particularly at their periphery, that may be mistaken for in an abscess or infarct, numerous activated microglial
a glioma if only those areas are sampled. For instance, cells (so-called gitter cells) may also be present. This cell
craniopharyngiomas of the suprasellar region may induce type has abundant, finely vacuolated cytoplasm without
a very pronounced gliotic capsular reaction that may processes and with uniform, central, round nuclei. These
be confused with astrocytoma if the tumor periphery is cells are rare in gliomas, except for some unusual lip-
sampled. idized astrocytomas.
Smears from nonneoplastic gliosis are usually low In most nonneoplastic processes, the nuclei lack
to moderate in cellularity (Table 23.1; Fig. 23.10). The pleomorphism or hyperchromasia. In low-grade astrocy-
distribution of the cells in the smears is very character- tomas, the neoplastic cells generally exhibit hyperchro-
istic. The cells are rather evenly distributed with some matic nuclei that are usually pointed or triangular-shaped
concentration around blood vessels but without a very and larger than those of benign astrocytes. When samples
irregular distribution, as seen in astrocytomas. In samples are taken from the periphery of the tumor and consist of
a mixture of neoplastic and benign cells, a definite diag- stouter, and longer compared to the delicate symmetrical
nosis may be impossible, and a new sample from a more processes seen in normal or reactive astrocytes. Astrocy-
representative area must be obtained. tomas may exhibit a microcystic pattern with the cysts
containing proteinaceous fluid.
The differential diagnoses include gliosis, anaplastic
TUMORS OF THE NEUROGLIA
astrocytoma, glioblastoma, and fibroblastic meningioma.
Excluding meningiomas, tumors of the neuroglia are the most The absence of endothelial proliferation and necrosis fa-
common primary neoplasms of the CNS and include astro- vor the diagnosis of glioblastoma while a pleomorphic
cytic neoplasms, oligodendrogliomas, ependymomas, and nuclear pattern and necrosis will support the diagnosis
choroid plexus neoplasms. Several subtypes in each group of anaplastic astrocytoma. Differentiation of astrocytoma
are encountered and are beyond the scope of this atlas. Only from gliosis may be quite difficult (Table 23.1).
the frequently encountered neoplasms will be discussed.
Pilocytic Astrocytoma
ASTROCYTIC TUMORS (Juvenile Pilocytic Astrocytoma)
Astrocytic tumors have been classified under several Pilocytic astrocytomas are discrete, well-circumscribed,
schemes, either based on morphology (i.e., types of astro- and often cystic, occurring most often in the cerebellum,
cytes: fibrillar, pilocytic, and gemistocytic) or based on the optic nerve, the hypothalamus, and the third ventricle
histologic parameters that are of prognostic significance, of children and young adults. This astrocytoma is slow
as in the WHO scheme. The latter is a three-tiered system growing, potentially curable with complete resection,
consisting of well-differentiated low-grade astrocytoma and does not display the tendency to dedifferentiate to a
(frequently referred to simply as astrocytoma), anaplastic more aggressive glioma, as is commonly seen in fibrillary
astrocytoma, and glioblastoma. Prognostic markers include astrocytomas.
nuclear atypia, mitotic activity, necrosis, and an endothe- Cytohistologically (Table 23.2; Figs. 23.12 and 23.13),
lial proliferation of blood vessels. A given glial neoplasm pilocytic astrocytomas are characterized by loose, tex-
may contain different morphologic types of astrocytes. The tured astrocytes in cystic areas, alternating with the com-
well-differentiated astrocytomas that occur in young adults pact foci of elongated fibrillary astrocytes. The neoplastic
may undergo anaplastic change to more malignant and less astrocytes are characterized by long, delicate, very thin
differentiated forms such as anaplastic astrocytoma or glio- hair-like or piloid glial processes forming a meshwork.
blastoma. Other subtypes of astrocytomas described below Their nuclei are round to ovoid, monotonous, and contain
include pilocytic and pleomorphic xanthoastrocytoma. bland chromatin. The loose areas typically contain bright
eosinophilic intracellular bodies, whereas the compact ar-
eas are associated with Rosenthal fibers and eosinophilic
Astrocytoma (Low-Grade or Well-Differentiated
granular debris. The Rosenthal fibers are bright pink cork-
Astrocytoma)
screw-shaped, irregular beaded, often with one broad end
This type of glioma is well-differentiated, predominantly and the other a tapered end. These stain intensely eosino-
occurring in young to middle-aged adults, involving the philic, are positive for beta-crystallin, and are negative for
cerebral hemisphere, the cerebellum, and the brain stem glial fibrillary acidic protein (GFAP). Eosinophilic granu-
in children. It is occasionally seen in the cerebellum and lar bodies are aggregates of minute, eosinophilic, spherical
the spinal cord. Radiologically, astrocytomas appear as droplets. They are highlighted with the PAS stain and are
ill-defined areas of low density with no enhancement with positive for beta-crystallin and ubiquitin. Rosenthal fibers
the administration of contrast material. These tumors are are not diagnostic of pilocytic astrocytomas since they can
diffusely infiltrative, merging imperceptibly with the adja- be present in the reactive gliosis surrounding neoplasms
cent brain parenchyma. such as craniopharyngiomas or in multiple sclerosis or
Cytohistologically, low-grade astrocytomas (Table syrinx. Eosinophilic granular bodies are also nonspecific
23.2; Figs. 23.11A and B) consist of areas of hypercellular- and can be a common feature of ganglion cell tumors and
ity alternating with hypocellular areas, in contrast to the pleomorphic xanthoastrocytoma. Both of these structures
even distribution of smears of normal parenchyma. The appear to favor a slow-growing, low-grade nature.
neoplastic astrocytes contain enlarged round, oval, and
cigar-shaped to triangular and tapered nuclei containing
Gemistocytic Astrocytoma
coarsely granular chromatin and smooth nuclear mem-
branes. The presence of nucleoli, mitosis, and necrosis are Gemistocytic astrocytomas consist predominantly of
not the features of low-grade astrocytoma. The cytoplasm large astrocytes lacking long glial processes. Instead, the
of the neoplastic astrocytes varies considerably in amount cell body around the nucleus is swollen with glial inter-
and confi guration. Most cells will display multiple cy- mediate protein filaments, and the processes are short and
toplasmic processes that are more numerous, irregular, stubby (Figs. 23.14A and B).
TABLE 23.2 CYTOPATHOLOGIC FEATURES OF GLIOMAS
Astrocytoma (Low- Anaplastic Pleomorphic

Pilocytic Astrocytoma Grade Astrocytoma) Astrocytoma Glioblastoma Xanthoastrocytoma Oligodendroglioma Ependymoma
Cellularity Variable Low Low to moderate High High Low to moderate Moderate to high
Presentation Marked fibrillary Pale granular Discrete with Discrete Discrete pleomorphic Infiltrating uniform Papillary/
deep eosinophilic background with aggregates of pleomorphic cells cells cells; calcifications pseudopapillary
background with aggregates of cells with pleomorphic cells with or without ⫹/−; lack a prominent pattern, rigid
frequent loose textured slightly pleomorphic coagulative necrosis gliofibrillary matrix blood vessels with
areas; fascicular nuclei; haphazard palisaded tumor
pattern ⫹ distribution cells on either side
Cells Elongated, spindle- Variable in size with Variably Pronounced Pronounced Uniform cells with Uniform, medium-
shaped; low N/C poorly defined cell pleomorphic pleomorphism; pleomorphism; very little stroma; sized, tadpole-
ratio; well-defined cell borders small to large; cells small to large, markedly atypical artifactual perinuclear shaped ⫹/⫺;
borders gemistocytic types; bizarre giant forms; astrocytic cells halos (fried eggs); fibrillary matrix
well to poorly cell borders well to anaplastic: more adjacent to vessel,
defined cell borders poorly defined; high cellular perivascular
N/C ratio nuclear-free zone
Nucleus Uniform in size Minimally variable in Considerable Markedly Marked variation Uniform size and Uniform, round,
and shape, ovoid, size and shape, round, variation in size pleomorphic; in size and shape; shape, round to oval to elongated;
oblong, cigar-shaped; oval, spindle-shaped to and shape, round, multinucleation multinucleation oval, smooth nuclear pale granular
smooth nuclear curved or triangular; oval, spindle- frequent; round, oval frequent; membrane, finely chromatin with
membrane; finely smooth nuclear shaped; chromatin to irregular; granular hyperchromatic; no granular uniformly micronucleoli;
granular, uniformly membrane; finely granular; smooth chromatin; smooth mitotic activity distributed chromatin, intranuclear
distributed chromatin; granular chromatin; nuclear membrane; nuclear membrane; inconspicuous inclusions ⫹/⫺
inconspicuous nucleoli; inconspicuous nucleoli; inconspicuous inconspicuous nucleoli; anaplastic:
no mitotic activity no mitotic activity nucleoli; rare nucleoli; mitoses pleomorphic nuclei,
mitotic activity present mitoses present
Cytoplasm Variable, bipolar, Variable, nondiscernible Variable, Variable, pale to Variable cytoplasmic Scant to absent, Variable, pale,
delicate processes to eosinophilic, longer cytoplasmic dense; vacuoles not vacuoles (lipid); delicate glial processes fibrillary,
thicker processes, processes present present; cytoplasmic anucleated globoid cytoplasmic
asymmetric origin in some neoplastic processes few structures present vacuoles ⫹/⫺
cells
Background No necrosis; bundles No necrosis; arborizing, No necrosis; Necrosis present; Necrosis absent; no Usually lack Minimal
of delicate fibrils; slender blood vessels; prominent blood marked vascular vascular endothelial gliofibrillary matrix; fibrillarity;
Rosenthal fibers and no vascular endothelial vessels, but endothelial proliferation delicate, branching prominent
eosinophilic granular proliferation lack vascular proliferation (chicken-wire) capillary myxoid matrix
bodies; vascular endothelial network; anaplastic: in myxopapillary
endothelial proliferation proliferation necrosis, microvascular ependymomas
not prominent proliferation present
A B
Figs. 23.12A and B. Juvenile or pilocytic astrocytomas showing uniform nuclei and long bipolar processes.
Fig. 23.13. Pilocytic astrocytoma showing Rosenthal fibers seen as

acidophilic extracellular masses (arrows).
A B
Figs. 23.14A and B. Gemistocytic astrocytoma. A: with abundant acidophilic cytoplasm. Note the paucity of the glial
processes. B: Large gemistocytes in the background of abundant glial processes and a prominent capillary network.
Fig. 23.15. Anaplastic astrocytoma. The astrocytic cells are haphaz-

ardly arranged and show remarkable pleomorphism with nuclear
atypia. There is considerable fibrillary network in the background.
A B
Figs. 23.16A and B. Anaplastic astrocytoma displaying increased cellularity, nuclear pleomorphism and hyperchro-
masia as compared to a low-grade astrocytoma. There is no necrosis or vascular proliferation.
Anaplastic Astrocytoma terfl y glioma), and involving the brain stem in children.
Radiologically, glioblastomas typically show an expansile
Intermediate in differentiation between the low-grade astro- mass with a central area of hypodensity surrounded by a
cytoma and glioblastoma, anaplastic astrocytoma occurs ring-like zone of contrast–enhancement.
in older patients—a decade earlier than glioblastoma.
Cytohistologically (Table 23.2; Figs. 23.15 and 23.16),
anaplastic astrocytomas exhibit increased cellularity, nucle- HISTOLOGIC FEATURES
ar pleomorphism, and hyperchromasia compared to low-
Histologically, glioblastomas are very cellular neoplasms,
grade astrocytoma. However, they lack the brisk mitotic
characterized by an infiltrative growth pattern and mark-
activity, vascular proliferation with marked endothelial
edly pleomorphic cells ranging from small to large, bizarre
hyperplasia, and necrosis that is characteristic of glioblas-
giant forms with multinucleation. Glial processes may
toma. The neoplastic cells tend to aggregate around the
be numerous, forming a heavy meshwork, or they can be
blood vessels. A prominent gemistocytic component is a
few. Mitoses are generally frequent. A cardinal feature is
frequent feature of some anaplastic astrocytomas, whereas
coagulative necrosis surrounded by pseudopalisading of
others are composed of a dense population of small cells
cells in a garland-like fashion. The stroma may be fibrillar
with scant cytoplasm.
or myxoid. The astrocytic nature of the neoplastic cells
may be more diffi cult to appreciate than in better differ-
Glioblastoma Multiforme
entiated astrocytomas. However, a few neoplastic cells
Glioblastoma is the most common glioma with a very with well-defined processes are usually present. Prolifera-
aggressive clinical behavior. It mainly occurs in older tion of blood vessels with marked endothelial prolifera-
people at and beyond the fi fth decade of life, involving tion often in syncytial-like and glomeruloid masses is a
the cerebrum, often bridging the two hemispheres (but- diagnostic feature of glioblastoma.
nostic of glioblastoma. Relatively large blood vessels sud-

denly end as short stubby bulbous structures, which on
Glioblastomas smear easily. The cytologic patterns are higher magnifi cation, are seen as glomeruloid structures
characterized by marked cellularity with a very broad formed from thin-walled capillaries (Fig. 23.18). The neo-
range of morphologic patterns that mirror the histology plastic cells contain long cytoplasmic processes that vary
(Table 23.2; Figs. 23.17 to 23.21). The neoplastic cells in intensity and can form a dense fibrillar background,
are remarkably variable in size and shape—a hallmark of almost obscuring the neoplastic cells. The glial processes
glioblastoma. They may be strikingly pleomorphic with can be scant in the small cell variant of glioblastoma.
small to large cells with giant to monstrous forms. The Morphologic variants of glioblastomas are multiple
vast majority have a combination of cell types. The nuclei and include the small cell type (Fig. 23.20), the giant
demonstrate considerable pleomorphism from small and cell type (Fig. 23.21A), and gliosarcoma (Figs. 23.21B
round to elongated, oval, spindle forms as well as sausage and C).
or rod-shaped forms or multinucleate ones. The nuclear The small cell variant tends to have a scant fibril-
membranes can be smooth to irregular with deep-stain- lar component that may not allow accurate typing. The
ing and fi ne to coarsely granular chromatin. Nucleoli small cell variant can mimic malignant lymphoma or a
are usually prominent and multiple with frequent giant high-grade neuroendocrine carcinoma. The presence of
forms. Mitotic fi gures are easily identifi ed in most cases. a spindle cell pattern can mimic meningioma or a soft
The smears may show a predominance of one or other tissue tumor.
cell type. The presence of abnormal blood vessels show- The giant cell variant of glioblastoma multiforme is
ing microvascular (capillary endothelial) proliferation—a characterized by the presence of bizarre giant malignant
readily recognizable feature—is characteristic and diag- cells with multinucleation (Fig. 23.21A).
A B
C D
Figs. 23.17A to D. A: Smear of a glioblastoma showing markedly atypical astrocytes. B, C, D: Smears of glioblastoma
showing different examples depicting the pleomorphic cell pattern. The nuclei are oval, elongated, sausage-shaped
and multinucleated. The nuclear chromatin is coarsely granular. The nucleoli are prominent.
A B
Figs. 23.18A to C. Glioblastoma with marked vascular hyperpla-

sia. A: Low power view showing broad club-shaped capillaries with
endothelial proliferation. Note the tumor’s giant cells with bizarre
multinucleated and elongated rod-shaped nuclei (arrows). B: High-
er magnification of the blood vessel with endothelial proliferation.
C C: Different field with pleomorphic neoplastic malignant astrocytes.
A B
Figs. 23.19A and B. Glioblastoma, fibrillar type. A: Extensive meshwork of delicate fibrillary processes almost
obscuring the pleomorphic cells of glioblastoma. B: Higher magnification to highlight the fibrillary network and
the pleomorphic cell population.
Gliosarcoma is a morphologic variant comprising 2%

IMMUNOPROFILE
of all glioblastomas, consisting of an admixture of gliom-
atous and sarcomatous (mesenchymal) components. The The cells of glioblastoma are immunoreactive to GFAP;
latter displays several patterns including fibrosarcoma- however, the absence of GFAP staining does not exclude
like (Figs. 23.21B and C), rhabdoid type, and undifferen- this diagnosis. While glioblastomas are generally nonre-
tiated type with heterologous elements. active to cytokeratins and EMA, occasional cases might
Fig. 23.20. Glioblastoma, small cell type showing a pleomorphic

small cell population with round, oval and spindle forms and scant
cytoplasm. Also seen in the background are larger cells with abun-
dant eosinophilic cytoplasm and few processes.
A B
Figs. 23.21A to C. A: Glioblastoma, giant cell type. The glioblas-

toma cells are of gigantic size with multinucleation. There are pleo-
morphic cells in the background with glial processes. B, C: Smears
of a gliosarcoma with marked cellularity formed by pleomorphic
C malignant cells with a prominent spindle cell component.
express cytokeratin AE1/AE3. Staining with CAM 5.2 is vascular proliferation, and necrosis. Extensive necrosis and
less likely to be present in glioblastomas. crush artifacts may preclude a satisfactory evaluation.
The diagnostic entities in the differential diagnosis
constitute an impressive list (Figs. 23.22 to 23.25). How-
ever, consideration should be given to clinical data and
The differential diagnosis of glioblastoma depends on imaging findings.
the cytologic pattern and sampling. The recognition of Infarcts and demyelinating lesions may clinically and
glioblastoma is usually easy with the key features being radiologically mimic glioblastomas and should always be
increased mitotic activity, nuclear pleomorphism, micro- considered in the differential diagnosis. Infarcts are highly
Differential Diagnoses of Glioblastoma Multiforme (See Figs. 23.22 to 23.27)
A B
Figs. 23.22A to C. A, B: Metastatic poorly differentiated carcino-

ma. Carcinomas lack the glial processes. C: metastatic small cell
carcinoma of the lung. Compare this with the small cell variant of
C glioblastoma (Fig. 23.20).
Fig. 23.23. Metastatic malignant melanoma with pleomorphic, dis-

crete malignant cell population without the history of melanoma,
and without apparent melanin pigment, these tumors mimic glio-
blastoma.
cellular and vascular lesions. They may exhibit necrosis presence of macrophages and lymphocytes urge caution
and reactive vascular hyperplasia, raising the concern for while interpreting cytologic preparations.
glioblastoma. However, the presence of macrophages and A predominant giant cell pattern requires the exclu-
liquefactive, not coagulative, necrosis entail caution. De- sion of other diagnostic entities that feature giant cells.
myelinating lesions may also be cellular and could be ac- Pleomorphic xanthoastrocytoma (PXA) contains pleo-
companied by reactive astrocytosis. However, the diffuse morphic giant cells and must be differentiated from
A B
Figs. 23.24A and B. Glioblastoma presenting a round cell pattern and sparse fibrillar background. A: Low power.
B: Higher magnification. The nuclei are quite pleomorphic with an occasional spindle form and appreciable cyto-
plasm. Scant glial processes and discrete round cells share the morphologic similarities with malignant lymphoma.
A B
Figs. 23.25A and B. Fibrillar glioblastoma may be misinterpreted as fibroblastic meningioma. A: Low power of
a glioblastoma with extensive fibrillar network of glial processes. Note the prominent proliferating blood vessels
favoring the diagnosis of glioblastoma. B: Higher magnification shows nuclear atypia.
glioblastoma. However, lipid-containing large cells, such

Pleomorphic Xanthoastrocytoma
as those seen in PXA (Fig. 23.26), are not present in glio-
blastomas. Also, PXA lacks capillary endothelial prolifer- PXA is an unusual but distinctive tumor of astrocytic ori-
ation and readily identifi able mitosis. Large pleomorphic gin that occurs superfi cially in the brain and frequently
malignant cells in the background of a scant to incon- involves the temporal lobes. This tumor tends to occur in
spicuous gliofibrillary matrix may be difficult to differen- younger individuals with a long history of seizures. The
tiate from a metastatic adenocarcinoma (Table 23.3; Figs. tumor is well-circumscribed and has the classic radiologi-
23.22A and B) or malignant melanoma (Fig. 23.23). This cal appearance of a cyst with a contrast-enhancing mural
diagnostic diffi culty is encountered when there is no his- nodule.
tory of primary malignancy. Malignant melanoma often Cytohistologically (Figs. 23.26A to D), PXA presents
remains a strong possibility (Fig. 23.23). a worrisome morphology with many pleomorphic, even
The small cell variant of glioblastoma (Figs. 23.20) bizarre, astrocytic cells and may be mistaken for anaplas-
with scant fibrillar glial processes must be differentiated tic astrocytoma or glioblastoma. However, it carries a bet-
from a small cell (neuroendocrine) carcinoma (Fig. 23.22C) ter prognosis, hence, correct identification is critical.
or a primary malignant lymphoma. A characteristic feature of PXA includes tumor cells
Glioblastoma with an extensive fibrillary background with fine to coarsely vacuolated cytoplasm reflecting large
may be mistaken for ependymoma or a fibroblastic men- amounts of lipid. Such cells are not present either in ana-
ingioma (Figs. 23.19 and 23.25; see Table 23.18; Figs. plastic astrocytoma or in glioblastoma. Globoid anucle-
23.48A to E). ated structures and eosinophilic granular bodies probably
TABLE 23.3 GLIOBLASTOMA & METASTATIC CARCINOMA
Glioblastoma Metastatic Carcinoma Poorly Differentiated

Cellularity High High
Presentation Cells isolated Cells isolated, in groups or aggregates and

in syncytial tissue fragments with or without
architectural configuration
Cells Markedly pleomorphic; small to large, giant and bizarre Markedly pleomorphic variable in size and shape
forms, elongated or spindle cells; astrocytic nature of depending on type of carcinoma; well to poorly
some cells may be identified; high N/C ratios; cell borders defined cell borders; high N/C ratios
indistinct
Nucleus Single to multiple; nuclear membrane smooth; chromatin Single to multiple, irregular nuclear membrane;
fine to coarsely granular; nucleoli not prominent; mitoses coarsely granular chromatin; nucleoli prominent,
frequent mitoses frequent
Cytoplasm Variable, ill-defined with cell processes in some cells Variable, quality dependent on type of
carcinoma; lack cell processes
Background Necrosis; prominent blood vessels with marked endothelial Necrosis; endothelial proliferation not prominent
proliferation; may be fibrillar due to cell processes
Immunoprofile
GFAP ⫹ ⫺
CEA ⫺ ⫹/⫺
Keratin ⫹/⫺a ⫹
S100 Protein ⫹ ⫺
a
Low molecular weight cytokeratin AE1/AE3 can be positive in some high-grade gliomas.
A B
Figs. 23.26A to B. Pleomorphic xanthoastrocytoma. A: There is increased cellularity (low power). B, C: The cells
are variable in size with large to giant forms, and contain pleomorphic nuclei. The cells contain abundant vacuolated
cytoplasm. There is no mitosis or necrosis. D: These acellular globoid structures are characteristic of pleomorphic
xanthoastrocytoma (Papanicolaou). (continued)
C D
Figs. 23.26C to D. (continued)
representing detached fragments of cytoplasm can also commonly in children than in adults. Ependymomas may
be found (Fig. 23.26D). The tumor does not display the occur along any part of the ventricular system and spinal
mitosis or necrosis found in true high-grade gliomas. The canal, most commonly seen in the fourth ventricle and as
differential diagnosis includes glioblastoma because of intramedullary tumors of the spinal cord in adults. They
the presence of multinucleated giant cells. may present with obstructive hydrocephalus or with the
effects of mass lesions.
ASTROBLASTOMA
Astroblastoma is a rare glial neoplasm that usually pres- GROSS AND HISTOLOGIC FEATURES
ents during the fi rst three decades of life. It is well-cir- Grossly, ependymomas appear as well-demarcated lobu-
cumscribed, often superfi cially situated, and can occur lated, soft, fl eshy, red–gray masses. Focal areas of calcifi-
throughout the cerebral hemispheres. This is a circum- cations may be present. Histologically, ependymomas are
scribed neoplasm and should not demonstrate areas of characterized by glial and epithelial differentiation with
infiltration. a broad morphologic spectrum ranging from fibrillary
Cytologically, astroblastomas are highly distinctive tumors with inconspicuous perivascular pseudorosettes to
and are characterized by uniform epithelioid cells ar- an epithelial-predominant pattern. However, the majority
ranged around blood vessels in a single layer. Char- show a mixed morphology.
acteristically, the glial processes that converge toward Ependymomas are characterized by a perivascular
blood vessels are shorter and broader. These astroblas- proliferation of neoplastic cells. The cellular areas are
tic pseudorosettes (Fig. 23.27) may be confused with separated by lighter nuclear-free zones with the latter ap-
those of the more common ependymomas. Another dis- pearing fi brillary, usually forming perivascular zones in
tinctive feature is vascular hyalinization and a thick- which tapering tumor cell processes converge upon blood
ening of the blood vessels. The pseudorosettes of as- vessels to form a perivascular pseudorosette—a charac-
troblastomas are often diffusely vimentin, S100, and teristic and diagnostic feature. True ependymal rosettes
GFAP positive. are very rare and exhibit epithelial features in the form of
round rosettes with central lumina.
EPENDYMOMA
Ependymomas arise from ependymal cells, which enjoy CYTOPATHOLOGIC FEATURES
a dual glial and epithelial origin; the features of both lin-
The ependymomas smear easily and demonstrate a wide
eages may be appreciated in some ependymomas.
spectrum of morphology (Table 23.4; Figs. 23.28A to
Ependymomas are of two main types: classic and
F and 23.29A to C). A pseudopapillary or papillary-
myxopapillary, which occurs exclusively in adults in the
like growth pattern may be a striking feature under low
cauda equina region of the spinal cord.
magnification, with branching rigid blood vessels and
palisaded groups of tumor cells arranged on both sides
Classic Ependymoma
of the long axis. A narrow anucleate area of fibrillary
Ependymomas constitute 2 to 6% of intracranial tumors processes may be seen between the palisaded nuclei
and 50 to 70% of intraspinal tumors. They occur more and the vessel wall. A prominent fibrillary matrix often
A B
Figs. 23.27A to C. Astroblastoma demonstrating uniform round

cells. Note the pseudorosettes (arrows) and the cells with thick cel-
C lular processes (arrowhead).
presents adjacent to the blood vessels or at the edges Rosettes are tissue fragments with specific architec-
of the tumor cells. The neoplastic cells are uniform tural patterns that are typically seen in various central
and medium-sized with scant to modest cytoplasm and nervous neoplasms and, although not diagnostic, many
poorly defined cell borders. Their nuclei are round to provide useful clues to the diagnosis. Table 23.5 describes
oval with pale granular chromatin and contain distinct different types of rosettes.
nucleoli. Glial processes appear to directly arise from
these nuclei. Perivascular pseudorosettes (Fig. 23.28B)
Myxopapillary Ependymoma
are easily recognized, while true rosettes are infrequent
(Fig. 23.28E). In the smears, ependymal cells may be Myxopapillary ependymomas constitute about 10%
present in aggregates lacking a relationship with the of ependymomas. These discrete intradural lesions
blood vessels (Figs. 23.28E, 23.29B and C). Ependymal occur almost exclusively at the conus medullaris/cauda
nature in the absence of glial processes may be difficult equina region at the distal end of the spinal cord. The
to establish. A helpful finding is the presence of tadpole- tumors smear easily, demonstrating high cellularity
shaped cells, which offers clues to ependymal differen- with a papillary growth pattern. The characteristic
tiation. The broad end housing the nucleus with the sur- feature of myxopapillary ependymoma is the presence
rounding cytoplasm and the tapered end with processes of an abundant myxoid matrix replacing the fibrillar
represent the dual differentiation of epithelial and glial stroma. The myxoid stroma appears as pale with a blu-
type, respectively. The foci of ependymal cells with mini- ish background in histologic sections and may not be
mal fibrillary processes may not be recognized as being readily apparent on smears (Figs. 23.30A to E). The
of ependymal origin. cytopathologic features of both types of ependymomas
The differential diagnoses of classic ependymomas are listed in Table 23.4.
include tumors that demonstrate rosettes or pseudoro- The myxopapillary ependymomas, because of the myx-
settes (Table 23.5) and neoplasms that present a papillary oid stroma, must be differentiated from lesions that contain
pattern. similar stroma (e.g., mucoid, myxoid; see Table 23.15).
TABLE 23.4 CLINICOCYTOPATHOLOGIC FEATURES OF EPENDYMOMAS
Classic Ependymoma Myxopapillary Ependymoma

Age Principally seen in childhood, but can occur in adults Exclusively in adults
Location In children involves the fourth and lateral ventricles; Cauda equina/filum terminale
spinal canal in adults
Gross Red-grey lobular masses; calcification frequent Encapsulated; calcification absent, often appears mucoid
Smear Smears easily Smears easily
Cellularity Generally high Generally high
Presentation Complex papillary pattern with branching blood Complex papillary pattern with branching blood
vessels with neoplastic cells arranged on both sides vessels with neoplastic cells arranged on both sides
of the blood vessels, attached to them with long, of the blood vessels, attached to them with long glial
tapering and narrow-based glial processes forming a processes forming a cell-free zone along the blood
cell-free zone along the blood vessels; the rigid blood vessels; the rigid blood vessels with glial processes
vessels with glial processes resemble a caterpillar; resemble a caterpillar; neoplastic cells may be loosely
neoplastic cells may be loosely cohesive or form cohesive or form pseudovascular rosettes; true rosettes
pseudovascular rosettes; true rosettes extremely rare extremely rare; abundant myxoid material permeating
through glial processes, not very apparent in smears
but stains pale blue; striking metachromatic with
Romanowsky stain; alcian blue ⫹
Cells Medium-sized; round, to elongated; tadpole forms; Medium-sized; round, to elongated; tadpole forms;
may or may not exhibit characteristics of dual may or may not exhibit characteristics of dual
differentiation; rounded cells with inconspicuous differentiation; rounded cells with inconspicuous
processes have well-defined borders and pale processes have well-defined borders and pale
cytoplasm that can be vacuolated cytoplasm that can be vacuolated
Nucleus Round, oval to elongated; finely granular chromatin Round, oval to elongated; finely granular chromatin
with micronucleoli; intranuclear inclusions ⫹/−; glial with micronucleoli; intranuclear inclusions ⫹/−; glial
processes often extend from the nucleus; processes often extend from the nucleus
Cytoplasm Variable, pale; vacuolated ⫹/⫺ Variable, pale; vacuolated ⫹/⫺; may contain basophil
granules
Background Fibrillar Myxoid substance, may be present as globules,

highlighted by PAS and alcian blue; mast cells⫹/⫺;
spherical “balloon” structures highlighted with
Masson’s trichrome, reticulin, PAS and alcian blue
Immunoprofile S100 ⫹; vimentin ⫹; GFAP ⫹ in the perivascular S100 ⫹; GFAP ⫹

processes; EMA ⫹/⫺ in the luminal surfaces of canals
and rosettes, and in an intracytoplasmic/paranuclear
pattern highlighting diminutive lumina
Differential Choroid plexus papilloma Chordoma

Diagnoses Metastatic papillary adenocarcinoma Chondrosarcoma
Glioblastoma Metastatic mucin producing adenocarcinoma
Meningioma Myxoid liposarcoma
Ependymoma (See Figs. 23.28 to 23.31)
A B
C D
E F
Figs. 23.28A to F. Ependymoma. A: Smear of an ependymoma showing aggregates of neoplastic cells in perivascu-
lar location forming perivascular pseudorosettes (medium power). B: Higher magnification of the pseudovascular
pseudorosette, to depict perivascular location of the ependymal cells with cytoplasmic processes converging on to the
blood vessel. C: Smear of an ependymoma showing cells with both epithelial and glial differentiation. D: A typical
perivascular pseudorosettes. The ependymoma cells have uniform and bland nuclear pattern. Note the polarized cells,
away from the blood vessel. E: Smear of an ependymoma demonstrating true rosette (arrow). F: Different case of
ependymoma with a blood vessel in longitudinal section with ependymal cells attached with glial processes. There
are dispersed ependymal cells in the background.
A B
Figs. 23.29A to C. Smears of an anaplastic ependymoma. A: Medi-

um power to show elongated blood vessels with peripherally placed,
crowded and overlapped ependymal cells. B: Higher magnification
showing ependymal cells with inconspicuous processes. The cells
are loosely cohesive and pleomorphic. C: The nuclei are very pleo-
C morphic and atypical (Papanicolaou).
TABLE 23.5 TYPES OF ROSETTES
Type Description
Homer Wright Nuclei around a central space containing solid fibrillary core; present in primitive
neuroectodermal tumors (e.g., neuroblastoma, medulloblastoma; peripheral
neuroectodermal tumors)
Flexner–Wintersteiner Nuclei around a central tubule; ultrastructure-cilia, no microvilli; present in

retinoblastoma
Fleurette Nuclei around central tubule; ultrastructure-projecting bulbous processes; seen in

retinoblastoma
Ependymal Perivascular Pseudorosette Anucleate radiating fibrillar zone with tapering cellular processes around central vessel;
seen in ependymoma
Ependymal True Rosette Nuclei around a central tubule; ultrastructure-cilia, microvilli; a true rosette
Pineocytomatous Nuclei around irregular often very large fibrillary areas; club ended argyrophilic
processes
Astroblastic Nuclei separated from central vessel (often thickened) by broad radiating eosinophilic
processes
Medulloepithelioma Pseudostratified cells around ovoid lumen; distinct outer limiting basement membrane
A B
C D
Figs. 23.30A to E. Myxopapillary ependymoma. A: Smear prepara-

tion showing branching papillary architecture with rigid vascular
cores with attached ependymal cells that are polarized. Note the
anucleate zones along the length of the blood vessel between the
palisaded nuclei and the vessel wall. Myxoid material is seen in focal
areas at this magnification. B: Higher magnification with polarized
ependymal cells and myxoid matrix (arrows). C: Smear of a myxo-
papillary ependymoma stained by Papanicolaou. Note the bluish
myxoid matrix (MM) in the background. D: Another example of a
myxopapillary ependymoma (low power) showing cross-sections of
papillary fronds. The presence of myxoid matrix is not always ap-
parent on the smears. E: Higher magnification showing perivascular
E pseudorosettes and suggestion of myxoid matrix.
posed of large papillary tissue fragments covered by

CHOROID PLEXUS NEOPLASMS
layers of cuboidal to columnar epithelium with poorly
Choroid plexus neoplasms present in the first decade of defined cell borders and pale cytoplasm. Their nuclei are
life as intraventricular masses, predominantly in the lat- perfectly round with smooth nuclear membranes and
eral and third ventricles. While papillomas can compress finely granular chromatin. Nucleoli are not conspicuous.
the brain parenchyma along a broad, indenting front, Mitotic activity and necrosis are not evident in papillo-
carcinomas are overtly invasive. The histomorphologic mas. The smear background is clean. Single columnar
spectrum is wide, ranging from well-differentiated papil- cells are often identified. A focal ependymal or glial dif-
lomas to anaplastic tumors and may be seen within the ferentiation may be present. Choroid plexus carcinomas
same neoplasm. Histologically, these tumors are com- are markedly cellular with poorly formed papillae and
show varying degrees of anaplasia and brisk mitotic form cells (Figs. 23.31B to D). Nuclear atypia, pleomor-
activity. phism, and brisk mitotic activity should raise suspicion
for carcinoma.
IMMUNOPROFILE
The choroids plexus neoplasms smear easily. The diag-
nosis can usually be made on low magnification (Table The epithelioid cells are strongly positive to GFAP and
23.6; Fig. 23.31A). The neoplasm appears as large clus- vimentin. Many are positive for CD34, with strong label-
ters of grape-like spherules bulging off of fibrovascular ing for the cell membrane. Some show positive reactivity
cores. The cell balls are syncytial, three-dimensional, to CK and EMA. MIB1 is low.
or may form honeycomb sheets of uniform cuboidal Choroid plexus lesions are immunoreactive for S100,
to columnar cells. A frequent pattern consists of cen- CAM 5.2, and transthyretin. EMA is usually focally and
tral fibrovascular cores surrounded by numerous uni- weakly expressed. The MIB1 labeling index is generally
TABLE 23.6 CYTOPATHOLOGIC FEATURES OF CHOROID PLEXUS PAPILLOMA/CARCINOMA
Soft Fleshy Smears Easily

Cellularity Marked
Presentation Striking low power presentation; papillary architecture; large grape-like spherules of cells bulging off
the fibrovascular stalks; three-dimensional cell balls; monolayered honeycomb sheets; carcinomas are
markedly cellular, with poorly formed papillae
Cells Uniform round, cuboidal to columnar; monomorphic cells; well-defined cell borders; carcinomas show
varying degrees of anaplasia and brisk mitotic activity
Nucleus Round, central to eccentric; granular, uniformly distributed chromatin; micronucleoli; nuclear atypia in
carcinoma
Cytoplasm Modest amount
Psammoma Bodies Present
Immunoprofile S100 ⫹, CK ⫹, EMA ⫹/⫺; MIB1 index ⬍ 10% in papillomas, ⬎ 25% in carcinomas
Differential Diagnoses Normal choroids plexus; ependymoma; metastatic papillary carcinoma
A B
Figs. 23.31A to B. Choroid plexus papilloma. A: Low power view of papillary neoplasm with a complex
branching architecture. B: Higher magnification showing central core of fibrovascular tissue lined by cuboidal
to elongated cells. (continued)
C D
Figs. 23.31C to D. (continued) C: Different field demonstrating syncytial tissue fragments of cuboidal to round cells
and a cross section of the papillary core. D: Higher magnification showing round to elongated cells. The nuclei are
round with smooth nuclear membranes and evenly distributed chromatin.
Differential Diagnoses of Papillary Lesions (See Fig. 23.32)
A B
Figs. 23.32A and B. Metastatic papillary adenocarcinoma originating in lung. A: Low power showing several branch-
ing papillary tissue fragments in the background of loosely cohesive and discrete cell population. B: Higher magni-
fication of the papillary tissue fragments, lined by clearly malignant epithelial cells with high N/C ratios. Note that
there are no glial processes.
less than 10% in papillomas and is higher (often greater lobes, but may involve the corpus callosum and extend
than 25%) in carcinomas. to the contralateral hemisphere. Radiologically, they pres-
ent as supratentorial lesions, 60% with calcifications,
and with areas of contrast enhancement in higher grade
tumors. Cytogenetic demonstration of the concurrent loss
The differential diagnoses include normal choroid plexus, of the short arm of chromosome 1 (1p) and the long arm
ependymoma, and metastatic papillary carcinomas (Fig. of chromosome 19 (19q) is considered diagnostic. The loss
23.32). In the pediatric age group, the differential diag- of 1p/19q is associated with a more favorable prognosis.
noses for choroids plexus carcinomas include embryonal
carcinomas and medulloepitheliomas.
Oligodendrogliomas smear easily. These are cellular neo-
OLIGODENDROGLIOMA
plasms presenting a uniform cell pattern with very little
Oligodendrogliomas comprise 5% of intracranial gliomas, stroma. Calcification is quite frequent. The nuclei are
occur primarily in adults, and offer a relatively better monotonous and have smooth nuclear membranes, finely
prognosis than astrocytomas. They principally involve the granular chromatin, and an absence of nucleoli (Table
cerebral cortex, particularly the white matter in the frontal 23.2; Figs. 23.33A to E). Frequently, perinuclear halos are
Oligodendroglioma (See Fig. 23.33)
A B
C D
Figs. 23.33A to E. Smears of oligodendroglioma. A: Low power,

showing small round cells in aggregates in a background of loose
matrix. B: Higher magnification highlighting the uniform small,
round cells with no nucleoli or cell processes. C: Smear stained by
Papanicolaou stain. D: Smear of an oligodendroglioma stained by
Papanicolaou, showing uniform round cells with bland chromatin
pattern. E: Low power of a smear from another case of oligoden-
droglioma demonstrating a characteristic network of thin capillar-
E ies referred to as a “chicken wire” pattern (arrows).
seen (the fried egg appearance); however, these are artifacts

of delayed fixation and are absent in promptly fixed speci-
OLIGODENDROGLIOMA
mens. The delicate, branching capillary network is char-
acteristic, referred to as a “chicken-wire” pattern, and is One of the diagnostic problems includes possible over-in-
usually recognizable irrespective of the grade (Fig. 23.33E). terpretation of normal oligodendrocytes in white matter
Anaplastic oligodendrogliomas have foci with cellular as oligodendroglioma. The neoplastic oligodendrocytes,
pleomorphism, mitoses, necrosis, and microvascular pro- although uniform, are larger in size, and the smears are
liferation. Oligodendrogliomas usually lack a gliofibrillary much more cellular. Occasionally, areas with irregular
matrix and do not tend to aggregate around blood vessels. nuclear contours reminiscent of astrocytomas may be
Differential Diagnoses Neoplasms with a Round Cell Pattern (See Figs. 23.34 to 23.39)
A B
Figs. 23.34A to C. A, B: Smears of a primary CNS lymphoma show-

ing monomorphic discrete, small, round cells strongly resembling
C oligodendroglioma. C: Multiple myeloma involving the CNS.
Fig. 23.35. Smear of a pituitary adenoma. The neoplastic cells are Fig. 23.36. Medulloblastoma. Smear showing uniform small round
small to medium-sized, uniform and round cells. cells with rosette formation (arrow).
present, thereby raising the challenging differential diag- CNS or systemic, neurocytoma, pineocytoma, clear cell
nostic considerations of diffuse astrocytoma and oligoas- ependymoma, meningioma, and pituitary adenoma (Table
trocytoma. The latter diagnosis should be reserved for 23.7; Figs. 23.34 to 23.39).
gliomas with a conspicuous mixture of the astrocytoma
and oligodendroglioma cell types.
PRIMARY CNS LYMPHOMA
Several neoplasms in the CNS are composed of small
round cells that morphologically resemble oligoden- Primary CNS lymphomas have increased in incidence and
drogliomas and include malignant lymphoma, primary are seen in the immunocompromised, particularly among
TABLE 23.7 DIFFERENTIAL DIAGNOSES OF CNS NEOPLASMS COMPOSED OF SMALL ROUND CELLS
Diagnostic Clues/
Oligodendroglioma Moderate to high cellularity; monotonous population GFAP ⫹/⫺ 23.33A to F
of single small round cell with ill-defined cell borders; Leu 7 ⫹/⫺; Concurrent
perinuclear clearing fried egg pattern; increased N/C loss of 1p/19q
ratios; smooth nuclear membrane; finely granular, evenly chromosomal arms
distributed chromatin; inconspicuous nucleoli; calcification
frequent; may contain astrocytes and thin-walled blood
vessels
Central Moderately cellular; individually dispersed small Age/location 23.38

Extraventricular monomorphic round cells; nuclei round with smooth Neuroendocrine markers:
Neurocytoma nuclear membrane, characteristic delicate stippled Synaptophysin ⫹, NSE ⫹,
chromatin; small nucleoli; mitoses absent; fine cellular chromogranin ⫹, GFAP ⫺
processes; perinuclear halo; no necrosis; calcification
Medulloblastoma Highly cellular; cells isolated in cohesive groups or in Age 23.36

syncytial tissue fragments; rosette formation ⫹/⫺; cells Location
small, round with round oval to carrot-shaped nuclei; Glial/neuronal markers
smooth nuclear membrane, coarsely granular deep-staining may be positive in
chromatin; nucleoli inconspicuous; mitoses ⫹; cytoplasm fibrillary zones
scant to indiscernible; no cell processes; necrosis ⫹
Primary CNS Highly cellular; cells isolated; 2.5–3 times the size of normal LCA ⫹ B/T-cell markers ⫹ 23.34A to C
Lymphoma lymphocytes; round nucleus; nuclear membrane irregularity Location
⫹/⫺; granular chromatin; nucleoli prominent; mitoses ⫹; B/T-cell gene
cytoplasm scant; no cell processes; necrosis ⫹; background rearrangement ⫹ for
may contain reactive astrocytes dominant clones
Pineocytoma Highly cellular, uniform small round cells; poorly defined Age 23.39
cell boarders; appear as bare nuclei; nuclei round, finely Location
granular chromatin; small nucleoli; cytoplasm, cell
processes
Pituitary Adenoma Highly cellular; cells small round to polygonal cells; cell Location 23.25
borders well to poorly defined; nuclei round, uniform with Synaptophysin; pituitary
smooth nuclear membrane; coarsely granular chromatin; hormones ⫹/⫺
nucleoli ⫺; mitoses absent; cytoplasm variable, scant to
abundant; no cell processes; no necrosis; may form cords,
ribbons or papillary structures, richly vascularized
Glioblastoma Highly cellular; no true cell cohesion but smears may be GFAP ⫹ neuroendocrine 23.21
Small Cell Type crowded with pseudosyncytial pattern; nuclei pleomorphic markers ⫺
but no coarse chromatin or nucleoli; scant cytoplasm
but cell processes should be visible in at least some cells;
mitoses, necrosis and pronounced endothelial proliferation
Syncytial Meningioma Highly cellular; cohesive, small cells with poorly defined Location 23.40A
cell borders; whirling pattern helpful, oval nuclei with EMA ⫹ vimentin ⫹ GFAP and D
finely granular chromatin; inconspicuous micronucleoli, ⫺
intranuclear inclusions; mitoses absent
Clear Cell Compact cellularity forming a solid neoplasm; uniform, GFAP ⫹ perivascular
Ependymoma small, round to oval nuclei with single, distinct zones
micronucleoli; perivascular nuclear-free zones and true EMA ⫹ luminal surfaces
ependymal rosettes
A B
Figs. 23.37A and B. A: Smear of a metastatic primitive neuroectodermal tumor with small round cells in a
neuropile matrix. B: Smear of a metastatic neuroendocrine carcinoma presenting a typical “salt & pepper”
chromatin.
Fig. 23.38. Neurocytoma showing small round cells with poorly Fig. 23.39. Pineocytoma. The smear shows uniform, small, round
defined cell borders, scant insignificant cytoplasm and round nuclei cells with ill-defined borders. The cytoplasm is scant with high N/C
with “salt & pepper” chromatin. The background shows neuropile. ratios. The nuclei are round, uniform with coarsely granular chro-
matin. There is usually a net work of thin blood vessels to which
the neoplastic cells cling not depicted here. The background is finely
filamentous.
the HIV positive, as well as in previously healthy patients, ated from glioblastomas with a small round cell pattern
particularly the elderly. The Epstein–Barr virus is a major (Fig. 23.24). Malignant lymphomas show no vascular
etiologic factor among the immunocompromised. Radio- endothelial proliferation, demonstrate wide dispersion of
logically, these present as single or multiple masses, often discohesive cells away from the blood vessels, and lack a
with a peripheral ring of contrast enhancement, as seen gliofibrillary matrix.
in glioblastomas. An overwhelming majority (92–98%)
of primary CNS lymphomas are of B-cell lineage, with
over 95% being diffuse large B-cell lymphomas. Lympho-
NEUROCYTOMA
mas are differentiated from oligodendrogliomas based
on the lymphoma’s larger nuclear size, coarsely granular
Neurocytoma
chromatin, and necrosis (Fig. 23.34). The tendency of
lymphoma to invade the blood vessels is only evident in Neurocytomas are neuroepithelial tumors that predomi-
histologic sections and not in smears. Malignant lympho- nantly present in young adults. These arise within the
mas, whether primary or secondary, must be differenti- lateral ventricles in the vicinity of the Foramen of Munro
(central neurocytoma) or within the brain parenchyma cellular shape may be round, oval, or polyhedral and the
(extraventricular neurocytoma). Their prognosis is bet- cytoplasm in most instances is acidophilic or faintly baso-
ter than most other tumors in that location and long- philic (Fig. 23.35). The tumors display abundant capillary
term remissions or cures are possible. These tumors are sinusoids like most other endocrine neoplasms; mitosis,
composed of cells that have uniformly round and medi- necrosis, cellular pleomorphism, and processes are very
um-sized nuclei with a characteristic delicately stippled seldom found. The cells are immunoreactive for synap-
chromatin pattern and fine cellular processes. These cells tophysin and chromogranin and, apart from a few null
have immunohistochemical and ultrastructural findings cell adenomas, also express one or more of the pituitary
of neuronal differentiation. In tissue sections, the cells hormones.
are characteristically arranged in single cell files that are The differential diagnoses include neoplasms with
separated by abundant mature neuropil. As in oligoden- small round cells that occur in the sellar or parasellar
drogliomas, interstitial calcifications may be abundant area, including meningiomas with a syncytial pattern and
but necrosis, mitosis, and pleomorphism are absent. oligodendrogliomas (Table 23.7).
Electron microscopy shows abundant mature neuro-
blastic processes, synapses, and neurosecretory gran-
ules. Immunostains for synaptophysin, neuron-specific
PRIMITIVE NEUROECTODERMAL
enolase, and the neuronal markers NeuN are positive.
TUMORS
The cytologic distinction between neurocytomas and
oligodendrogliomas may be exceedingly subtle, and a Primitive neuroectodermal tumors (PNETs) (see Chapter
definite diagnosis is not always possible intraoperatively 25) usually occur in childhood and include medulloblas-
(see Table 23.12). The more granular, stippled (“salt & toma, ependymoblastoma, pineoblastoma, retinoblas-
pepper”) appearance of the chromatin in a neurocytoma toma, and neuroblastoma; all are composed of primitive,
is probably its most useful distinguishing cytological small, round cells with scant cytoplasm and round hyper-
feature (Fig. 23.38). The characteristic orderly arrange- chromatic nuclei. Of these tumors, medulloblastoma is
ment of neurocytomas and particularly immunostains the most frequent.
for neuronal markers may require study of the perma-
nent sections.
Medulloblastoma
Medulloblastoma is the most common solid primary
tumor of the CNS in childhood but can also be found
PITUITARY ADENOMA
in young adults. Radiologically, these are usually dis-
Pituitary adenomas are one of the most common benign crete, contrast-enhancing masses. In children, the tumor
neoplasms of the CNS. Typically intrasellar or, more presents as a solid mass in the midline (cerebellar vermis
rarely, suprasellar, these tumors may produce character- or roof of the fourth ventricle) and has a characteristic
istic endocrine symptomatology and visual disturbances “undifferentiated” histological pattern (classic type). In
or headaches. Sometimes very small tumors (less than 1 adults, it may appear as a lateral cerebellar hemispheric
cm) may be responsible for endocrine disturbances (e.g., mass and display nodular pale islands that represent areas
amenorrhea and galactorrhea in women). In these cases, of maturation (nodular/desmoplastic type).
the surgeon may submit for intraoperative consultation Smears of medulloblastomas are extremely cellular,
a very small fragment of the tumor to confi rm that it is as a rule, regardless of the histologic type (Fig. 23.36).
really a neoplasm and not a normal pituitary gland. In The predominant cell is a relatively small one (2–4 times
other instances, an intrasellar pituitary tumor must be dif- the size of a resting lymphocyte) with a chromatin pattern
ferentiated from other tumors that can occur within this that is predominantly fi nely stippled with no nucleoli.
region or in its vicinity. Some of these neoplasms, such as The cytoplasm is scant, represented by a small basophilic
craniopharyngiomas, astrocytomas of the third ventricle, rim around the nucleus. Nuclear molding is frequent.
germ cell tumor, or metastatic carcinomas, can be easily Mitotic fi gures and individual cell necrosis are always
distinguished from pituitary adenomas, but other tumors present and clearly evident. Cell processes are scant and
composed of small uniform cells such as certain types of difficult to visualize in most cells. Homer–Wright (neuro-
meningiomas and oligodendrogliomas may be more dif- blastic) rosette-like structures are present in some cases
ficult to distinguish. and may provide helpful diagnostic clues, but they are
Although pituitary adenomas may display a large neither required nor necessary for diagnosis. The classic
variety of growth patterns, cytologic smears are usually type is characterized by a patternless arrangement. In the
quite cellular and composed of closely packed tumor cells nodular/desmoplastic type, the foci of nodular reticulin-
with small to medium-sized central nuclei containing fine- free areas with relatively reduced cellularity (pale islands)
ly granular chromatin and small indistinct nucleoli. The may be present. These nodules represent areas of more
advanced neuronal maturation, including small or large Germ cell tumors of the pineal gland include em-
neurons. Several other variants such as anaplastic, large bryonal carcinoma, yolk sac tumor, and germinoma—a
cell, myogenic, and melanocytic have been recognized. tumor that resembles seminoma of the testis. The differ-
In permanent sections, the tumors are usually positive, ential diagnosis between pineocytoma and germinoma
at least focally, for neuronal markers including microtu- is important, particularly in view of the radiosensitiv-
bule-associated proteins, neurofilaments, synaptophysin, ity of germinoma (Table 23.9). Both neoplasms occur
and chromogranin. GFAP highlights background reac- in late childhood and adolescence. A significant pitfall
tive astrocytes and pale islands; in a minority of cases, in interpreting brain smears or frozen sections of this
it may be expressed in classic medulloblastoma cells. Ul- region is the identification of a normal nonneoplastic
trastructurally, the tumor cells exhibit features similar to pineal gland. The normal organ due to its lobular and
those described in neuroblastomas. Common cytogenetic cellular architecture may be misidentified as a menin-
abnormalities associated with medulloblastomas include gioma, germ cell tumor, or even as a metastatic neo-
the amplification of N-myc and c-myc and the loss of the plasm by those unfamiliar with its normal microscopic
short arm of chromosome 17 (17p). Medulloblastomas appearance.
spread via cerebrospinal fluid and may be detected in the
CSF sample (Fig. 23.4). Five percent of medulloblastomas
MENINGIOMAS
may metastasize systemically to the bones. One of the im-
portant diagnostic pitfalls encountered in CNS cytology is Meningiomas are the most common primary benign
differentiating normal cerebellar, small cortical, granular tumors derived from meningothelial cells of the arach-
neurons from medulloblastoma (Table 23.8; Fig. 23.9A). noid membrane. They are more common in females and
occur predominantly in middle age to late adulthood, with
childhood examples tending to be more aggressive. They
PINEAL TUMORS
can arise anywhere in the CNS including the intracranial
Tumors of the pineal region present germ cell tumors and spinal meninges, within the ventricular system, and
arising in the pineal gland. Pineal parenchymal tumors in the optic nerve sheath. Meningiomas display a wide
include the pineoblastoma—a primitive embryonal tumor array of histologic patterns with many tumors show-
that resembles cytologically cerebellar medulloblastoma ing more than one pattern (Table 23.10). Except for the
and the more common and mature pineocytoma, which is meningothelial (or syncytial), transitional, and fibroblas-
composed of small neuroblastic cells (Fig. 23.39). These tic types, most of the morphologic variants are encoun-
tumors are immunoreactive for synaptophysin, and the tered only infrequently. The cytopathologic features of
expression of neurofilament protein increases with greater meningiomas are listed in Table 23.10 and illustrated in
differentiation. Figures 23.40 to 23.46.
TABLE 23.8 CYTOPATHOLOGIC FEATURES DIFFERENTIATING NORMAL CEREBELLAR CORTEX

& MEDULLOBLASTOMA
Normal Cerebellar Cortex Medulloblastoma

Presentation Discrete cells; no syncytia or rosette formation Discrete cells or syncytia with or without rosette
formation ⫹/⫺
Cells Very small, about the size of a normal lymphocyte; 2–4 times the size of a normal lymphocyte
uniform, poorly defined cell borders; high N/C ratios
Nucleus Uniform, round nuclei; smooth nuclear membrane; Pleomorphic in size; round to oval or carrot-shaped;
compact, dense-staining chromatin; no nucleoli; no smooth nuclear membrane; finely stippled to coarsely
mitoses granular chromatin; nucleoli not conspicuous;
mitoses ⫹
Cytoplasm Indiscernible Scant, dense
Background No necrosis; Purkinje cells present; granular Necrosis ⫹; Purkinje cells not present
background
TABLE 23.9 CYTOPATHOLOGIC DIFFERENTIATION BETWEEN PINEOCYTOMA & GERMINOMA
Pineocytoma Germinoma
Presentation Discrete cells, rosettes, pseudorosettes; no lymphoid Discrete cells in the background of lymphocytes; no
cells in the background rosettes/pseudorosettes
Cells Uniform, small round; high N/C ratios; appear as Uniform, round medium-sized; moderately increased
naked nuclei N/C ratio
Nucleus Uniform, round; smooth nuclear membrane; Uniform, round; smooth nuclear membrane; granular
finely granular chromatin; nuclear atypia ⫹/⫺; chromatin; prominent macronucleolus
micronucleoli
Cytoplasm Indiscernible to scant; club-shaped cell processes Scant to moderate amount, no cell processes
⫹/⫺
Background Finely stippled Lymphoid cells; epithelioid cells; tigroid pattern
Immunostains Neuronal markers (NSE, synaptophysin, Placental alkaline phosphatase (may also contain
chromogranin, neurofilament protein) HCG positive trophoblastic cells), CD117 (c-kit),
OCT-4
Special Stains Silver stains (Bielschowsky, Bodian) stain highlight PAS: Abundant glycogen (may require alcohol
processes fixation)
Ultrastructure Neurites neurosecretory granular No specific findings
Atypical (Fig. 23.45) and malignant meningiomas tumors such as schwannoma or fibrillary astrocytomas
(Figs. 23.46A to D) are infrequent and cytologically dem- and fibroblastic glioblastomas. Nerve sheath tumors
onstrate nuclear pleomorphism, hyperchromasia, macro- (schwannoma and neurofibroma) in an intracranial loca-
nucleoli, necrosis, mitotic activity, loss of lobular pattern tion typically arise from the vestibular part of the eighth
(sheeting), small cell change, and invasion of the brain. cranial nerve and grow in the region of the cerebellopon-
They very rarely metastasize systemically. Meningothe- tine angle and internal auditory canal. They may also
lial origin may be suggested if lobular arrangement and arise from spinal nerves. The cytologic differentiation
whorls are retained even focally. The atypical and malig- may, at times, be difficult. The features are listed in Table
nant meningiomas must be differentiated from glioblas- 23.11 (see Figs. 23.51 and 23.52).
toma, metastatic carcinomas, and soft tissue tumors.
SCHWANNOMA
IMMUNOPROFILE
Schwannomas are benign neoplasms arising from periph-
The meningiomas are immunoreactive to epithelial mem- eral nerve sheaths. Most intracranial schwannomas are
brane antigen (EMA) and vimentin, variably immunore- located in the cerebellopontine angle arising in the vestib-
active for S100 and cytokeratin. The progesterone recep- ular part of the eighth cranial nerve (acoustic neuroma).
tor is considered prognostically signifi cant with a loss of In the spine, they may arise from the spinal nerve roots at
expression in atypical meningiomas. all levels and present signs and symptoms depending on
their location.
Grossly, the tumors have a firm, rubbery texture with
a whorled appearance. Cystic degeneration and hemor-
The differential diagnoses of meningioma depend on their rhage may be present. Schwannomas form a discrete mass
histologic type. The syncytial type with small round cells that displaces the nerve while neurofibromas expand the
must be differentiated from other round cell neoplasms nerve. Schwannomas are encapsulated and rubbery to
encountered in the CNS (Table 23.7); fibrous types with fi rm, with areas of cystic change. Histologically, the neo-
a spindle cell pattern can be a diagnostic dilemma and plasm consists of dense collagenous tissue with bundles
must be differentiated from intracranial nerve sheath or fascicles of spindle cells and hyalinized blood vessels.
TABLE 23.10 HISTOCYTOPATHOLOGIC FEATURES OF MENINGIOMAS
Histologic Features Cytopathologic Features

Meningothelial Lobules of plump meningothelial Cellular; syncytial tissue fragments; large, oval to polygonal plump
Type cells; often arranged in a whorled cells; poorly defined cell borders; abundant, wispy, veil-like, pale-
configuration; nuclei round, staining cytoplasm often drawn into processes; nucleus small,
small and uniform; intranuclear round to oval with low N/C ratios, with smooth nuclear membrane,
pseudoinclusion; psammoma bodies; uniformly distributed finely granular chromatin; frequent intranuclear
scant stroma inclusions; micronucleoli inconspicuous; psammoma bodies ⫹/⫺
Differential Glioblastoma multiforme

Diagnoses of
Meningothelial
Type
Fibroblastic Type Fascicular architecture; elongated Nucleus small, round, oval or oblong with low N/C ratios; smooth
cells with increased collagen; nuclear membrane, uniformly distributed finely granular chromatin;
intranuclear inclusions and frequent intranuclear inclusions; micronucleoli inconspicuous;
psammoma bodies infrequent psammoma bodies usually absent
Differential Schwannoma
Diagnoses of Gliomas
Fibroblastic Astrocytomas
Meningioma Fibrillar glioblastoma multiforme
Ependymomas
Hemangiopericytomas/solitary fibrous tumor
Transitional Type Combination of meningothelial & Syncytial tissue fragments of plump meningothelial cells with or
(Mixed) fibroblastic patterns; prominent without whorls; spindle-shaped cells surrounding the syncytia or in
lobules and whorls; centers of lobules loosely cohesive groups; psammoma bodies in variable numbers
are syncytial & the periphery appears
fibroblastic, with individual cells
streaming from the lobule
Secretory Type Basic meningothelial pattern with Syncytial tissue fragments of plump neoplastic meningothelial cells
eosinophilic, hyaline-like cytoplasmic with or without whorls; presence of pseudopsammoma bodies
inclusions seen as small round eosinophilic bodies within the cytoplasm or
extracellular; strongly PAS ⫹; CEA ⫹; surrounding neoplastic cells
react positively with CK
Psammomatous Meningothelial pattern with an Similar to meningothelial type but with a large number of
Type abundance of psammoma bodies psammoma bodies
Atypical Sheeting architecture (loss of lobular Increased cellularity; large syncytial tissue fragments; neoplastic
pattern); prominent cellular and meningothelial cells pleomorphic in size; cytoplasm variable; high
pleomorphism; increased mitotic N/C ratios; nuclei large, round to oval; binucleation; thick nuclear
activity; disorganized architectural membrane; finely granular chromatin, prominent nucleoli; nuclear
pattern; macronucleoli clefts and grooves; mitotic figures usually present; intranuclear
inclusions ⫹; necrosis
Malignant Loss of lobular pattern with sheeting Cellular smears with malignant cells isolated, in loosely cohesive
architecture; conspicuous necrosis; groups and in syncytial tissue fragments without any architectural
obvious malignant cytology (may patterns
look like carcinoma or sarcoma); Cells pleomorphic in size and shape; small to large, round to
high mitotic rate; invasive features; spindle-shaped
presence of metastasis Poorly defined cell borders; variable cytoplasm
Nuclei pleomorphic; round to spindle-shaped; high N/C ratios;
hyperchromatic; nucleoli prominent; mitoses ⫹; necrosis ⫹
Meningioma, Morphologic Spectrum (See Figs. 23.40 to 23.46)
A B
C D
Figs. 23.40A to E. Smears of meningothelial meningioma. A, B: Small

to medium-sized cells with poorly defined cell borders forming syn-
cytial architecture. The cytoplasm is variable and pale. The nuclei
are round to oval with smooth nuclear membranes with evenly
distributed chromatin. C: Smear of a meningioma consisting of
larger cells with considerable eosinophilic cytoplasm. Their nuclei
re round with granular chromatin, nucleoli and prominent intranu-
clear inclusions (arrows). D: A different case of meningioma show-
ing syncytial architecture. The cells have poorly defined cell bor-
ders with abundant cytoplasm. Their nuclei are uniform with finely
granular chromatin and micronucleoli. Note the frequent presence
of intranuclear inclusions (arrows). E: Meningothelial meningioma
showing the typical and characteristic concentric arrangement of
E the cells, referred to as “whorl” (Papanicolaou).
Schwannomas smear with difficulty, resulting in thick, chromatic and very atypical. The stroma is collagenous
unreadable clumps of tissue demonstrating a frayed rope and lacks a fibrillar background. Palisades of these nuclei
appearance (Figs. 23.47A to D). They consist of cohesive alternating with cytoplasmic process-rich anucleate areas
spindle cells in fascicles. A majority of schwannomas dem- form the characteristic Verocay bodies. The Antoni B ar-
onstrate hypercellular (Antoni A) and hypocellular (Antoni eas have loosely arranged cells with relatively plumper
B) areas, imparting a biphasic appearance. The Antoni A nuclei and shorter cytoplasmic processes. The interlacing
areas exhibit compact cells with elongated, undulating, bundles of fi laments crisscrossing at right angles support
comma-shaped or club-shaped nuclei that can be hyper- the diagnosis of schwannoma.
Fig. 23.41. Meningioma, psammomatous type. The syncytial tissue Fig. 23.42. Meningioma, transitional type showing both menin-
fragment of meningothelial cells contains several psammoma bodies gothelial and fibroblastic patterns.
(arrows).
A B
Figs. 23.43A and B. Meningioma, fibroblastic. A, B: Spindle-shaped cells with long, cytoplasmic processes and oval
to elongated nuclei with bland chromatin pattern.
Fig. 23.44. Meningioma, secretory type. Papanicolaou stained

preparation showing a syncytial tissue fragment of meningothelial
cells with secretory vacuoles and cytoplasmic globules.
A B
Figs. 23.45A to C. Atypical meningioma. A: Increased cel-

lularity and nuclear pleomorphism. Tendency to form whorls
is persistent (arrow). B: Marked nuclear atypia with extreme
pleomorphism. There is no necrosis or mitotic activity. C: Pa-
panicolaou stained preparation to demonstrate nuclear aty-
pia. Note the formation of a cellular whorl. The nucleoli are
C conspicuous.
A B
Figs. 23.46A to C. Malignant meningioma. A: Medium power

view of a cellular smear composed of pleomorphic spindle cells
with atypical nuclei (Papanicolaou). B: Same case as A. The ma-
lignant cells are discrete and loosely cohesive, vary in size and
shape and contain very pleomorphic large nuclei with prominent
nucleoli. C: FNA metastatic malignant meningioma to the lung,
showing markedly cellular aspirate with fascicles of spindle cells.
C (continued)
Figs. 23.46D. (continued) D: Higher magnification highlights the

D malignant nature of the cells (Papanicolaou).
TABLE 23.11 DIFFERENTIAL DIAGNOSES OF FIBROUS MENINGIOMA WITH SPINDLE CELL PATTERN
Diagnostic Clues/
Fibrous Meningioma Difficult to smear, cellularity variable, generally higher than EMA ⫹ Vimentin ⫹ 23.48E
schwannoma cells; spindle-shaped with cytoplasmic processes S100 ⫹ in 80%
and intercellular fibrillary acellular material; syncytia and whorls Progesterone
⫹/⫺; round to oval nuclei with smooth nuclear membrane; finely receptor ⫹
granular, evenly dispersed chromatin; inconspicuous nucleoli;
intranuclear inclusions; scant cytoplasm
Schwannoma Very difficult to smear; cellularity low; cells predominantly in S100 ⫹ Pericellular 23.48A
tissue fragments; single cells rare; palisading of nuclei; Verocay reticulin ⫹
bodies; cells spindle-shaped; cell borders poorly defined; nuclei
round, delicate, or curried, wary, coma-shaped; smooth nuclear
membrane; chromatin finely granular, evenly dispersed to compact;
nucleoli inconspicuous; cytoplasm scant; degeneration ⫹/⫺; foamy
histiocytes; inflammatory cells
Pilocytic Astrocytoma Easy to smear; elongated spindle-shaped cells with long bipolar GFAP ⫹ 23.48B
processes, the latter may be present in fascicles; nuclei oval with
smooth nuclear membrane; finely granular, evenly dispersed
chromatin; inconspicuous nucleoli; cytoplasm-Rosenthal fibers and
eosinophilic granular bodies present
Glioblastoma Easy to smear; elongated spindle-shaped cells with scant cellular GFAP ⫹ 23.48C
processes; nuclei oval with smooth to irregular nuclear membrane;
hyperchromatic to finely granular, evenly dispersed chromatin;
inconspicuous nucleoli; microvascular proliferation; mitoses ⫹;
necrosis ⫹
Ependymoma Easy to smear; elongated spindle-shaped cells with long bipolar EMA ⫹ lumina 23.48D
processes, the latter may be present in fascicles; nuclei oval with GFAP ⫹
smooth nuclear membrane; finely granular, evenly dispersed perivascular
chromatin; inconspicuous nucleoli; cytoplasm-Rosenthal fibers and fibrillary zones
granular bodies present
Hemangiopericytoma/ Cellular smears; sheets and fascicles with randomly oriented, Pericellular 23.54B
Solitary Fibrous Tumor oval to elongated nuclei; poorly defined cell borders, indistinct reticulin ⫹ and C
cytoplasm; characteristic network of staghorn blood vessels
surrounded by neoplastic cells
Differential Diagnoses of Meningioma (See Fig. 23.47)
A B
C D
Figs. 23.47A to D. Schwannoma. A: This lesion is difficult to smear, resulting in thick tissue fragments (low power).
B: Medium power. Note the crisscrossing fascicles of loose spindle cells with intervening bundles of collagenous
tissue. C, D: Higher magnification. Variable loose to dense stroma and spindle cells with delicate coma-shaped nuclei.
CEREBELLAR HEMANGIOBLASTOMA
LESIONS WITH SPINDLE CELLS AND A Hemangioblastomas are slow-growing vascular tumors,
FIBRILLAR MATRIX typically of young to late adulthood. They may arise in the
setting of Von Hippel–Lindau (VHL) syndrome or may
be sporadic. VHL-associated tumors may be multiple and
CNS lesions that demonstrate a spindle cell pattern in the
affect the brainstem, spinal cord, and nerve roots, while
background of a fi brillar matrix include astrocytomas,
sporadic cases are commonly present in the cerebellar
fi broblastic glioblastomas, ependymomas, meningiomas,
hemispheres. Patients with VHL syndrome also have an
and schwannomas (Table 23.11). Their cytologic features
increased frequency of renal cell carcinoma (RCC); thus,
are illustrated in Figures 23.48A to E.
the distinction between cerebellar hemangioblastoma and
metastatic RCC is important (Table 23.12; Figs. 23.49
and 23.50). Even in patients without VHL syndrome,
TUMORS OF THE CEREBELLUM AND FOURTH
metastatic RCC remains a differential diagnostic consid-
VENTRICULAR REGION
eration since both tumors are richly vascular and may be
Tumors of the cerebellum and fourth ventricle are rela- predominantly composed of cells with clear cytoplasm.
tively common in children and young adults and include Radiologically, hemangioblastoma may classically pres-
medulloblastomas, juvenile pilocytic astrocytomas (cer- ent as a cyst with a contrast-enhancing mural nodule.
ebellar astrocytomas), ependymomas, and hemangioblas- Grossly, hemangioblastomas are red to yellow, reflecting
tomas. The former three neoplasms have already been their vascularity and lipid content. Hemangioblastomas
discussed. are diffi cult to smear, forming predominantly irregular,
Spindle Cell Neoplasms with Fibrillar Processes (See Figs. 23.48 to 23.55)
A B
C D
Figs. 23.48A to E. A: Smear of an acoustic nerve Schwannoma. B:

Juvenile or pilocytic astrocytoma showing a spindle cell population
with bipolar processes. C: Glioblastoma with a dense network of
glial processes. The nuclei of the glioblastoma cells are very pleo-
morphic. D: Ependymoma showing glial processes. Note that the
nuclei are uniform. E: Fibrous meningioma showing a predominant
spindle cell pattern with cytoplasm drawn into processes. The nuclei
E appear bland.
thick cellular groups. These crowded groups are com- cytoplasmic vacuoles that indent the nuclear surface. The
posed of many capillaries, astrocytes, and stromal cells of nuclei tend to be hyperchromatic or pleomorphic, but
uncertain histogenesis. The stromal cells show ill-defined mitoses are rare. Young stromal cells are smaller with few
cell borders, acidophilic fi nely granular cytoplasm, and vacuoles, whereas old stromal cells are larger with more
uniform oval nuclei, as well as evenly distributed chro- vacuoles and more bizarre nuclei. The vacuolar cytoplasm
matin with no nucleoli or chromocenters. On histologic of the stromal cells seen in the histologic sections is much
sections, these large cohesive cells have irregular outlines less apparent in the cohesive fragments seen on smears,
and characteristic multiple small to large lipid-containing making them difficult to recognize.
TABLE 23.12 DIFFERENTIATING FEATURES BETWEEN CEREBELLAR HEMANGIOBLASTOMA

& METASTATIC RENAL CELL CARCINOMA
Cerebellar Hemangioblastoma Metastatic Renal Cell Carcinoma

Gross Features
Single Mass in the Cerebellum Yes Single or multiple brain lesions,

anywhere in the CNS
Hemorrhagic Lesion Yes Yes
Cytology/Histology
Distinctive Cell Type Histology—stromal cell (large cell with abundant finely None (pleomorphic renal carcinoma
vacuolated cytoplasm; vacuoles indent the surface of the cells arranged in loosely cohesive
nuclei) smears ill-defined, acidophilic; granular cytoplasm groups)
Clear Cytoplasm of Tumor Yes (mostly lipid); finely or coarsely vacuolated Yes (lipid, glycogen), but generally not
Cells vacuolated
Mixture of Cell Types Yes (stromal cells, capillaries, reactive glial, histiocytes) No (metastatic renal carcinoma cells
and capillaries)
Rich Vascular Network Yes Yes
Necrosis Absent Present
Immunoprofile Stromal cells: NSE, CD56; Factor XIIIa ⫹; EMA, Carcinoma cells: Vimentin, CD10 ⫹
cytokeratin, GFAP, endothelial markers (Factor Factor XIIIa ⫺
VIII8 etc.) ⫺
Fig. 23.49. Hemangioblastoma. Smear showing an aggregate of Fig. 23.50. Hemangioblastoma. Smear showing a mixed round and
large stromal cells with abundant eosinophilic cytoplasm. spindle cell population with several large polygonal “stromal” cells
with abundant, foamy to clear cytoplasm (arrows).
Stromal cells variably express vimentin, neuron-spe- vacuolated cytoplasm and both could be associated with
cifi c enolase and neural cell adhesion molecule (CD56), VHL syndrome (Fig. 23.51).
and Factor XIIIa and are generally negative for GFAP,
keratin, EMA, and endothelial markers. Vascular en-
CRANIOPHARYNGIOMA
dothelial growth factor (VEGF) is, however, highly ex-
pressed. The differential diagnosis of hemangioblastoma Craniopharyngiomas are benign, partly cystic, epithelial
includes metastatic RCC. Both demonstrate morphologic neoplasms that arise in the sella turcica and suprasellar
similarities with large round cells containing abundant, space. Less frequently, they may be located in the third
Fig. 23.51. Metastatic renal cell carcinoma. The malignant cells are
large, round to polygonal with abundant eosinophilic, granular cy-
toplasm and bland nuclei with low N/C ratios.
TABLE 23.13 CRANIOPHARYNGIOMA
Adamantinomatous Papillary
Occurs in pediatric age group Occurs in adults
Location: Suprasellar ⬎ third ventricle Location: Third ventricle or suprasellar
Cystic; cyst fluid thick viscous with appearance and Solid and less often, cystic; conspicuous papillae; no wet keratin
consistence of ‘motor oil’; composed of anucleated squames,
cholesterol crystals and histiocytes forming ‘wet keratin’
Sheets, nodules and trabeculae of polygonal, basaloid or Solid sheets of well-differentiated squamous epithelium forming
columnar squamous epithelium; peripheral palisading of pseudopapillae; papillary architecture with central fibrovascular
nuclei cores; no peripheral palisading of nuclei
Dystrophic calcifications present No dystrophic calcifications
Differential Diagnoses Differential Diagnoses

Rathke’s cleft cyst Metastatic squamous carcinoma
Colloid cyst of the third ventricle
Epidermoid cyst
Dermoid cyst
ventricle. These tumors comprise up to 5% of intracra- Papillary craniopharyngioma consists of sheets of

nial neoplasms. They occur mainly in children and dem- well-differentiated squamous epithelium forming pseu-
onstrate a second peak in adults at about 50 years of age. do-papillae and a fi brovascular stroma. There are no
Radiologically, craniopharyngiomas generally show par- peripheral palisading, cholesterol crystals, dystrophic cal-
tially calcifi ed, mixed cystic, or solid patterns but can be cifi cation, or wet keratin, as seen in adamantinomatous
predominantly cystic. lesions.
Histologically, two patterns are identified, namely, Craniopharyngiomas are associated with reactive
adamantinomatous, which is commonly seen in the first gliosis at the periphery. The capsule may show prominent
two decades of life, and papillary, which occurs almost Rosenthal fibers, and biopsy from such areas may be mis-
exclusively in adults. interpreted as pilocytic astrocytoma. The cytopathologic
Adamantinomatous craniopharyngiomas show a mul- features of craniopharyngiomas are listed in Table 23.13
tilocular cystic pattern with nodules, cords, and broad trabe- and illustrated in Figures 23.52A to E.
culae of squamous epithelium with a peripheral palisading
of nuclei. The squamous cells may be polygonal, basaloid,
or columnar. The cystic component shows anucleated
squames, cholesterol crystals, and histiocytes. Diagnostic The differential diagnoses of craniopharyngioma include
features include “wet keratin” and dystrophic calcification. Rathke’s cleft cyst, colloid cyst of the third ventricle,
A B
C D
Figs. 23.52A to E. Craniopharyngioma. A, B: Smears of an ada-

mantinomatous type craniopharyngioma showing loosely cohesive
elongated cells with oblong nuclei. C: Large tissue fragment of
squamous cells. Note the wet keratin (arrows). D: Squamous type
craniopharyngioma demonstrating discrete and a tissue fragment
of benign squamous cells. E: Different field with mature benign
E squamous cells.
epidermoid cyst, and dermoid cyst, as well as metastatic they present as irregular, destructive midline lesions that
squamous carcinoma. may extend into soft tissues.
CHORDOMA GROSS AND HISTOLOGIC FEATURES

Chordoma is a neoplasm derived from the remnants of Grossly, chordomas are bulky, lobulated, soft, gray,
the notochord, with a predilection for proximal and distal and glistening. Histologically, chordomas show a com-
extremes of the axial skeleton. It is more frequent over bination of patterns characterized by lobules of large
the age of 30 years. The majority occur in the sacrococ- polygonal neoplastic cells arranged as nests and cords
cygeal and the spheno-occipital regions. Radiologically, within an abundant myxoid to mucoid stroma. The large
TABLE 23.14 CYTOPATHOLOGIC FEATURES OF CHORDOMA
Presentation Neoplastic cells mostly discrete, in aggregates or in tissue fragments
Architecture of the Sheets, cords, trabeculae, concentric pearl-like formations; large cells with voluminous
Tissue Fragments multinodulated cytoplasm with interconnecting cytoplasmic membranes forming spider web pattern
Cells Variable in size, small to large, round and short spindle-shaped; low N/C ratio; single or binucleated
Nucleus Small, round, central to eccentric compact chromatin; intranuclear cytoplasmic inclusions
Cytoplasm Voluminous, septate with multiple vacuoles to densely eosinophilic
Background Abundant, fibrillar, myxoid/mucoid matrix
Immunoprofile Positive reactivity to cytokeratin, vimentin, EMA, S100 protein; negative reactivity to CEA, GFAP
Histochemistry Alcian blue at pH 1 ⫹; mucicarmine ⫹
Ultrastructure Prominent bundles of intermediate filaments, large vacuoles and lumina bordered by microvillus
projections; well-developed desmosomes
Differential Diagnoses With abundant chondroid stroma:

Chondrosarcoma
With abundant myxoid stroma:
Myxoid Chondrosarcoma
Myxoid Liposarcoma
Metastatic Colorectal Adenocarcinoma
Myxopapillary Ependymoma
With clear cell pattern and scant stroma:
Metastatic Renal Cell Carcinoma
physaliphorous (Greek: Bubble-bearing) cells have vacu- eosinophilic cytoplasm resemble hepatocytes. The stroma
olated, bubbly cytoplasm and small bland nuclei. Also can be abundant and mucoid, staining strongly with
present are small cells with deeply eosinophilic, nonvacu- alcian blue. The tumor cells are positive with PAS and are
olated cytoplasm and central small nuclei with uniform diastase resistant.
chromatin. Malignant foci, when present, are characterized by
marked cellular pleomorphism, increased mitotic activity,
and the appearance of a malignant spindle cell compo-
CYTOLOGIC FEATURES
nent. Chordomas may also show areas of cartilaginous
Chordomas smears easily and their cytologic pattern differentiation.
reflects their histomorphology (Table 23.14; Figs. 24.53A
to D). The neoplastic cells can be isolated, in loosely cohe-
IMMUNOPROFILE
sive groups, and in syncytial tissue fragments without any
architectural patterns. The cells of chordoma are pleo- Chordoma shows positive reactivity to cytokeratin, vimen-
morphic, medium to large, and round to polygonal with tin, and EMA and has variable reactivity with S100.
well-defi ned cell borders and low N/C ratios. The nuclei
are small, central to eccentric, and round to oval with a
DIFFERENTIAL DIAGNOSES OF CHORDOMA
smooth nuclear membrane and finely granular, uniformly
distributed chromatin. The neoplastic cells can have vari- The differential diagnoses of chordoma depend on its
able, voluminous, and clear cytoplasm with the physali- location as well as the area sampled and include diagnos-
phorous cells appearing ballooned and multi-vacuolated. tic entities such as chordoid meningioma, myxopapil-
Their nuclei are small with uniform chromatin. The larger, lary ependymoma, chondrosarcoma, metastatic mucin-
nonvacuolated neoplastic cells with polygonal shape and producing adenocarcinoma, and metastatic clear cell
A B
C D
Figs. 23.53A to D. Chordoma. A: Cellular smear with a striking mucoid background. The cells are in syncytial
arrangement without any architectural pattern. B: Mucoid-myxoid background and epithelial cells. C: Round to
elongated cells. D: Characteristic large physaliphorous cells containing small bland nuclei.
carcinoma of the kidney (Table 23.15; Figs. 23.53A to

PARAGANGLIOMA
D; also refer to Table 24.10).
Paragangliomas uncommonly involve the CNS and are
almost always confi ned to the region of cauda equina.
HEMANGIOPERICYTOMA/SOLITARY
They may also invade the cranial cavity as local exten-
FIBROUS TUMOR
sions from the skull base. They arise from neural crest
Hemangiopericytomas are currently considered to rep- cells associated with autonomic paraganglia throughout
resent solitary fi brous tumor (see Chapter 24). Those the body.
involving CNS are dural-based lesions and are uncom- Smears show a large population of discrete and
mon, although more frequent in males, occurring at any loosely cohesive cells with variable size and pleomorphic
age but most frequently in the fourth to the sixth decade shapes (Figs. 23.55). In keeping with their neuroendo-
of life. crine morphology, the nuclei of the paraganglioma cells
The smears are cellular, consisting of sheets and fas- are round, eccentric, and have a salt & pepper chromatin
cicles of cells with randomly oriented, oval to elongated pattern. The differential diagnosis in this region includes
nuclei (Figs. 23.54). Their cell borders are poorly de- myxopapillary ependymoma.
fi ned and their cytoplasm is indistinct. The characteristic
feature is the network of branching blood vessels with
METASTATIC LESIONS
a “staghorn” pattern (Fig. 23.54B) and with neoplastic
cells around them. A variably dense and pervasive pericel- Metastatic tumors are by far the most common neoplasms
lular network of reticulin is a characteristic histochemical in the CNS and outnumber the primary neoplasms. The
feature. relative frequency with which different primary tumors
TABLE 23.15 DIFFERENTIAL DIAGNOSES OF CHORDOMA
Diagnostic Clues/ See

Tumor Type Cytopathologic Features Ancillary Tests Fig(s).
Chordoma Physaliferous cells; low N/C ratio; small, round cells with dense CK ⫹; vimentin ⫹ 23.53
cytoplasm; short spindle-shaped cells; compact nuclei; abundant EMA ⫹/⫺; S100 protein ⫹/⫺; 24.83
myxoid, fibrillar stroma GFAP ⫺; CEA ⫺
Renal Cell Large round cells with clear cytoplasm; small central nuclei; low N/C Lack septae vacuoles; CK ⫹; 23.51
Carcinoma ratio; finely granular chromatin with micro/macronucleoli; clean vimentin ⫹/⫺; S100 protein ⫺;
background EMA ⫹; CEA ⫺; GFAP ⫺
Chondrosarcoma Single cells in lacunar spaces; cells in aggregates; well-defined cell CK ⫺; 24.81
borders; foamy to vacuolated cytoplasm; large cytoplasmic vacuoles; vimentin ⫹/⫺; EMA ⫺; S100
bi- or multinucleated cells; chondroid stroma protein ⫹; CEA ⫺; GFAP ⫺
Myxoid Malignant spindle-shaped cells with lipoblasts containing nuclear CK ⫺; vimentin ⫹; EMA ⫺; 24.79
Liposarcoma indentations due to vacuoles (not seen in physaliferous cells); myxoid S100 protein ⫺; CEA ⫺;
background GFAP ⫺
Mucinous Round to columnar malignant cells in tissue fragments with acinar to CK⫹; vimentin⫺; EMA ⫹; 24.84
Adenocarcinoma papillary pattern; round to elongated nuclei; fine to coarsely granular S100 protein ⫺; CEA ⫹;
chromatin; micronucleoli; cytoplasmic vacuoles with signet-ring cells; GFAP ⫺
abundant mucoid stroma
Myxopapillary Cells cuboidal to columnar or elongated, forming papillary tissue CK ⫺; vimentin ⫺; EMA ⫺; 24.82
Ependymoma fragments with central mucinous core; well-defined cell borders; S100 protein ⫺; CEA ⫺;
abundant cytoplasm; centrally directed cytoplasmic processes; peripheral GFAP ⫹; mucin stain ⫹
nuclei; nuclei pleomorphic in size and hyperchromatic; bizarre
multinucleated cells ⫹/⫺; scattered ependymal cells; myxoid background
Chordoid Meningothelial cells forming short cords/small aggregates within an EMA ⫹; vimentin ⫹; CK ⫹/⫺
Meningioma abundant myxoid matrix
A B
Figs. 23.54A to C. Hemangiopericytoma. A: Smear showing a predominant round cell pattern with poorly defined
cell borders, scant cytoplasm and round to oval nuclei containing finely granular, uniformly distributed chromatin.
B: Different case; low power view showing branching tissue fragments of spindle cells. (continued)
C
Figs. 23.54C. (continued) C: Higher magnification. The cells are Fig. 23.55. Smear of a paraganglioma of cauda equina with a
medium-sized with round to oblong nuclei with a bland chromatin pleomorphic cell population occurring discrete, in a fibrillar back-
pattern (Papanicolaou). ground. The nuclei are eccentric. The cells demonstrate unipolar
rudimentary processes.
metastasize to the CNS is variable. The most common pri- lung are common sources of spinal epidural metastases. A
mary tumors metastasizing to the brain are carcinomas of host of other malignant neoplasms may also metastasize
the lung (particularly small cell carcinoma and adenocar- to the CNS, and often the primary tumor may prove to
cinoma), the breast and the kidney, and malignant mel- be elusive. The cytomorphologic patterns of metastases
anoma. Carcinomas of the prostate, the breast, and the are easily recognizable on smears.
SUGGESTED READINGS
Baisden BL, Hamper UM, Ali SZ. Metastatic meningioma in fine- Joseph JT. Diagnostic Neuropathology Smears. Philadelphia: Lip-
needle aspiration (FNA) of the lung: cytomorphologic findings. pincott Williams & Wilkins, 2007.
Diagn Cytopathol 1999;20:291–294. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK. WHO Classifica-
Burger PC, Scheithauer BW. Atlas of tumor pathology. Tumors of tion of Central Nervous System. 2nd ed. Lyon, France: IARC
the Central Nervous System. Washington DC: Armed Forces of Press, 2007.
Institute of Pathology, 2007. Parwani AV, Berman D, Bueger PC, et al. Gliosarcoma: Cyto-
Burger PC, Scheithauer BW, Vogel FS. Surgical Pathology of the pathologic characteristics on fine needle aspiration (FNA) and
Nervous System and its Coverings. 4th ed. New York: Churchill intraoperative touch imprint. Diagn Cytopathol 2004;30:
Livingston, 2002. 77–81.
Ellison D, Love S, Chimelli L, Harding BN, Lowe J, Vinters HV. Zarka M, Moes G. Intraoperative cytology of CNS lesions. Pre-
Neuropathology. 2nd ed. Philadelphia: Elsevier, 2004. sentation at the Spring Meeting of the Michigan Society of
Ironside JW, Moss TH, Louis DN, Lowe JS, Weller RO. Diagnostic Pathologists, 2009.
Pathology of Nervous System Tumours. New York: Churchill
Livingstone, 2002.
APPENDIX
CYTOLOGICAL PREPARATIONS DURING

INTRAOPERATIVE CONSULTATIONS OF
THE CENTRAL NERVOUS SYSTEM LESIONS
Smear Preparations: The sampled tissue fragments are
CYTOLOGICAL PREPARATIONS placed on a flat glass slide, about three-quarters of the way
toward the labeling area. Using two surgical blades, this
Preparation: The clinical and radiological information tissue is separated (teased), prior to the smear preparation,
is collected prior to performing the intraoperative con- into fine grains. This technique involves a combination of
sultation. This helps the pathologist understand what the teasing, mincing, and cutting the tissue, akin to preparing
surgical question is. Equally and importantly, it helps the “pea soup” or “guacamole.” Separation of the tissue by
appropriate triage of the fresh stereotactic biopsy speci- this method helps the tissue to spread more evenly dur-
men since various special studies might be required but ing the smearing. It reduces the number of cohesive thick
cannot be performed on fixed tissue. fragments that cannot be adequately examined or inter-
preted. Further, it increases the likelihood that monolayer
Gross Examination: Upon receiving the fresh specimen
areas would contain well-preserved cells of interest that
from the operating room, gross examination is performed
have not been distorted by the smearing process. While
to differentiate normal, pathological and necrotic areas.
performing this separation, it is essential to keep the tis-
This gross examination also helps determine whether
sue together to prevent air-drying of the thinner areas. A
cytological examination is suffi cient for adequate intra-
drop of normal saline might also be used to keep the tis-
operative assessment. Frozen sections might serve the
sue moist during the mincing procedure.
needs of the surgeon better if the tissue is relatively more
Adequately separated tissue is then placed along
cohesive or fi rm and is unlikely to shed or spread evenly
a line, and a second glass slide is placed longitudinally
for adequate cytologic preparations.
on the fi rst, with the tissue being approximately three-
There are three types of preparations utilized for rapid
quarters of the way toward the label of both slides. Slight
assessment: touch preparations, squash preparation, and
pressure is applied, and the slides are drawn apart in one
the smear.
smooth motion along the longitudinal direction to make
Sampling: Representative minute tissue fragments, about a smear. Both slides are immediately dipped in the fixative
1 cmm from each of the various grossly abnormal or dif- solution to minimize air-drying artifacts.
ferent areas are sampled carefully. Suffi cient residual tis- The residual tissue is kept slightly moist with normal
sue should be left for special st udies, for paraffin embed- saline during the entire consultation to prevent air-drying.
ding, and for the final histologic diagnosis. It should be transferred to a fixative as soon as it is deter-
Touch Preparations or Imprints: The softer tissue is mined that diagnostic tissue from this biopsy has indeed
pressed momentarily but fi rmly against a glass slide to been evaluated in the cytological preparations.
prepare touch imprints. The slides are marked prior to
taking the imprints and smears. The slides are then imme-
diately immersed in a fi xative solution of 95% alcohol INTRAOPERATIVE MICROSCOPIC
to minimize air-drying artifacts. If the specimen appears ASSESSMENT OF INTRACRANIAL
bloody or excessively moist, additional slides might be TUMORS: A PATTERN BASED APPROACH
used to prepare multiple touch imprints. Blotting the
excess blood or saline from the tissue with a gauze or
The initial purpose of the examination of intraoperative
paper towel prior to taking the imprints might lead to a
cytologic smears from intracranial specimens is to assess
loss of diagnostic material.
1. Whether there is lesional tissue present in the biopsy
Squash or Crush Preparations: The sampled tissue frag-
specimen; and
ments are placed toward the center of a flat glass slide. A
2. Whether the amount of lesional tissue is sufficient for
second fresh glass slide is gently placed on top of the first,
an accurate diagnosis.
sandwiching the sampled tissue fragments between them.
Gentle pressure is now applied to crush the tissue fragments This decision is facilitated by a rapid identification
between the two slides. The slides are then drawn apart in and categorization of the smeared material. This pro-
one smooth motion along the longitudinal direction to make cess is facilitated by a pattern-based approach, whereby
a smear and are immediately placed in the fixative solution. neuropathologists may form a preliminary periopera-
tive differential diagnosis based on cytologic patterns. Alternatively, the relationship of neoplastic cells
Following are a few morphologic patterns that may to blood vessels, type of blood vessels, and the back-
help in more rapid triage, and even diagnosis, of a ground can provide diagnostic clues.
neurosurgical biopsy. It is essential to understand that 1. Relationship of the tumor to blood vessels:
these are broad generalizations, and accurate diagnosis
involves a comprehensive cytologic and histological ex- a. Perivascular gradient pattern: The tumor cells may
amination and correlation with clinical and radiologic aggregate close to blood vessels, with decreasing
findings. concentration away from the blood vessels.
Differential diagnoses: Gliomas.
1. Epithelial pattern: Touch preparations may be mod-
erately cellular with cohesive cell groups. Smears are b. Angiocentric and diffuse pattern: The tumor cells
cellular. The neoplastic cells form cohesive groups with infi ltrate blood vessel walls and are also seen in a
well-defined cell borders. Monolayer and multilayered diffuse, discohesive pattern away from vessels.
sheets, acini, and papillary structures may be focally Differential diagnoses: Malignant lymphomas.
present.
c. Randomized clusters: The tumor cells are randomly
Differential diagnoses: Metastatic carcinoma, cyst with distributed close to and away from blood vessels.
an epithelial lining, and choroid plexus neoplasms.
Differential diagnoses: Metastatic carcinomas.
2. Pseudoepithelial or epithelioid pattern: Touch prep- d. Vascular corona pattern: The tumor cells are perivas-
arations are typically paucicellular. The smears are cular, with their cytoplasmic processes oriented
moderately cellular, and the neoplastic cells are towards the vessel wall.
present within cohesive groups. The cell borders
are not well-defined, and the cells appear to form Differential diagnoses: Ependymoma, melanoma,
syncytia. metastatic adenocarcinoma, and metastatic renal
cell carcinoma.
Differential diagnoses: Meningioma, melanoma, and
2. Blood vessel type:
pituitary adenoma (occasional).
a. Thin-walled blood vessels: Small caliber blood ves-
3. Glial–fibrillary pattern: Touch preparations are usu-
sels are normal and demonstrate flat endothelial
ally paucicellular. The smears are smooth and even.
cells with well-separated nuclei.
The background is fibrillary and may be better appre-
ciated without the microscope condenser. The cells Differential diagnoses: Gliosis, low-grade glioma
have fine cytoplasmic processes that radiate in differ- (oligodendroglioma, astrocytoma), lymphoma, and
ent directions and may intertwine, forming eosino- metastatic carcinoma.
philic glial webs. b. Endothelial cell proliferation: Small caliber blood
Differential diagnoses: Normal brain parenchyma, glio- vessels have plump endothelial cells. The endothe-
sis, and glial tumors (astrocytoma, oligodendroglioma). lial cell nuclei are crowded and overlapping and
may occasionally demonstrate nucleoli.
4. Stroma–fibrillary pattern: Touch preparations are
Differential diagnoses: Glioblastoma, metastatic
paucicellular to acellular. They do not smear easily,
carcinoma, and lymphoma.
and the smears have cohesive fragments in a fibrillary
background. The cells are bipolar and have slightly 3. Background fibrillary matrix:
thicker fi brillary processes arranged parallel to each a. Fibrillary background: There are fine, well-defined
other, which may be better appreciated without the glial processes that may be better appreciated with-
microscope condenser. The nuclei within these frag- out the microscope condenser.
ments are oval to elongated and are polarized in the
same direction. Differential diagnoses: Gliosis and astrocytoma.
Differential diagnoses: Schwannoma and meningioma. b. Felt-like pattern: The background is finely granular
and a fibrillary pattern is not seen.
5. Dispersed pattern: The smears and touch preparations
are highly cellular, consisting of dispersed and disco- Differential diagnoses: Normal brain parenchyma,
gliosis, and metastatic carcinoma.
hesive single cells. They usually have scant cytoplasm,
and there may appear to be naked nuclei. c. No fibrillary background: There are no fibrillary
processes in the background, and the cells are ran-
Differential diagnoses: Infl ammation, pituitary ade-
domly dispersed.
noma, neuroblastoma, lymphoma, undifferentiated
neoplasms, and primary or metastatic small round Differential diagnoses: Lymphoma and pituitary
blue cell tumor. adenoma.
Staining Procedure: for 20 seconds, and a second bath of 100% ethanol

(a) Usually, 95% ethanol is used as the fixative solution for 30 seconds. The first bath of 95% ethanol ensures
for the slides. that the excess eosin is completely rinsed before the
(b) Prehematoxylin hydration in running water. maximum possible dehydration in the two subsequent
(c) Hematoxylin staining for 60 seconds. baths of the purer 100% ethanol.
(d) Rinsing in running water until the excess hematoxylin (j) Clearing in xylene: Three separate consecutive baths
is removed, and the water is running clear. of xylene are used, with the slides being dipped for 15
(e) Lithium carbonate as a mordant for 20 seconds. seconds, 20 seconds, and 30 seconds. Passing the slides
(f) A short water rinse for approximately 20 seconds to through consecutive baths ensures that the final two
completely remove the excess mordant. baths have the purest solutions of xylene and so help
(g) Dehydration in 95% ethanol for 20 seconds before in maximal clearing of the preparations.
eosin staining. (k) Finally, the slides are allowed to stay in the last bath of
(h) Eosin counter-staining for 30 seconds. xylene until a coverslip of the appropriate size is ready
(i) Dehydration in alcohol: Following eosin, the slides are to be placed.
dipped in 95% ethanol for 15 seconds, 100% ethanol
24 SOFT TISSUES AND BONES
FNA biopsy is considered to be of limited value in the ● Reactive lesions may show marked cellular and nuclear
diagnosis of soft tissue and bone lesions. Most clinicians atypia with increased mitotic activity leading to a false-
dealing with such lesions are reluctant to accept the FNA positive diagnosis.
biopsy diagnosis in determining the treatment modality ● Several diverse soft tissue neoplasms share morpho-
for a primary soft tissue or bone tumor. One of the major logic features and require ancillary tests for accurate
factors in limiting the use of FNA biopsies is inadequate diagnosis.
experience in the cytopathology of the bone and soft tis- The small size of the specimen obtained by FNA bi-
sue tumors on the part of the cytopathologist. First of opsy may not allow ancillary diagnostic tests that are nec-
all, these tumors are uncommon and are not encountered essary for the correct typing of the tumor.
in routine cytopathology practice. Unfamiliarity with the The cytologic features and diagnostic criteria of soft
cytologic presentations is also a major limiting factor. tissue tumors are less frequently documented. In general,
Indications for FNA biopsies are most pathologists/cytopathologists lack familiarity with
● To confi rm a recurrent or metastatic soft tissue or the cytopathology of soft tissue and bone tumors.
bone tumor (review of previous material is absolutely
essential).
● To identify a suspected metastatic malignancy with or
SOFT TISSUES
without a known primary.
● To identify an infectious process.
● To differentiate epithelial from lymphoproliferative Over the last few decades, signifi cant developments have
disorders. taken place in the pathology of soft tissue tumors. Several
● To provide morphologic support for alternative ther- neoplasms are reclassifi ed based on findings from utiliz-
apy in cases of inoperable malignancy. ing newer diagnostic techniques. There is a clear recog-
● To monitor the effects of radiation/chemotherapy in nition of solitary fi brous tumors in soft tissues and the
patients with malignant tumors who refuse amputation. realization that most cases of hemangiopericytomas
In many instances, FNA biopsy does allow a definite belong to this category. There has been a reclassification
diagnosis of malignancy and even allows the typing of a of lesions formerly labeled as myxoid malignant fibrous
primary malignant soft tissue or bone tumor. A team ap- histiocytoma and its definite allocation to the fibroblastic
proach is a prerequisite, and clinical data as well as radio- category. Specifi cally, there have been significant changes
logic fi ndings must be taken into account. Preoperative in understanding synovial sarcoma. Voluminous informa-
radiation/chemotherapy given solely on the basis of cy- tion on molecular and genetic studies on many neoplasms
tologic diagnosis has reduced bulky unresectable tumors, is now available. Many fi ndings are of diagnostic impor-
rendering the lesions amenable to surgical excision. tance and are used in the diagnostic process.
Consideration in the cytopathologic evaluation of soft The classification of soft tissue tumors includes a lengthy
tissue and bone lesions should be given to the following: list of both benign and malignant neoplasms. Not all are
subjected to fine needle biopsies. In fact, only a small pro-
● Vascular or desmoplastic malignant tumors often yield portion finds their way across the desk of a cytopathologist.
inadequate or poorly cellular samples that may lead to This chapter will focus on tumors that are more commonly
a false-negative diagnosis.
encountered in the routine practice of cytopathology.
● Infi ltrative characteristics of a malignant neoplasm
The soft tissue tumors have diverse morphologic pat-
composed of cells with bland nuclear pattern can only
be evaluated histologically and cannot be appreciated terns. They can be classifi ed according to 1) the cell or
in cytological specimens. tissue of origin (e.g., fi brous tissue tumors, smooth or
● Number of mitoses per high-power fi eld is a criterion skeletal muscle tumors, adipose tissue, and neural tissue);
often used in histopathologic evaluation to determine 2) cell morphology (e.g., spindle cell tumors, pleomorphic
malignant potential or malignancy. This feature is not cell sarcoma, and round cell tumors); and 3) background
appreciated in cytologic samples. matrix (e.g., tumors with myxoid stroma, chondroid
919
matrix, and osteoid). The approach based on cell mor- a soft gelatinous texture. Histologically, it is composed
phology is practical for differential diagnostic purposes, of plump spindle-shaped cells (fibroblasts or myofibro-
particularly since specifi c typing is not possible for most blasts) containing bland nuclei but may show numerous
of the tumors, and many neoplasms share morphologic regular mitoses. A given lesion may be very cellular. The
features. The interpretation of the tumors in the latter stroma can be loose myxoid with a feathery, tissue cul-
group depends on clinical and radiologic data as well as ture–like appearance. The amount of collagen is variable.
ancillary studies. Both approaches have been used here, In cellular areas, the growth pattern may demonstrate
fi rst, to present a general overview of the different types C- or S-shaped fascicles of spindle cells or a storiform
of tumors and, second, to provide diagnostic consider- pattern.
ations for each group (see Tables 24.5 to 24.7, 24.10).
The aspirates demonstrate varying cellularity. The cyto-
TUMORS AND TUMOR-LIKE LESIONS
logic picture of nodular fasciitis (Figs. 24.1 and 24.2) is
OF FIBROUS TISSUE
characterized by oval to elongated spindle-shaped cells
occurring in tissue fragments (Figs. 24.1A, 24.2A, and
This group is also referred to as fibroblastic/myofibro- 24.2C), isolated, or in groups. The tissue fragments are
blastic tumors as many contain cells with both fibroblas- present in fascicles or irregularly placed spindle cells
tic and myofibroblastic features. without any pattern, separated by variable stromal
Tumor-like lesions and tumors of the fibrous tissue matrix (Fig. 24.2D). The spindle-shaped cells are delicate,
that are generally biopsied using a fine needle include nod- with bipolar processes, round to ovoid nuclei, contain-
ular fasciitis, fibromatosis, solitary fibrous tumor, and fib- ing fi nely granular chromatin and micronucleoli. Mitotic
rosarcoma. All of these lesions are dominated by a spindle fi gures may be frequent but of regular type. The myxoid
cell pattern and must be differentiated from other entities stroma can be abundant, separating the cells, and is per-
that demonstrate a spindle cell pattern (see Table 24.5). meated by infl ammatory cells. The differential diagnoses
include granulation tissue, myxoid fibrosarcoma, and
liposarcoma.
NODULAR FASCIITIS
Nodular fasciitis is a fairly commonly occurring pseudos-
SOLITARY FIBROUS TUMOR/
arcomatous, self-limiting, mass-forming, reactive lesion
HEMANGIOPERICYTOMA
arising from the superfi cial fascia and occasionally from
the deep fascia of the arms and the trunk. The patients are Solitary fi brous tumor (SFT) is a benign tumor of prob-
generally young—20 to 40 years of age—presenting with ably fi broblastic origin, which shows a prominence of
a rapidly enlarging tender movable mass. hemangiopericytoma-like branching vascular pattern
Grossly, the lesions are well-circumscribed, nonen- and morphologically resembles the solitary fibrous tumor
capsulated, soft lesions of up to 2 centimeters and show of the pleura. In fact, most neoplasms interpreted as
A B
Figs. 24.1A and B. Nodular fasciitis. A: Low power showing tissue fragments and dispersed spindle cells in a loose
myxoid background. B: Higher magnification. The spindle cells are delicate with bipolar cytoplasmic processes. Their
nuclei are elongated containing finely granular, uniformly dispersed chromatin.
Chapter 24: Soft Tissues and Bones 921
A B
C D
Figs. 24.2A to D. Nodular fasciitis. A: FNA of a parotid mass. The aspirate is very cellular consisting of tissue frag-
ments and discrete spindle cells in a loose fibrillar matrix (medium power). B: Higher magnification. The spindle cells
are very uniform with low N/C ratios. (Courtesy of Dr. Catherine S. Abendroth, Hershey Medical Center, Pennsylva-
nia State University, Hershey, Pennsylvania.) C: FNA of another case of nodular fasciitis that was extremely cellular
containing large tissue fragments of spindle cells, embedded in loose matrix. D: Higher magnification. The cells are
crowded, nuclei are uniform. Surgical excision confirmed nodular fasciitis.
hemangiopericytomas in the past are now considered to Hemangiopericytoma in the section on Vascular Tumors
be the same as a solitary fibrous tumor. These tumors can (see Figs. 24.26 and 24.27).
occur in a number of locations. The immunoprofi le includes positive reactivity to
Grossly, SFTs present as well-circumscribed masses CD34. The cytogenetic abnormality includes trisomy 21.
ranging widely in size from 1 to 25 centimeters, appearing
multinodular and firm with frequent areas of necrosis and
MYOFIBROBLASTOMA
hemorrhage. Histologically, SFTs show a combination of
hypercellular and hypocellular areas that are separated Myofibroblastoma is a benign mesenchymal tumor com-
from each other by broad bands of tissue and branching posed of spindle-shaped cells with features of myofibro-
blood vessels with a staghorn pattern. The cellular com- blasts, embedded in a stroma that contains coarse bands
ponent is represented by bland spindle cells in varying of hyalinized collagen and conspicuous mast cells and is
numbers. Malignant SFT are usually hypercellular with admixed with variable amounts of adipose tissue.
moderate to marked atypia. Histologically, these tumors are nonencapsulated but
Cytologic findings include varying cellularity consist- well-circumscribed, composed of a mixture of spindle
ing of uniform short spindle cells that are loosely cohesive, cells and adipose tissue. The spindle cells are character-
in aggregates, or in fascicles, separated by loose myxoid or ized by oval to tapered nuclei containing finely granu-
fibrous collagenous stroma (see Chapter 7, e-Fig. 24.43). lar, uniformly dispersed chromatin; micronucleoli; scant
The spindle cells have scant cytoplasm and uniform round cytoplasm; and poorly defi ned cell borders. The spindle
nuclei with finely granular chromatin and micronuclei. See cells are frequently wavy in contour and are frequently
A B
Figs. 24.3A and B. FNA myofibroblastoma. The moderately cellular aspirate contains an admixture of spindle and
round cells in a loose myxoid matrix.
Figs. 24.4A and B. Fibromatosis. FNA of an ill-defined breast mass

A B showing poor cellularity and consisting of spindle cells with vari-
able nuclear atypia. The cells are separated by collagen.
arranged in fascicles. Stroma is collagenous with a big Grossly, it appears fi rm and grayish–pink with a
band. The myofibroblasts can appear epithelioid. Nuclear whorled pattern on a cut surface. Cytohistologically, the
atypia may be present. lesions are variably cellular, depending on the collagen
The aspirates are variably cellular and consist of content. The predominant cell is a spindle type that is
spindle-shaped cells with poorly defi ned cell borders, dispersed either singly or in groups, with ill-defined cell
elongated nuclei with finely dispersed chromatin, and mi- borders and variable amounts of intervening fibrillar to
cronucleoli. Fragments of collagen may be present (Figs. collagenized stroma (Fig. 24.4). Their nuclei may be bland
24.3A and B). Round to polygonal cells are present in the or atypical, simulating a fi brosarcoma. Clinical correla-
epithelioid type. tion is absolutely essential to avoid misinterpretations.
The cells of myofi broblastoma react positively to
desmin, vimentin, actin, and CD34.
FIBROSARCOMA
Fibrosarcoma is a malignant tumor of fibroblasts with
FIBROMATOSIS
variable collagen production and, in classic cases, pres-
Fibromatosis is a benign fibroproliferative lesion that ents herringbone architecture. Fibrosarcomas account
occurs at all ages, involves any body site, and may be for less than 15% of malignant soft tissue tumors. Most
localized or diffuse. Its behavior is intermediate between occur in the deep soft tissues of the legs, the head and the
a benign fibroblastic lesion and a fibrosarcoma. It pres- neck, and in the trunk. These occur at all ages and with
ents either as a single nodule or as an ill-defined con- equal frequency in both sexes. The tumors are rarely
glomerate of several nodular masses with an infiltrative larger than 10 centimeters and can be well-defined or
pattern. infiltrative.
A B
Figs. 24.5A and B. Fibrosarcoma. A: Low power view showing a markedly cellular aspirate consisting of fascicles
of spindle cells. B: Higher magnification depicting fibroblastic cells with elongated nuclei containing granular
chromatin and micronucleoli.
Histologically, fi brosarcomas are composed of uni- collagenized and myxoid zones and deceptively bland
form spindle-shaped cells in interlacing bundles or in a spindled cells with a whirling growth pattern and curvi-
herringbone pattern, separated by collagen. Mitoses are linear blood vessels. These neoplasms are also known as
frequent. hyaline spindle cell tumors with giant rosettes. The cyto-
The aspirates show varying cellularity, demonstrat- logic features of low-grade fi bromyxoid carcinomas are
ing spindle cell in tissue fragments with a fascicular ar- rarely documented in the literature.
rangement (Fig. 24.5) with branching. The tumor cells are
spindle-shaped with bipolar processes and are separated
by delicate collagen. FIBROUS HISTIOCYTIC TUMORS
These tumors were believed to be of histiocytic origin,
MYXOFIBROSARCOMA where the histiocyte can transform into a fibroblast and
produce collagen. Ultrastructural studies suggest their ori-
Myxofibrosarcoma is a malignant fibroblastic lesion with gin to be primitive mesenchymal cells that can differentiate
a variable myxoid stroma, pleomorphism, and a distinc- into histiocytes or fibroblasts and may also contain myo-
tively curvilinear vascular pattern. It was previously con- fibroblasts. The most benign counterparts of fibrous his-
sidered a myxoid type of malignant fibrous histiocytoma. tiocytic tumors arise in the dermis or subcutaneous tissues
Myxofi brosarcomas are the most common sarcomas in while the malignant ones occur deep in the soft tissues.
elderly patients. Histologically, myxofibrosarcomas pres-
ent a broad spectrum of features, characterized by varying Benign Fibrous Histiocytoma
cellularity and pleomorphism with proliferative activity,
multinodular growth pattern, incomplete fibrous septae, Benign fibrous histiocytomas are well-circumscribed
and myxoid stroma. tan–yellow lesions that histologically exhibit interlac-
The cytologic presentation includes varying cellular- ing bundles of spindle cells in a cartwheel pattern. The
ity and myxoid, granular to filamentous stroma. The cel- tumors may also contain multinucleated giant cells with
lular component consists of round to spindled cells with nuclei arranged in a ring-like fashion called Touton cells.
a wide range of shapes and sizes. Their nuclei are gen- Also present are hemosiderin laden histiocytes. The cyto-
erally large and pleomorphic with coarse chromatin and logic features include isolated cells and aggregates of
nucleoli. The cytoplasm is scant to dense and tapered. The stellate and spindle cells containing scant to abundant
low- to medium-grade sarcomas can be recognized on ac- cytoplasm, well-defined cell borders, and round to oval
count of myxoid stroma. In high-grade lesions, with the nuclei with evenly distributed chromatin. Micronucleoli
stroma being scant and the cellularity high, separation maybe identified (Fig. 24.6; see also Chapter 15, Figs.
from other high-grade sarcomas is not possible. 24.56 and 24.57).
Low-Grade Fibromyxoid Sarcoma Atypical Fibroxanthoma

Low-grade fi bromyxoid sarcoma is a distinctive variant Atypical fibroxanthoma usually involves actinic-damaged
of fibrosarcoma, characterized by an admixture of heavily skin in elderly patients. Cytohistologically, this tumor is
Fig. 24.6. FNA benign fibrous histiocytoma with slightly pleomor- Fig. 24.7. FNA atypical fibrous xanthoma showing markedly pleo-
phic, isolated spindle and round cells with bland nuclei. morphic cells and xanthoma cells (Romanowsky stain).
composed of pleomorphic cells consisting of spindle-shaped, proportions of spindle cells in fascicles with a storiform
round, or polygonal cells containing irregular bizarre nuclei pattern, pleomorphism, and giant cells.
with frequent multinucleation and numerous mitotic figures
(Fig. 24.7). The cells may contain lipid (xanthoma cells) and Malignant Fibrous Histiocytomas, Myxoid Type (High-
PAS positive, diastase resistant material. Atypical fibroxan- Grade Myxofibrosarcoma). This subtype is characterized
thoma is histologically indistinguishable from malignant by abundant myxoid stroma with a profuse network of
fibrous histiocytoma but follows a benign course. capillaries and cellular areas showing storiform and a
pleomorphic pattern.
Malignant Fibrous Histiocytoma (MFH)
The term “malignant fi brous histiocytoma” has under- Malignant Fibrous Histiocytomas, Giant Cell Type
gone signifi cant changes over the last several years. They (Pleomorphic Undifferentiated Sarcoma with Giant
were considered to be of histiocytic origin. Studies by Cells). This type of MFH exhibits a predominant giant
immunochemistry have shown that these tumors are cell pattern including osteoclast type cells and storiform
more related to fibroblasts than to histiocytes. Some with pleomorphic areas.
extensive studies can be typed in to known sarcomas. The
term “malignant fi brous histiocytoma” is reserved for
Malignant Fibrous Histiocytomas, Inflammatory Type
neoplasms that show no defi nable line of differentiation
(Pleomorphic Undifferentiated Sarcoma with Prominent
and by ultrastructural studies show fibroblastic/myofi-
Inflammation). An unusual variant of MFH, inflamma-
broblastic differentiation. These are now referred to as
tory type, presents an aggressive behavior and occurs
“pleomorphic undifferentiated sarcomas.”
predominantly in the retroperitoneum. It is characterized
Malignant fibrous histiocytomas that were considered
by lipid-containing xanthoma cells, inflammatory cells
to be the most common malignant soft tissue sarcomas oc-
including histiocytes, and a smaller component of fibro-
curring in middle-aged patients are now considered to rep-
blasts and collagen.
resent less than 5% of adult sarcomas. The sites frequently
involved are the back and the lower extremities. They vary
widely in size from 3 centimeters to bulky tumors of over
20 centimeters; grossly, they are lobulated, fleshy masses. The wide spectrum of morphologic patterns described
Histologically, malignant fibrous histiocytomas above is also noted cytologically in FNA biopsy speci-
are characterized by pleomorphic spindle cells; bizarre, mens (Table 24.1; Figs. 24.8 to 24.10). Differential diag-
multinucleated giant cells; and histiocyte type cells with noses depend on the dominant cellular component. These
phagocytic activity. Their nuclei are very pleomorphic and include neoplasms with spindle cell pattern, pleomorphic
hyperchromatic. The mitotic activity is increased. Based cell pattern, round and polygonal (epithelioid) cell pat-
on the dominant features, several morphologic variants tern, and neoplasms with myxoid stroma (see Tables 24.5
are recognized. to 24.7 and 24.10).
The application of immunocytohistochemistry is lim-
Malignant Fibrous Histiocytomas, Storiform-Pleomorphic ited in the diagnosis of malignant histiocytoma and is
Type. This is the most common type of MFH with varying more often helpful in excluding other neoplasms.
TABLE 24.1 CYTOPATHOLOGIC FEATURES OF MALIGNANT FIBROUS HISTIOCYTOMA
Presentation Dispersed cells or in aggregates, tissue fragments
Cells Pleomorphic in size and shape; round, oval, polygonal, spindle shapes; small, large to giant forms; well-defined
to poorly defined cell borders; high N/C ratios
Nucleus Mononuclear to bi- and multinucleation; central to eccentric location; round, oval to spindle-shaped with
tapering ends; varying sizes; smooth to irregular nuclear membrane; finely to coarsely granular chromatin;
micro/macronucleoli; intranuclear cytoplasmic inclusions; mitoses
Cytoplasm Variable; scant to abundant, pale, dense to vacuolated phagocytosis; ingested cells, acidophilic granules;
intracytoplasmic hyaline structures
Background Varied; necrosis ⫹Ⲑ⫺; inflammatory cells, xanthoma cells; fibrillar, myxoid, proteinaceous
Immunoprofile Nondiagnostic with most antibodies; helpful in ruling out most other soft tissue tumors
Ultrastructure Spindle cells with abundant rough endoplasmic reticulum; intra & extracellular collagen fibrils, round to
polygonal cells with less prominent organelles, phagocytic vacuoles, lipid droplets and nuclear indentation
A B
Figs. 24.8A and B: FNA of malignant fibrous histiocytoma. A: Low power view showing markedly cellular aspirate
consisting of closely packed spindle cells in fascicles with myxoid stroma. B: Higher magnification demonstrating
very pleomorphic spindle and round malignant cells.
A B
Figs. 24.9A to C. FNA malignant fibrous histiocytoma. All three images show a predominant spindle cell pattern. The
cells contain pleomorphic nuclei and are separated by variable myxoid matrix. (continued)
A B
Figs. 24.10A to C. Malignant fibrous histiocytoma. A: Pleomorphic

spindle cells. B, C: These three images show bizarre, multinucleated
C malignant giant tumor cells in an inflammatory background.
Ultrastructurally, the fibroblast-like spindle cells TUMORS OF THE ADIPOSE TISSUE

show abundant rough endoplasmic reticulum, intra-
cytoplasmic and extracellular collagen fibrils, and ir-
LIPOMA
regular membrane projections. The histiocyte-like,
round to polygonal cells contain less prominent organ- Lipomas are benign tumors of mature fat cells that
elles, phagocytic vacuoles, lipid droplets, and nuclear can occur anywhere in the body. They grossly appear
indentations. as bright yellow lobulated masses of varying sizes.
Cytohistologically, lipomas are composed of lobules of ● Myxoid type—the most common variant containing
mature fat cells (adipocytes) with large clear vacuoles lipoblasts and a complex network of capillaries in a
formed as a result of the dissolving of fat pushing the myxoid background. These may show a predominant
nucleus to the periphery. A delicate capillary network is spindle cell pattern.
characteristic. Morphologic variants include pleomorphic Differential diagnoses include other neoplasms with
and spindle cell types. a myxoid background. Myxoid liposarcomas present a
broad spectrum of patterns ranging from highly differ-
Spindle Cell Lipoma/Pleomorphic Lipoma
entiated myxoid tumors with lipoblastic differentiation
Spindle cell/pleomorphic lipomas mostly occur in men to poorly differentiated round cell tumors referred to as
who are 45 to 60 years of age. They occur in the subcu- “round cell liposarcomas” with inconspicuous lipoblas-
taneous tissues of the posterior neck, the shoulder, and tic differentiation. They may contain low cellular areas
the back approximately 80% of the time. The remaining with enhanced cellularity at the periphery or consist of
20% can occur anywhere in the head and the neck area. bland fusiform to round cells suspended individually in
Grossly, spindle cell lipomas resemble the usual type a myxoid matrix composed of hyaluronic acid. Mitoses
of lipoma, with their size varying from 3 to 5 centimeters. are generally rare. A delicate plexiform capillary net-
They are well-circumscribed and may show a myxoid cut work is a characteristic feature. The presence of lipo-
surface. Their texture is fi rmer than the usual lipomas. blasts is diagnostic. Lipoblasts can be univacuolated
The histologic pattern varies widely from bland spindle to multivacuolated, and the vacuoles that indent the
cells separated by fat cells and thick ropy collagen. The hyperchromatic nucleus result in forming scalloped nu-
spindle cells have elongated nuclei and narrow bipolar clear edges. The nucleus stains deep. The myxoid round
cytoplasmic processes. The nuclear chromatin is finely cell type occurs in a younger age group (25 to 45 years)
granular and uniform with inconspicuous nucleoli. Multi- with translocation t(12:16). They recur and metastasize
nucleated giant cells with peripherally arranged nuclei depending on the round cell component.
(the floret cells) may be present. These morphologic vari- Round cell type liposarcoma consists of small round
ants of benign lipomas mimic the cytohistologic patterns cells with an epithelioid pattern. In the absence of cyto-
of a well-differentiated liposarcoma. plasmic vacuoles that are suggestive of lipoblasts, this
type may not be recognized as liposarcoma.
Cytopathologic Features. Aspiration biopsy specimens
are usually very cellular (Fig. 24.11A) and consist of vary- ● Pleomorphic type is composed of large bizarre cells
ing-sized tissue fragments of spindle or polygonal stromal with one or more nuclei and lipoblasts. This type must
cells admixed with adipocytes or individual fat cells, con- be differentiated from other sarcomas with a pleomor-
phic cell pattern (see Table 24.7).
taining abundant clear cytoplasm. Their nuclei are elon-
● The de-differentiated type of liposarcoma, which
gated and contain finely granular uniform chromatin. The
can occur as a progression of low-grade liposarcoma
stroma can be myxoid. Floret cells can be present. No representing a late complication into a higher grade.
lipoblasts are present. Histologically, de-differentiated liposarcomas show
The differential diagnoses include atypical lipoma/ areas of ATN/WD to a nonlipogenous component
well-differentiated liposarcoma. with abrupt transition and a sharp interface. The
two patterns may merge or commingle. It may pres-
LIPOSARCOMA ent a pattern of high-grade sarcoma. Some unusual
morphologic changes include undifferentiated large
Liposarcomas are one of the most common malignant cells resembling epithelial malignancy or malignant
soft tissue tumors occurring in the deeper tissues of the melanoma. The neoplastic spindle cells may present a
extremities, the inguinal region, and in the retroperito- whorled pattern seen in meningiomas or nerve sheath
neum. They occur in adults beyond the fourth decade of tumors or may show a pericytic pattern. The dediffer-
life. One-third to one-half of all liposarcomas occur in entiated liposarcoma recurs locally and metastasizes.
Genetic abnormality includes the ring chromosome
the younger age group with a peak in the fifth decade.
and translocation t(12:16).
More frequent in the extremities, they also occur in the
retroperitoneum.
Grossly, the tumors are soft to firm, yellow to gray, mul- Immunoprofile
tinodular masses. Histologically, several patterns are noted: Liposarcoma is reactive to vimentin and S100 protein.
● Atypical lipomatous neoplasm/well-differentiated lipo-
sarcoma (ATN/WD) that closely resembles pleomor- Cytopathologic Features
phic and spindle cell lipoma. The well-differentiated
liposarcomas may recur locally, and do not metastasize The aspirates of liposarcomas present a very broad spec-
but can de-differentiate. Genetic abnormality includes trum (Table 24.2; Figs. 24.11B to 24.15) corresponding
the presence of the giant ring chromosome. to a varied morphology.
TABLE 24.2 CYTOPATHOLOGIC FEATURES OF LIPOSARCOMA
Cellularity Variable, low in well-differentiated; high in pleomorphic type
Presentation Cells individually dispersed, or in aggregates, may be attached to blood vessels; extensive and complex
capillary network—a diagnostic feature
Cells Round to oval, spindle-shaped to pleomorphic types; cell borders well-defined; lipoblasts uni- or
multivacuolated with scalloped nuclei; small vacuoles in elongated cells
Nucleus Eccentric, mostly single, multiple in bizarre forms; nuclei may be indented or scalloped by cytoplasmic
vacuoles; fine to coarsely granular chromatin; micronucleoli ⫹; mitoses rare
Cytoplasm Pale, vacuolated; single to multiple vacuoles
Background Clean to myxoid magenta stain with Romanowsky, pale lavender with Papanicolaou; necrosis ⫹Ⲑ⫺
Histochemical Stains Glycogen diastase sensitive ⫹; alcian blue ⫹; hyaluronidase nonresistant
Immunoprofile Vimentin ⫹; S100 protein ⫹; (may be negative in poorly differentiated tumors)
Genetic and Molecular Typical translocation t(12:16)(q:p11); fusion transcript CHOP.TLS, (fusion gene product); giant ring
Studies chromosome
A B
Figs. 24.11A and B. A: Spindle cell lipoma. The aspirate is moderately cellular, consisting of loosely cohesive spindle
cells with elongated nuclei, containing finely granular chromatin. B: well-differentiated liposarcoma showing swirls
of spindle cells containing elongated bland nuclei.
A B C
Figs. 24.12A to C. FNA liposarcoma. A, B: These two images depict lipoblasts with cytoplasmic vacuoles, indenting
the nucleus. C: Sparse spindle cells in a myxoid background. Note the lipoblasts with cytoplasmic vacuoles and
curlicue capillaries.
928
A B
Figs. 24.13A and B. FNA myxoid liposarcoma. Discrete, pleomorphic round to spindle cells in a myxoid back-
ground. A: Romanowsky. B: H&E.
Fig. 24.14. FNA liposarcoma. A cellular aspirate comprising round

cells in myxoid matrix.
A B
Figs. 24.15A and B. FNA liposarcoma. Pleomorphic type consisting of varying-sized round and spindle cells in
myxoid stroma.
The well-differentiated liposarcomas (ALN/WD) are with ovoid to cigar-shaped nuclei and varying amounts
usually low to moderately cellular consisting of spindle of collagenized stroma. Aspirates of leiomyomas are
cell proliferation in the form of fascicles separated by adi- encountered only on rare occasions. The cytologic pat-
pocytes (Fig. 24.11B). The spindle cells often have bland tern is characterized by low to moderate cellularity
nuclei. Lipoblasts are rare. with predominantly small tissue fragments of spindle
The myxoid liposarcomas, as the name implies, dem- cells forming fascicles with a parallel alignment of
onstrate abundant myxoid matrix with a delicate capil- nuclei. The latter are elongated, uniform, and cigar-
lary network (Figs. 24.12 and 24.13). The cellularity is shaped with blunt ends. The nuclear chromatin is finely
variable, represented by pleomorphic spindle to round granular and evenly dispersed, and the micronucleoli
cells suspended in the myxoid matrix. Lipoblasts are easy are inconspicuous.
to identify.
The round cell type liposarcoma tends to be more cel-
lular with the tissue fragments of pleomorphic round cells LEIOMYOSARCOMA
demonstrating poorly defi ned cell borders and scant to
vacuolated cytoplasm (Fig. 24.14). Their nuclei show a These malignant neoplasms of the smooth muscle
variable degree of atypia and may demonstrate scalloping mostly occur in the uterus and in the gastrointestinal
membranes due to cytoplasmic vacuoles. tract. They also occur in the soft tissues of the retro-
The pleomorphic types of liposarcomas are hyper- peritoneum including the pelvis, in large blood vessels,
cellular (Figs. 24.15A and B) with a dispersed cell pat- and in the skin. They account for 5 to 10% of all soft
tern. The malignant cells show great variation in size and tissue sarcomas. The soft tissue leiomyosarcoma usu-
shape with marked nuclear pleomorphism. Multinucle- ally occurs in middle-aged or older individuals with a
ated giant cells are a predominant feature of this vari- significant number occurring in the retroperitoneum
ant. Lipoblasts are rare. The background often shows including the pelvis and in large blood vessels. These
necrosis. tumors are circumscribed, grayish–pink, smooth to
lobulated, often bulky, hemorrhagic, and demonstrate
Differential Diagnoses of Liposarcoma necrosis. Histologically, leiomyosarcomas may be well-
to poorly differentiated with fascicles of spindle-shaped
The differential diagnoses of liposarcomas depend on cells containing eosinophilic cytoplasm and elongated,
the type. The low-grade liposarcomas (ATN/WD) must cigar-shaped nuclei with blunt ends, often arranged in
be differentiated from hibernomas and spindle cell a palisading fashion. Mitoses may be numerous, and
lipomas. necrosis is frequent. Well-differentiated leiomyosarco-
With liposarcomas presenting a myxoid background, mas are difficult to differentiate from leiomyomas. This
several lesions that produce a myxoid background enter distinction is often based on infiltrative margins and the
the differential diagnosis (see Table 24.10; Figs. 24.79 to number of mitoses per high-power field—features that
24.84). Liposarcomas with a round cell pattern need to be can only be evaluated on a histologic examination and
differentiated from rhabdomyosarcomas. The differenti- not by cytologic evaluation.
ated ones present a pattern similar to pleomorphic undif-
ferentiated sarcoma (MFH). Cytopathologic Features
The aspirates of leiomyosarcomas demonstrate variable
cellularity and consist of fascicles of compactly arranged
TUMORS OF THE SMOOTH MUSCLE spindle cells with no intervening stroma or matrix mate-
rial (Table 24.3; Figs. 24.16 to 24.18). The spindle cells
LEIOMYOMA have poorly defi ned cell borders and scant to moderate
cytoplasm with bipolar processes. Their nuclei are elon-
Leiomyomas are benign tumors of the smooth muscle, gated with blunt ends (cigar-shaped) containing fine to
occurring in the viscera and the soft tissues, with the coarsely granular chromatin and nucleoli. A dispersed cell
former being the most frequent. Among the visceral pattern as well as nuclear pleomorphism is also noted in
leiomyomas, the uterus is the most common site fol- less differentiated tumors. The latter may also show an
lowed by the gastrointestinal tract. Visceral leiomyo- epithelioid cell pattern.
mas are mostly submucosal, can attain a large size, and
are not usually subjected to FNA biopsy. Soft tissue
Immunoprofile
leiomyomas occur in the skin, the sub cutis, and rarely,
in the deep soft tissues. Leiomyomas vary in size and The cells of leiomyosarcomas react positively to smooth
are well-circumscribed. Histologically, they are charac- muscle actin/muscle-specifi c actin, HHF-35, and desmin
terized by interlacing bundles of spindle-shaped cells 40 to 50%.
TABLE 24.3 CYTOPATHOLOGIC FEATURES OF LEIOMYOSARCOMA
Cellularity Variable, low in well-differentiated; high in poorly differentiated
Presentation Malignant cells isolated, in loose aggregates or in bundles with palisading of nuclei
Cell size Uniform (in well-differentiated) to pleomorphic spindle-shaped; cell borders poorly defined; round and variable
in size in epithelioid type
Nucleus Ovoid, spindle-shaped to elongated, cigar-shaped with blunt ends; smooth to irregular nuclear membrane; fine
to coarsely granular chromatin; multinucleation⫹Ⲑ⫺ in poorly differentiated forms; nucleoli present; mitoses
frequent
Cytoplasm Variable, pale, perinuclear vacuoles; bipolar cytoplasmic processes
Background Clean to necrotic; bare nuclei in poorly differentiated types
Immunoprofile Muscle specific actin ⫹; HHF 35 ⫹
Ultrastructure Numerous well-oriented thin myofilaments, dense bodies; deeply clefted nuclei
A B
Figs. 24.16A and B. Leiomyosarcoma. Cellular aspirate with loosely cohesive, delicate spindle cells with variable
cytoplasm, drawn into delicate bipolar processes. Their nuclei are elongated with blunt ends. The nuclear chromatin
is finely granular.
Fig. 24.17. Leiomyosarcoma, metastatic to lung. The malignant

cell population consists of round and spindle cells with poorly de-
fined cell borders. The nuclei are pleomorphic in size and shape.
A B
Figs. 24.18A and B. Leiomyosarcoma. A: The malignant cells are discrete with a dispersed pattern. The cell borders
are poorly defined with high N/C ratios. Their pleomorphic nuclei are round, oval to elongated, with blunt ends. The
nuclear chromatin is granular and contains micronucleoli. B: The malignant cells are spindle shaped, loosely cohesive
and in fascicles with delicate elongated nuclei.
Fig. 24.19. FNA metastatic gastrointestinal stromal tumor to cer- Fig. 24.20. FNA of a gastrointestinal stromal tumor showing loose
vical lymph node. These cells are small, epithelioid and contain aggregates of cells with very long cytoplasmic processes. The nuclei
scant cytoplasm. are very slender, long and thin.
GASTROINTESTINAL STROMAL TUMOR (GIST) Rhabdomyosarcomas mostly occur in the pediatric

age group and in adolescents, with only a small propor-
Gastrointestinal stromal tumors (GIST) are defined as
tion occurring in adults and the elderly. Three histologic
mesenchymal tumors displaying differentiation toward
types are recognized: pleomorphic, alveolar, and embryo-
the lines of interstitial cells of Cajal and, typically, express
nal. The botryoid type, previously considered a separate
CD117/c-kit.
type, is now included as a morphologic variant of embry-
GISTs are a recently described entity that was previ-
onal type rhabdomyosarcoma. An overlap exists between
ously interpreted as smooth muscle tumors such as leio-
these morphologic variants.
myoma, leiomyosarcoma, or leiomyoblastoma (Figs. 24.19
Pleomorphic rhabdomyosarcoma seen in adults is
and 24.20) and are discussed in detail in Chapter 8.
extremely rare. Cytohistologically, it is characterized by
markedly pleomorphic spindle cells, large round cells,
and racket-shaped or strap cells, with abundant dense
TUMORS OF THE SKELETAL MUSCLE
eosinophilic cytoplasm. The nuclei may be single or
multiple, pleomorphic in size, and are located at the ex-
Rhabdomyomas are benign neoplasms of rare occurrence panded end of the cells. Longitudinal and cross-striations
that are almost never encountered in the usual practice of in the cytoplasm, when present, are helpful diagnos-
cytopathology. tic features. The differential diagnoses of pleomorphic
rhabdomyosarcomas include other neoplasms with a

pleomorphic cell pattern, particularly pleomorphic ma-
lignant fibrous histiocytoma (see Table 24.6).
The alveolar and embryonal types of rhabdomyosar-
comas occur predominantly in childhood and in adoles-
cents and are discussed in Chapter 25.
TUMORS OF VASCULAR ORIGIN
Benign tumors of vascular origin include hemangiomas,

lymphangiomas, and several different entities. With the
exception of hemangiomas, the rest are not encountered
Fig. 24.21. FNA of liver involved by multiple nodules, showing
in the practice of cytopathology. FNA biopsy is performed epithelioid hemangioendothelioma. The aspirate shows discrete
only in specifi c instances (e.g., cavernous hemangioma pleomorphic cells with poorly defined cell borders.
involving the liver, presenting as a mass lesion or as cystic
hygroma, which presents as a large mass) (refer to Chap-
ter 12). The cytologic features are nondescript with only
blood or lymphocytes. have large eccentric nuclei containing fine to coarsely
Among the malignant tumors of vascular origin, only granular chromatin, one or more distinct nucleoli, and
epithelioid hemangioendothelioma, Kaposi’s sarcoma and occasional pseudoinclusions. Their cytoplasm is vari-
angiosarcoma are discussed. able with sharply demarcated vacuoles. Multinucleated
giant cells are occasionally present. The neoplastic cells
exhibit positive immunoreactivity to factor VIII and
EPITHELIOID HEMANGIOENDOTHELIOMA CD31.
The differential diagnoses include spindle cell neo-
Epithelioid hemangioendothelioma is a rare tumor of
plasms (Table 24.5) and adenocarcinomas with an epi-
vascular origin with a biologic behavior that is interme-
thelioid pattern and cytoplasmic vacuoles.
diate between benign hemangiomas and angiosarcomas.
Hemangioendotheliomas occur predominantly in adults
and at any site (e.g., superficial and deep soft tissues or
ANGIOSARCOMA
the viscera such as the liver, the lung, and the bones).
Hemangioendotheliomas recur locally with some ability Angiosarcoma is a malignant tumor, the cells of which
to metastasize. An angiocentric tumor, it develops as a variably recapitulate the morphologic and functional
solitary mass. Approximately 50% of cases are closely features of normal endothelium. Angiosarcomas are
associated with or arise from a blood vessel, usually rare, highly aggressive, malignant tumors and include
a vein, and may completely occlude it, resembling a hemangiosarcomas and lymphangiosarcomas. These
thrombus. tumors, which involve any site or organ, can be soli-
Histologically, epithelioid hemangioendothelioma is tary or multifocal and diffuse. Angiosarcomas are often
composed of cords and nests of round to elongated en- related to lymphedema, radiation therapy, or thorotrast
dothelial cells. The cells are mostly uniform with bland administration.
nuclei and show intracytoplasmic lumens, which may be Angiosarcomas present a varied morphology from a
seen as clear spaces that may distort the nucleus, referred bland hemangioma-like pattern to anaplastic types. Their
to as “blistering” the cell. The lumens may contain red morphologic spectrum ranges from a purely spindle cell
blood cells. The stroma can be myxoid or hyaline. Ap- pattern to an epithelioid pattern. The low-grade angiosar-
proximately, one-third of cases may exhibit considerable comas consist of infi ltrating and anastomosing blood
nuclear atypia and mitotic activity. channels lined by one or more layers of endothelial cells.
The latter may be in the form of concentrically arranged
whorls, pseudoacini, or rosettes. Their nuclei are round,
plump, vary in size, have fi nely granular chromatin, and
Aspiration biopsy specimens of hemangioendothe- present deep clefting. The nuclei often exhibit molding.
liomas reveal discohesive, pleomorphic, round, epithe- Their cytoplasm is vacuolated and sometimes shows
lioid, endothelial cells with variable numbers of spindle- erythrophagocytosis. Mitotic activity is low, and necrosis
shaped cells (Figs. 24.21 and 24.22). The neoplastic cells is generally not present.
A B
Figs. 24.22A to C. FNA of a 1-centimeter mass involving the lower

lip, consisting of a mixed population of small round and spindle
cells, varying in size. The cell borders are poorly defined and the pale
cytoplasm is variable in amount. The nuclear chromatin is finely
granular and uniform. The surgical excision confirmed the diagnosis
C of epithelioid hemangioendothelioma.
The high-grade angiosarcomas histologically show a The differential diagnoses of high-grade angiosarco-
solid pattern. The aspirates consist predominantly of in- mas include poorly differentiated carcinomas or soft tis-
dividual cells that are oval or spindle to stellate shapes sue sarcomas (see Table 24.7).
and variable in size with giant forms. The nuclei have an
irregular membrane, coarsely granular chromatin, promi-
nent nucleoli, and longitudinal clefting. Mitotic activity KAPOSI’S SARCOMA
is increased. The neoplastic cells have variable cytoplasm
Kaposi’s sarcoma predominantly involves skin occurring as
(Fig. 24.23).
solitary or multiple reddish–brown to bluish–red slightly
The epithelioid type consists of pleomorphic cells
elevated nodules. These small nodules of a few millimeters
(Fig. 24.24) that are loosely cohesive or in syncytial tis-
in diameter may spread all over the body and also involve
sue fragments, usually without any architectural patterns,
the visceral organs. The incidence of Kaposi’s sarcoma is
but they may form pseudoacinar structures that contain
quite high in immunosuppressed individuals with AIDS.
red blood cells (angioformative). Their nuclei may be ec-
Cytologic findings include the presence of spindle-
centric, showing varying degrees of atypia with frequent
shaped cells that are individually dispersed and in tissue
mitoses. Their cytoplasm is variable and finely granular
fragments. The cell borders are indistinct with nuclear
with intracytoplasmic hemosiderin in some cases. Bi-
overlap. The individual cells are short and elongated
and multinucleation is rare. The background is usually
with fibrillar cytoplasm and cytoplasmic processes.
bloody.
They may appear rounded in cytologic preparations
(Fig. 24.25). Their nuclei are oval to elongated with
Immunoprofile
finely granular chromatin and inconspicuous nucleoli.
The cells of angiosarcomas react positively to vascular The background is bloody with hemosiderin-laden
markers such as factor VIII and to CD31 and CD34. macrophages.
A B
Figs. 24.23A to C. FNA of a postmastectomy angiosarcoma of the

breast showing discrete, pleomorphic and bizarre spindle-shaped
malignant cells (Courtesy of Dr. Ann T. Moriarty, Indianapolis,
C Indiana.)
A B
Figs. 24.24A and B. Lymphangiosarcoma presenting with pleural effusion. A, B: The smears from the effusion fluid
showed predominantly pleomorphic epithelioid cells, discrete, in loosely cohesive groups and in syncytial tissue
fragments. The vascular origin of the tumor is not apparent from the cytomorphology and the final diagnosis was
established from ultrastructural studies.
Fig. 24.25. Kaposi’s sarcoma. Scrape preparation of a lymph node

involved by Kaposi’s sarcoma. The malignant cells are epithelioid
and minimally pleomorphic (H&E).
Figs. 24.26. Hemangiopericytoma/solitary fibrous tumor. FNA of

large mass involving the lower extremity showing tightly packed
spindle-shaped cells with scant cytoplasm, poorly defined cell bor-
ders, oval to elongated nuclei, and finely granular chromatin.
HEMANGIOPERICYTOMA/SOLITARY or herringbone patterns are absent. A characteristic pat-

FIBROUS TUMOR tern includes branching endothelial-lined capillaries with
a staghorn pattern.
Hemangiopericytoma is currently believed to be a neo-
plasm that is closely related to the entity referred to as
a solitary fibrous tumor. Hemangiopericytoma was con-
sidered to be arising from vascular pericytes; however, The cytopathologic features include spindle cells that
this concept is not proven. Nevertheless, it is included in are either scattered, in aggregates, or in tissue fragments,
the section on vascular tumors. Hemangiopericytomas forming arcades or anastomosing to enclose spaces with a
are rare tumors; occur in adults as a solitary, slow- gland-like pattern. The neoplastic cells are round to spindle
growing, painless mass; and are located deep and intra- forms and have poorly defined cell borders and granular,
muscularly with no predilection for any specific site but scant cytoplasm sometimes with vacuoles (Figs. 24.26 to
are seen in the lower extremities, the retroperitoneum, 24.27C). Their nuclei are round to oval with finely granu-
the head and the neck as well as the dura. Hemangio- lar chromatin and micronucleoli. Malignancy is suggested
pericytomas are potentially malignant with frequent by cellular and nuclear pleomorphism, increased mitotic
recurrences. Metastasis, when it occurs, involves the activity, and necrosis. Hemangiopericytomas are immuno-
lungs and the bones. logically reactive to CD34 and nonreactive to factor VIII,
Histologically, the tumor is very cellular with tightly desmin, and myoglobulin, while being reactive to S100
packed, small, round to oval, uniform cells surround- protein, actin, and vimentin. These tumors are associ-
ing the endothelium-lined vascular places. The stroma is ated with abnormalities involving chromosome 12q. The
scant. Features such as fascicular arrangement, storiform, differential diagnoses include other spindle cell lesions
A B
Figs. 24.27A to C. Hemangiopericytoma. A, B: FNA of lung mass

consisting of a large population of spindle cells with elongated nu-
clei containing finely granular chromatin. There is a fine capillary
network within the aggregates of the neoplastic cells. The surgical
excision confirmed a hemangiopericytoma. (Courtesy of Dr. Claire
W. Michael, University of Michigan Health System, Ann Arbor,
Michigan.) C: Scrape preparation of a dural mass showing uniform
spindle cells along the capillary network. The neoplastic cells are
round to spindle-shaped with uniform nuclei. The lesion was histo-
C logically confirmed as hemangiopericytoma.
(see Table 24.5). Also refer to Solitary Fibrous Tumor in glandular formation and has specific chromosomal trans-
the section on Fibroblastic Tumors. location t(X:18)(p11.2:11.2). Although it is commonly
referred to as synovial sarcoma, this neoplasm does not
arise from or differentiate toward synovium. Because of
its epithelial features, it has been proposed that synovial
TUMORS OF THE SYNOVIUM sarcoma should be renamed as a carcinosarcoma of soft
tissue. However, the term “synovial sarcoma” continues
to be in use.
GIANT CELL TUMORS OF THE Synovial sarcomas account for 5 to 10% of all soft
TENDON SHEATH tissue sarcomas. They present as a painful mass, with the
Giant cell tumors are benign tumors of the tendon sheath common sites being the lower extremities followed by the
and the synovium. They are of common occurrence with upper extremities, the head and the neck, and the trunk.
a peak incidence during the fourth to the sixth decades of Recurrence and metastasis, particularly to the lungs, are
life. The sites frequently involved are the hands, the inter- frequent. They are most prevalent in adolescents and
phalangeal joints, the feet, the ankles, and the knees. They young adults who are 15 to 40 years of age and are slightly
are slow-growing and range from 0.7 to 5 centimeters. more common in males.
Cytohistologically, these tumors consist of mononuclear Histologically, synovial sarcomas present two major
cells, multinucleated giant cells, and xanthoma cells (lipid categories: monomorphic (monophasic) and biphasic.
containing histiocytes) in varying proportions in a back- The biphasic synovial sarcomas contain distinct epithelial
ground of collagenized stroma (Fig. 24.28). and a spindle cell component in varying proportions. The
monophasic type contains either an exclusive spindle cell
or an epithelial component forming glandular structures.
SYNOVIAL SARCOMA A vast majority of synovial sarcomas are of the mono-
Synovial sarcoma is a mesenchymal spindle cell tumor phasic type with a spindle cell component. These consist
that displays variable epithelial differentiation including of fascicles and sheets of relatively small ovoid cells. Mast
Fig. 24.28. FNA of a giant cell tumor of the tendon sheath, show-
ing pleomorphic dispersed cell pattern with numerous multinucle-
ated cells.
A B
Figs. 24.29A and B. Synovial sarcoma. FNA showing spindle-shaped and round cells with poorly defined cell
borders, scant cytoplasm, and containing round to ovoid bland nuclei.
cells may be present in large numbers. Poorly differen- from round, oval, and spindle-shaped to comma-shaped.
tiated synovial sarcomas demonstrate high cellularity, Nucleoli are inconspicuous to prominent. The spindle
increased mitotic activity, necrosis, and consist of small cells may be seen in fascicles. Nuclear pleomorphism is
round cells resembling PNET. not a feature of synovial sarcomas. The stroma is variable
Monophasic epithelioid types are rare and cannot be and can be myxoid (Fig. 24.32B). Cells from the epithelial
differentiated from adenocarcinomas without ancillary component are not readily identified in aspirates.
tests. Synovial sarcoma with a biphasic pattern can be
readily recognized. However, a monophasic variant must Immunoprofile
be differentiated from other spindle cell sarcomas. The
spindle cells are very uniform with nuclei containing finely Synovial sarcoma cells react positively with S100 protein.
granular chromatin and inconspicuous nucleoli. The epi-
thelioid component is positive with mucin stains. Cytogenetics and Molecular Studies
In over 90% of synovial sarcomas, the translocation
t(X:18)(p11.2:11.2) has been demonstrated and has
The aspirates of biphasic and fibrous type monophasic syn- become the hallmark of the tumor. The translocation has
ovial sarcomas tend to be moderate to highly cellular (Figs. resulted in fusion product SYT-SSX, which can be identi-
24.29 to 24.32), consisting of a large population of spindle fi ed with FISH. The genes affected by the t(X:18) have
cells, either dispersed or in loosely cohesive groups. The been isolated (SS18 or SSXT) from chromosome 18, and
neoplastic cells are short and spindle-shaped with poorly SSX1, SSX2, and SSX4 have been isolated from the X
defined cell borders, scant tapering cytoplasm with high chromosome. FISH demonstrates the fusion product SYT-
N/C ratios, and bland nuclei. The nuclear shapes range SSX1, SYT-SSX2, and SYT-SSX4.
A B
Figs. 24.30 A and B. Synovial sarcoma FNA consisting of spindle-shaped and round cells with glandular structures
(arrows).
Fig. 24.31. FNA of a synovial sarcoma with a pleomorphic cell pat-

tern. The stroma is myxoid (Romanowsky).
A B
Figs. 24.32A and B. FNA of synovial sarcoma. A: The neoplasm is monomorphic composed of spindle cells with
poorly defined cell borders and oval to elongated bland nuclei. B: Synovial sarcoma with a spindle cell pattern and
abundant myxoid stroma.
anywhere in the body, but 45% are found in the head

TUMORS OF THE PERIPHERAL NERVES and the neck and are seen in an older age group (30
to 60 years); women are more often involved. Patients
Benign tumors of the peripheral nerves that are encountered are generally asymptomatic. Schwannomas are gener-
in the practice of cytopathology include schwannomas and ally small but vary in size, are circumscribed, and are
neurofibromas. Schwannomas are exclusively composed pale yellow with myxoid to cystic areas. Histologically,
of Schwann cells, while neurofibromas consist of Schwann schwannomas are characterized by compactly arranged
cells and neurites. Cytologically, it is often not possible to delicate spindle cells (Antoni type A) mixed with
differentiate between schwannoma and neurofibroma. myxoid loose areas (Antoni type B). The presence of
Verocay bodies is characteristic. They consist of tissue
fragments of spindle cells with palisading nuclei and
SCHWANNOMAS central fibrillar cores. Cytologic features of schwan-
Schwannomas (neurilemmoma) are benign, encapsu- noma are listed in Table 24.4 and illustrated in Figures
lated tumors of Schwann cell origin. They can occur 24.33 and 24.34.
TABLE 24.4 CYTOPATHOLOGIC FEATURES OF SCHWANNOMA & MALIGNANT

PERIPHERAL NERVE SHEATH TUMORS
Schwannoma Malignant Peripheral Nerve Sheath Tumors

Cellularity Poor to moderate Moderate to marked
Presentation Cells mostly in tissue fragments or in fascicles; Dispersed cells, small aggregates or tissue fragments; lack
Verocay bodies; single cells infrequent fascicular arrangement
Cells Fusiform, elongated with cytoplasmic processes; Pleomorphic in size, plump; not as elongated or spindle-
poorly defined cell borders; low N/C ratio shaped as in benign counterpart; tadpole, comet shapes
Nucleus Elongated, wavy; smooth nuclear membrane; Large pleomorphic; high N/C ratio; round, oval to
finely granular, evenly distributed chromatin; irregular; coarsely granular chromatin, parachromatin
inconspicuous nucleoli clearing; prominent nucleoli; mitoses ⫹Ⲑ⫺
Cytoplasm Variable, pale, fibrillar to hyaline Variable, fibrillar to hyaline; scant and indistinct in poorly
differentiated forms
Background Fibrillar material; collagen; histiocytes Bare nuclei; necrosis
Immunoprofile S100 protein ⫹ S100 protein ⫹

Vimentin ⫹ Vimentin ⫹
A B
Figs. 24.33A to C. A: FNA of a schwannoma showing large and thick tissue fragments of spindle cells in densely
collagenized stroma (low power). B: Higher magnification showing haphazard distribution of spindle cells with
elongated nuclei. The stroma is dense. (continued)
Figs. 24.33C. (continued) C: FNA of a neurofibroma showing pleo-

morphic spindle cells separated by collagenous stroma. The nuclei
C are elongated, wavy and delicate.
Fig. 24.34. Bronchial brushings of a metastatic malignant peripheral Fig. 24.35. FNA of a peripheral malignant nerve sheath tumor
malignant nerve sheath tumor showing an epithelioid cell pattern showing fascicles of spindle cells.
Fig. 24.36. FNA of a metastatic peripheral malignant nerve sheath Fig. 24.37. FNA of a metastatic peripheral malignant nerve sheath
tumor exhibiting an epithelioid cell pattern, mimicking an adeno- tumor depicting a very pleomorphic epithelioid cell pattern
carcinoma.
MALIGNANT PERIPHERAL NERVE

hausen’s disease. They may occur along the nerve trunks
SHEATH TUMOR (MPNST)
in the extremities and, occasionally, in the abdomen and
Malignant peripheral nerve sheath tumors (also called the mediastinum.
neurogenic sarcoma, malignant schwannoma, neurofi- Histologically, MPNSTs resemble fibrosarcomas but
brosarcoma) are uncommon malignant neoplasms, pre- the spindle cells exhibit markedly irregular contours, since
senting as an isolated lesion or as part of von Reckling- they are wavy, serpentine, and comma-shaped in profile
and are asymmetrically oval en face. Their cytoplasm Infrequently, soft tissue tumors may present a strik-
is indistinct. The cells are arranged in densely cellular ing morphology with large, bizarre, giant tumor cells.
sweeping fascicles, alternating with loosely cellular ones. Although the diagnostic possibilities are limited, they in-
Parallel orientation of the cells and nuclei is lacking; some clude osseous lesions, epithelial neoplasms, as well as he-
may have a nodular curlicue or whorled appearance. Cells matopoietic lesions, and malignant melanomas also need
may be rounded or short fusiform. The background may to be considered (Table 24.7; Figs. 24.55 to 24.60).
contain hyaline fibrillar matrix, which is scant to absent Certain uncommon lesions of questionable origin de-
in poorly differentiated lesions. scribed below in the section on miscellaneous soft tissue
tumors need to be considered in the differential diagnos-
tic possibilities.
Finally, considerable overlap between soft tissue tu-
The aspirates are usually cellular (Table 24.4; Figs. 24.34 mors and cellular osseous neoplasms may result in diag-
to 24.37), consisting predominantly of spindle-shaped nostic difficulties.
cells that are isolated, in groups, or in fascicles. The spin-
dle cells contain characteristically wavy, serpentine, and
comma-shaped nuclei. The cell borders are poorly defined
and the chromatin is granular with nucleoli. The epithe- MISCELLANEOUS SOFT TISSUE TUMORS
lioid forms may exhibit considerable nuclear pleomor-
phism and resemble an epithelial malignancy (Figs. 24.34,
24.36 and 24.37). GRANULAR CELL TUMORS
Ultrastructurally, the cells show nontapered Granular cell tumors are benign distinctive neoplasms of
branching cytoplasmic processes that extend from the neural lineage, occurring as small, poorly circumscribed,
cell body for a long distance and contain microtubules single or multiple nodules and are often discovered as
and neurofilaments. These may be coated with basal incidental findings. They involve any body site and occur
lamina. Differential diagnoses include other soft tissue at any age but are common between the fourth and sixth
sarcomas. decades of life with an increased incidence in females.
Granular cell tumors present as painless nodules in the
dermis or the subcutaneous tissues and are also present in
the submucosa of the internal organs. Cytohistologically,
and Differential Diagnosis
granular cell tumors consist of large, round to polygonal,
The cytohistomorphology of soft tissue tumors is very uniform cells with well-defi ned borders and abundant,
versatile. The mesenchymal cells can be spindle shaped, coarsely granular cytoplasm with small bland nuclei con-
round to polygonal or epithelioid; small to large with taining nucleoli (Fig. 24.61). The differential diagnoses
giant forms; and binucleated to multilobulated and mul- include lesions composed of large, round to polygonal
tiloculated. Their cytoplasm, likewise, varies consider- cells (see Table 24.7).
ably. The various tumors elaborate different types of
matrix material. The growth patterns differ as well. A
given soft tissue tumor may be composed exclusively of
one cell type or may be pleomorphic, incorporating two EPITHELIOID SARCOMA
or more cell types. With variations in cell composition, These unusual malignant tumors of uncertain histogen-
growth patterns, and overlap with different tumor types, esis occur in adolescents and young adults—involving
the cytohistomorphology spectrum becomes limitless. mainly the extremities—as fi rm nodules in the dermis or
Problems compound when mesenchymal tumors pres- the subcutaneous tissues and may cause ulceration. These
ent morphology that overlaps with nonmesenchymal tumors may metastasize to distant organs. Histologically,
tumors. epithelioid sarcomas show central necrosis surrounded by
A spindle cell pattern is the most common presenta- a rim of polygonal to oval neoplastic cells with eosino-
tion of soft tissue sarcomas. Spindle cell morphology is philic cytoplasm. The aspirate consists of aggregates of
also exhibited by nonmesenchymal neoplasms as well as polygonal cells with large nuclei containing coarsely
several non-neoplastic entities. Table 24.5 lists the various granular chromatin and pale to dense cytoplasm. Spindle
diagnostic entities and their cytomorphologic features and tadpole forms with eccentric nuclei may be present.
(Figs. 24.38 to 24.48). The differential diagnoses of tumors composed of polygo-
Soft tissue tumors can present a pleomorphic pat- nal cells include squamous carcinoma; however, immu-
tern with an admixture of varied cell shapes and sizes nostains with a negative reaction to keratin rules this out.
and include many nonmesenchymal neoplasms as dif- Malignant melanoma, breast or thyroid carcinomas, and
ferential diagnostic possibilities (Table 24.6; Figs. 24.49 paraganglioma must also be considered in the differential
to 24.54). diagnoses.
TABLE 24.5 DIFFERENTIAL DIAGNOSES OF SPINDLE CELL LESIONS

Diagnostic Entity Cytopathologic Features Ancillary Tests Fig(s).
Exuberant Cellular, polymorphic cell population, round to spindle-shaped with Clinical history 24.38A
Granulation Tissue cytoplasmic processes; round, oval to elongated nuclei; smooth nuclear and B
membrane; finely granular chromatin; micro/macronucleoli; low N/C
ratio; abundant granular cytoplasm; inflammatory cells in the background
Nodular Fasciitis Variable cellularity; oval to elongated spindle-shaped fibroblasts, Of short duration; 24.1A
individually or in aggregate; slender, bipolar cytoplasmic processes; well- rapidly growing and B
defined cell borders; oval to elongated nuclei; smooth nuclear membrane; 24.2A
finely granular chromatin; micronucleoli; mitoses ; background- to D
mixed inflammatory cells, hemosiderin containing macrophages;
multinucleated giant cells; granular, fibrillar or myxoid material
Fibromatosis Variable cellularity; scant to moderate dependent on collagen content of Clinical history 24.4A
stroma; spindle-shaped cells, dispersed or in aggregates; ill-defined cell and B
borders, ovoid to elongated nuclei; smooth nuclear membrane; finely
granular chromatin; micronucleoli; bipolar or cytoplasmic processes;
background granular to fibrillar
Fibrosarcoma Variable cellularity dependent on collagen content; spindle-shaped cells, Vimentin 24.7A
discrete or in fascicles; nuclei oval to elongated; chromatin fine to coarsely and B
granular; nucleoli ; background – fibrillar; necrosis ; well-
differentiated cannot be differentiated from fibromatosis; poorly differen-
tiated lesions cannot be differentiated from other spindle cell sarcoma
Schwannoma Variable cellularity; tissue fragments with single cells; fibrillar matrix; Pain during 24.33A
Neurofibroma nuclear palisading; Verocay bodies; cells elongated; comma-shaped aspiration biopsy and B
nuclei ; scant, delicate cytoplasm; degenerative changes procedure
S100 protein
Neurogenic Sarcoma Cellular aspirate; malignant cells isolated and in fascicles; pleomorphic S100 protein 24.35
(MPNST) in size, spindle-shaped cells with ill-defined cell borders; large elongated
nuclei with pointed ends; pleomorphic forms frequent; nuclear borders
smooth to irregular; cytoplasm variable; scant, bare nuclei; necrosis
Leiomyosarcoma Variable cellularity; spindle-shaped cells dispersed and in fascicles, Actin 24.16 to
pleomorphic in size; large cigar-shaped nuclei with blunt ends; ill-defined HMB-35 24.18
cell borders; variable cytoplasm; perinuclear vacuoles ; mitoses in
poorly differentiated; background – bare nuclei; fibrillar matrix
Malignant Fibrous Very cellular; cells isolated in aggregates and in tissue fragments; Vimentin 24.8A
Histiocytoma spindle-shaped cells; bland to pleomorphic nuclei with coarsely and B
Storiform– granular chromatin; micro/macronucleoli; mitoses ; necrosis ; 24.9A
Pleomorphic Type background – fibrillar to C
Synovial Sarcoma Cellular; uniform spindle cells in tissue fragments; ovoid to elongated Look for 24.29A
Monophasic nuclei; smooth nuclear membrane; finely granular, evenly dispersed epithelioid cells
chromatin; nucleoli inconspicuous; background clean Keratin
Vimentin
Hemangiopericytoma/ Very cellular; large tissue fragments, enclosing arcade spaces; closed Factor VIII − 24.26,
Solitary Fibrous packed, short, delicate, spindle-shaped cells; round to ovoid nuclei; short Vimentin 24.27
Tumor cytoplasmic processes; tumor cells attached to the capillaries; mast cells; S100 protein
background clean Actin
Angiosarcoma Variable cellularity, discrete pleomorphic spindle-shaped cells with Factor VIII 24.24
pleomorphic nuclei; coarsely granular chromatin; prominent nucleoli;
clefting; mitoses ; variable cytoplasm
(continued)
943

Diagnostic Entity Cytopathologic Features Ancillary Tests Fig(s).
Myxoid Liposarcoma Variable cellularity; spindle-shaped cells with few lipoblasts; nuclei Capillaries 24.13A
with Spindle Cell round to oval with finely granular chromatin; micronucleoli; myxoid Vimentin and B
Pattern background; capillary network S100 protein 24.15B
Glycogen
Alcian blue
Carcinoma with Cellular; malignant cells isolated, in loosely cohesive groups or in tissue CEA 24.40
Pseudosarcomatous fragments; very pleomorphic, round, oval to elongated nuclei with Keratin
Pattern smooth to irregular nuclear membrane; coarsely granular chromatin; Vimentin
prominent nucleoli; variable pale, to dense cytoplasm; mitoses ;
necrosis
Malignant Melanoma Variable cellularity; cells dispersed, in aggregates; spindle-shaped cells of S100 protein 24.41
various sizes; cytoplasmic processes; unipolar and bipolar; well-defined HMB-45
cell borders; nuclei eccentric to central; smooth to irregular cell borders; Vimentin
fine to coarsely granular chromatin; parachromatin clearing; prominent Melan-A
micro/macronucleoli; intranuclear cytoplasmic inclusions; cytoplasm
variable; melanin pigment ; background; necrosis
Malignant Variable cellularity; cells isolated, in loosely cohesive groups, and in CK 24.45
Mesothelioma, Spindle syncytial tissue fragments; size variable; spindle-shaped with cytoplasmic Calretinin
Cell Type processes; pleomorphic, oval to spindle-shaped nuclei; finely granular cytoplasmic and
chromatin; smooth nuclear membranes; micronucleoli; mitoses ; nuclear staining
fibrillar stroma HBME1
CEA ; EMA
US slender
bushy microvilli
Gastrointestinal Short to elongated spindle cells, round, cuboidal, plasmacytoid to Strong and 24.20
Stromal Tumor polygonal; variable in size; cell borders well to poorly defined; dispersed, consistent
in aggregates, or in syncytial tissue fragments; small nests, fascicles, or reactivity to
whorls; traversing capillaries through tissue fragments /; round, CD117/c-kit
oval to spindle-shaped nuclei with smooth to irregular membranes;
binucleation /; eccentric nuclei; fine to coarsely granular chromatin;
micronucleoli; intranuclear inclusions /; nuclear grooves /; nuclear
pleomorphism mild in benign types to marked in malignant ones; mitosis
in malignant variety; delicate long wispy cytoplasmic processes
Neuroendocrine Spindle cells, pleomorphic in size, delicate unipolar processes; eccentric Neuroendocrine 24.47
Tumors Spindle Cell nuclei; salt & pepper chromatin; intranuclear inclusions / markers
Carcinoid Tumor
Medullary Thyroid Spindle cells, pleomorphic in size, delicate unipolar processes; eccentric Calcitonin 24.48
Carcinoma nuclei; salt & pepper chromatin; intranuclear inclusions / Neuroendocrine
markers
Malignant Mixed Highly atypical with malignant glandular and mesenchymal components Clinical history 24.44
Müllerian Tumor CK; EMA
Vimentin
Endometrial Stromal Spindle cells with bland nuclear pattern Clinical history 24.43
Sarcoma CD10
Vimentin
ER, PR
Differential Diagnoses of Spindle Cell Lesions (See Figs. 24.38 to 24.48)
A B
Figs. 24.38A and B. Exuberant granulation tissue. A: Low power showing a cellular aspirate consisting of spindle
cells with proliferating capillaries. B: Higher magnification showing proliferating fibroblasts, capillaries and inflam-
matory cells.
Fig. 24.39. FNA of a recurrent osteosarcoma consisting predomi- Fig. 24.40. FNA of a sarcomatoid squamous carcinoma showing
nantly of spindle cells with pleomorphic nuclei, separated by acel- pleomorphic spindle cells with clearly malignant appearing nuclei.
lular stromal matrix, probably osteoid.
Fig. 24.41. FNA of a metastatic amelanotic malignant melanoma Fig. 24.42. FNA of an anaplastic thyroid carcinoma with a spindle
with a spindle cell pattern. cell pattern.
Fig. 24.43. FNA of a metastatic endometrial stromal sarcoma Fig. 24.44. FNA of large peritoneal implants of a malignant mixed
showing a spindle cell population. Müllerian tumor of the endometrium, exhibiting an admixture of
spindle and round cells.
Fig. 24.45. FNA of a pleural based mass consisting of discrete pleo- Fig. 24.46. FNA of a germ cell tumor metastatic to the lung exhibit-
morphic spindle cell population, proven to be a sarcomatous malig- ing spindle cells in myxoid stroma.
nant mesothelioma.
Fig. 24.47. FNA of peripheral mass lesion of the lung consisting of Fig. 24.48. FNA of a metastatic medullary thyroid carcinoma to the
fascicles of spindle cells with nuclei demonstrating typical “salt & soft tissues showing discrete cells with spindle cell pattern.
pepper,” chromatin, consistent with a carcinoid tumor.
TABLE 24.6. DIFFERENTIAL DIAGNOSES OF PLEOMORPHIC SARCOMA

Type of Tumor Cytopathologic Features Ancillary Tests Fig(s).
Malignant Fibrous Very cellular; pleomorphic cell population; mono-, bi- or multinucleated CEA 24.49
Histiocytoma marked variable in size and shape; round, oval, spindle to polygonal; Keratin
abundant foamy or vacuolated cytoplasm some with ingested debris Vimentin
Rhabdomyosarcoma Very pleomorphic; spindle-shaped, round, strap cells, racket-shaped; Actin

mono-multinucleated; central to marginal location of nuclei at broad
end of racket-shaped; dense cytoplasm; eosinophilic; coarse chromatin;
macronucleoli; longitudinal and cross striations
Osteosarcoma Very pleomorphic; spindle-shaped, round, strap cells, racket-shaped; Clinical and 24.53
mono-multinucleated; central to marginal location of nuclei at broad radiologic findings
end of racket-shaped; dense cytoplasm; eosinophilic; coarse chromatin;
macronucleoli; no cross striations; intra & extracellular osteoid
Malignant Very cellular; markedly pleomorphic cells, consisting of small, large to LeuM 1 24.59
Lymphoma Hodgkin giant forms with bi- and multinucleation; coarsely granular chromatin with CD30
(Syncytial Type) macronucleoli
Malignant Lymphoma Very cellular; pleomorphic, round to spindle cells; large nuclei; high N/C LCA 24.16
Anaplastic Large Cell ratio; coarsely granular chromatin; micronucleoli CD30 24.17
Type EMA
Malignant Melanoma Highly cellular; dispersed cell pattern, markedly pleomorphic malignant History of 24.60
cells with frequent giant forms; irregular nuclei with coarsely granular, melanoma 24.50
clumped chromatin with parachromatin clearing; single/multiple prominent HMB-45
nucleoli; intranuclear cytoplasmic inclusions; mitoses ; necrosis ; S100 protein
variable cytoplasm Melan-A
Giant Cell Highly cellular, dispersed cell pattern, markedly pleomorphic malignant Thyroglobulin + 24.51
Carcinoma (Lung, cells with frequent giant forms; irregular nuclei with coarsely granular, (for thyroid) 24.52
Thyroid, Kidney) clumped chromatin with parachromatin clearing; single/multiple prominent Vimentin (for
nucleoli; intranuclear cytoplasmic inclusions; mitoses ; necrosis ; renal cell)
variable cytoplasm Keratin
Germ Cell Tumors Highly cellular, dispersed cell pattern, markedly pleomorphic malignant AFP 24.57
(Embryonal cells with frequent giant forms; irregular nuclei with coarsely granular, PLAP
Carcinoma) clumped chromatin with parachromatin clearing; single/multiple prominent BHCG
nucleoli; intranuclear cytoplasmic inclusions; mitoses ; necrosis ; CEA
variable cytoplasm Keratin
Differential Diagnoses of Pleomorphic Cell Tumors (See Figs. 24.49 to 24.54)
The malignant neoplasms illustrated in the following images all present a very pleomorphic cell pattern, including giant tumor cells. A specific
diagnosis of any particular type is not possible without clinical data, radiologic findings, and ancillary tests.
Fig. 24.49. Malignant fibrous histiocytoma. Fig. 24.50. Metastatic amelanotic malignant melanoma.
947
Fig. 24.51. Anaplastic thyroid carcinoma. Fig. 24.52. Metastatic giant cell carcinoma of the lung to the
soft tissues.
Fig. 24.53. Osteosarcoma showing medium to large cells with Fig. 24.54. Interdigitating dendritic cell sarcoma presenting as a
pleomorphic nuclei. retroperitoneal mass showing markedly pleomorphic malignant
cells with an admixture of spindle and round, polygonal and racket-
shaped cells.
Degeneration and necrosis impart the pseudoalveolar

ALVEOLAR SOFT PART SARCOMA
pattern. The cytoplasm contains glycogen and PAS and
Alveolar soft part sarcomas are rare malignant neo- diastase resistant material in the form of rhomboid or
plasms that are clinically and morphologically distinc- rod-shaped crystals. The differential diagnoses include
tive, comprising 0.5 to 1% of all malignant soft tissue neoplasms composed of large, round to polygonal cells
tumors. They occur in adolescents to young adults and (see Table 24.7).
are more common in females. Alveolar soft part sar-
comas are slow-growing and involve mostly the lower
CLEAR CELL SARCOMA
extremities but rarely the head and the neck area. The
neoplasms are poorly circumscribed and friable with This malignant neoplasm (also called malignant melanoma
areas of hemorrhage and necrosis. Histologically, the of soft parts) is uncommon, affects young adults between
tumor is composed of sharply defined nests and aggre- 20 to 40 years of age, and has a higher incidence in women.
gates of large, round to polygonal cells arranged in lob- These are deep seated lesions involving the extremities.
ules. The neoplastic cells are uniform with well-defined Grossly, they are circumscribed, multinodular, and lobu-
cell borders containing abundant, granular, eosino- lated neoplasms. Cytohistologically, clear cell carcinomas
philic cytoplasm and large, eccentric, atypical nuclei. consist of compact nests of fusiform to round, polygonal
TABLE 24.7 DIFFERENTIAL DIAGNOSES OF SARCOMAS WITH LARGE ROUND
AND POLYGONAL CELLS

Type of Tumor Cytopathologic Features Ancillary Tests Fig(s).
Alveolar Soft Individually dispersing large, round polygonal cells; well-defined cell PAS
Part Sarcoma borders; large eccentric nuclei with coarsely granular chromatin; Diastase resistant
abundant granular cytoplasm; PAS diastase resistant materials; Rhomboid crystals
rhomboid or rod-shaped crystals Keratin
EMA
Neurofilament protein
GFAP
Vimentin
Granular Cell Uniformly large round to polygonal cells; well-defined cell borders; Keratin 24.61
Tumor abundant granular cytoplasm; small nuclei with finely granular S100 protein
nucleoli; low N/C ratio Neuron specific
GFAP
Enobe
Neurofilament protein
Epithelioid Large polygonal cells with occasional spindle and tadpole forms; large Keratin
Sarcoma nuclei, often eccentric, coarsely granular chromatin; pale to dense Vimentin
cytoplasm EMA
Desmin
Malignant Individually dispersed large round to polygonal cells, variable in HMB-45 24.50
Melanoma size; well-defined cell borders; large pleomorphic nuclei with bi- and S100 protein
(Amelanotic) multinucleation; granular chromatin; multiple micro/macronucleoli; Melan-A
intranuclear cytoplasmic inclusions; variable pale to dense cytoplasm;
mitoses ; necrosis
Clear Cell Large polygonal cells with occasional spindle and tadpole forms; large HMB-45 24.62
Sarcoma nuclei, often eccentric, coarsely granular chromatin; pale to vacuolated S100 protein
cytoplasm; melanin Melan-A
Squamous Round to polygonal cells; discrete tissue fragments ; well-defined Keratin 24.20
Carcinoma cell borders; dense cytoplasm; central nuclei; coarsely granular
chromatin with nucleoli; keratinization
Adenocarcinoma Discrete large cells, syncytial tissue fragments ; cell borders well Keratin for breast 24.42
Kidney, Breast, to poorly defined; nuclei – central to eccentric; N/C ratios variable; Keratin and vimentin for
Thyroid (Giant finely granular chromatin; abundant nucleoli and granular cytoplasm kidney
Cell, Hürthle Keratin − and thyroglobulin
Cell) for thyroid
Paraganglioma Discrete large round to polygonal cells; cell borders well-defined; Neuroendocrine markers
(with central to eccentric nuclei; N/C ratios variable; coarsely granular S100 protein with
Monomorphic chromatin; nucleoli ; abundant cytoplasm pale to dense or sustentacular cells
Cell Pattern) granular
Malignant Very cellular; pleomorphic; round to spindle cells; large nuclei; high LCA 24.16
Lymphoma N/C ratio; coarsely granular chromatin; micronucleoli CD30 24.17
Anaplastic Large EMA
Cell Type
Malignant Oval to polygonal discrete cell, large, variable in size; well-defined cell Nonreactive with most 24.8
Fibrous borders; large bizarre nuclei with bi- and multinucleation; intranuclear antibodies 24.9
Histiocytoma cytoplasmic inclusions
949
Differential Diagnoses of Giant Cell Tumors (See Figs. 24.55 to 24.60)
Fig. 24.55. Malignant fibrous histiocytoma, showing bizarre giant Fig. 24.56. Osteosarcoma containing a bizarre binucleated giant
tumor cell in an inflammatory background. malignant cell.
Fig. 24.57. FNA of an embryonal carcinoma. Fig. 24.58. FNA of a metastatic giant cell carcinoma, showing bi-
zarre tumor giant cells.
Fig. 24.59. Hodgkin lymphoma showing a multinucleated Hodgkin Fig. 24.60. Malignant melanoma with discrete pleomorphic malig-
cell. nant cells with giant forms.
Miscellaneous Tumors (See Figs. 24.61 and 24.62)
A B
Fig. 24.61. Granular cell tumor consisting of large round to polygo- Figs. 24.62A and B. Clear cell sarcoma. The aspirate consists of
nal cells with well to poorly defined cell borders, abundant granular loosely cohesive large round to polygonal cells with eccentric nuclei.
cytoplasm and small bland nuclei.
cells with clear cytoplasm in a background consisting of a

delicate framework of fibrocollagenous tissue (Fig. 24.62). BONE TUMORS
Their nuclei are large and contain prominent nucleoli.
FNA biopsy of bone tumors is used more frequently
EXTRASKELETAL CHONDROSARCOMA to confi rm a metastatic process or to confirm recurrent
lesions than to identify a primary bone lesion. Sometimes,
Extraskeletal chondrosarcomas are rare malignant neo- when malignant lymphomas are suspected, rapid assess-
plasms that occur in the superficial and deep tissues of ment is required to submit the specimen for lymphoma
the lower limbs in adults with a median age of 40 to 48 work up. An FNA biopsy is performed prior to the core
years. Histologically, two types are recognized: myxoid biopsy. The reasons for the limited use of FNA have
and mesenchymal. The former is lobulated and composed already been stated in the introduction.
of nodules of rounded or slightly elongated, uniform cells, It is critical that the cytopathologists involved in in-
separated by mucoid stroma. The neoplastic cells present terpreting the aspirates of bone lesions be familiar with
features of chondroblasts, small pyknotic nuclei, perinu- clinical and radiologic fi ndings, and more importantly,
clear clearing, and a thin rim of peripheral deeply eosino- that they are familiar with the histopathology and cyto-
philic cytoplasm. Cytologically, aspirates of the myxoid pathology of bone tumors.
type are cellular with loosely cohesive groups of round Although benign and primary malignant bone tu-
or spindle cells invested in myxoid stroma. The nuclei are mors make up a large list of primary bone neoplasms,
round to oval, central to eccentric, and often show clefts only the common ones will be discussed. The frequently
or grooves. The chromatin is finely stippled, and micro- encountered primary malignant bone tumors are multiple
nucleoli may be identified. The variable cytoplasm may myeloma, osteosarcoma, chondrosarcoma, and Ewing’s
contain vacuoles. Immature cartilaginous cells may be sarcoma/PNET.
present in lacunae. Extraskeletal chondrosarcoma must
be differentiated from tumors with myxoid stroma (see
MULTIPLE MYELOMA
Table 24.10).
Spindle cell lesions involving the soft tissues can rep- Intraosseous plasma cell neoplasms manifest either as soli-
resent nonneoplastic proliferations, benign neoplasms, or tary lesions or involve multiple areas of the bone and/or mul-
malignant neoplasms; all may show morphologic overlap tiple bones. It is the most common primary bone neoplasm,
(Table 24.5). Benign lesions will be very cellular, masquer- accounting for nearly half of surgically diagnosed bone
ading as malignant. Conversely, malignant lesions may be tumors. Plasmacytomas are rare before the age of 40 years
deceptively bland. Several of these lesions also demon- and peak between 50 to 80 years with a slightly higher inci-
strate a very pleomorphic pattern (Table 24.6) with bi- dence in males. Presenting signs and symptoms are diverse.
zarre giant forms and contain varying-sized single malig- Nearly all are associated with increased plasma levels of
nant cells (Table 24.7). monoclonal immunoglobulins. The radiologic appearance is
Primary Neoplasms of the Bone (See Figs. 24.63 to 24.69)
A B
Figs. 24.63A and B. Multiple myeloma showing immature large plasma cells. A: Papanicolaou stain.
B: Romanowsky stain.
distinctive but nondiagnostic, consisting of sharply punched TABLE 24.8 CYTOPATHOLOGIC FEATURES OF
out destructive areas in the bone without a peripheral zone OSTEOSARCOMA
of sclerosis. Cytohistologically, plasmacytomas show closely
packed plasma cells of varying maturity (Figs. 24.63A and Cellularity Generally cellular
B). Amyloid may be present in the background.
Presentation Cells mostly isolated; in aggregates or small
tissue fragments
OSTEOSARCOMA
Cells Markedly pleomorphic; small large to giant
Osteosarcomas are the most common primary malignant forms, oval to plasmacytoid, polygonal to
bone tumors; occurring in the second decade of life, they spindle-shaped with bipolar processes; N/C
are more common in males. The sites of involvement ratios increased; well-defined cell borders
include the metaphyseal regions of the long bones such as
the femur, the tibia, and the humerus. The radiologic find- Nucleus Variable in size; central to eccentric; bi-
ings include a destructive lesion extending into the soft multinucleation; markedly pleomorphic;
tissues. A signifi cant amount of calcifying and ossifying irregular, lobulated, bizarre forms; coarsely
osteoid substance is present. granular to compact chromatin; micro-
Several morphologic variants are described: macronucleoli; mitosis
1. Osteoblastic (epithelioid) type with plump rounded Cytoplasm Variable, dense; small cytoplasmic vacuoles
cells containing eccentric round to oval nuclei and a
single large macronucleolus. Background Pink to fibrillar matrix (osteoid), may be
2. Pleomorphic type resembling malignant fibrous histio- present between neoplastic cells; osteoblasts
cytoma. ; chondroid matrix in chondroblastic
3. Chondroblastic type with gelatinous chondroid matrix, variant
yielding a slimy viscid aspirate. The matrix stains magenta
and appears granular to feathery in Romanowsky prep-
arations and has a bluish–green granular film in Papani-
colaou stained material. pleomorphic cell population with bizarre multinucleated
4. Small cell type. giant tumor cells containing eccentric nuclei and dense
5. Fibroblastic type. cytoplasm (Table 24.8; Figs. 24.64 to 24.69). Small to
large spindle cells are also present. The nuclei have sharp
nuclear membranes. The chromatin is coarsely granular
Cytopathologic Features to compact, with or without prominent nucleoli. The
cytoplasm is variable, containing bright red material.
The cellularity of the aspirate is inversely proportional Osteoid, when present, appears acellular with a thick,
to the matrix content of the tumor. The cellular composi- woven texture and well-defined borders. It stains metach-
tion ranges from normal-appearing osteoblasts to a very romatically in Romanowsky preparations (Fig. 24.69B).
A B
Figs. 24.64A and B. Osteosarcoma. A: Marked cellularity with large tissue fragments of spindle cells (low power).
B: Pleomorphic malignant cells infiltrating the skeletal muscle.
Fig. 24.65. Osteosarcoma. Pleomorphic cell pattern with giant Fig. 24.66. Osteosarcoma. Pleomorphic cell pattern with giant
forms. forms. There is no osteoid. The cellular pattern mimics a soft tissue
sarcoma.
Fig. 24.67. Osteosarcoma showing discrete, very pleomorphic large

malignant cells with prominent nucleoli with brisk mitotic activity.
A B
Figs. 24.68A to C. FNA of an osteosarcoma. A, B: Discrete, pleo-

morphic small round to spindle cells. C: FNA of a histologically
confirmed chondroblastic osteosarcoma showing discrete pleomor-
C phic malignant cells. Osteoid matrix is not present.
A B
Figs. 24.69A and B. Osteosarcoma. A: Low power view of a moderately cellular aspirate with spindle cell popula-
tion scattered in a myxoid background. Note the bright magenta colored osteoid. B: Higher magnification showing
osteoid surrounded by pleomorphic malignant cells (Romanowsky).
The neoplastic cells are often seen within or surrounding cleoli. The pleomorphic type resembles malignant fibrous
the osteoid. The chondroblastic osteosarcomas are high- histiocytoma. The fi broblastic variant contains minimal
grade osteosarcomas, characterized by chondroid matrix osteoid and demonstrates a cytologic pattern similar to
with osteoblastic and chondroblastic components. The any spindle cell sarcoma. The small cell variant consists
malignant cells are large and pleomorphic with abundant of small, malignant cells that are either round or short
cytoplasm, containing large central nuclei with micronu- spindle-shaped, associated with osteoid.
The differential diagnosis depends on the cytologic males. The tumor affects the diaphysis or the metaphysis
pattern (e.g., with a pleomorphic and epithelioid pattern and presents typical radiologic findings.
and in the absence of recognizable osteoid, other pleo- Histologically, chondrosarcomas may be well-differ-
morphic sarcomas must be considered). entiated or poorly differentiated and are characterized
Chondroblastic osteosarcomas must be differentiated by abundant blue–gray cartilage matrix forming vary-
from chondrosarcomas, and the small cell type (very rare) ing-sized lobules. These lobules contain chondrocytes
must be differentiated from other small cell neoplasms that vary considerably in size. Their nuclei are mild to
such as malignant lymphomas, myelomas, Ewing’s sar- moderately atypical, and binucleation is frequent. Chon-
coma/PNET, and metastatic small cell carcinomas. drosarcomas are graded on a scale of 1 to 3, based on
cellularity, nuclear staining and size, and the amount of
matrix.
CHONDROSARCOMA
Chondrosarcomas are the second most common malig-
nant bone tumors. They occur in adults during the fifth to
the seventh decades, commonly involving the pelvis, the The cytopathologic features depend on the grade (Table
ribs, and the shoulder girdle. The incidence is higher in 24.9; Figs. 24.70 to 24.76). The cellularity of the aspirates
TABLE 24.9 CYTOPATHOLOGIC FEATURES OF CHONDROSARCOMA
Cellularity Variable, scant in low-grade, increased in high-grade
Presentation Cells isolated, in groups and in syncytial tissue fragments; groups of two or more cells in lacunae in low-grade
tumors
Cells Variable in size; small to large; giant forms; round, oval to spindle-shaped; cell borders well to poorly defined;
N/C ratios variable
Nucleus Variable in size; central or eccentric; round to oval; binucleation ; sharp nuclear membrane; coarsely
granular chromatin; clefts and grooves ; micronucleoli; pyknotic nuclei in cells within lacunae
Cytoplasm Variable; scant to abundant; clear, pale or vacuolated
Background Myxoid (pale) to cartilaginous (chondroid); dense (bright) magenta staining in Romanowsky stained
preparation; fibrillar in high-grade tumors
Chondrosarcoma (See Figs. 24.70 to 24.76)
A B
Figs. 24.70A to C. FNA of a low-grade chondrosarcoma. The malignant chondrocytes are very large containing
mildly pleomorphic nuclei. Bi- and multinucleation is present. (continued)
Fig. 24.71. FNA of a low-grade chondrosarcoma showing abun- Fig. 24.72. Higher magnification of Figure 24.71 showing the tumor
dant dense-staining chondroid matrix (medium power). to be sparsely cellular with large differentiated chondrocytes.
A B
Figs. 24.73A and B. FNA chondrosarcoma. A: Low power showing myxoid stroma and scattered discrete spindle
and round cells. B: Higher magnification showing discrete small to medium-sized round cells with clear to pale
cytoplasm, and containing plump nuclei.
A B
Figs. 24.74A and B. FNA chondrosarcoma. Poorly differentiated chondrosarcoma. A: Low power showing scant
stroma and increased cellularity. B: Higher magnification exhibiting discrete cells with poorly defined cell borders, high
N/C ratios. The nuclei are large and pleomorphic with granular chromatin and nucleoli.
A B
Figs. 24.75A to C. FNA chondrosarcoma. A: Poorly differentiated

chondrosarcoma with syncytial tissue fragments (medium power).
B: Higher magnification showing syncytial fragments of round cells.
Chondroid nature is not apparent in this field. C: Different area
consisting of myxoid matrix, which are embedded a population of
pleomorphic round and spindle cells. This neoplasm was histologi-
C cally confirmed as high-grade chondrosarcoma.
A B
Figs. 24.76A and B. FNA. A: Poorly differentiated chondrosarcoma. Note the lacunar cells containing large nuclei.
B: These cells are clearly malignant but their cartilaginous nature is not apparent.
is variable; being sparse in low-grade chondrosarcomas, genetic/molecular abnormalities. This subject is discussed
the latter yield abundant, viscous material contain- in detail in Chapter 25.
ing metachromatic chondroid matrix that stains deep The cytohistologic pattern of Ewing’s sarcoma is char-
magenta in Romanowsky preparations and dense pink acterized by undifferentiated, uniform, small, round cells.
in the Papanicolaou stain. The malignant chondroblasts In the setting of bone aspirates, Ewing’s sarcoma must be
occur singly or in aggregates, often within lacunar struc- differentiated from other small, round cell tumors that
tures (Figs. 24.70 to 24.72). The cells are large with well- involve the bones such as osteosarcoma with a small cell
defi ned cell borders, containing single, oval, eccentric pattern, malignant lymphomas, and other pediatric round
to central nuclei with coarsely granular chromatin and cell tumors metastasizing to the bones that may present
nucleoli. Binucleation is frequent. Mitotic activity is not morphologically similar features.
seen. The cytoplasm is pale, foamy, and vacuolated. The
moderately to poorly differentiated chondrosarcomas are
highly cellular with clearly malignant cells in a myxoid
PRIMARY MALIGNANT LYMPHOMA
matrix (Figs. 24.73 to 24.76) and contain minimal to no
chondroid matrix. Primary malignant lymphomas constitute approximately
Differential diagnoses of chondrosarcomas vary 7% of all bone sarcomas and 5% of extranodal lympho-
with its grade. The low-grade chondrosarcomas resem- mas. They are also seen in the pediatric age group. Most
ble chondromas, while the poorly differentiated ones malignant lymphomas are of the diffuse large cell type.
need to be differentiated from other types of sarcomas. Their cytologic pattern is the same as that of malignant
Chondrosarcomas with an extensive mucoid/myxoid non-Hodgkin lymphoma, as discussed in Chapter 14.
background share features with several other neoplasms, The differential diagnoses include other small cell lesions
as listed in Table 24.10 and illustrated in Figures 24.77 such as myelomas, Ewing’s sarcoma/PNET, small cell type
to 24.83. osteosarcoma, and metastatic neuroendocrine tumors.
In the pediatric age group, their differential diagnoses
include metastatic involvement by lymphoma/leukemia,
neuroblastomas, and metastatic medulloblastomas, (see
EWING’S SARCOMA/PNET
Chapter 25, Fig. 25.25) although these are rare.
These tumors rank as the fourth most common pri-
mary malignant bone tumors occurring in adolescents
and young adults. They comprise 8.6% of primary bone
malignancies. Although any site can be involved, Ewing’s MISCELLANEOUS
sarcomas arise most commonly in the femur, followed
by the ilium and the fi bula. The metaphysis is involved
GIANT CELL TUMORS OF THE BONE
more commonly, as is the diaphysis. Ewing’s sarcoma rep-
resents one end of the morphologic spectrum of tumors These tumors have an unpredictable biologic behavior,
known as Ewing’s sarcoma/peripheral neuroectodermal are prone to frequent recurrence, and rarely metastasize.
tumors (PNET), sharing same histogenesis and common Giant cell tumors occur commonly in young adults and
TABLE 24.10 DIFFERENTIAL DIAGNOSES OF SOFT TISSUE TUMORS WITH MUCOID/MYXOID STROMA
Diagnostic Clues/
Type of Tumor Cytopathologic Features Ancillary Tests See Fig(s).
Ganglion Cysts Aspirate viscous; clear to amber; poor cellularity; scattered round Occur typically in the 24.77
to spindle cells with granular cytoplasm; small nuclei; low N/C dorsal aspect of wrist
ratios; abundant pale myxoid material
Intramuscular Mucoid aspirate; poor cellularity; few spindle-shaped and Occurs in skeletal muscles; 24.78
Myxoma triangular cells; well-defined cell borders, small bland nuclei; lack cellular and nuclear
uniformly distributed finely granular chromatin; inconspicuous atypia; cells with well-
nucleoli; abundant myxoid material in the background defined cell borders; lack
arborizing blood vessels
Myxoid Moderate cellularity; cells isolated or in aggregates; pleomorphic Lipoblasts and arborizing 24.79
Liposarcoma in size and shape; round to spindle-shaped; large nuclei – bland blood vessels in the stroma
to pleomorphic in poorly differentiated; eccentric location in
lipoblasts with single or multiple vacuoles indenting or scalloping
the nucleus; abundant myxoid material with complex ramifying
blood vessels
Malignant Moderate to marked cellularity; pleomorphic cells population, KEA 24.80

Fibrous isolated or in aggregates or in tissue fragments; spindle cells, Keratin
Histiocytoma, mononuclear histiocyte-like with multinucleated bizarre type; Vimentin /
Myxoid Type pleomorphic nuclei with irregular borders; coarsely granular Lysosome /
chromatin; multiple prominent nucleoli; numerous mitoses; Neurofilament protein /
abundant myxoid material lacking blood vessels Alpha I-antitrypsin /
Acid phosphates /
Chondrosarcoma Single cells in lacunar spaces; cells in aggregates; well-defined CK 24.81
cell borders; foamy to vacuolated cytoplasm; large cytoplasmic Vimentin /
vacuoles; bi- or multinucleated cells; chondroid stroma EMA
S100 protein
CEA
GFAP
Myxopapillary Cells cuboidal to columnar or elongated, forming papillary tissue CK 24.82

Ependymoma fragments with central mucinous core; well-defined cell borders; Vimentin
abundant cytoplasm; centrally directed cytoplasmic processes; EMA
peripheral nuclei; nuclei pleomorphic in size and hyperchromatic; S100 protein
bizarre multinucleated cells /; scattered ependymal cells; CEA
myxoid background GFAP
Mucin stain
Metastatic Round to columnar malignant cells in tissue fragments with acinar CK 24.84
Mucin Producing to papillary pattern; round to elongated nuclei; fine to coarsely Vimentin
Adenocarcinoma granular chromatin; micronucleoli; cytoplasmic vacuoles with EMA
signet-ring cells; abundant mucoid stroma S100 protein
CEA
GFAP
Chordoma Variable cellularity; discrete aggregates or tissue fragments of Site–sacrococcygeal or 24.83

large, round to polygonal cells with abundant pale to clear sphenoidal area
vacuolated cytoplasm (physaliferous cells); small bland nuclei; Keratin
abundant myxoid material Vimentin
EMA
S100 protein / CEA
Differential Diagnoses of Lesions with Myxoid Stroma (See Figs. 24.77 to 24.86)
Figs. 24.77. Ganglion cyst. The cyst aspirate is sparsely cellular and
containing round, foamy cells in myxoid background.
A B
Figs. 24.78A and B. Intramuscular myxoma showing abundant poorly cellular myxoid stroma with rare stellate and
round cells.
A B
Figs. 24.79A and B. A: Liposarcoma with a myxoid background and round to spindle-shaped cells in large tissue
fragments (low power). B: Higher magnification showing discrete small pleomorphic malignant cells.
Figs. 24.80. Malignant fibrous histiocytoma showing abundant

myxoid stroma (Romanowsky).
A B
Figs. 24.81A and B. A: FNA chondrosarcoma with abundant myxoid background (low power). B: Higher
magnification showing chondrocytes with large pleomorphic nuclei.
A B
Figs. 24.82A and B. Myxopapillary ependymoma. A: Medium power showing branching papillary cores with
external ependymal cells. B: Higher magnification showing myxoid stroma (Romanowsky).
A B
Figs. 24.83A to C. Sacrococcygeal chordoma: All three images

C show large physaliphorous cells in a myxoid background.
Fig. 24.84. FNA of a metastatic mucin producing adenocarcinoma.
involve the epiphysis of the long bones, particularly near small nucleolus. Their cytoplasm is moderate in amount
the knees. The radiologic picture is characteristic. and finely granular without vacuoles. Hemosiderin-laden
The aspirates are moderately to highly cellular, con- macrophages are frequently present (Figs. 24.85A and B).
sisting of an admixture of multinucleated osteoclast type
giant cells and polygonal to oval, single, mononuclear cells.
LANGERHANS CELL HISTIOCYTOSIS
The former may be a prominent component and contain
(EOSINOPHILIC GRANULOMA)
3 to 50 nuclei. The mononuclear cells resemble histiocytes
or osteoblasts with central to eccentric, round to oval Langerhans cell histiocytosis (eosinophilic granuloma),
nuclei containing finely granular chromatin and a single previously referred to as histiocytosis X, represents a
A B
Figs. 24.85A and B. Giant cell tumor of the tendon sheath. A: Several multinucleated osteoclast-type giant cells
scattered among a large population of discrete round and spindle-shaped cells. B: Mononuclear stromal cells.
A B
Figs. 24.86A to C. Eosinophilic granuloma of the skull bones. As-

piration biopsy showing aggregates of Langerhans histiocytes and
C eosinophils (arrows).
proliferation of Langerhans cells accompanied by a domi- Patients may present with soft tissue swelling and pain.
nant population of eosinophils, along with lymphocytes, Radiographs show lytic lesions in the medulla and, rarely,
neutrophils, and scattered plasma cells. Eosinophilic in the cortex of the involved bones.
granuloma can occur at any age (1 month to 71 years) Cytohistologically, eosinophilic granuloma shows a
with the majority occurring during the first three decades variety of cells including varying numbers of the diagnostic
of life. The lesions may be solitary or multiple and involve Langerhans cells and eosinophils (Figs. 24.86A to C). The
any bone, with the most frequent site being the calvarium. latter may be in large aggregates, forming an eosinophilic
abscess. Langerhans cells have ill-defined cell borders and METASTATIC TUMORS
varying amounts of pale, eosinophilic cytoplasm. The OF THE BONES
nuclei are bean-shaped and convoluted with grooves.
Their chromatin is fi nely granular with margination at Metastatic tumors to the bone outnumber the primary
the nuclear membrane. The identifi cation of Langerhans malignant bone neoplasms. They are more frequently
cells may be diffi cult with a dominant eosinophilic cell encountered than primary bone tumors in the practice
component. Ultrastructurally, Langerhans cells contain of cytopathology. Certain types of malignant neoplasms
diagnostic Birbeck granules (refer to Chapter 25). have a predilection for involving the bones. These are
For information on the cytologic features of bone le- the lung, the breast, the kidney, the prostate, the thyroid,
sions that are not described here, the reader is referred to and melanoma. The cytologic features of the metastatic
the literature. lesions are similar to the primary lesions.
SUGGESTED READINGS
Akerman M. Benign and malignant soft tissue tumours. In: Gray Klijanienko J, Caillaud J-M, Lagace R, Vielh P. Fine-needle
W, ed. Diagnostic Cytopathology. Edinburgh, UK: Churchill aspiration of leiomyosarcoma. A correlative cytohistopatho-
Livingstone, 1995;851–885. logical study of 96 tumors in 68 patients. Diagn Cytopathol
Akerman M, Ryd W, Skytting B. Fine-needle aspiration of synovial 2003;28:119–125.
sarcoma: criteria for diagnosis: retrospective reexamination of Layfield LJ. Cytopathology of Bone and Soft Tissues. New York:
37 cases, including ancillary diagnostics. A Scandinavian Sar- Oxford University Press, 2002.
coma Group study. Diagn Cytopathol 2003;28:232–238. Lin F, Staerkel G, Fanning TV. Cytodiagnosis of primary lym-
Ayala AG, Ro JY, Fanning CV, Flores JP, Yasko AW. Core needle phoma of bone on fine needle aspiration cytology specimens:
biopsy and fine needle aspiration in the diagnosis of bone Review of 25 cases. Diagn Cytopathol 2003;28:205–211.
and soft tissue lesions. Hematol Oncol Clin North Am Niemann TH, Bottles K. Cytologic diagnosis of metastatic epithe-
1995;9:633–650. lioid sarcoma. A cytologic mimic of squamous carcinoma. Am J
Berardo MD, Powers CN, Wakely PE, Almeida MO, Frable WJ. Clin Path 1993;100:171–173.
Fine-needle aspiration cytopathology of malignant fibrous his- Niemann TH, Bottles K, Cohen MB. Extraskeletal myxoid chond-
tiocytoma. Cancer 1997;81:228–237. rosarcoma. Fine needle aspiration biopsy findings. Diagn Cyto-
Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia: pathol 1994;11:363–366.
Churchill Livingstone, 2006. Powers CN, Berardo M, Frable WJ. Fine needle aspiration biopsy:
Elsheikh T, Silverman JF, Walkely PE, Holbrook CT, Joshi W. Fine Pitfalls in the diagnosis of spindle cell lesions. Diagn Cyto-
needle aspiration cytology of Langerhans cell histiocytosis pathol 1994;10:232–241.
(eosinophilic granuloma) of bone in children. Diagn Cytopathol Raab SS, Silverman JF, McLeod DL, Beuning TL, Geisinger KR.
1991;7:261–266. Fine needle aspiration biopsy of fibromatosis. Acta Cytol
Fletcher CDM, Unni KK, Mertens F. WHO Classification of 1993;37:323–328.
Tumors. Pathology and Genetics. Tumors of Soft Tissues and Wakely PE Jr, Frable WJ. Fine needle aspiration biopsy cytol-
Bone. Lyon, France: IARC Press, 2002. ogy of giant cell tumor of tendon sheath. Am J Clin Pathol
Kilpatrick SE, Cappellari JO, Bos GD, et al. Is fine needle aspira- 1994;102:87–90.
tion biopsy a practical alternative to open Biopsy for the pri- Wakely PE Jr, Geisinger KR, Cappellari JD, Silverman JF, Frable
mary diagnosis of sarcoma? Experience with 140 patients. Am WJ. Fine needle aspiration cytopathology of soft tissue:
J Clin Pathol 2001;115:59–68. Chondromyxoid and myxoid lesions. Diagn Cytopathol
Kilpatrick SE, Geisinger KR. Soft tissue sarcomas. The usefulness 1995;12:101–105.
and limitations of fine needle aspiration biopsy. Am J Clin Walaas L, Kindblom LG, Gunterberg B, Bergh P. Light and elec-
Pathol 1998;110:50–68. tron microscopic examination of fine needle aspirates in the
Klijanienko J, Caillaud J-M, Lagace R, Vielh P. Comparative fine- pre-operative diagnosis of cartilaginous tumors. Diagn Cyto-
needle aspiration and pathologic study of malignant fibrous pathol 1990;6:396–408.
histiocytoma: Cytodiagnostic features of 95 tumors in 71 Weiss SW, Goldblum JR. Soft Tissue Tumors. 5th ed. Philadelphia,
patients. Diagn Cytopathol 2003;29:320–326. Mosby Elsevier, 2008.
25 NEOPLASMS IN THE PEDIATRIC
AND ADOLESCENT AGE GROUPS
The application of cytopathology in pediatric practice is Malignant neoplasms in the pediatric population are
limited. The majority of the disease processes in pediatric rare. An estimated 10,730 new cases were expected to oc-
and adolescent patients are medical and do not require the cur among children aged zero to 14 years in 2009. De-
aid of cytopathologic analysis. FNA biopsy is an extremely spite this low incidence, malignancy is the second most
useful technique in the evaluation of mass lesions, whether common cause of death, after accidents.
superficial and palpable or deep-seated. This technique is Malignant neoplasms occurring in the pediatric pop-
widely used in the adult population because of the sim- ulation present several distinctive features as compared
plicity of the procedure and high diagnostic rates, mini- to those encountered in the adult population. They are
mal complications, and cost-effectiveness. It can be eas- often derived from primitive cells; they try to recapitu-
ily applied in pediatric practice. Despite the advantages, late the embryonal structures; and they are frequently a
many pediatric centers in the United States shy away from nonepithelial type. The primary sites are different as well.
FNA biopsy as a diagnostic procedure. Indications for The entire spectrum of neoplasms in infants, children,
FNA biopsy are and adolescents is very broad and beyond the scope of
this atlas. Neoplasms that are more frequently encoun-
● Mass lesions
tered are listed in Table 25.1 and these alone will be dis-
● High-risk surgical candidate
cussed in this chapter.
● Nonresectable tumors
Many childhood tumors are characterized by small
● Confirmation of metastasis
round cells with high N/C ratios, hyperchromatic nu-
● Support for clinical diagnosis
clei, and scant cytoplasm lacking functional differen-
● For planning treatment strategy.
tiation at a light microscopy level in routinely stained
The diagnostic accuracy is variable. In terms of preparations. Although these neoplasms arise from dif-
differentiating benign from malignant, the specificity ferent sources, they share several morphologic features
is greater than 95%. However, the nature of pediatric and are collectively referred to as “small round cell tu-
malignant tumors is such that very often a specific type mors of childhood” or “round blue cell tumors” (see
cannot be rendered at the site of biopsy, since it requires Table 25.7).
the support of ancillary tests for establishing an accurate
● Malignant non-Hodgkin lymphoma
diagnosis. It is recommended that the pathologist always
● Neuroblastoma
be present for on-site evaluation of the aspirated sample.
● Wilms’ tumor
Appropriate clinical and radiologic data are necessary
● Ewing’s sarcoma/primitive neuroectodermal tumors
for a meaningful cytologic evaluation and for rendering
● Rhabdomyosarcoma
a preliminary diagnosis. Once a tentative diagnostic im-
● Medulloblastoma
pression is made, the pathologist must always make sure
● Retinoblastoma
to request additional samples for cell block, ancillary
● Intra-abdominal desmoplastic small cell tumor
testings, and fixation in glutaraldehyde for ultrastruc-
tural studies.
Other types of specimens that can be evaluated in
pediatric practice for diagnostic purposes are cerebrospi-
NON-HODGKIN LYMPHOMA
nal fl uid and serous effusion fl uid. At times, malignant
neoplasms may initially present with pleural effusion or
ascites. Metastatic tumors from known primary malig- The most common primary malignancy in the pediat-
nant neoplasms can also cause effusion. Cytologic exami- ric age group is hematologic malignancy, namely, leu-
nation can accurately identify the presence of neoplastic kemias and malignant lymphomas. Of the several types
cells and offer accurate typing. of non-Hodgkin lymphomas, precursor T-cell or B-cell
965
TABLE 25.1 COMMON CHILDHOOD logically, the same subtypes described for adult Hodgkin
MALIGNANCIESa are also noted (Chapter 14) in Hodgkin lymphomas seen
in the pediatric age group. The common histologic vari-
Leukemias ants include nodular sclerosis and mixed types.
Central nervous system tumors
Malignant lymphomas PRIMARY CENTRAL NERVOUS

SYSTEM TUMORS
Non-Hodgkin type
Hodgkin lymphoma Primary CNS tumors are the second most common can-
cers in childhood. These include medulloblastomas, cer-
Primitive neuroectodermal tumors ebellar astrocytomas, ependymomas, brain stem and
optic nerve gliomas, choroid plexus papillomas, and
Neuroblastoma craniopharyngiomas. Less frequent tumors include germ
cell tumors of the pineal gland. Most occur in the poste-
Medulloblastoma rior fossa accounting for 50 to 55% of all intracranial
neoplasms. The majority involve the cerebellum or the
Ewing’s sarcoma/peripheral neuroectodermal tumors (PNET) fourth ventricle. For a detailed description, please refer
to Chapter 23.
Renal tumors
Wilms’ tumor
NEUROECTODERMAL AND
Malignant rhabdoid tumors NEUROENDOCRINE TUMORS
IN CHILDHOOD
Intra-abdominal desmoplastic tumors
Neuroectodermal and neuroendocrine tumors in child-
Germ cell tumors
hood encompass a broad group of neoplasms. The fre-
quently encountered ones are
Bones
● Neuroblastic tumors including neuroblastoma, gangli-
Osteosarcoma oneuroblastoma, and ganglioneuroma.
● The Ewing sarcoma family of tumors including Ewing’s
Soft tissue sarcomas sarcoma, Askin tumor, and peripheral primitive neu-
roectodermal tumors (PNET).
Rhabdomyosarcoma ● Desmoplastic small round cell tumors.
Other types
Hepatoblastoma
NEUROBLASTOMA
Neuroblastoma and the related neoplasms such as gangli-
Other Epithelial tumors oneuroblastoma arise from primitive cells of neural crest
a
For a complete listing of childhood malignancies, the reader may refer to origin. It is one of the common solid tumors of infancy
standard textbooks. and childhood and the fourth most common malignancy
in this age group, after leukemia, brain tumors, and
malignant lymphomas. The majority are diagnosed in
lymphoblastic, Burkitt’s, and large cell type dominate the children who are less than fi ve years of age. The annual
childhood lymphomas (see Chapter 14 for morphology). incidence in the United States is reported to be 9.2 per
million children. The incidence is higher in Japan at
19 million children as a result of prenatal screening. Neu-
roblastomas occur in various paraspinal locations and
HODGKIN LYMPHOMA in the parenchymal organs, with the most frequent sites
being the adrenal medulla, the extra-adrenal retroperito-
Hodgkin lymphoma is less common than non-Hodgkin neal areas, the mediastinum, the cervical ganglia, and the
lymphoma in the pediatric age group. A higher incidence head and the neck region. Children with neuroblastomas
in males is noted with a male:female ratio of 10:1. Histo- often appear systemically sick and have symptoms related
Chapter 25: Neoplasms in the Pediatric and Adolescent Age Groups 967
to metastatic disease. High urine and serum levels of cat- TABLE 25.2 CYTOPATHOLOGIC FEATURES OF
echolamines are characteristic. NEUROBLASTOMA

Grossly, neuroblastomas vary in size and consistency. Presentation Mostly isolated and in loosely cohesive
groups with or without rosette
They are often well-circumscribed with a lobulated con-
formations (Homer-Wright type)
tour. They may be reddish–purple to grayish homogenous
with microcalcifications. Cells Generally uniform small, round (slightly
The histomorphology of neuroblastomas presents a larger than lymphocytes); variation
wide spectrum, dependent on the maturation of the neo- in size may be present; cell borders
plastic cells (e-Fig. 25.1). The classic pattern consists of indistinct
uniform, small round cells with large hyperchromatic
nuclei arranged in nests and separated by fibrovascular Nucleus Round to oval; very high N/C
septae. The cells may demonstrate a rosette formation. ratios; nuclear membrane smooth to
Mitoses are not frequent. Neuroblastomas may show dif- slight irregularity; coarsely granular
ferentiation toward ganglion cells. The latter are identified chromatin, evenly dispersed; nucleoli
by their large size, round to polygonal shape, and abun- inconspicuous; molding /; mitoses
infrequent; larger cells with or without
dant granular cytoplasm. They may be mononucleated,
binucleation, prominent nucleoli, and
binucleated, or multinucleated with coarsely granular
granular cytoplasm suggest ganglionic
chromatin and a prominent macronucleolus. Neuroblas- differentiation
tomas often show fibrillar or bubbly intercellular ma-
trix representing neural processes referred to as neuropil. Cytoplasm Very scant, pale; unipolar cytoplasmic
Neuroblastoma cells immunocytochemically express most tails
of the neuroendocrine markers. Ultrastructurally, neuro-
blastoma cells show membrane-bound dense core secretory Background Fibrillar to granular matrix (neuropil)
granules, neural filaments, and microtubules (see Fig. 25.4B).
The dense core granules are found in small aggregates in the Immunoprofile Neuroendocrine markers
elongated cell processes as well as in the cell body. (synaptophysin, chromogranin, neuron
specific enolase) , CD56 and CD57
Cytopathologic Features Ultrastructure Neurosecretory granules

The cytologic features of neuroblastomas depend on the dif-
ferentiation ranging from undifferentiated cells to the cells Cytogenetics and Loss of heterozygosity of 1p(1p36) and
Molecular Studies 11q(11q23)
maturing toward ganglion cells (Table 25.2). The aspirates
MYCN amplification
are usually highly cellular, consisting of a large population
of small round cells with poorly defined cell borders and
scant cytoplasm with high N/C ratios (Figs. 25.1 to 25.5).
The nuclei are round to oval with deep-staining chroma-
Ultrastructure
tin and inconspicuous nucleoli. Nuclear molding may be
present. The cells form syncytial tissue fragments with or The neuroblastoma cells present neural differentiation in
without rosette formations (Homer–Wright type). The the form of dendritic processes that contain parallel arrays
rosettes consist of central matrix or neuropil surrounded of microtubules and dense core secretory granules. The neu-
by neuroblastoma cells. The latter may possess a unipolar ral processes form interweaving matted medusa-like aggre-
cytoplasmic process or tailing. The presence of ganglion gates, particularly in the central portions of the rosettes.
cells indicates a maturation process, seen in ganglioneuro-
blastomas (Fig. 25.6). The background may contain neuro-
Molecular/Cytogenetic Features
fibrillar matrix or neuropil.
Neuroblastomas show amplifi cation of MYCN and a
consistent loss of heterozygosity of 1p and 11q.
Immunoprofile
The neuroblastoma cells react positively to all neuroen-
docrine markers: neuron-specifi c enolase, chromogranin,
and synaptophysin. They also react positively to protein The differential diagnosis of neuroblastoma includes
gene product PCP9.5, CD57 (Leu 71), and CD56. Neuro- small round cell tumors of childhood (see Table 25.7;
blastomas do not react to GFAP or myelin basic protein. Figs. 25.23 to 25.31). The presence of rosettes, neuropil,
A B
Figs. 25.1A to C. FNA neuroblastoma. A: Low power view of a

cellular aspirate of a mediastinal mass in a youngster consisting
of several tissue fragments of small cells along with dispersed cells
in the background. B: Higher magnification demonstrating small
round cells with high N/C ratios; darkly stained nuclei with coarsely
granular chromatin and insignificant cytoplasm. Rosette formation
can be appreciated (arrows). C: Different field showing tissue frag-
ments of small round cells with rosette formation. Note the neuro-
C pile (NP).
Fig. 25.2. FNA neuroblastoma. The malignant cells are small with Fig. 25.3. FNA neuroblastoma. The syncytial tissue fragment con-
poorly defined cell borders and scant indiscernible cytoplasm. Some sists of small primitive cells.
exhibit nuclear molding. Note the rosette formations (arrows)
(Romanowsky stain).
and ganglion cells will certainly offer an accurate diagno-

GANGLIONEUROBLASTOMA
sis. Diffi culties arise when these features are not present,
and the cells are completely undifferentiated. Ganglioneuroblastomas consist of a variable proportion
Neuroblastic tumors frequently contain lymphoid of ganglion cells and neuroblastic cells (Fig. 25.6).
cell aggregates that may result in diagnostic problems in Ganglioneuromas are completely differentiated tu-
differentiating primitive cells. Immunostains for CD45 mors with spindle cell matrix of Schwann cells inter-
are helpful in identifying the lymphoid cells. spersed with aggregates of mature ganglion cells.
A B
Figs. 25.4A and B. FNA neuroblastoma metastatic to liver. The patient is a four-year-old boy. A: The malignant cells
are small with poorly defined cell borders. Cytoplasm is indistinct. An occasional giant nucleus is present. Note the
rosette formation. B: Ultrastructure demonstrating neurosecretory granules (arrow).
Fig. 25.5. FNA neuroblastoma, showing small discohesive malig- Fig. 25.6. FNA ganglioneuroblastoma showing maturing neuro-
nant cells in a background of abundant neuropile (NP). blastoma cells and ganglion cells.
EWING’S SARCOMA AND PRIMITIVE

tumors into one group referred to as “Ewing’s sarcoma/
NEUROECTODERMAL TUMORS (PNET)
PNET family of tumors.” These three types of neoplasms
The term “primitive neuroectodermal tumor” (PNET) represent different morphologic expressions of the same
was first used to describe tumors composed of small, biologic entity.
round, and undifferentiated cells resembling germinal or Ewing’s sarcoma/PNETs most commonly develop in
matrix cells of the embryonic neural tube and arising in the second decade of life and show a slight male prepon-
the CNSs of children and young adults. The term “central derance. They may also be seen in childhood and older in-
PNET” (cPNET) has been used to describe such tumors dividuals. Typical presenting signs and symptoms include
that arise in the brain or the spinal cord, with cerebellar a mass and/or pain at the primary site. Ewing’s sarcomas
medulloblastoma being the most common and the best or the bone PNETs most often arise in the long bones of
characterized cPNET. The PNET concept has also been the extremities as metaphyseal or diaphyseal lesions. Soft
applied to non-CNS tumors of the soft tissues, the bones, tissue PNETs are usually found in the chest wall and in
and the nerves with morphologic features of the germinal paravertebral extradural locations but may also be found
neuroepithelium. These small round cell neoplasms have in the extremities, the retroperitoneum, and sometimes in
been referred to as “peripheral primitive neuroectodermal association with large nerves. These tumors are highly ag-
tumors” (PPNET). gressive and progress rapidly with metastases to the lungs,
In the last decade or two, the common genetic ab- the bones, and the bone marrow. The term “Askin tumor”
normality shared by neoplasms such as Ewing’s sarcoma, refers to thoracopulmonary small round cell tumor, prin-
PNET, and Askin tumor has resulted in including all three cipally occurring in young adults.
Gross and Microscopic Features more mature, and the elongated hair-like cytoplasmic
extensions coalesce to form rosettes. Most rosettes are
Although these neoplasms are the members of the same
similar to those seen in neuroblastomas, containing a
family of tumors, there is variation in the morphologic
central solid core of neurofi brillary material, referred to
patterns of Ewing’s sarcoma and PNET.
as Homer–Wright rosettes. Some tumors demonstrate
Histologically, Ewing’s sarcoma is characterized by a
cords and trabeculae, bearing a resemblance to carcinoid
solid growth pattern consisting of sheets of monotonous
tumors or small cell carcinomas. Between 10 to 20% of
small cells with poorly defi ned cell borders and scant
PNETs display a spindle cell component.
cytoplasm that often contains glycogen. The nuclei are
round with smooth nuclear membranes, finely granular
chromatin, and micronucleoli. The N/C ratios are high.
Sometimes there are light and dark areas, with the latter Although Ewing’s sarcoma and primitive neuroectoder-
being formed by hyperchromatic compact nuclei. Mitotic mal tumors belong to the same family by virtue of com-
activity may be brisk. Spindle cells or rosettes are rare. mon genetic alterations, the morphologic patterns do
The stroma is very scant to absent. The cells do not have differ and, therefore, are listed separately (Table 25.3;
processes. No neuropil is present. Figs. 25.7 to 25.10). The cytopathologic features of
PNETs histologically resemble neuroblastomas. They these tumors are sparsely documented in the literature
are composed of sheets and lobules of small round cells since Ewing’s sarcoma/PNET are very uncommon and,
containing deep-staining, round to oval nuclei. Their cy- as is the practice, are not routinely subjected to FNA
toplasm is indistinct except in areas where the cells are biopsy.
TABLE 25.3 CYTOPATHOLOGIC FEATURES OF EWING’S SARCOMA/PNETa
Ewing’s Sarcoma PNET

Cellularity Highly cellular Highly cellular
Presentation Dispersed cell population, rare syncytial tissue Dispersed cell population; syncytial tissue
fragments; rosettes extremely rare; perivascular fragments; rosettes frequent
aggregates
Cells Small, round, monomorphic; poorly defined cell borders; Small to slightly larger; poorly defined cell borders;
high N/C ratios, no spindle cells high N/C ratios; unipolar cytoplasmic tags or
processes /; spindle forms in 10–20% of the
cases
Nucleus Round; smooth, crisp nuclear membranes; finely granular Round to oval; smooth to irregular nuclear
evenly dispersed chromatin; micronucleoli after membranes; chromatin fine to coarsely granular,
micronucleoli; mitosis /; no molding salt & pepper type; micronucleoli ; mitoses /;
molding /
Cytoplasm Scant, pale; vacuolated / glycogen, PAS positive; Scant, cytoplasmic vacuoles /
diastase sensitive
Background Clean; necrosis / Clean to necrotic; bloody; neuropil /; no

ganglion cells; no lymphoglandular bodies in Diff-
Quik preparations
Immunoprofile CD99 ; neuroendocrine markers /; CD99 ; neuroendocrine markers ; PGP9.5
Ultrastructure Scarce organelles; absent dense core granules; absent Neurosecretory granules; glycogen; neural
neurotubules; neuritic processes absent; abundant differentiation seen with dendritic processes and
glycogen; poorly developed Golgi apparatus; few arrays of microtubules
mitochondria
Cytogenetic Reciprocal translocation between the long arms of Reciprocal translocation between the long arms of
Analysis chromosomes 11 and 22 [t(11:22)q24:q12] chromosomes 11 and 22 [t(11:22)q24:q12]
a
Ewing’s sarcoma and primitive neuroectodermal tumors represent two ends of the morphologic expressions of the same biologic entity.
Fig. 25.7. FNA Ewing’s sarcoma. Cellular aspirate with dispersed, Fig. 25.8. FNA Ewing’s sarcoma. The malignant cells are in a
very uniform discrete, small round cells with poorly defined cell bor- syncytial tissue fragment with no architectural pattern. The cells
ders and scant pale cytoplasm. The nuclei are round with smooth are small with poorly defined cell borders and indiscernible cy-
nuclear membranes. The finely granular chromatin is uniformly dis- toplasm. The nuclear chromatin is finely granular and uniformly
persed. There are micronucleoli. distributed.
Fig. 25.9. FNA PNET. The cellular aspirate consists of a large popu-
lation of uniform small round cells with poorly defined cell borders
and scant insignificant cytoplasm Vague rosette formations (arrows)
can be appreciated. The nuclei are round to oval, with coarse chro-
matin with micronucleoli.
A B
Figs. 25.10A to B. FNA PNET. A: Cellular aspirate consisting of uniform small round cells in syncytial tissue frag-
ments. The cells have insignificant cytoplasm. The malignant cells exhibit no differentiation. B: Different case of
PNET, showing a cellular smear consisting of a pleomorphic cell population with some spindle forms. (continued)
Ultrastructure
Ewing’s sarcoma cells ultrastructurally demonstrate poorly
formed cell junctions and few organelles and show abundant
glycogen. Neurosecretory granules are found only rarely.
PNET cells show variable numbers of neurosecretory gran-
ules, cytoplasmic glycogen, and intermediate filaments.
Cytogenetic Analysis
A finding common to Ewing’s sarcoma, Askin tumor, and
PNET leads to the conclusion that these tumors belong
to the same family and are represented by a reciprocal
translocation between the long arms of chromosomes 11
C and 22 [t(11:22)q24:q12].
Figs. 25.10C. (continued ) C: FNA of a PNET stained by Romanowsky.
The differential diagnosis of Ewing’s sarcoma/PNET
includes all childhood tumors referred to as small blue
In general, the aspirates of Ewing’s sarcoma (Figs. round cell tumors (see Table 25.7; Figs. 25.23 to 25.31).
25.7 and 25.8) tend to be very cellular, consisting of a
large population of small, very uniform, monomorphic, DESMOPLASTIC SMALL ROUND
round cells presenting as discrete, in small loosely cohe- CELL TUMOR (DSRCT)
sive groups, and in syncytial tissue fragments. A dispersed
cell pattern is more common. The malignant cells are The desmoplastic small round cell tumor (DSRCT) is a
round with poorly defi ned cell borders, scant cytoplasm, rare, aggressive, malignant neoplasm with unique gene
and high N/C ratios. Their nuclei are round with smooth fusion, a wide anatomic distribution but a predilection for
nuclear membranes, containing fi nely granular chroma- the abdomen/pelvis with diffuse peritoneal involvement, a
tin and few micronucleoli. The cytoplasm is scant, pale, variety of phenotypic expressions, and a poor prognosis.
and vacuolated due to glycogen. A second population of DSRCT is considered a member of the Ewing’s sar-
dark cells with compact chromatin may be identified. The coma/PNET family of tumors. It is seen predominantly in
background may show necrosis. adolescent and young adult males ranging from eight to
The aspirates of PNET are cellular, consisting of a 38 years. Most patients present with abdominal pain and
small cell population seen as discrete dispersed cells in distension with widespread abdominal and pelvic disease.
loosely cohesive groups or in syncytial tissue fragments Involvement of the testes, the pleura, the head and the
(Figs. 25.9 and 25.10). Homer–Wright type rosettes may neck, the cranial cavity, and the extremities may occur.
be present in varying numbers. The neoplastic cells are Patients often have large ascites.
often seen lined up against the capillaries and produce
pseudorosettes. The malignant cells are round with poor- Gross and Histologic Features
ly defi ned cell borders and scant cytoplasm with high
Grossly, there is often a huge mesenteric or omental mass
N/C ratios. Cellular and nuclear pleomorphism may be
or multifocal masses in the abdomen without an obvious
present in a small number of tumors and include spin-
organ-related mass. Histologically, desmoplastic small
dle forms. Some cells demonstrate unipolar cytoplasmic
cell tumors are characterized by a solid or nesting growth
processes. The nuclear membranes are smooth, and the
pattern formed by small to medium-sized cells in a des-
chromatin is fine to coarsely granular, evenly distributed,
moplastic stroma. The neoplastic cells have ill-defined
and deep-staining. Nucleoli are variably present. Nuclear
cytoplasm and vesicular ovoid nuclei containing finely
molding and mitoses are infrequent. No ganglion cells are
granular chromatin, micronucleoli, and frequent mitoses.
present.
There may be necrosis in the background.
Immunoprofile Cytopathologic Features

The Ewing’s sarcoma/PNET cells react positively to neu- The cytologic diagnosis of DSRCT can be provided by
roendocrine markers and CD99 (O13, MIC 2). Variable an examination of the effusion fluid, which shows syncy-
reactivity is demonstrated with cytokeratin and S100 pro- tial tissue fragments of small malignant cells without any
tein and negative reactivity is demonstrated with desmin architectural pattern (Table 25.4; Fig. 25.11A and B). The
and CD45 (LCA). malignant cells are also present as discrete or in loosely
TABLE 25.4 CYTOPATHOLOGIC FEATURES OF DESMOPLASTIC SMALL

ROUND CELL TUMOR
Cellularity Moderate
Presentation Syncytial tissue fragments without any architectural pattern, loosely

cohesive groups, isolated cells
Cells Small round cells with poorly defined cell borders; high N/C ratios
Nucleus Round to oval, evenly distributed, finely granular chromatin;

micronucleoli; mitoses frequent; nuclear molding rare
Cytoplasm Scant, indiscernible
Background Necrosis /; fragments of collagenous stroma /
Immunoprofile NSE ; desmin ; CK
Ultrastructure Paranuclear collection of intermediate filaments
Genetics Translocation t(11:22)(p13:q12)
A B
C D
Figs. 25.11A to B. Desmoplastic small round cell tumor. A, B: Massive ascites and a large bulky mass involving the peritoneum in a teen-
age male. The smears of the effusion fluid showing tissue fragments of malignant cells without any architectural pattern. The cells are small
with poorly defined cell borders, scant to modest, pale to vacuolated cytoplasm and high N/C ratios. The debulking of the tumor was
done. Histologic examination confirmed a desmoplastic small cell tumor. C: Peritoneal fluid from another case of desmoplastic small cell
tumor, showing discrete malignant cells with poorly defined cell borders and high N/C ratios. These cells can easily be overlooked in the
background of mesothelial cells. D: FNA of an abdominal mass proven to be desmoplastic small cell tumor. The syncytial tissue fragment
consists of small round cells and does not allow further classification (Romanowsky). (continued)
E Figs. 25.11E. (continued ) E: Same case stained with H&E.
cohesive groups. The single malignant cells are often dif- RENAL NEOPLASMS OF INFANCY
ficult to identify in the background of mesothelial cells AND CHILDHOOD
(Fig. 25.11C). The malignant cells are slightly pleomor-
phic with poorly defined cell borders and scant cytoplasm,
which may show vacuolization. Several types of tumors are known to arise in the kidneys
In FNA biopsy specimens, DSRCT yields a fairly cel- during infancy and childhood (Table 25.5), of which neph-
lular sample consisting of neoplastic cells that are small roblastoma or the Wilms’ tumor is the most frequent.
in size and that occur in tight syncytial tissue fragments
with no architectural patterns (Figs. 25.11D and E). Their NEPHROBLASTOMA
nuclei are round to oval with granular chromatin and in- (WILMS’ TUMOR)
distinct nucleoli. The N/C ratios are high with scant cy-
toplasm and ill-defined cell borders. Single cells are infre- Nephroblastoma, also known as Wilms’ tumor, is the
quent. Fragments of desmoplastic stroma may be present fourth most common solid neoplasm of infancy and
in the background. The stroma stains metachromatically childhood, next to CNS tumors, malignant lymphomas,
with a Romanowsky stain. and neuroblastoma, and accounts for 5% of all child-
hood malignancies. The annual incidence is stated to be
Immunoprofile seven per one million children. Most occur in children less
The cells of DSRCT show mesenchymal, epithelial, and
neural features and react strongly to keratin, EMA, TABLE 25.5 CYTOPATHOLOGIC FEATURES OF
myogenic regulatory protein, myo-1, myogenin, muscle- NEPHROBLASTOMA (WILMS’ TUMOR)
specific actin, desmin, and myoglobin.
● Polymorphic cell pattern representing blastemal, epithelial,
Ultrastructure and mesenchymal elements in varying proportions.
● Blastemal cells—small, round with scant insignificant
Ultrastructurally, the cells demonstrate scant cell junctions cytoplasm; round to oval nuclei with high nuclear/
and paranuclear aggregates of intermediate filaments. cytoplasmic ratio; granular chromatin and micronucleoli.
● Epithelial cells as isolated, loosely cohesive groups,
Cytogenetic and Molecular Testing or syncytial type tissue fragments with or without
DSRCT is characterized by a specific chromosomal abnor- acinar, trabecular/tubular pattern; generally small in
size with scant cytoplasm; round to oval nuclei with
mality t(11:22)(p13:q12) that is unique to this tumor, involv-
micronucleoli.
ing two chromosomal regions previously implicated in other ● Mesenchymal or stromal cells as spindle-shaped cells,
malignant tumors. The translocation results in a fusion of elongated with long cytoplasmic processes; plump, large
the Ewing’s sarcoma gene (EWS) on chromosome 22q12 polygonal, or strap cells; nuclei pleomorphic with nucleoli;
and the Wilms’ tumor gene WT1 on chromosome 11p13. cross striations may be present.
● Anaplasia represented by single, very pleomorphic
Differential Diagnoses cells; bizarre nuclei, multilobulated or multinucleated,
coarsely granular chromatin, parachromatin clearing,
DSRCT can be differentiated from other small round cell
multiple micronucleoli/macronucleoli, mitoses; cytoplasm
tumors of childhood by positive immunoreactivity to variable.
keratin and ultrastructural fi ndings (see Table 25.7; Figs. ● Background—necrosis, inflammation.
25.23 to 25.31).
than 5 years of age with no striking preference for either When the aspirates present a small cell pattern, the
sex. There is increased frequency of nephroblastoma in differential diagnosis of “small blue round cell tumors
patients with several but uncommon developmental dis- of childhood” must be considered (see Table 25.7; Figs.
orders (e.g., aniridia, hemihypertrophy, genital malforma- 25.23 to 25.31). A polymorphic cell pattern strongly sug-
tions, and neurofibromatosis). gests Wilms’ tumor.
Clinically, nephroblastomas present as an abdominal
mass. They are usually unilateral, well-circumscribed, and
RHABDOID TUMOR
replace the renal parenchyma, distorting the renal pelvis
and may attain a large size. The cut surface of a nephro- Rhabdoid tumor is a rare malignant neoplasm, character-
blastoma is grayish–white, firm, and lobulated with focal ized by a monomorphic population of large noncohesive
hemorrhage, necrosis, cyst formation, and calcification. cells with prominent acidophilic cytoplasm resembling
Histologically, this embryonal neoplasm arising from myoblasts and vesicular nuclei with macronucleoli.
nephrogenic blastemal cells expresses several lines of dif- Immunochemically and ultrastructurally, the cells of
ferentiation including blastemal, epithelial, and stromal rhabdoid tumor lack the features of the skeletal muscle.
(e-Fig. 25.2A to D). The presence of all three constitutes These tumors are seen in infants or very young children,
the classic triphasic pattern. However, one or more may with the mean age being 13 months.
predominate with biphasic or monophasic patterns. Grossly, the tumors are soft, nonencapsulated but
well-demarcated, pale, bulging, and large. Histologically,
Cytopathologic Features rhabdoid tumors present a monomorphic pattern com-
posed of sheets of large loosely cohesive cells with well-
The cytomorphology of the aspirated cells is variable, defined cell borders and abundant eosinophilic cytoplasm
depending on the histologic subtype (Table 25.5; Figs. with characteristic cytoplasmic inclusions (e-Fig. 25.3). The
25.12 to 25.14). cytologic pattern echoes the histomorphology (Fig. 25.15).
A B
C D
Figs. 25.12A to D. FNA Wilms’ tumor. A: Showing epithelial component. B: Blastemal component. C, D: Stromal or
sarcomatous component.
A B
Figs. 25.13A and B. FNA Wilms’ tumor. Another example of Wilms’ tumor. A: Blastemal component. B: Epithelial
components.
Fig. 25.14. FNA metastatic Wilms’ tumor to the lung. The malig- Fig. 25.15. FNA malignant rhabdoid tumor showing monomorphic
nant cell population is predominantly sarcomatous type. round cells with abundant eosinophilic cytoplasm. There are eo-
sinophilic hyaline globules in the cytoplasm.
entities with embryonal tumors having genetic lesions

CLEAR CELL SARCOMA OF THE KIDNEY
related to the loss of heterozygosity and aberrant parental
This is an extremely rare malignant neoplasm of the kid- imprinting, while alveolar tumors contain genetic fusion
ney with a marked frequency of bone involvement. The between PAX and forkhead genes. The two morphologic
tumor shows a signifi cant component of clear cells and variants—embryonal and alveolar types—occurring in
carries a poor prognosis. childhood, have a predilection for different body sites.
For example, embryonal rhabdomyosarcomas frequently
occur in the head and the neck and in the gastrointestinal
tract. The botryoid sarcoma occurs in hollow organs such
RHABDOMYOSARCOMA
as the urinary bladder, the vagina, and the nasopharynx,
while alveolar types are common in the extremities and
Rhabdomyosarcomas are principally a disease of chil- the trunk.
dren and adolescents, accounting for 50% of pediat-
ric soft tissue sarcomas and comprising 5 to 8% of all
Embryonal Rhabdomyosarcoma
childhood malignancies. Childhood rhabdomyosarcomas
include two of the three known histologic types, which The embryonal type is the most common childhood soft
include embryonal (including botryoid type) and alveo- tissue sarcoma affecting children less than 10 years of age
lar. The third type, known as the pleomorphic variant, and accounts for up to 75% of all rhabdomyosarcomas.
occurs mainly in adult life (see Chapter 24). These differ- Cytohistologically, embryonal rhabdomyosarcomas
ent morphologic variants appear to be separate biologic (Table 25.6) consist of varying proportions of primitive
TABLE 25.6 CYTOPATHOLOGIC FEATURES OF RHABDOMYOSARCOMAS
Embryonal Rhabdomyosarcoma Alveolar Rhabdomyosarcoma

Cellularity Variable, usually very cellular Variable, usually very cellular
Presentation Diffuse population of malignant cells in syncytial Diffuse population of malignant cells in syncytial
tissue fragments without any architectural patterns, tissue fragments without any architectural patterns,
dispersed cells and loosely cohesive groups dispersed cells and loosely cohesive groups
Cells Small, primitive appearing cells to medium-sized, Predominantly small to medium-sized, uniform,
with monomorphic to pleomorphic pattern; spindle round cells; multinucleated tumor giant cells with
cells /; myoblastic differentiation in the form of peripherally located nuclei, rendering a floret cell
strap cells or tadpole cells appearance; strap cell /
Nucleus Round to oval; often eccentric Fine to coarsely granular chromatin; micronucleoli
Cytoplasm Variable; scant to abundant and dense; cross Cross striations extremely rare
striations frequently present
Background Myxoid stroma / Necrotic debris /
Immunoprofile Desmin ; myogenin/myoD1 Desmin ; myogenin/myoD1
Ultrastructure Typical mixture of thick (myosin) and thin (actin) Typical mixture of thick (myosin) and thin (actin)
fibrils; distinct Z-bands at several places fibrils; distinct Z-bands at several places
Cytogenetic Analysis Specific translocation t(2;13)(q35;q14)
mesenchymal cells; undifferentiated, small, round cells acterized by sparse cellularity and abundant myxoid
with scant cytoplasm; spindle-shaped cells; and differenti- stroma. The malignant cells are short, slender, and have
ated cells (rhabdomyoblasts) containing abundant eosino- fragile cytoplasmic processes and dark pyknotic nuclei.
philic cytoplasm in which cross-striations may occasion- Undifferentiated, small, round cells may also be present
ally be seen. The nuclear chromatin is coarsely granular (Fig. 25.21).
to compact in undifferentiated forms and finely granular
in differentiated cells. Nucleoli may be prominent in the Alveolar Rhabdomyosarcoma
latter type. Binucleated to multinucleated forms are not
uncommon. Perivascular condensation of neoplastic cells Alveolar rhabdomyosarcoma is the second most com-
may be present. Myxoid stroma is present in variable pro- mon type, comprising up to 20% of rhabdomyosarcomas
portions (Figs. 25.16 to 25.20). A key feature in recogniz- and affecting children and adolescents who are 10 to 25
ing the lesion as rhabdomyosarcoma is the presence of years old. These tumors involve the extremities and often
rhabdomyoblast—a cell with an eccentric round nucleus metastasize via the lymph nodes. Histologically, alveolar
and variable, brightly eosinophilic cytoplasm in H&E sec- rhabdomyosarcoma is composed of solid masses of undif-
tions and also cyanophilic in Papanicolaou-stained prepa- ferentiated small round cells, separated by fibrous septae
rations. Rhabdomyoblasts assume several shapes and are (e-Figs. 25.4A and B). Aspiration biopsy shows a large
referred to as strap cells, tadpole cells, tennis racquet cells, population of small, round, undifferentiated cells (Table
or spider cells. 25.6; Figs. 25.22A to C). The presence of differentiated
Botryoid rhabdomyosarcomas are considered vari- rhabdomyoblasts allows correct identification. Also pres-
ants of embryonal rhabdomyosarcomas, accounting for ent are multinucleated tumor giant cells with peripherally
5 to 10% of all rhabdomyosarcomas and involving the arranged nuclei. The presence of myxoid stroma is not
hollow organs such as the urinary bladder, the vagina, characteristic of alveolar rhabdomyosarcoma.
and the nasal cavity. This morphologic type derived
its name because of the gross appearance resembling a
IMMUNOPROFILE
bunch of grapes. They arise submucosally, protruding
into the lumen with a polypoid growth pattern, and are Rhabdomyosarcomas immunologically react to desmin,
covered by mucosa. The cytohistologic pattern is char- myoglobin, and muscle-specific actin.
Fig. 25.16. FNA embryonal rhabdosarcoma showing syncytial tis- Fig. 25.17. FNA embryonal rhabdosarcoma of orbit. The ma-
sue fragments of undifferentiated small round cells. lignant cells are discrete, mildly pleomorphic in size, round with
poorly defined cell borders and scant cytoplasm. The nuclear chro-
matin is granular with nucleoli. The background shows myxoid
stroma.
Fig. 25.18. FNA embryonal rhabdosarcoma metastatic to the lung

showing several discrete small round and strap cells (arrows).
A B
Figs. 25.19A and B. FNA embryonal rhabdosarcoma, metastatic to lung. Spindle-shaped and small round
malignant cells.
Fig. 25.20. FNA embryonal rhabdosarcoma, mandible. Slightly Fig. 25.21. Sarcoma botryoides of vagina with myxoid background
pleomorphic small round malignant cells with high N/C ratios. and small round to spindle-shaped cells with few strap (rhabdomyo-
blasts) cells (arrow).
A B
Figs. 25.22A to C. FNA alveolar rhabdomyosarcoma, arising in the

soft tissues of the hand, presented with an enlarged epitrochlear
lymph node. A, B: The cellular aspirate consists of slightly pleomor-
phic, round cells with insignificant cytoplasm and high N/C ratios.
The nuclei contain granular chromatin. C: Different field from the
same case showing a multinucleated giant tumor cells with periph-
C erally located nuclei (arrow).
ULTRASTRUCTURE
GERM CELL TUMORS
Ultrastructurally, the cells exhibit myofi brils and rudi-
mentary Z-bands.
Germ cell tumors derived from primordial germ cells may
The differential diagnoses of embryonal and alveolar be benign or malignant and arise either in the gonads
rhabdomyosarcoma include other small, round cell tu- or at extragonadal sites. The majority of the germ cell
mors of childhood (Table 25.7; Figs. 25.23 to 25.31). tumors in children are extragonadal; only 20% arise in
TABLE 25.7 DIFFERENTIAL DIAGNOSES OF SMALL ROUND CELL TUMORS OF CHILDHOOD CYTOPATHOLOGIC FEATURES
Ewing’s Sar-
coma/Primitive Desmoplastic Rhabdomyosarcoma
Malignant Lymphoma Neuroectodermal Nephroblastoma Small Cell (Embryonal &
Non-Hodgkin Type Neuroblastoma Tumor (PNET) (Wilms’ Tumor) Tumor Alveolar)
Cellularity Highly cellular Highly cellular Variable, usually very Highly cellular Variable Highly cellular
cellular
Presentation Cells discrete Cells discrete, in Cells discrete and Cells in loosely cohesive groups and Cells discrete Cells discrete and
loosely cohesive in loosely cohesive in tissue fragments generally mixed and in syncytial in loosely cohesive
groups and in groups; branching population (triphasic); blastemal, tissue fragments, groups
syncytial tissue blood vessels with stromal, and epithelial no architectural
fragments; Homer– attached cells, Homer– patterns
Wright rosettes Wright rosettes /
Cells Round, monomorphic; Small, round to oval, Uniform, small, Blastemal cells—small, round, Small, round; Uniform, small, round
high N/C ratios; size mild variation in size; round; cell borders isolated, loosely cohesive or in mildly cells, minimal degree
variable, dependent on ganglion cells /; indistinct, spindle tissue fragments pleomorphic, of pleomorphism; few
morphologic type, 3–3.5 high N/C ratios cell cells / Epithelial cells—small to slightly well to poorly spindled or polygonal
times the size of resting borders indistinct; larger than blastemal, in tissue defined cell cells; cell borders
lymphocyte; cell borders large, round to fragments with or without tubular borders indistinct
indistinct polygonal ganglion pattern
cells / Mesenchymal cells—round, polygonal
to spindle-shaped to fiber forms
Nucleus Round to oval; lobulated or Round to oval, Round to oval, Blastemal cells—small, round to Round to Round to oval,
cleaved; smooth to irregular smooth to uniform; nuclear oval with granular chromatin and oval; evenly smooth to irregular
nuclear membranes; irregular nuclear molding ; micronucleoli distributed, nuclear membrane;
fine to coarsely granular membranes; fine to nuclear membrane Epithelial cells—round, central to finely granular chromatin finely
chromatin; nucleoli coarsely granular smooth to slightly eccentric, smooth to irregular chromatin; granular; nucleoli
inconspicuous to prominent chromatin; nucleoli irregular; nucleoli nuclear membrane; granular micronucleoli ; inconspicuous;
(Morphology Dependent inconspicuous; inconspicuous; chromatin with nucleoli, mitoses frequent; intranuclear inclusions
on Type of Lymphoma, ref. nuclear molding ganglion cells not parachromatin clearing nuclear molding /; bi- to
Chapter 14, Table 14.3) /; ganglion cells present Mesenchymal cells—pleomorphic, rare multinucleated cells
have prominent round to elongated, smooth to
nucleoli irregular nuclear membranes; fine
to coarsely granular chromatin;
multiple micro/macro nucleoli
Cytoplasm Insignificant to scant Variable, scant, Scant, vacuoles /; Variable, dependent on the cell type Scant; vacuoles Scant, differentiated
pale with unipolar unipolar cytoplasmic / rhabdomyoblast have
cytoplasmic tags; glycogen in EW moderate eosinophilic
tails; granular in PAS cytoplasm
differentiated cells
Background Karyorrhexis /; Neuropil – fibrillar Neuropil in PNET Necrosis / Clean to bloody; Myxoid matrix;
lymphoglandular bodies to granular matrix / no background bare nuclei;
(Romanowsky stain) consisting of tangled material lymphoglandular-
neuritic processes like bodies; tigroid
background in
Romanowsky stained
preparation
Immunoprofile Neuroendocrine Neuroendocrine Neuroendocrine Neuroendocrine markers Neuroendocrine Neuroendocrine

markers markers markers Vimentin / markers markers
LCA S100 protein CD99 Desmin / Vimentin Vimentin
T or B – Phenotype CK CK / CK Myoglobin
NSE LCA Desmin Desmin
CK CD56 CK
CD57
Ultrastructure No cytoplasmic organelles; Microtubules; cell Rare dense cores; Well-formed intercellular junctions; Scant cell Myosin filaments;
lack of cell junctions processes with granules; glycogen microvilli; phagolysosomes junctions; Z-bands
dense core granules; /; no microtubules paranuclear
primitive cell aggregates of
junctions intermediate
filaments
Other Tests Catecholamine No catecholamine

secretions secretions
Cytogenetics 8:14 translocation in Loss of Reciprocal Translocation Specific translocation

Burkitt’s lymphoma heterozygosity translocation between t(11:22) t(2;13(q35;q14)
of 1p(1,p36) and the long arms of (p13:q12)
11q(11q23) MYCN chromosomes 11 and
amplification 22 [t(11:22)q24q12]
Differential Diagnoses of Small Round Cell Tumors (See Figs. 25.23 to 25.38)
Fig. 25.23. Malignant lymphoma. FNA of anterior mediastinal Fig. 25.24. FNA neuroblastoma. The malignant cells are small and
mass in a 16-year-old teenager. The cellular aspirate shows a large primitive. There is suggestion of a rosette formation and neuropile
population of discrete monomorphic round cells with poorly de- (arrow).
fi ned cell borders and uniform round nuclear with granular chro-
matin and micronucleoli.
Fig. 25.25. FNA of a lytic lesion of the shoulder in an 18-year-old Fig. 25.26. FNA, PNET. A syncytial tissue fragment of undifferenti-
young man with a history of medulloblastoma. The aspirate consists ated small round cells, histologically confirmed as PNET.
of scattered small round cells with scant cytoplasm, high N/C ratios
and insignificant cytoplasm, consistent with medulloblastoma.
Fig. 25.27. FNA Ewing’s sarcoma. Malignant cell population com- Fig. 25.28. FNA Wilms’ tumor showing small round undifferenti-
prised of slightly pleomorphic small cells with scant but variable ated cells.
pale cytoplasm, high N/C ratios, round to oval nuclei containing
finely granular chromatin and micronucleoli.
982
Fig. 25.29. FNA alveolar rhabdomyosarcoma. A syncytial tissue Fig. 25.30. Ascetic fluid containing a syncytial tissue fragment of
fragment of small round cells with indiscernible cytoplasm and no small undifferentiated malignant cells. The laparotomy revealed a
differentiating features. large mass involving the peritoneum, histologically confirmed as
desmoplastic small cell tumor.
Fig. 25.31. FNA hepatoblastoma depicting loosely cohesive small

round cells with poorly defined cell borders, high N/C ratios and
scant cytoplasm. Portion of the tumor presented typical morphol-
ogy of hepatoblastoma.
the ovaries or the testes. Germ cell tumors account for histiocytosis includes the diseases known as Letterer Siwe
3% of childhood and adolescent cancer. The frequent disease, Hand—Schuller–Christian disease, and eosino-
extragenital sites are the sacrococcygeal area, the medi- philic granuloma. It is considered a lymphoproliferative
astinum, the retroperitoneum, the head and the neck, and disorder.
the CNS. Germ cell tumors encompass several different The clinical presentation of Langerhans histiocytosis
neoplasms including a yolk sac tumor (e-Fig. 25.6; Figs. is variable, with mild discomfort, irritability, malaise, fe-
25.32A and B; Fig. 25.33), embryonal carcinomas (Fig. ver and weight loss, chronic otitis media, and diabetes in-
25.34), and teratomas (e-Figs. 25.5A and B; Figs. 25.35A sipidus. The disease may be localized or widespread with
and B). Germ cell tumors are described in detail in Chap- multisystem involvement. A hallmark of this disorder is
ter 22. A summary of cytopathologic features of some the finding of solitary or multiple punched-out lytic bone
germ cell tumors is listed in Table 25.8 and illustrated in lesions. Patients may have generalized lymphadenopathy,
Figures 25.32 to 25.35. hepatosplenomegaly, dermatitis, and sometimes pancy-
topenia. The outcome of the disease is variable but gener-
ally self-limiting.
Cytohistologically, lesions of Langerhans histiocytosis
LANGERHANS HISTIOCYTOSIS
are characterized by the proliferation of Langerhans cells,
which are dendritic histiocytes that primarily reside in the
Langerhans histiocytosis is part of the spectrum of child- skin and the lymph nodes and are also found in other loca-
hood histiocytosis—a very rare and diverse group of dis- tions in the body (Table 25.9). Langerhans cells are medi-
orders. Previously known as histiocytosis X, Langerhans um-sized with pale cytoplasm, poorly defined cell borders,
TABLE 25.8 CYTOPATHOLOGIC FEATURES OF GERM CELL TUMORS
Diagnostic
Clues/
Summary of Clinicopathologic Ancillary
Features Cytopathologic Features Tests See Fig(s).
Germinoma 15% of all germ cell tumors in children; High cellularity; dispersed pattern; AFP 17.22
frequent location—pineal area; discrete large round cells with clear to BHCG 17.32
histologically composed of island of vacuolated cytoplasm; high N/C ratio; CEA 22.20
discrete large round cells with large large central targetoid macronucleolus PLAP 22.21
round nucleus; eosinophilic cytoplasm; characteristic; well-defined cell borders; CK
lymphoid cells and focal granulomas lymphoid cells in the background; CD117
epithelioid cells / /c-kit
OCT4
Embryonal Poorly-differentiated germ cell tumor; High cellularity; pleomorphic malignant AFP 25.33
Carcinoma common locations—testes; age—young cells in syncytial tissue fragments with PLAP 25.34
adults; often occurs in association or without acinar pattern and in loosely CK
with other germ cell tumors such as cohesive groups; poorly-defined cell CD117/ 17.29
teratoma and endodermal sinus tumor; borders, coarse chromatin; multiple c-kit 17.33
histologically—presents an epithelial nucleoli; mitoses ; necrosis OCT4 22.22
pattern with solid and glandular
features; necrosis /
Endodermal Most common malignant germ cell Highly cellular, malignant cells in loosely AFP 25.32
Sinus Tumor tumor in pediatric age groups; either cohesive groups or in syncytial tissue PAS 25.33
(Yolk Sac alone or in combination; major site – fragments with or without acinar and PLAP
Tumor) sacrococcygeal are in newborns and papillary pattern; cell borders poorly- CD117/ 17.34
infants, ovary in older children and defined; pleomorphic irregular nuclei; c-kit
adolescents; may occur in mediastinum; intra and extracellular hyaline droplets OCT4
retroperitoneum, pineal area and vagina,
also occurs in testis; grossly soft pale
tan yellow, slimy cut surface with cystic
areas and foci of necrosis; histology ñ
variegated pattern, ranging from nests
of malignant cells resembling embryonal
carcinoma to distinct papillary and
net-like reticular formations; Schiller-
Duval bodies or papillary projections
and characteristic perivascular sheath of
cells; intra & extracellular; PAS and
AFP ; hyaline droplets
Teratoma Common occurrence; frequent site Cellularity variable; mature polymorphic Variable 25.28
– sacrococcygeal area; histologically cell population representing benign glial depending to
classified into three subtypes – mature, respiratory or intestinal epithelium; on malignant 25.30
immature and malignant malignant – immature component; cells component
representing one or more of malignant
germ cell component, e.g. germinoma,
embryonal carcinoma, endodermal sinus
tumor and choriocarcinoma
PLAP, placental alkaline phosphatase; CD117, (c-kit), membrane staining; CK, cytokeratin; OCT4, nuclear transcription factor (nuclear staining)
A B
Figs. 25.32A and B. FNA, yolk sac tumor. Endodermal sinus tumor in sacrococcygeal area of an infant. A: Showing
syncytial tissue fragments of malignant cells. B: Malignant cells with cytoplasmic vacuoles.
Fig. 25.33. FNA yolk sac tumor involving sacrococcygeal area. The Fig. 25.34. FNA embryonal carcinoma of the pineal gland. The ma-
cellular aspirate consists of medium-sized epithelial cells forming an lignant cells are forming an acinar pattern.
acinar pattern. The background is myxoid.
A B
Fig. 25.35A and B. FNA teratoma. Retroperitoneal teratoma in a newborn. A: Mucin secreting epithelial cells.
B: Megakaryocytes and eosinophilic myelocytes.
TABLE 25.9 CYTOPATHOLOGIC FEATURES OF and deeply indented nuclei with low N/C ratios. Their chro-
LANGERHANS HISTIOCYTOSIS (HISTIOCYTOSIS-X) matin is finely granular, and micronucleoli may be pres-
ent. The lesions of Langerhans histiocytosis may be purely
Cellularity Variable histiocytic or mixed histiocytic with variable numbers of
eosinophils to predominant eosinophils (Figs. 25.36 and
Presentation Polymorphic cell population with 25.37A) (see section on Eosinophilic Granuloma, Chapter
predominance of one or more types (see 24). Multinucleated foreign-body type giant cells may be
cell composition); dispersed cell pattern
present along with necrosis. Ultrastructurally, Langerhans
cells contain diagnostic Birbeck granules in their cytoplasm
Cell Langerhans cells—round to polygonal,
Composition abundant pale cytoplasm; cell borders
(Fig. 25.37B). Immunocytochemically, Langerhans cells re-
poorly defined; cell processes /; act to S100 protein, CD1, CD11, and CD14.
nucleus oval to kidney-shaped with deep The differential diagnoses include malignant lympho-
grooves; nucleoli ma and reactive lymphadenitis.
Eosinophils mature, bilobed eosinophils
Lymphocytes
Multinucleated foreign-body type giant cells
Macrophages EPITHELIAL NEOPLASMS
Immunoprofile Positive reactivity to S100 protein, CD1, Epithelial neoplasms in the pediatric age group and in
CD11, CD14
adolescents are not common but are occasionally seen
in organs such as the thyroid, the salivary glands, the
Ultrastructure Birbeck granules in the cytoplasm
liver, the pancreas, the nasopharynx, and so on. The
majority of the superficial organs are easily accessible to
Differential Reactive lymphadenitis
Diagnoses Malignant non-Hodgkin lymphoma FNA biopsy procedures, which offer a high diagnostic
accuracy.
Fig. 25.36. Langerhans cell histiocytosis (Histiocytosis X). Poly-

morphic cell population with mononuclear cells of varying sizes and
scattered eosinophils.
A B
Figs. 25.37A and B. Langerhans cell histiocytosis (Histiocytosis X). A: Polymorphic cell pattern with mononuclear cells
of varying sizes and scattered eosinophils. B: Electron micrograph showing characteristic Birbeck granules (arrows).
Thyroid Liver (Hepatoblastoma)

Solitary cold thyroid nodules are uncommon in the Hepatoblastoma is a malignant tumor of embryonic or
pediatric age group. The incidence of thyroid neo- fetal hepatocytes that often contains mesenchymal ele-
plasm is reported to be 3% and that of malignancy is ments and occurs prior to three years of age. It is the most
reported to be 25% in children with cold nodules. The common primary hepatic malignancy in childhood. The
most frequent malignancy is papillary thyroid carci- incidence is reported to be 0.2 per 100,000 children and
noma, often arising in the background of Hashimoto’s 4.7% of pediatric malignant tumors. There is a male pre-
thyroiditis. Other types of neoplasms include follicular dominance. Ninety percent of the tumors occur within
adenomas, Hürthle cell tumors, and medullary carcino- the first five years of life.
mas. An increased incidence of papillary thyroid carci- Histologically, hepatoblastomas are subclassified into
noma has been noted in children exposed to radiation epithelial, mixed epithelial—mesenchymal, and small cell
in Chernobyl. undifferentiated type. The epithelial type may exhibit a
fetal pattern, an embryonal pattern, or a combined fetal
and embryonal pattern, along with extramedullary he-
Nasopharyngeal Carcinomas (Lymphoepithelioma)
matopoiesis. The mixed epithelial–mesenchymal pattern
Nasopharyngeal carcinomas are the most common epi- includes an epithelial component admixed with mesenchy-
thelial malignancy of the head and the neck in children mal tissue. The undifferentiated or anaplastic type shows
(refer to Chapter 12). a pattern similar to round cell tumors of childhood.
The fetal and embryonal type have trabecular growth
patterns. The cells of the fetal type are smaller, contain
Salivary Glands
eosinophilic cytoplasm, and have a low N/C ratio. The
Salivary gland neoplasms in the pediatric age group embryonal type has large cells with a high N/C ratio
account for less than 5% of salivary gland tumors. Most and basophilic cytoplasm. Extramedullary hematopoi-
involve the parotid glands, with pleomorphic adenoma esis may be seen in the fetal type. The mesenchymal
and mucoepidermoid carcinoma being most frequent (see elements include osteoid, chondroid, and spindle cells.
Chapter 15). The anaplastic variant has a poorer prognosis. It has an
infiltrative pattern unlike the usual circumscription of
hepatoblastoma.
Breast
Cytologically, these tumors present a trabecular pat-
Neoplasms of the breast are usually encountered in ado- tern with an endothelial lining similar to that seen in
lescents. Fibroadenoma in females and gynecomastia in adult hepatocellular carcinoma (Table 25.10; Figs. 25.31
males are the most common lesions.
TABLE 25.10 CYTOPATHOLOGIC FEATURES OF HEPATOBLASTOMA

(EPITHELIAL TYPE)
Presentation Neoplastic cells isolated, in loosely cohesive groups, and in syncytial tissue
fragments
Architecture of the Trabecular with branching and anastomosis, enveloped by endothelial

Tissue Fragments lining; tissue fragments traversed by capillaries; pseudoacinar pattern
Cells Small to medium-sized, round to polygonal (miniature hepatocytes); well-

defined cell borders; high N/C ratios
Nucleus Round to oval; central location; smooth to irregular nuclear membrane;

fine to coarsely granular chromatin; prominent nucleoli
Cytoplasm Scant to moderate; pale, vacuolated to dense
Background Clean, hematopoietic cells /
Immunoprofile Reactive to Hep Par-1

A B
Figs. 25.38A and B. Hepatoblastoma. A: Very cellular aspirate presenting broad trabeculae with branching and anasto-
mosis (low power). B: Higher magnification showing miniature hepatocytes presenting a trabecular pattern.
and 25.38). The neoplastic cells, however, are smaller Pancreas

(miniature) hepatocytes with the occasional formation of
Epithelial neoplasms of the pancreas that infrequently
rosettes. Cytoplasmic glycogen and/or fat render the cyto-
occur in the pediatric age group and adolescents include
plasm clear. The mesenchymal elements and hematopoi-
pancreatoblastoma, acinar cell carcinoma, and solid and
etic cells are generally not seen in aspirates.
papillary tumor (ref Chapter 19).
Immunoprofile. Hepatoblastoma cells react to -fetoprotein Pancreatoblastomas are extremely rare, malignant,
and Hep Par-1. epithelial neoplasms showing multiple lines of differentia-
The differential diagnoses of hepatoblastoma include tion. They are also referred to as the pancreatic carcinoma
the small round cell tumors of childhood. of childhood. The cytologic documentation is limited to
an occasional case report.
SUGGESTED READINGS
Caraway NP, Fanning CV, Amato RJ, et al. Fine needle aspiration Parham DM, Ellison DA. Rhabdomyosarcomas in adults and
of intra-abdominal desmoplastic small cell tumor. Diagn Cyto- children. An update. Arch Pathol Lab Med 2006;130:
pathol 1993;9:465–470. 1454–1464.
Crapanzano JP, Cardillo M, Lin O, et al. Cytopathology of des- Stocker JT, Dehner LP. Pediatric Pathology. 2nd ed. Philadelphia:
moplastic small round cell tumor: A series including findings in Lippincott Williams & Wilkins, 2002.
ThinPrep. Cancer Cytopathol 2002;96:21–31. Weiss SW, Goldblum JR. Soft Tissue Tumors. 5th ed. Philadelphia,
Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia: Mosby Elsevier, 2008.
Churchill Livingstone, 2006.
Parham DM. Neuroectodermal and neuroendocrine tumors princi-
pally seen in children. Am J Clin Pathol 2001;115(suppl 1):
S113–S128.
Index
Note: Page locators followed by f and t indicate figure and table, respectively.
A Adenocarcinoma in situ (AIS), of pituitary, cytopathology of, 351t

Abnormal squamous epithelial endocervix, 115, 117 pleomorphic, in salivary gland,
reactions, 216–217, 221–223 cytopathologic features of, 117, 573–575
Acinar carcinomas, of pancreas, 779 118f–120f, 118t of thyroid. See Follicular adenoma
cytologic pattern of, 779, differential diagnoses of, Adenoma, See specific sites
780f–781f, 780t 124–126, 124t, 125f Adenoma malignum, 121, 123f
differential diagnoses of, 779, 781f differentiating features between Adenosis, of breast, 713, 715, 717
gross and microscopic features HSIL, 126t Adenosis, sclerosing type, 715
of, 779, 779f Adenocarcinomas not otherwise Adenosquamous carcinoma, 272–273
immunoprofile and ultrastructure specified (NOS), of breast, of breast, 698f, 704
of, 779 690t–691t, 692f–693f of endocervix, 121
Acinic cell carcinoma, of salivary cytopathologic features of, of endometrium, 103
gland, 638 699t–701t, 702 Adipose tissue tumors, 926–930
cytopathologic features of, 639, differential diagnosis of, 701t Adrenal cortex, 832
639t, 640f–642f, 642 Adenocarcinomas not otherwise lesions of, 834–838
diagnostic accuracy of, 642 specified (NOS), of salivary zona reticularis of, 832
differential diagnoses of, 642, glands, 618, 630–634 Adrenal cortical adenoma, differenti-
643f, 643t cytopathologic features of, 630, ation from hyperplasia, 834
gross and histologic features of, 631f–632f, 631t, 633 Adrenal cortical carcinomas, 835
638–639 differential diagnosis of, 633, cytologic features of, 835, 836f–
Actinomyces, in cervical-vaginal 633f–634f 838f, 836t, 837
smears, in I.U.D. users, 42t gross and histologic features of, 630 diagnostic difficulties and differen-
Actinomycosis, pulmonary, 283t immunoprofile of, 633 tial diagnoses of, 838, 839t
Adenocarcinomas. See specific sites Adenoid cystic carcinoma (ACC), gross and microscopic features
basal cell, in salivary glands, 243, 274 of, 835
598t, 600, 601f–602f of breast, 705 immunoprofile of, 837
bronchioloalveolar, 205t–206t of lungs, 243, 274 Adrenal cortical nodules, differen-
bronchogenic, 205t–206t of salivary glands, 642 tiation from well differenti-
colonic, 142, 143f cytopathologic features of, ated adrenal cortical carci-
differentiation from malignant 644, 645f–649f, 645t nomas, 839t
mesothelioma, 152–153 diagnostic problems in, 644 Adrenal cysts, 847
of endocervix, 115, 117 differential diagnoses of, 644, Adrenal gland, 832
of endometrium, 98 649f–651f adrenal cysts, 847
of esophagus, 297, 297f gross and microscopic features FNA biopsy for, use of, 832
of fallopian tube, 141 of, 642, 644 ganglioneuromas of, 847
gastric, 301, 301t immunoprofile of, 644 lesions of adrenal cortex
lungs, 223–224 Adenolymphoma, of salivary glands. adrenal cortical carcinomas,
metastatic to breast, 167–170 See Warthin’s tumor 835–838
metastatic to gastrointestinal Adenoma adrenal cortical hyperplasia
tract, 172, 174f, 175 basal cell, of salivary gland, and adenoma, 834, 835f
metastatic to genitourinary tract, 593–594, 598f–600f metastases to, 847
175, 175f, 177 lactating and tubular, of breast, myelolipomas of, 847, 849t,
metastatic to lung, 170–172 719, 724t 850f–851f
metastatic to ovary, 172 malignum, endocervical, 121, 123f neuroblastoma of, 847
of pancreas, 770, 772, 773t microcystic, pancreatic, 800 normal histology and cytology of,
poorly differentiated, metanephric, 813 832, 833f–834f, 834t
endometrial, 110t nephrogenic, 344 peripheral neuroectodermal
of uterine cervix, 115 parathyroid, cytopathology of, 529 tumor, 847
989
990 Index
Adrenal gland (Cont.) Anaplastic K-1 malignant cytopathologic features of, 44,
tumors of adrenal medulla, 838 lymphoma, 389f 45t
extra-adrenal paragangliomas, Anaplastic large cell lymphoma differential diagnosis, 133t–134t
842, 842t, 843t–844t, 845, (ALCL), cytopathologic Asbestos fibers, 193
845f–846f features of, 560f ASC. See Atypical Squamous Cells
pheochromocytomas, 838– Anaplastic thyroid carcinoma ASC-US/LSIL triage study (ALTS),
842, 842t (ATC), 481 32, 91
Adrenal medulla cytopathologic features of, 483, Askin tumor, 969
pheochromocytomas, 838–842, 483t, 485–486 Aspergillosis, 284
842t differential diagnoses of, 486, ASR. See Arias–Stella reaction
differential diagnoses of, 842 486t Asteroid bodies, 195
Adrenal myelolipoma, 847, 849t, cytologic features of differential Astroblastoma, 887, 888f
850f–851f diagnostic entities in, 487t Astrocytes, 873
Adult respiratory distress syndrome giant cell type, 481, 484f Astrocytic tumors, of CNS, 877–
(ARDS), 202–203 gross and histologic features of, 885, 886f–887f, 887
cytopathologic features, 202– 481, 483 Astrocytomas, 873, 877
203, 203t immunoprofile of, 486 anaplastic, 880
AGC. See Atypical glandular cells paucicellular variant of, 481, gemistocytic, 877, 880
AIS. See Adenocarcinoma in situ , of 485f, 486 low grade, 877
endocervix rhabdoid variant of, 483 pilocytic, 877, 879f
ALTS. See ASC-US/LSIL triage study spindle cell type, 481, 484f Atrophic cervical–vaginal smear,
Alveolar histiocytes, 192, 194t Angiomyolipoma, renal, 814, 814t cytopathologic features
Alveolar pneumocytes cytopathologic features of, 814, of, 39t
hyperplasia of type II cells, 243, 814t Atrophic smear
244t differential diagnoses of, 849t, differential diagnoses of cellular
diagnostic pitfalls, 243 851f changes in, 89t
Alveolar proteinosis Angiosarcoma, 933–934, 935f with squamous cell atypia, 78
differential diagnosis of, 288t cytopathology of, 934 Atrophy, in cervical-vaginal
lamellar bodies in, 193 differential diagnoses of, 934, smears, 89t
Alveolar rhabdomyosarcoma, in 949t Blue blobs in, 39t, 40f
children, 976, 977 of breast, 708 cellular changes in, 38–39, 39t
cytopathology of, 977t, in liver, 764 differentiation from ASCUS, 86
978f–979f Apocrine carcinoma, of breast, differentiation from HSIL, 89t
differential diagnosis of, 690t–691t, 696f, 699t– Atypical adenoma, of thyroid, 416f,
980t–981t 701t, 703 417, 417t
metastases from, 977, 979f differentiation from cystic change Atypical carcinoid tumor, 259
Alveolar soft part sarcomas, 948, 949t with florid apocrine cytopathologic features, 259,
Ameloblastoma, of mandible, 400, metaplasia, 715t 259f
400f Appendix histologic features of, 259
Amine Precursor Uptake and carcinoid of, goblet cell type, Atypical endometrial hyperplasia,
Decarboxylation (APUD) 182f 96–97
cells, 350 carcinoid tumor cells in Atypical fibroxanthoma, 923–924
Amyloid, 195 effusion fluid, 169f, 179f, Atypical follicular adenoma, 417
Amyloid goiter, 500, 500t 180, 189 Atypical glandular cells (AGC), 113,
Amyloidoma, 270, 271t, 582f pseudomyxoma peritoni, 189 126, 129f–132f
Amyloidosis Architectural patterns of tissue cytopathologic clues in, 135t
pulmonary, 271t, 288t fragments in neoplasms, 6 differential diagnoses of, 128t,
soft tissue in neck, differentiation Areola scraping, 725 133t–134t
from pleomorphic ARDS. See Adult Respiratory Dis- differentiation from Arias-Stella
adenoma, 582f tress Syndrome (ARDS) reaction, 133t–134t
Anal cytology, use of, 308 Argentaffin cells, 366 differentiation from endocervical
Anal intraepithelial neoplasia (AIN), Argyrophil cells, 366 adenocarcinoma, 133t–134t
308 Arias–Stella reaction (ASR), 44 differentiation from lower uterine
Anal malignant melanomas, 308, in cervical smears, during preg- segment cells, 133t–134t
308f–309f nancy and postpartum differentiation from microglandu-
Anaplastic astrocytoma, 878t, 880f states, 44, 45t lar hyperplasia, 133t–134t
Index 991
differentiation from squamous cytopathologic features of, 593, BRAF V600E mutation, 208
carcinoma in situ, 597, 598f–600f, 598t Breast
133t–134t differential diagnosis, 597, 661t acute mastitis, 717, 718t
differentiation from tubal microscopic features of, 593 adenocarcinomas
metaplasia, 133t–134t Basal cell carcinoma, of head and cytopathologic features of,
Atypical endometrial hyperplasia, neck, 382, 384t 167, 168t, 169f–170f, 170
96, 97 Benign neoplasms, of lungs, 272, differentiation from pregnancy
Atypical mycobacterial infection, 272t lactation changes, 724t
152, 245, 246f, 282 The Bethesda System (TBS 2001), for morphologic variants of,
Atypical squamous cells (ASC), 32 gynecologic cytology 31, 48 702–704
management of women with, 91 for FNA biopsy, 402 adenoid cystic carcinomas of, 705
mimics of, 90t–91t The Bethesda System (TBS 2007), adenosquamous carcinoma, 698f,
overview, 82 for thyroid cytology, 402, 704
significance of, 91 540t apocrine carcinoma, 690t–691t,
Atypical squamous cells of unknown Bile duct brushings, 319, 319f, 323t 696f, 699t–701t, 703
significance (ASC-US) Bile duct carcinoma, 315, 317 areola scrapings, 725, 725f
cytopathologic features of, 88t Bile duct, normal cytology of, benign neoplasms of, 705–708
HPV testing for, 91 314–315 carcinomas of, 692–702
mimics of, 90t–91t Bile duct adenocarcinoma, 315–318 cytologic features of, 698t
morphologic changes, 82 cytopathologic features, 317, carcinoma with osteoclast type
in intermediate type 318f giant cells, 697f, 704
squamous, 82–83 differential diagnosis, 319 collagenous spherulosis of, 720
in mature squamous cells, 82 Bile pigment, in hepatocellular carci- colloid carcinoma. See Mucinous
in metaplastic squamous cell, noma, 749, 750t (colloid) carcinoma
86, 88 Biliary tract, 314 comedocarcinoma, 716t, 718t
in parabasal squamous cell, normal cytology of, 314 cystic lesions of, differential diag-
86, 88 Birbeck granules, 29t, 563f, 567 noses of, 712–713, 716t
overview, 82 Bladder wash, 327 differential diagnosis of, 713t,
significance of, 91 Body cavity fluids. See Serous 714f–715f
vs. atrophy-associated changes, effusions duct adenocarcinoma, NOS,
86 cytopreparatory techniques, 149 690t–691t, 692f, 693f,
vs. decidua, 83, 86 wet mount technique, 189 699t–701t
vs. inflammation-associated Blue blobs, 146f, 147 fat necrosis, 717, 718t
changes, 83 Bone, fine needle aspiration biopsy fibroadenomas, 705
vs. LSIL, 83 of, 919–964 cytopathologic features of,
vs. orangeophilia, 86 giant cell tumors of, 958, 962, 705, 706t, 707f–708f
vs. radiation-associated changes, 963f and diagnostic difficulties, 706
83 Bone tumors differential diagnosis of, 708t
Automatic processors, 189 chondrosarcomas, 955–958 differentiation from prolifera-
Azzopardi, J.G., 1 Ewing’s sarcoma, 958 tive breast disease, 720t
FNA biopsy of, use of, 951 fibrocystic change in, 712–713
B giant cell tumors, 958, 962 FNA biopsy of, 688–730
BAC. See Bronchioloalveolar carci- Langerhans cell histiocytosis, decline in, 688
noma (BAC) 962–964 diagnostic problems in,
Background, in cytologic specimens, metastatic tumors, 964 688–689
6, 23 multiple myeloma, 951–952 granular cell tumor of, 720
BAL. See Bronchoalveolar lavage osteosarcomas, 952–955 gynecomastia, 725, 728
(BAL) Botryoid rhabdomyosarcomas, in intraductal carcinoma of, 720,
Barrett’s esophagus, 295–296, children, 977 725
296f Brain metastases, in cerebrospinal intraductal papillomas, 705f,
Basal cell, 33 fluid, 871 710f
Basal cell adenocarcinoma, of Branchial cleft cysts, 380 differential diagnosis of, 709t
salivary gland, 598t, 600, cytopathology of, 380 differentiation from papillary
601f–602f differential diagnosis of, 381t carcinoma, 706t
Basal cell adenomas, of salivary Bowen’s disease, 60 nipple discharge associated
gland, 593 BRAF inhibitor, 208 with, 725, 726t, 727f–728f
992 Index
Breast (Cont.) pregnancy and lactational changes Breast diseases, specimen types
invasive duct adenocarcinoma, in, 719–720, 723f, 724t for, cytologic diagnosis of,
NOS, 698 proliferative disease of, 717–719, 690t–691t
ancillary studies for, 702 718f–719f Breast lesions, with small cell pat-
cytopathologic features, 702 radial scar, 717 tern, differential diagnosis
gross and microscopic scrapings of nipple and areola, of, 721t
features, 698 cytologic evaluation of, 725 Bronchi, 192
immunoprofile of, 702 secretory carcinoma of, 705 Bronchial brushings, and washings,
and molecular biology, 702 signet-ring carcinomas of, 705 198f–200f, 290
juvenile carcinoma. See Secretory specimens types from, for cyto- atypical reparative/reactive
carcinoma pathologic evaluation, 688, changes in, 196t
lactating adenoma of, 724t 689t goblet cells in, 196t
lesions with small cell pattern, spindle cell lesions of, 708, 712f, goblet cell hyperplasia, 196t
differential diagnoses of, 713t hyperplastic epithelium in, 196t
721t, 722f–723f subareolar abscess of, 716t, 717 non-specific inflammatory changes/
lobular carcinoma, 690t–691t, tubular carcinoma, 690t–691t, irritation forms, 196t
696f–697f, 699t–701t, 694f, 699t–701t, 703 radiation-induced changes, 196t
703–704 unusual malignancies of, Bronchioles, 192
male, breast, carcinoma of, 728, 704–705 structure of, 193
729f Breast aspirates, with mucinous Bronchioloalveolar carcinoma
medullary carcinoma, 690t–691t, background, differential (BAC), 203
693f, 699t–701t, 702 diagnosis of, 724t, 725 cytopathologic features, 242
metaplastic carcinomas, 697f, with papillary epithelial tissue histologic features, 241–242
704, 704t fragments, differential diag- immunoprofile of, 242
metastatic cancers, diagnostic nosis of, 721t morphologic spectrum of,
markers for, 702 with spindle cell pattern, 708, 230f–232f
metastatic tumors of, 725 712f, 713t nonmucinous, 242–243
micropapillary carcinomas, 703 Breast cancer, diagnostic guidelines overview, 241
mucinous (colloid) carcinoma, for, 689, 729t specimens types from, breast, for
690t–691t, 694f, 699t– false negative diagnosis of, 689 cytopathologic evaluation,
701t, 703, 724t molecular biology, 702 688, 689t
mucocele-like tumor of, 724t, Breast carcinoma, 692 ultrastructure of, 242
725 cytologic features of, 698t Bronchoalveolar lavage (BAL), 191,
neuroendocrine carcinomas of, estrogen-progesterone receptors 200f, 290
705 in, 702 Bronchogenic adenocarcinoma,
nipple discharges, abnormal, 725, morphologic variants of, cytopa- clinicohistomorphologic
726t, 727f–728f thology of, 699t–701t features, 205t–207t
nodular fasciitis, 713t Breast disease, nonproliferative, Burkitt lymphoma, cytopathologic
nonproliferative diseases of, 712–717 features of, 552t, 559f
712–717 Adenosis/sclerosing adenosis,
adenosis, 713, 715, 717 713, 715, 717 C
fibrocystic change, 712, 713, fibrocystic change, 712–713 Calcitonin. See Medullary carci-
715t inflammatory lesions of, 717, 718t noma, of thyroid
inflammatory lesions, 717, radial scar, 717 Calcitonin, 494
718t Breast disease, proliferative, 717–719 Calcifying epithelioma of Malherbe.
radial scar, 717 cytopathologic features of, 701t See Pilomatrixoma
normal components of, 689 differential diagnosis of, 709t Calcium oxalate crystals, 195
Paget’s disease differentiation from fibroadeno- Calretinin, 157
cytopathologic features of, ma, 706, 708t Cancer cells, in vaginal smears, 31
689t differentiation from tubular Candida albicans, in cervical-vaginal
scraping of areola, 724t carcinoma, 690t–691t, smear, 41t
papillary carcinoma, 690t–691t, 694f, 699t–701t, 703 Canthus lesions, 396
695f, 699t–701t, 703 differentiation from well differ- Carcinoid tumors. See also Pulmo-
differential diagnosis of, 709t, entiated duct adenocarcino- nary carcinoid tumors
710f–712f ma, 690t–691t, 692f, 693f, atypical, 259
phyllodes tumor, 708, 711f–712f 699t–701t gastrointenstinal, 308
Index 993
in lungs, 254–258 smear preparation, technique neuroglia tumors of, 877

of ovaries, 863 of, 873 normal components of, 873
spindle cell type, 255 astroblastoma of, 887, 888f normal cerebellum, smear of,
Carcinoid tumors, in lungs, 254 astrocytic tumors of, 877 874f
atypical, 254t, 259 anaplastic astrocytoma, 880 normal cerebral cortex, smear
cytopathology of, 255, 256t astrocytoma, 877, 878t of, 874f
Carcinoid syndromes, 863 gemistocytic astrocytomas, oligodendrocytes of, 873–875
Carcinoma, with pseudosarcoma- 877, 879f, 880 oligodendrogliomas of, 894–896
tous pattern, cytopathology glioblastoma, 880–885 paragangliomas of, 913, 915f
of, 944t pilocytic astrocytomas, 877, pattern based approach for,
Carcinoma in situ. See High grade 878t, 879f 916–917
squamous intraepithelial pleomorphic xanthoastrocy- pineal tumors, 898f, 900, 901t
lesions toma, 885, 886f–887f, 887 pituitary adenomas of, 896f,
Cat-scratch disease, cytopathology cerebellum and fourth ventricle 897t, 899
of, 544t tumors, 907 primary CNS lymphomas, 896,
Catheterized urine, 326t, 327 cerebrospinal fluid, 870 897t, 898
Cavitary squamous carcinoma vs. cytologic evaluation of, 870 primary tumors, 966
cavitary lung lesions, 213– metastatic tumors in, 871, schwannomas of, 901, 903, 906t,
214, 213t, 214f–216f 872f 907f
CD57, 366–367 neoplastic processes in, 871, Central nervous system lesions, as-
CD99, 367 871f–872f piration biopsy of, with ste-
Cell block technique, 6, 190 nonneoplastic processes in, 870 reotactic CT guidance, 870
Cell in Health and Disease, 3 normal components in, 870 crush smear of, 870
Cells primary CNS tumors in, cells Central nervous system lymphomas,
atypical functional differentia- of, 871 primary, cytopathology of,
tion, 3 chordomas of, 911–913, 912t, 897t
biologic behavior, 3 913f, 914t Central nervous system neoplasms,
cytoplasmic characteristics of, 4 choroid plexus neoplasms of, with small round cells,
degeneration(retroplasia), 3, 892–894 differential diagnosis of,
2t–3t, 4f craniopharyngiomas of, 909–911, 897t
functional differentiation, 3 910t, 911f Central neurocytoma, 898–899
general activity of, morphologic cytological preparations during Central PNET (cPNET), 970
characteristics of, 3, 2t–3t, 4f intraoperative consulta- Cerebellar cortex, normal differen-
hyperplasia/hypertrophy, tions, 915–916 tiation from medulloblas-
repair/regeneration/ differentiation between gliosis toma, 900t
dysplasia(proplasia), 3, and astrocytoma, 876t Cerebellar hemangioblastoma, dif-
2t–3t, 4f ependymomas of, 887–892, 889t, ferentiation from metastatic
malignant criteria of, 4 890f–892f renal cell carcinoma, 908t
neoplasia, 3, 2t–3t, 4f gliomas, cytopathologic features Cerebellum tumors, 907
normal or resting (euplasia), 3, of, 878t Cerebrospinal fluid (CSF), 870
2t–3t, 4f gliosis in, 875f, 876–877 brain metastases in, 870,
Cellular follicular adenomas, 410t, hemangioblastomas of, 907–909, 871f–872f
411–414, 412f–414f 909f, 909t choroid plexus cells in, 870,
Cellular morphology, 2t–3t, 7f–21f, hemangiopericytomas of, 913, 871f–872f
11–23 914f–915f. See also Solitary Cryptococcus neoformans in,
cell composition, 11, 12, 13 fibrous tumor, Soft tissue 870, 871f–872f
cell shapes, 13 tumors lymphocytic pleocytosis in, 870,
cell size, 11 lesions with spindle cell pattern, 871f–872f
cytoplasmic qualities, 15, 22 differential diagnoses of, medulloblastoma in, 870,
nuclear characteristics, 15 906t, 907, 908f 871f–872f
stroma, 22 meningiomas of, 900–901, 902t, meningeal carcinomatosis in,
Central nervous system (CNS), 903f–906f 871, 871f–872f
870–917 metastatic tumors in, 913, 915 metastatic tumors in, 871,
aspiration biopsy of CNS lesions, neurocytomas of, 898–899, 898f 871f–872f
under stereotactic CT neuroectodermal tumors of, neoplastic processes in, 870,
guidance, 873 primitive, 899–900 871f–872f
994 Index
Cerebrospinal fluid (Cont.) botryoid rhabdomyosarcomas, thyroid neoplasm in, 987

non-neoplastic processes in, 870, 977, 979f Chlamydia trachomatis, in cervical
871f–872f breast neoplasm in, 987 vaginal smears, 41t
normal components of, 870, central nervous system tumors in, Cholangiocarcinomas, 317, 758, 764
871f–872f primary, 871 Ciliated columnar cells, 192
primary CNS tumors in, 871, clear cell sarcoma in, 976 Chondroid syringomas, 385, 386f
871f–872f craniopharyngioma in, 910 Chondrosarcomas, 955–958
Cervical cancer, 31 cytopathologic features of, 986t cytopathologic features of,
association with HPV, 31 Desmoplastic small round cell 955–958, 955f–957f, 955t
glandular type. See Endocervical tumor (DSRCT) differential diagnoses of, 958,
adenocarcinoma embryonal rhabdomyosarcoma, 959t, 960f–962f
misdiagnosis of, 31 977, 977t, 978f Chordoma, 911
routine screening for, 31 endodermal sinus tumor in, cyto- cytologic features of, 912, 912t,
squamous type. See Squamous pathology of, 984f, 985t 913f
cell carcinoma ependymomas in, 887 differential diagnoses of,
Cervical cytology, 32–33 epithelial neoplasms in, 988 912–913, 914t
Cervical epithelial neoplasia, 31 Ewing’s sarcoma, 958, 966 gross and histologic features of,
Cervical intraepithelial neoplasia cytopathologic features, 970, 911–912
(CIN), 48, 49 970t, 971f–972f immunoprofile of, 912
cytopathologic features of, 49 differential diagnosis of, 972 Choriocarcinoma, 868, 869f
histologic features of, 49 ganglioneuroblastoma in, 968 Choroid plexus cells in CSF, 870
Cervical intraepithelial neoplasia, hepatoblastoma in, 987 Choroid plexus neoplasms, 892–893
Richart’s classification of, 31 cytopathologic features, 987t cytopathologic features of, 893,
Cervical squamous carcinoma, Hodgkin lymphoma in, 966 893f–894f, 893t
terminology for, 49 intra-abdominal desmoplastic differential diagnoses, 894
Cervical–vaginal cytology, 31 small cell tumor, 965 immunoprofile of, 893–894
diagnosis, TBS of, 31 Langerhans histiocytosis, Choroid plexus papilloma, 893t
Cervical-vaginal smears, 31 983–986 in central nervous system, 870
Arias–Stella reaction, 44, 45t liver neoplasm in, 987–988 in children, 871
atrophic, cellular changes in, lymphoepithelioma in, 987 Chromaffin cells, 350
38–39, 39t malignancies, 966t Chromogrannin, 366
columnar cells in, 28t, 34 malignant lymphoma, 980t–981t Chromophobe type renal cell car-
differential diagnoses of multi- malignant non-Hodgkin lympho- cinoma, clinicopathologic
nucleated giant cells in, ma in, 965 features of, 815, 816t–817t
146t–147t, 147 medulloblastoma in, 898f, 897t, Chronic lymphocytic thyroiditis,
endometrial adenocarcinoma 899–900, 900t 509t
in, 94 nasopharyngeal carcinomas in, Chronic sclerosing sialadenitis,
endometrial cells in, 35f–39f, 95 987 677–678, 678t, 680f–681f
for endometrial lesions, diagnos- nephroblastoma in, 974–976 CIN. See Cervical intraepithelial
tic problems in, 94 cytopathologic features of, neoplasia
evaluation of, 32 974t, 975 Cirrhosis of liver, 751
metastatic malignancy in, differential diagnosis of, 975 Clara cells, 193
142f–143f neuroblastoma in, 966–969 Classic Hodgkin lymphoma (CHL),
pregnancy-associated changes in, cytopathologic features of, 556, 562f, 563f, 566
40, 43f–45f, 44–45, 45t 967, 967t Reed–Sternberg cell in, 556, 561f,
psammoma bodies in, 144, 144f– differential diagnosis of, 969 562f, 563f
146f, 144t neuroectodermal tumors in, 966 Clear cell carcinoma, 138, 667, 668f
reporting guidelines for, 31 neuroendocrine tumors in, 966 cytopathologic features of, 124t
squamous cells in, 32, 34t renal neoplasms of, 974–976 in DES-exposed women, 138
squamous lesions. See Squamous rhabdoid tumors in, 976f renal
lesions rhabdomyosarcomas in, 976–979 clinicopathologic features,
squamous metaplasia in, 36, 36t salivary gland neoplasm in, 987 816t
Charcot-Leyden crystals, 193 small round cell tumors in, 972 cytopathologic features, 817t
Children differential diagnosis of, of salivary gland, differential
alveolar rhabdomyosarcoma, 980t–981t diagnosis of, 667–668
977, 979f teratoma in, cytopathology of, 984t vaginal, 138, 139f
Index 995
Clear cell neoplasms, of salivary Cystadenoma, 668 D

gland, differential diagnosis Cystic hygroma, of head and neck, Decidua, differentiation from
of, 667–668 380 atypical squamous cells of
Clear cell sarcoma, 948, 949t Cystic lesions undetermined significance,
in children, 976 in breast, differential diagnosis 83, 86
Clear cell tumor, benign of, lung, of, 716t in pregnancy, 40
272t in head and neck, differential Deep endometrial stromal cells, 95
Cloacogenic carcinoma, 307, 307f diagnosis of, 380–381 Dendritic cell sarcoma, 564f, 568
Collagenous spherulosis, 720 in kidney, differential diagnosis Dermatopathic lymphadenitis, of
Colloid adenoma, 409–410, 410t, of, 812, 824t lymph node, cytopathology
411f in ovaries, differential diagnosis of, 544t
Colloid carcinoma, of breast, of, 852t, 853t–854t Dermoid cysts, ovarian, 852, 868
clinicopathologic features in pancreas, differential diagnosis DES. See Diethylstilbestrol
of, 703 of, 789, 794t, 795t–799t, Desmoplastic malignant mesothe-
Colloid nodule, of thyroid, 409, 810 lioma (DMM), 276
536t in salivary gland, differential Desmoplastic small round cell
Colonic adenocarcinoma, 142, diagnosis of, 673t tumor (DSRCT), 972–974,
307f, 767 in thyroid, differential 973t, 973f
Colorectal brushings, 305–306, 307f diagnosis of, 522f, cytogenetic testing, 971
Columnar cells, characteristics 523–525, 524t, 525f, cytopathologic features,
of, 34 526f 972–974, 973t, 973f
ciliated, respiratory tract, 192, Cystic neoplasm, pancreatic, 800 differential diagnoses of, 974
194t Cystic nephroma. See Multilocular FNA biopsy specimens, 974
endocervical, 114 cyst, of kidney gross and histologic features, 972
tissue fragments of, 34 Cystic nodular goiter, cytopathology immunoprofile of, 974
Columnar epithelium, specialised, in of, 463f, 464f, 465, 466t molecular testing, 974
Barrett’s esophagus, 295 Cystic ovarian lesions, cytopathology Diethylstilbestrol (DES), 138
Combined small cell carcinomas, of, 852t, 853t–854t Differential diagnosis, in
266 Cystic papillary carcinomas, 455, cytopathology, 1–2
Condyloma, in cervical-vaginal 458, 459f–464f, 465 approach to, 23–24, 24t
smears, 48 and cystic nodular goiter, 463f, electron microscopy, 29
Congenital cysts, of head and neck, 464f, 465, 466t flow cytometry, 29
380 Cystic teratoma, ovarian, 852, histochemical stains in, 25, 25t
Contaminants, in respiratory speci- 853t–854t image cytometry, 29
mens, 195 Cystitis cystica, 338t, 339, 341f immunochemical stains in, 25,
Corpora amylacea, 193, 195 Cystosarcoma phyllodes. 26t–27t, 27
Corpus luteal cysts, 853t–854t, See Phyllodes tumors, molecular techniques of, 29–30
855–856, 856f of breast Diffuse large B-cell lymphoma
cPNET. See Central PNET Cytomegalovirus infection, cytopa- (DLBCL), 275, 518
Cruschmann spirals, 193 thology of, 544t anaplastic, 554t, 560f, 561f
Craniopharyngioma, 909–910, Cytokeratin 7, 208 centroblastic, 553t, 560f
911f Cytologic evaluation, 6 cytopathologic features of,
adamantinomatous, 910, 910t Cytologic specimens 518–519, 519t, 520f, 521f
differential diagnoses of, application of molecular tech- differential diagnosis of, 521,
910–911 niques to, 29–30 523t
papillary, 910, 910t evaluation of, 5 immunoblastic, 553t, 560f
Creola bodies, 198f Cytomegalovirus, 138 l-Dihydroxyphenylalanine (DOPA),
Crowded cells, microbiopsy of, 88 infections due to, in lungs, 365
Cryptococcus neoformans, 284 effusion fluids, 284t DLBCL. See Diffuse large B-cell
in cerebrospinal fluid, 870 infections, 294 lymphoma (DLBCL)
infection from, 870 Cytopathology, basic concepts DMM. See Desmoplastic malignant
Cutaneous metastasis, to head and of, 1 mesothelioma (DMM)
neck, 388 Cytoplasm, 36 Döderlein bacilli, in cervical vaginal
Cyclophosphamide effect on ure- Cytoplasmic keratinization, 209 smear, 41t
thellial cells, 338t, 344 Cytopreparation, 5 Duodenum, 305
Cystadenocarcinoma, 668 methods for, 5 “Drunken honeycombs”, 772, 774f
996 Index
DSRCT. See Desmoplastic small squamous carcinoma, in patients on HRT, 96

round cell tumor 133t–134t Endometriotic cysts, 853t–854t,
Duct adenocarcinoma NOS, of squamous carcinoma in situ, 859, 860f
breast, clinicopathologic 133t–134t Endometrial hyperplasia, 96
features of, 690, 698t–701t, tubal metaplasia, 133t–134t cytopathologic features of, 96–97
702 endocervical adenocarcinoma in Endometrial lesions, in cervical-
Duct hyperplasia situ, 115, 117, 124t vaginal smears, 94
in breast, 709t morphologic variants of, Endometrial metaplasias, 96
in chronic pancreatitis, 776, 777t 121–124 Endometrial papillary syncytial
Ductal cells, pancreatic, charecteris- mucinous tumors, 121 metaplasia
tics of, 770t vs. ASR changes, 128t cytopathologic features of, 106t
Duodenum, 305 Endocervical adenocarcinoma in Endometrial stromal sarcomas,
Dust cells, 192 situ (AIS), 115, 117, 124t 112–113, 113f
Dysgerminoma, cytopathology of, Endocervical brush, 32, 105 Endometrioid endometrial
865t Endocervical cells, 114 carcinoma
Dyskeratosis, 54 Endocervical glandular epithelium, differential diagnoses of, 106t
Dysplasia, cervical/vaginal characteristics of, 34 Endometriosis, 186
squamous epithelium, 48, Endocervix Endometrium
49 in AIS, 115, 117 adenocarcinoma of, 97–98
in Barrett’s esophagus, 295 cytology of, 114 direct sampling of, 96
cytopathologic features of, 49 glandular changes in, 114 MMMT, 111
histologic features of, 49 histology of, 114 overview, 94
Reagen’s classification of, 31 microglandular hyperplasia of, Endosalpingiosis
urothelial, 333, 336t, 345t 114, 115t, 116f cytopathologic features of, 186,
overview, 113–114 186t
E tubal metaplasia of, 114–115, differential diagnosis of, 186
EBUS. See Endoscopic bronchial 115t, 116f–117f Endoscopic bronchial ultrasound
ultrasound (EBUS) Endocrine status, 38 (EBUS), 191
Echinococcus granulosus, hydatid Endodermal sinus tumor, in chil- Endoscopic retrograde cholang-
cysts from, 750 dren, cytopathology of, iopancreatography (ERCP),
Effusion fluids 866–867 314, 769
cytopreparation of, 188–189 Endometrial adenocarcinoma, Endoscopic ultrasound guided biop-
metastatic squamous carcinoma 97–98 sies (EUS), 769
in, 180f cytopathologic features of, 98– Eosin, 189
papillary adenocarcinomas in, 99, 99t, 100f–102f, 106t Eosinophilic granuloma. See Langer-
179f diagnostic accuracy and differen- hans cell histiocytosis
EGFR gene, 208 tial diagnoses of, 105–109, Epidermal inclusion cyst, head and
Elastin fibers, 195 107t, 108f–109f neck, 380, 381t
Electron microscopy, 29 differential diagnoses of poorly Epithelial malignancies, 167
Embryonal carcinoma, 866 differentiated, 110t Epithelial mesotheliomas, 153
Embryonal rhabdomyosarcoma, in FIGO grading system for, 98 Epithelial neoplasms, in pediatric
children, 977 immunoprofile of, 99 age group and adolescents,
Endobronchial lesions, 152 pattern of, 98 986–988
Endocervical adenocarcinoma UPSC, 102–104, 103f, 104t breast, 987
adenoma malignum, 121 Endometrial carcinoma liver, 987–988
adenosquamous carcinoma, 121 differential diagnoses of, 106t nasopharyngeal carcinomas, 987
association with HPV, 31 histologic classification of, 98 pancreas, 988
clear cell carcinoma, 124, 124t Endometrial cells, 34 salivary glands, 987
differential diagnoses of, 124t in cervical/vaginal cytologic spec- thyroid, 987
differentiation from, imens, 104–105, 105f Epstein–Barr virus, 282
atypical glandular cells, abnormal/atypical of, 104–105 Ependymomas, 887
133t–134t normal-appearing of, 104 classic, 887
endometrial adenocarcinoma, cytomorphology of, 95–102 cytopathologic features of, 887–
133t–134t in lower uterine segment, 95–96, 888, 889t, 890f–891f
microglanular hyperplasia, 96t gross and histologic features of,
133t–134t from menstrual endometrium, 95 887
Index 997
myxopapillary, 888, 889t, 892f inflammatory conditions of, 315, of bone, 951–964
Epithelial–myoepithelial carcinoma, 315f–317f of central nervous system tumors,
of salivary glands, 652, 656, malignancies in bile duct brush- 870–917
657f, 658, 658f ings, 319f of head and neck region,
Epithelioid hemangioendothelioma, normal cytology of bile ducts, 380–400
in liver, 933, 933f, 934f 314–315, 315f of kidney, 812–830
Epithelioid sarcoma, 942, 949t Extramedullary hematopoiesis, 182, of liver, 749–751
Esophagus 184f of lymph nodes, 543–569
adenocarcinoma of, 297, 297f in lungs, FNA of, 271t of orbit, 391
Barrett’s esophagus, 295–296, Extramedullary myeloid tumor of parathyroid gland, 528
296f (EMT), 564f, 567 of retroperitoneum, 851
brushings of, 294 Extraskeletal chondrosarcomas, 951 of salivary gland lesions,
indications for, 294 Extrauterine malignancy, cells from, 571–587
nonneoplastic lesions of in cervical-vaginal smears, of soft tissues, 919–951
infections, 294 141–147 Fixatives, selection of, for specimen
reflux esophagitis, 294–295, Exuberant granulation tissue, evaluation, 5
295t cytopathology of, 800, Florid follicular hyperplasia, of
normal architecture of, 294 943t lymph node, cytopathology
radiation-induced changes in, Exudates, 151 of, 544t
295 Eyebrow lesions, 396 Flow cytometry, 29
reparative/regenerative changes Eyelid lesions, 396 for DNA, 29
at ulcer margins in, 297, Focal nodular hyperplasia, hepatic,
298f–300f F 751, 753t, 759t
small cell carcinoma of, 297 Fallopian tube adenocarcinoma, differentiation from hepatocellu-
squamous carcinoma of, 296– cells from, in cervical- lar carcinoma, 759t
297, 296f, 297f vaginal smears, primary, Fluorescence in situ hybridization
Esthesioneuroblastoma, 397, 398f 141 (FISH), 30
Estrogen, 38 False negative diagnosis, in cytopa- FNA. See Fine needle aspiration
Estrogen receptors, 637, 782, thology, 1 (FNA)
783t False positive diagnosis, in cytopa- Foamy macrophages in respiratory
Euplasia, 3, 4f thology, 1 specimens
Ewing’s sarcoma, 184, 184f–185f, Fatty change, in liver disorders, differential diagnoses of,
958, 966. See also PNET 750 247t–248t
cytogenetic analysis, 972 Female genital tract, cytopathologic Focal nodular hyperplasia, 751,
cytopathologic features, 970, features of, 172, 172f–173f 751f, 759t
971f–972f, 970t Ferruginous bodies, 193 Follicular adenomas, 409
differential diagnosis of, 972 Fibroadenoma, of breast, 705–708, cellular follicular adenomas,
gross and microscopic features, 706t, 708t 411–414, 412f–414f
970 cytopathology of, 705, 706t with clear cell change, 416–417,
immunoprofile of, 972 differential diagnosis of, 417t
molecular markers for, 367 707t–708t colloid adenoma, 409–410, 410t,
overview, 969 Fibrocystic breast disease, 712 411f
ultrastructure of, 972 Fibromatosis, in breast, 922, 922f conventional type of, 409, 409t
Exfoliative cytology specimens, 5 Fibrosarcoma, 922–923, 923f cytopathologic features of,
Extra-adrenal myelolipoma, 847 Fibrous histiocytic tumors, 410t
Extrauterine cancers, in cervical- 923–926 differential diagnoses of, 417t
vaginal smears, 141, 142f– atypical fibroxanthoma, 923– gross and microscopic features
143f, 144 924, 924f of, 409
Extrahepatic bile duct carcinomas, benign, 923, 924f morphologic variants of, 409,
317 malignant, 924–926, 925f–926f, 409t, 414
Extrahepatic biliary tract 925t atypical adenoma, 416f, 417,
abnormalities of, 314 Fibrous meningioma, 906t, 908 417t
carcinomas of, 315, 317, 319 Fine needle aspiration biopsy follicular adenoma with clear
diagnostic categories for, 323t (FNA), 5, 191 cell change, 416–417, 417t
and diagnostic difficulties, 319, of adrenals, 832–851 follicular adenoma with papil-
320f–324f of breast, 688–730 lary hyperplasia, 417, 417t
998 Index
Follicular adenomas (Cont.) Gastrointestinal carcinoid tumors, Gitter cells, 876, 876t
hyalinizing trabecular ad- 308–309, 309f Glandular epithelium, benign cel-
enomas, 414–416, 414f, Gastric mucosa, normal, 300 lular changes in, cervical
415f–416f, 415t Gastroesophageal reflux, 295 smears, 40, 42t–43t
with papillary hyperplasia, 417, Gastrointestinal stromal tumor Glial fibrillar acidic protein (GFAP),
417t (GIST), 309, 310, 932, 932f 616
radiologic features of, 409 cytopathologic features of, 310, Glioblastoma multiforme, 880
simple adenoma, 410–411, 410t, 311f–314f, 311t cytopathologic features of, 878t,
411f differential diagnoses of, 881f–883f
Follicular carcinomas, thyroid, 417– 310–311 differential diagnosis of, 883–
423, 424t–425t, 425f–429f gross and microscopic features 885, 884f–885f
cytopathologic features of, 418, of, 310 histologic features of, 880
419t immunoprofile of, 310 immunoprofile of, 882–883
of poorly differentiated follicu- Gastrointestinal tract, 294 and metastatic carcinoma, 886t
lar carcinomas, 418, 419t, anal malignant melanomas, 308 Gliosis, 876–877
421f–422f cloacogenic carcinoma of, 307 differentiation from astrocytoma,
of well-differentiated follicular colorectal brushings, 305–307 876t
carcinomas, 418, 419f– duodenum, 305 Goblet cells, 192
420f, 419t esophagus, 294–300 in mucoepidermoid carcinomas,
differential diagnoses of, 422– extrahepatic biliary tract, 314–324 614t
423, 424t–425t, 425f–429f gall bladder, 313–314 Goblet cell hyperplasia, in broncus,
gross and microscopic features GIST of, 310–311, 311–313f 196t
of, 418 mesenchymal neoplasms of, Goiter, nodular. See Nodular
immunoprofile of, 420 309–310 goiter
vs. papillary carcinomas, 417 neuroendocrine tumors of, Gonads, FNA of, 852–869
Follicular cysts, 852, 853t–854t, 308–309 Granular cell tumors, 720, 942,
855, 855f smooth muscle tumors of, 311 949t
Follicular lymphoma, cytopatho- stomach, 300–305 of breast, 720
logic features of, 551t, Gartner’s cyst, 138 of bronchus, 272t, 273t
559f–560f Gemistocytic astrocytomas, 877, differential diagnoses of, 273t,
Follicular neoplasms, cytopathology 879f, 880 950f
of, 448t Germ cell tumors, 181, 980 of soft tissues, 942, 949t
Follicular patterned lesions of in children, 980–984 Granulocytic sarcoma, 567–568
thyroid, 404, 404f cytopathologic features of, 985t Granulomas, in cytologic specimens.
Follicular variant of papillary in effusion, 181 See also specific sites
carcinoma, 448t mediastinal, 249t, 251t, 731, 747 in effusion fluid, 152
Frost, J.K., 1 with mediastium, 747–748, 747f in lymph nodes, 545
Fungal infection, of lymph node, ovarian, 864 in lungs, 289
cytopathology of, 544t pineal, 900 in salivary gland aspirates, 681f
pulmonary, 282, 284 in retroperitoneum, 851 in thyroid, 507, 508t
Germinal cell, in squamous epithe- Granulosa cell tumor, cells of, in
G lium, 33 effusion fluid, 186, 187t
Gall bladder, carcinomas of, 313– Germinal inclusion cysts, ovarian, Granulomatous inflammation,
314, 314f differential diagnosis of, 289
Ganglion cysts, cytopathology of, 959t 853t–854t Granulomatous lymphadenopathy,
Ganglioneuroblastomas, 847, 968 Germinoma, in children, cytopathol- 545
Ganglioneuromas, adrenal, 847 ogy of, 900, 901t, 985t Granulomatous thyroiditis, 508,
Gardnerella vaginalis, 40 GFAP. See Glial fibrillar acidic 510t, 534t
Gastric adenocarcinomas, 300–301 protein Granulosa cell tumors, ovarian,
differential diagnoses of, 304f– Giant cell carcinomas, pulmonary, 856–857, 857f–859f, 857t
305f, 305t, 306f–307f 282 cells in peritoneal/pelvic wash-
gastric type, 301t Giant cell carcinomas of thyroid, ings, 186, 187t
intestinal type, 301t 947t Call-Exner bodies in, 186, 187t,
and reparative/regenerative cells, Giant cell tumors 856, 857t, 857f
differentiation between, 302t of bones, 958, 962, 963f cytopathology of, 857t
Gastric lymphoma, 301 of tendon sheath, 937 differential diagnosis of, 857
Index 999
Growth patterns, of neoplasms, 23 metastatic malignancy to para- gross and microscopic features
Gynecomastia, 725, 728 nasal sinuses, 397–398, 399f of, 752
cytopathologic features of, 729t nasopharyngeal carcinomas, immunoprofile of, 758
396 poorly differentiated, differential
H parapharyngeal space tumors, diagnosis of, 760f, 761t,
Hamartoma, pulmonary, 271t, 272 398, 399f 762f–764f
FNA of, 751 neck cysts and squamous cells, differentiation from adenocar-
Hashimoto’s thyroiditis, 508 differential diagnoses, 381t cinoma, 761t
and benign neoplasms, 514 orbit and periorbital lesions, 391 differentiation from hepatocel-
cytopathologic features of, 509, in adults, 393–395, 394f–395f lular carcinoma, 761t
509t, 510f–513f, 513 in childhood, 393, 393f differentiation from malignant
diagnostic accuracy of, 513 periorbital area lesions, 396, 396f melanoma, 761t
differential diagnoses of, 513, sinonasal undifferentiated carci- differentiation from neuroen-
515t–516t noma (SNUC), 396–397 docrine tumor, 761t
gross and histologic features of, soft tissue (mesenchymal) lesions, differentiation from renal cell
508–509 390–391 carcinoma, 761t
juvenile type of, 509 Hemangioblastoma, cerebellar, differentiation from squamous
lymphoepithelial cysts in, 509 differentiation from meta- carcinoma, 761t
and malignant lymphoma, 514 static renal cell carcinoma, well differentiated, differential
oxyphilic change in epithelium in, 909t diagnosis of, 759f–760f,
508–509 Hemangioendothelioma, epithelioid, 759t
and papillary carcinoma, 514 933 differentiation from focal
radiologic features of, 508 Hemangioma, hepatic, 751 nodular hyperplasia, 759t
vs. follicular neoplasm, 512f Hemangioblastoma, cerebellar, differentiation from hepatocel-
vs. Hürthle cell neoplasm, 511f 907–909 lular adenoma, 759t
vs. other diseases, 513–514 Hemangiopericytomas. See Soft differentiation from reactive
Head and neck lesions tissue tumors, Solitary hepatocytes, 759t
cutaneous lesions fibrous tumor Hepatocytes, normal morphology
basal cell carcinomas, 382, of CNS, 913, 914f–915f of, 749, 753t
383f of soft tissues, 936–937, 937f fatty change in, 750
cervical (extra-adrenal) para- Hematoidin crystals, in pregnancy, 40 pigments in, 749
ganglioma, 390, 390t Hemosiderin, 749 reactive changes in, 749–750
chondroid syringomas, 385, Hemosiderin-containing mac- Hepatocytes, pigments in, 749
386f rophages, 186 Herpes simplex virus, 138
cutaneous neoplasms, 381–382 Hematopoiesis, extramedullary, dif- in cervical-vaginal smears, 41t,
infections, 381 ferential diagnosis of, 182, 146t
malignant melanomas, 383, 183f–184f endocervical cellular changes, 114
383f Hematoidin crystals, in cervical- in esophagus, 294, 298f
Merkel cell carcinoma, 385– vaginal smears, 40, 45t in pulmonary specimen, 282,
388, 387f–389f, 387t Hematoxylin, 189 284t
metastatic malignancy, 388, Hemochromatosis, 749, 752 HHV8. See Human herpes virus 8
389f Hemosiderin, 437 (HHV8)
pilomatrixoma, cytologic Hepatic abscesses, 750 High-grade squamous intraepithelial
feature of, 383–385, Hepatic cysts, 750 lesions (HSIL), 48
384f–385f, 384t Hepatoblastoma, 764 cytomorphology of, 59
squamous carcinoma, 383, cytopathologic features of, 988f, cytopathologic features of,
383f 987t 53f–54f, 54, 55t
cystic lesions, in head and neck, overview, 987 diagnostic problems & differen-
380–381 Hepatocellular adenomas, 751–752 tial diagnoses, 61t
exfoliative and aspiration cytopa- cytopathologic features of, 752 differential diagnoses, discrete in
thology of, 380, 381t differential diagnoses of, 759t situ type cell, 61, 65
lachrymal gland lesions, 395 Hepatocellular carcinomas (HCC), vs. endometrial stromal cells,
mandible and maxilla, lesions of, 752 61, 61t
400 cytopathologic features of, 752– vs. immature squamous meta-
nasopharynx and sinonasal tract, 753, 753t, 754f–758f plasia, 61, 61t
lesions of, 396 FNA of, 754f–758f vs. IUD Associated Cells, 61, 61t
1000 Index
High-grade squamous intraepithelial Lacunar cells, 567t cytopathologic features,

lesions (Cont.) nodular lymphocyte predomi- 414–416, 415f–416f,
differential diagnoses of tissue nant, 556, 566 415t
fragments of in situ type Reed–Sternberg cells in, 746 differential diagnoses of, 417t
cells, 65 Homer–Wright rosettes, 970 gross and microscopic features
vs. atrophic squamous epithe- Hormonal replacement therapy of, 414, 414f
lium, 65, 66 (HRT), 96 immunoprofile of, 414
vs. endocervical glandular endometrial cells in patients on, 96 Hydatid cysts, hepatic, 750
epithelium with tubal HPV. See Human papilloma virus Hydrops tubae profluens, 141
metaplasia, 66–67 HPV vaccine, 31 5-Hydroxytryptophan, 365
vs. endocervical glandular HRT. See Hormonal replacement Hyperinvoluted goiter, 405, 405f,
lesions, 67 therapy 410
vs. endometrial adenocarci- HSIL. See High-grade squamous Hyperkeratosis, 39–40, 82
noma, 67–68 intraepithelial lesions Hyperplasia, atypical lymphoid, in
vs. microglandular hyperpla- Human papilloma virus (HPV), 48, Hashimoto’s thyroiditis,
sia, 67 138, 275 521
vs. squamous metaplasia, 65 cytopathologic features of, 51– differentiation from malignant
histologic features of, 53–54 52, 52f lymphoma, 515t–516t
keratinizing, differential diagno- histologic features of, 51–52 Hyperplasia duct of breast, 709t,
ses of, 68 infections and changes in, 50–52, 717
overview, 52 51t Hyperplasia, endometrial, 96
severe dysplasia/carcinoma in situ Hürthle cell metaplasia cytopathology features of,
of, 52 in Hashimoto’s disease, 437t, 96–97
severe keratinizing dysplasia, 59–60 438, 439f Hyperplasia, follicular epithelium,
Hilar cholangiocarcinomas, 317 in nodular goiter, 406f, 407, 438f in nodular goiters, 468
Hilar lymph nodes, 254 Hürthle cell neoplasms, 423 Hyperplasia, follicular epithelium, in
Hilum, 192 adenomas vs. carcinomas, Hashimoto’s thyroiditis,
Histochemical stains, 23–24, 24t, 25 435–436 508
HistoGel, 189 diagnostic accuracy and differen- Hyperplasia, mesothelial, cyto-
Histiocyte-like endometrial carci- tial diagnoses of, 432, 435 pathology of, 153t, 161,
noma cells, 98 Hürthle cell adenomas, 423, 427 162f–163f
Histiocytic sarcoma, 568 cytopathologic features of, Hyperplasia, microglandular, of
Histiocytoma, benign fibrous, 919 428–429, 430t, 431f cervix, 114, 115t
Histiocytoma, malignant fibrous, gross and histologic features Hyperplasia, reserve cell, of bronchi-
924–925 of, 427–428 al epithelium, 264, 265t
cytopathology of, 924–925, 925t Hürthle cell carcinomas, 430, differentiation from small cell
differential diagnosis of, 924–925 430t, 432 carcinoma, 265t
histiologic types of, 924 cytopathologic features of, Hyperplastic bronchial epithelium,
Histiocytosis, Langerhans cell, 430t, 432, 433f–435f 198f
962–964, 984 gross and histologic features Hyperplastic endometrial glands, 96
Histiocytosis X, 984 of, 432 Hyperplastic mesothelial cells
Histochemical stains, 25 papillary variant of, 432 cytomorphology of, 150t
HIV infections vs. medullary carcinoma, 439 cytopathologic features of,
in lymph nodes, cytopathology vs. other neoplasms, 438 160t–161t
of, 544t vs. Hürthle cell metaplasia in differentiation from adenocarci-
pulmonary, 247t nodular goiter, 436, 437t, noma, 164f
Hodgkin disease. See Hodgkin 438 differentiation from malignant
lymphoma vs. Hürthle cell nodules in mesothelioma, 162f–163f
Hodgkin lymphoma, 182, 556, 966 Hashimoto’s thyroiditis, histocytologic feature of, 151
in children, 966 437t, 438, 439f Hyperplastic respiratory epithelium,
classic, 556, 561f–563f vs. nonneoplastic Hürthle cell 242
cytologic features of, 561f–565f, nodules, 436, 437t Hypertrophic mesothelial cells
567t Hürthle cells, 423 cytomorphology of, 150t
diagnostic accuracy of, 566 Hyaline cartilage, 193, 195 cytopathologic features of,
differential diagnoses of, 566, 568t Hyalinizing trabecular adenomas, 160t–161t
Hodgkin cells, 567t 414–416 histocytologic feature of, 151
Index 1001
I Intraepithelial noninvasive lesions, malakoplakia, 814

Idiopathic reactive hyperplasia, of in bladder, 333–336, 336t metanephric adenoma, 813
lymph node, cytopathology Intranuclear cytoplasmic inclusions, papillary adenoma, 814
of, 544t 474, 477f renal angiomyolipoma, 814,
Ileal bladder (conduit) specimen, Intraosseous plasma cell neoplasms, 814t
327 951 renal oncocytoma, 813–814,
Image cytometry, for DNA, 29 Intrauterine device (IUD), 42t, 61, 813t
Immunoblastic lymphoma, 865t, 144t xanthogranulomatous pyelo-
867t in cervical-vaginal smears, 42t nephritis, 814
Immunochemical stains, 25–28 Invasive adenocarcinoma, carcinomas of renal pelvis and
Infants. See Children endocervix ureters, 815, 829f–830f,
Infections, benign cellular changes, cytologic features of, 120–121, 829t
in cervical-vaginal smears, 122f–124f clear cell sarcoma of, 976
42t differential diagnoses of, 126 cystic lesions of, 812–813
Infections, pulmonary, 282 immunoprofile, 121 diagnostic problems in aspiration
Infectious mononucleosis, cytopa- Invasive squamous carcinoma, of cytology of, 812
thology of, 544t uterine cervix FNA biopsy of, use of, 812
Inflammation associated changes, in cytopathologic features of, 70, malignant lymphoma of, 815
cervical-vaginal smears, 83 70t metastasis to, 816, 827
Inflammatory lesions histologic features of, 70 multilocular cyst of, 813
of breast, 717, 718t moderate to poorly normal components of, 812
of salivary glands, 677–682 differentiated, 73 renal cell carcinoma, 814–815
acute sialadenitis, 677 Islet cell tumors, 351, 352t chromophobe RCC, 816t,
amyloidosis, 682 pancreatic, with cystic change, 817t, 822f, 823f, 828t
chronic sclerosing sialadenitis, differential diagnosis of, 782 clinicopathologic features and
677–678, 678t, 680f–681f Islet cells, characteristics of, 349 cytomorphology of, 816t,
chronic sialadenitis, 677, 678t, Isthmus, of cervix, 95 817t, 818f–823f
679f–681f diagnostic difficulties and dif-
necrotizing sialometaplasia, J ferential diagnoses of, 815,
678, 681 Juvenile carcinoma, of breast, 705 823f, 824t, 825f–827f
Instrumentation effect on urothelial Juvenile pilocytic astrocytoma. See renal tumors composed of granu-
cells, 343 Pilocytic astrocytomas lar eosinophilic cells, differ-
Insular carcinomas, of thyroid, 477 ential diagnoses of, 828t
cytopathologic features of, 479, K spindle cells in adult renal/perirenal
479t, 480f Kaposi’s sarcoma, 934, 936f neoplasms, differential diag-
diagnostic accuracy of, 479–481 Kaposi’s sarcoma-associated herpes- noses of, 828t
differential diagnoses of, 481, virus (KSHV), 275 tumors of, 816
482t–483t Karyorrhexis, 248 Klatskin tumor, 317
gross and histologic features of, Keratin, 209 Koilocytosis, 51–52
477, 479 Keratin pearls, benign, in cervical- KSHV. See Kaposi’s sarcoma-
immunoprofile of, 479 vaginal smears, 91t associated herpesvirus
Instrumentation effect on urothelial Keratin pearls, malignant, in (KSHV)
cells, 341 cervical-vaginal smears, 704 Kulchitsky (K) cells, 193, 194t, 351,
Intestinal metaplasia, incomplete, in Keratinization, 49 351t
Barrett’s esophagus, 295 Keratinized pleomorphic squamous Küttner tumor, in salivary gland,
Intraductal papillary mucinous cells, 78 677–678, 678t
neoplasms (IPMN), of pan- Keratinizing lesions, in cervical-
creas, 802–803 vaginal smears, differential L
cytopathologic features of, 805f– diagnosis of, 48, 54, 78, Lachrymal gland, lesions of, 395
808f, 805t 78t, 80t, 80, 90t Langerhans cell histiocytosis (LCH),
diagnostic difficulties and Keratinizing squamous carcinoma 563f, 567, 962–964, 963f,
differential diagnoses of, vs. keratinizing HSIL, 81 983
805, 807 vs. keratinizing lesions, 79t in children, 986
gross and microscopic features of well-differentiated, 210t Birbeck granules in, 986, 986t
of, 803–804, 804f Kidney cytopathologic features of,
Intraductal papilloma of breast, 709t benign neoplasms of, 813–814 986f, 986t
1002 Index
Large cell lymphoma, mediastinal, Lipofuscin, 378–379, 749 primary hepatic neoplasms of,
566, 746 Lipomas, 926–927 751–758
Large cell neuroendocrine spindle cell lipoma/pleomorphic hemangiomas, 751
carcinoma (LCNEC) lipoma, 927 hepatocellular adenomas,
cytopathologic features, 260, atypical lipoma/well differenti- 751–752, 752f, 753t, 759t
260f–261f, 262t ated liposarcoma, 927 hepatocellular carcinomas,
differential diagnoses of, 261 Lipophages, 98, 99t 752–758, 754f–760f
histologic features, 260 Liposarcoma, 927, 928f spindle cell lesions in, differential
immunoprofile of, 261 cytopathologic features of, 927, diagnoses of, 768
overview, 259–260 928t, 930 squamous carcinomas, 765, 767
Large cell undifferentiated carcino- differential diagnoses of, 930 Liver neoplasms, in children,
ma (LCUC) pulmonary, 248 myxoid, 927, 929f 987–988, 988t
cytopathologic features of, round cell, 927 Lobular carcinoma, of breast, clini-
249f–250f, 249t, 262t, 664, well-differentiated liposarcoma, copathologic features of,
664t, 665f, 666 927 703–704
differential diagnoses of, 250, Liver, 749–768 cytopathology of, 699t–701t
251t–252t, 252, 666, 666t aspirate, fine needle, normal differential diagnosis of, 721t
immunoprofile of, 248 components of, 749, Lower uterine segment cells (LUS),
morphologic variants of, 252 750t 95
ultrastructure of, 248 cholangiocarcinomas, 751–758, cytomorphologic features of, 96t
salivary glands, 660 764, 764f Low-grade squamous intraepithelial
cytopathologic features of, FNA biopsy of, 749 lesions (LSIL), 48
664t, 664, 665f, 666 diagnostic problems in, 749 cytopathologic features, 49, 50f,
differential diagnoses of, 666, indications for, 749 51t
666t hemangioendotheliosarcoma, differential diagnoses of, 52
gross and microscopic fea- 764, 765f histologic features of, 49
tures, 660, 664 hepatoblastoma, 764 human papilloma virus associ-
immunoprofile of, 666 hepatocellular carcinomas, poorly ated changes, 49t, 51t
Large cleaved cell lymphomas, differentiated, differential LP cells. See Lymphocytic and
differential diagnosis of, diagnoses of, 760f, 761t, histiocytic (L&H) cells,
543, 544t, 746 762f–763f Hodgkin lymphoma
Large epithelial tissue fragments, metastatic malignancy to, 765, LSIL. See Low-grade squamous
in cervical-vaginal smears, 765f–767f intraepithelial lesions
124, 125f adenocarcinomas, 765, 767 Lung cancers
Large noncleaved cell lymphomas, leiomyosarcomas, 768 clinicohistomorphologic features
differential diagnosis of, malignant lymphoma, 768 of, 205t–207t
543, 544t, 746 malignant melanoma, 767 cytologic and histologic interpre-
LCNEC. See Large cell neuroendo- neuroendocrine tumors, 767 tations on, 204
crine carcinoma (LCNEC) renal cell carcinoma, 767 cytomorphology of, 191
LCUC. See Large cell undifferenti- sarcomas, 768 cytopathologic features of, 170,
ated carcinoma (LCUC) squamous carcinomas, 765, 170f–171f, 171t, 172
Leiomyomas, 311, 930 767 diagnostic markers for, 208
Leiomyosarcomas, 768, 930 urothelial (transitional cell) diagnostic pitfalls, 204
cytopathologic features of, 930, carcinomas, 767–768 false-negative errors, 204
931f–932f, 931t nonneoplastic lesions of, false-positive errors, 204
immunoprofile of, 930 749–751 incidence of, 204
Leukemia, 182 cirrhosis, 751 morphologic diagnosis of, 204
Leukemic cells, in effusions, 568 fatty change, 750 overview, 204
Leukemic infiltrate, 393 focal nodular hyperplasia, predictive markers for, 208
in CSF, 871f 751, 751f, 759t signs and symptoms of, 204
in effusion fluids, 169f, 179f, hepatic abscesses, 750 types of, 204
180, 189 hepatic cysts, 750 WHO classification of, 204, 224
in lymph nodes, 545, 566 hydatid cyst, 750 Lungs
Lingula, 192 inflammatory conditions, 750 adenocarcinoma in effusions, 26t,
Lipid pneumonia, differential diag- reactive/regenerative changes, 170, 171t, 208
nosis of, 245, 246f 749–750 benign neoplasms of, 272, 272t
Index 1003
primary malignant lymphomas Male breast, carcinoma of, 728, in effusion, 176t, 178f, 181
of, 275 729f exfoliative and aspiration
tumor-like lesions of, 271t lesions of, 728 cytopathology of, 370
uncommon malignant neoplasms Malignant criteria, general, 98 in head and neck, 383, 392
of, 272–280 Malignant effusion, 167 thepatic, 761t
LUS. See Lower uterine segment cells differential diagnoses of, 176t histocytologic features of,
Lymphadenopathies Malignant fibrous histiocytoma 370–377, 371f–377f, 371t
benign, 543, 544t (MFH), 276, 924 immunoprofile of, 377
granulomatous lymphadenop- cytopathology of, 924–925, 925t in vagina, 140
athy, 545 differential diagnosis of, 924 ultrastructure of, 377
reactive lymphoid hyperplasia, giant cell type, 924 Malignant mesothelioma
543, 545 inflammatory, 924 aspiration biopsy for, 280t
cytology of normal lymph nodes, myxoid type, 924 cytopathologic features of,
543, 544t storiform-pleomorphic type, 924 160t–161t, 280t
fine needle aspiration biopsy of, Malignant lymphoma, 564f–565f, cytopathologic features of
543–569 568 epithelioid type, 153, 153t,
diagnostic problems with, 543 anaplastic large cell, 555t 154f–157f, 156
indications for, 543 Burkitt’s, 552t differential diagnoses of, 159,
malignant lymphomas, 545 in children, 980t–981t 159t, 161, 162f–163f
Hodgkin lymphoma, 556, 566, chronic lymphocytic, 547t differentiation from malignant
567t diffuse large B-cell, 553t melanoma, 159t
non-Hodgkin lymphoma DLBCL-anaplastic, 554t differentiation from metastatic
(NHL), 545, 546t–555t, 556 DLBCL-immunoblastic, 553t adenocarcinoma, 160t–
Lymphadenopathy secondary to in effusion, 168t, 176t 161t, 161, 166
Dilantin, cytopathology of, follicular, 551t differentiation from papillary
544t vs. Hashimoto’s thyroiditis, 521 adenocarcinoma, 167t, 179f
Lymphoblastic lymphoma, 746–747 Hodgkin’s type, 746 differentiation from peritoneal
Lymphocytic pleocytosis, 870 lymphoblastic, 546t serous papillary tumors, 166f
Lymphocytic and histiocytic (L&H) lymphoplasmacytic, 548t differentiation from reactive/
cells, 566 manntle cell, 549t hyperplastic mesothelial
Lymphoepithelial carcinomas, 667 mediastinal, 746 cells, 159, 160t–161t, 161,
Lymphoepithelial cysts, 523, 671 marginal zone lymphoma, 550t 162f–163f
benign, 671, 672f non-Hodgkin’s type, morphologic differentiation from squamous
HIV-associated benign, 671–672, variants, 545, 546t–555t carcinoma, 159t
672t, 673t, 674f peripheral T-cell, 554t gross and microscopic features,
Lymphoepithelial lesions, 517, 518, primary, of lungs, 275 152–153
519t primary, of thyroids, 514, 519t immunohistochemical stains for,
Lymphoepithelial sialadenitis in pulmonary specimens, 256t 158t
(LESA), 682, 683f differentiation from atypical immunoprofile, 157
Lymphofollicular cervicitis, 106 carcinoid, 256t vs. metastatic malignancies, 161
Lymphoglandular bodies, 519 differentiation from carcinoid in pleomorphic cells, 166
Lymphoid lesions, orbit, 391, tumors, 256t psammoma bodies in, 159t
393–394 differentiation from LCNEC, of serous membrane, 152
Lymphoid tangles, 510f, 519 256t tubulopapillary patterns of, 153
Lymphoma, 182 differentiation from small cell ultrastructural findings of, 159
Lymphomatosum, papillary cysta- carcinoma, 256t Malignant mesothelioma, sarcoma-
denoma, of salivary gland, in salivary gland, 682 tous type, 153, 157, 158t,
600 small lymphocytic, 547t 273–274
Lymphoproliferative disorders, 182 Malignant melanoma, 181, 370–379 Malignant mixed mesodermal
amelanotic, 176t, 252t tumors (MMMT),
M anus, 308 endometrial, 109
Macrofollicular adenoma, 409–410, cytopathology of, 266t, 370, cytopathologic features of, 111,
417t, 449 371t 111t
Malakoplakia, lung, 271t and diagnostic problems, 377 differential diagnosis of, 112
Malakoplakia, renal, 814 differential diagnoses of, Malignant neoplasms, in pediatric
Michales-Guttman bodies, 814 377–379, 378t population, 965
1004 Index
Malignant non-Hodgkin’s lymphoma, differential diagnoses of, 500, vs. metastatic adenocarcinomas,
in children, 965–966, 966t 500t, 501t–502t, 503f–504f 159, 161
Malignant peripheral nerve sheath gross and histologic features of, Mesothelial tissue fragments, 191,
tumor (MPNST), 941–942, 494–495 243
941f immunocytohistochemical profile Mesothelioma. See Malignant
cytopathologic features of, 940t, of, 500 mesothelioma
942 radiologic features of, 494 Mesothelium, 193
diagnostic difficulties and dif- ultrastructure of, 495 Metanephric adenoma, 813
ferential diagnosis of, 940, Medulloblastoma, 896f, 897t, Metaplasia, 3
941t 899–900, 900t apocrine, in breast, 715t
MALT balls, 517 in children, 899 endometrial (Müllerian), 106
MALT lymphomas, of salivary classical type, 899 intestinal, in Barrett’s esophagus,
gland, 684 cells in CSF, 871 295
MALT. See Mucosa-associated cytopathology of, 900t squamous metaplasia, in cervical-
lymphoid tissue (MALT) desmoplastic type, 899 vaginal smears, 36, 36t
Mammary carcinoma cells, differentiation from normal Metaplastic carcinoma, of breast,
metastatic, in cervical- cerebellar cortex, 900t 704, 704t
vaginal smears, 142 Medulloepithelioma, 891t Metaplastic squamous cells, 36t
Mammary duct adenocarcinoma, Megakaryocytes, in pleural effusion, Metastatic carcinoma. See Respective
636t, 702 182 areas
Mantle cell lymphoma, differential Megakaryocytes, in thyroid Metastatic malignancy to paranasal
diagnosis of, 549t, 556 aspirates, 486 sinuses, 397–398, 399f
Marginal zone B-cell lymphoma MEK inhibitor, 208 MFH. See Malignant fibrous
(MZBL), 514, 517 Melan A, 377, 725 histiocytoma (MFH)
cytopathologic features of, Melanin pigment, 181 MGH. See Microglandular
517–518, 518f, 519t Melanoma. See Malignant hyperplasia
differential diagnosis of, 521, 522t melanoma Membrane filter Michales–Güttman bodies, 814
MART-1 (Melan-A), 377 technique, 189 Microbiologic flora, 40, 41t
Mediastinum. See also Thymus Meningeal carcinomatosis, in Microcystic adenoma, pancreatic,
aspirates with spindle cell, differ- cerebrospinal fluid, 871 differential diagnosis of,
ential diagnosis of, 732 Meningioma, 900–901, 903f–905f 790t, 794t
cysts of, 748 cytopathologic features of, 902t Microfollicular adenoma (fetal
and diagnostic challenges, 731 differential diagnoses of, 897t, adenoma), 411. See also
FNA biopsy of, 731–748 901, 906t, 907f Cellular follicular adenomas
germ cell tumors of, 747–748 fibrous, 906t Microglial cells, 874
Hodgkin’s disease of, 746 with spindle cell pattern, Microglandular hyperplasia (MGH),
lesions of, 732t differential diagnosis of, 114
malignant lymphomas of, 906t of cervix, 114, 115t, 116f
746–747 immunoprofile of, 901 Microinvasive squamous carcinoma,
mesenchymal tumors of, 748 Menstrual endometrium, 95 of cervix
metastatic malignancy, 748 cytopathologic features of, 95t cytopathologic features of, 69, 69f
non-Hodgkin’s lymphoma of, Merkel cell carcinoma, 385–386 diagnosis of, 69
746 cytopathologic features of, 386, FIGO staging system of, 69
neurogenic tumors of, 748 387f, 387t overview of, 69
primary neoplasms, 748 differential diagnoses of, 388, Midline cysts, of head and neck, 380
thymoma, malignant, 746–748 388f–389f Mild dysplasia. See Low-grade
Medullary carcinoma, of breast, gross and microscopic features squamous intraepithelial
clinicopathologic features of, 386 lesions (LSIL)
of, 690t–691t, 702 immunoprofile of, 386 Misinterpreted cases (errors), in
Medullary carcinoma, of thyroid, ultrastructure of, 386 cytologic evaluation, 1
352, 361f–362f, 494–500 Mesenchymal tumors of gastrointes- Mitomycin C effect on urothellial
amyloid in, 495, 496t tinal tract, 309–310 cells, 338t
calcitonin immunostain for, 494 Mesothelial cells Mixed mesodermal tumors,
cytopathologic features of, 495– cytomorphology of, 150t malignant (MMMT), 109
496, 496t, 497f–499f, 499 variations in, 151 Mixed tumor. See Pleomorphic
diagnostic accuracy of, 500 vs. malignant mesothelioma, 159 adenoma
Index 1005
MMMT. See Malignant mixed Multilocular cysts, renal, 813 Nephrogenic adenoma, 344, 345t
mesodermal tumors Multinucleated giant cells, in Nephroma, cystic, 813
Moderate dysplasia. See High grade cervical/vaginal smears, Nerve sheath tumors, peripheral,
squamous intraepithelial 147t–148t, 148 malignant, cytopathology
lesions Multinucleated giant cells, in of, 940t
Molecular techniques, 29 thyroid aspirates, 475t Neurilemmoma, 940
Molluscum contagiosum, 138 Multiple myeloma, of bone, Neural cell adhesion molecules
Mucinous (colloid) carcinoma, of 951–952, 952f (NCAMs), 366
breast, 690t–691t, 694f, Mycobacterial infection, of lymph Neuroblastoma, 966–967
703, 724t node, cytopathology of, 544t cytopathologic features, 967,
Mucinous cystadenocarcinomas pulmonary, 282, 283t 967t
of ovary, 173f, 863, 864f Mycobacterium tuberculosis, 152, differential diagnoses of,
of pancreas, 807–808, 809f 282 967–968
Mucinous cystadenomas, 853t–854t, Mycotic infection, pulmonary, 282, gross and microscopic features,
862–863, 863f 283t 967
Mucinous cystic neoplasms (MCN), Myeloid (granulocytic) sarcoma, histomorphology of, 967
of Pancreas, 807 564f, 567 immunoprofile of, 967
cytopathologic features of, Myelolipoma, adrenal and extra- molecular/cytogenetic features of,
795t–799t, 805t, 808, 809f adrenal, 847, 849 967
differential diagnosis of, differential diagnoses of, 849t, molecular markers for, 367
795t–799t 850f–851f olfactory, 352t, 397
gross and microscopic features Myoepithelial carcinomas, salivary ultrastructure of, 968
of, 807 glands, 589, 590t, 593f Neurocytoma, of central nervous
Mucinous neoplasms, of pancreas, Myoepitheliomas, salivary glands, system, 898–899
802–808, 809f–810f 588–589, 588t Neuroectodermal tumors, in
Mucinous noncystic adenocarci- cytopathologic features of, 589, childhood, 966
noma, 808 590f–592f, 590t Neuroendocrine carcinoma, 181,
Mucocele-like tumors, of breast, differential diagnoses of, 181f–182f, 569
724t, 725 594f–597f cytopathologic features of, 75
Mucoepidermoid carcinoma, of gross and microscopic features grade I, 254–256
broncus, 274 of, 589 grade II, 259
Mucoepidermoid carcinoma, of sali- Myofibroblastoma, 921–922, 922f grade III, 261–262
vary glands, 612, 614, 615f Myxofibrosarcoma, 923 histologic features of, 73, 75
cells of, 614t Myxoid liposarcoma, 889t of urinary bladder, 336
cytologic features of, 616, 617t, cytopathology of, 912t Neuroendocrine cells, 193, 349, 350
618f–620f with spindle cell pattern, 944t markers for, 366
high-grade, 622f–623f Myxoma, cytopathology of, 959t CD57, 366–367
intermediate-grade, 622f Myxopapillary ependymoma, cyto- CD99, 367
diagnostic difficulties of, 616 pathology of, 888, 889t chromogranin proteins, 366
differential diagnoses of, 616, 624t cytosolic markers, 366
high-grade, 628f–630 N enzymes, 366
low- and intermediate-grade, Nasal cavity lesions, 396 intermediate filaments, 366
624f–628f Nasopharyngeal carcinomas, 396 NCAMs, 366
gross and histologic features of, in children, 987 peptide hormones and amines,
614, 616 National Cancer Institute,concensus 366
immunoprofile of, 616 meeting, for cervical-vaginal synaptophysin, 366
Mucosa-associated lymphoid tissue cytology reporting, 31 TTF-1, 366
(MALT), 394–395 Necrosis, 153 Neuroendocrine system, diffuse,
Multilocular cyst, of kidney, 813 Neoplasms, 1, 5, 13, 22 349, 350f
Mucin stains, 188 immunocytohistochemistry, historical perspective on,
Mucoepidermoid carcinomas, 274 26t–27t 349–350
Mucosa-associated lymphoid tissue ultrastructural features of, 28, neural component of, 350–351
(MALT), 275 28t–29t overview of, 349
Mucus, 193 Neoplastic processes, cells of, Neuroendocrine tumors. See also
Müllerian inclusions, 186 cerebrospinal fluid, 870 Neuroendocrine cells
Müllerian system, 96, 186 Nephroblastoma. See Wilm’s tumor ancillary diagnostic tests for
1006 Index
Neuroendocrine tumors (Cont.) radiologic features of, 402 Normofollicular adenoma (simple
autofluorescence, 362 squamous metaplasia in, 407, adenoma), 409–410, 410t,
electron microscopy, 366 407f 411f
histochemistry, 366 stromal cells in, 407, 408t NSE. See Neuron specific enolase
immunochemistry, 366–367 Nonchromaffin, 350 Nuclear morphology, 15
molecular biology, 367 Non-Hodgkin lymphoma (NHL), Nuclear nippling, of endocervical
clinicopathologic features of, 545, 965–966 cells, 114
253t–254t classification of, 545
cytopathologic features of, 256t, cytologic diagnosis of, limitations O
257f–258f in, 545 Occult carcinoma, thyroid, 454
epithelial type, 352 morphologic types of, differential Olfactory neuroblastoma, 352t, 397
atypical carcinoid tumors, diagnoses of, 545, 556 Oligodendrocytes, 873
grade II, 355f–356f anaplastic large cell lymphoma, Oligodendrogliomas, 894
carcinoid tumors, grade I, 555t cytopathologic features of,
353f–354f Burkitt lymphoma, 552t, 894–895, 895f
large cell carcinoma, neuroen- 559f differential diagnoses of,
docrine grade III, 356f–357f chronic lymphocytic leukemia, 895–896, 897t
small cell carcinoma, neuroen- 547t, 557f Oncocytic carcinoma, of salivary
docrine grade III, 357f–360f diffuse large B-cell lymphoma- glands, 610
of gastrointestinal tract, centroblastic, 553t, 560f cytologic features of, 608t, 610,
308–309, 309f DLBCL—anaplastic, 554t, 610f–611f
neural type, 352, 360, 362, 560f, 561f differential diagnoses of, 611,
362f–365f DLBCL—immunoblastic, 612t, 613f–614f
nomenclature of, 351 553t, 560f gross and microscopic features
recommended terminology, follicular lymphoma, 551t, of, 610
352t 559f–560f Oncocytoma, 608
traditional terminology, 351t lymphoblastic leukemia/ cytologic pattern of, 608, 608t,
overview, 252 lymphoma, 546t, 557f 609f, 610f
parathyroid adenoma, 360, 365f lymphoplasmacytic lympho- gross and histologic features of,
pathologic features of, 351–352 ma, 548t, 557f 608
pituitary adenoma, 360, 365f mantle cell lymphoma, 549t, renal, 813–814
of thymus, 739t, 743, 745, 745f 558f cytopathology of, 813t
WHO/IASLC classification of, marginal zone lymphoma differential diagnosis of,
252 (MZL), 550t, 558f 813–814
Neuroepithelioma, peripheral, peripheral T-cell lymphoma, One slide technique, for cervical
adrenal, 351t 554t cancer screening, 94
Neurogenic sarcoma, cytopathology small lymphocytic lymphoma, Optic nerve neoplasms, 391, 393
of, 943t 547t, 557f Oral cavity lesions, 673t
Neuropile, in neueoblastoma, 873 Nonneoplastic effusions, 151 Orangeophilia, differentiation
Neuron-specific enolase (NSE), 366 Nonneoplastic epithelial alterations, from atypical squamous
Nipple discharge, 725 cytopathologic features of, cells of undetermined
Nodular fasciitis, 920, 920f–921f 195, 196t–197t, 202 significance, 86
cytopathologic features of, 920 Nonneoplastic lymphadenopathies, Orbit, metastases to, 391
differential diagnosis of, 920 cytopathology of, 544t Orbital lesions, of head and neck,
in salivary gland, 594t Nonneoplastic processes, in cerebro- 393–395
Nodular goiter, in thyroid, 402–408 spinal fluid, 870 in adults, 393–395
cytopathologic features of, Nonpapillary carcinoma in situ, in astrocytoma, 394f
403–407, 403t, 404f–407f urinary bladder, characteris- in childhood, 393
and diagnostic errors, 407–408 tics of, 336t FNA of, in the diagnosis of, 391
differential diagnoses of, 408, Nonproliferative breast disease, metastasis, 393
408t 712–713, 713t meningioma, 393, 394f
gross and histologic features of, Non-tyrosine crystals in cystic primary lymphoma, 395
402–403 lesions of the parotid vitreous fluid examination of,
Hürthle cell metaplasia in, 406f, glands, 586, 587t and the diagnosis of, 391
407, 438f Normal endometrial cells, cytomor- Orbital neoplasms, in childhood,
psammoma bodies in, 407 phology of, 95 393
Index 1007
Osteoid, 952 adenocarcinomas of, ductal type, cytopathologic features of,

Osteosarcomas, 952–955 770, 772 802, 802f–804f
cytopathologic features of, cytologic features of, 772, gross and microscopic features
952–954, 952t, 953f–954f 773f–776f, 773t, 776 of, 801–802, 802f
differential diagnosis of, 955 and diagnostic difficulties, 776 solid pseudopapillary tumors of,
morphologic variants of, 952 differential diagnosis of, 776, 779, 781
Ovarian-type stroma in mucinous 777f–778f, 777t, 791t cytopathologic features of,
neoplasm of pancreas, 807 gross and microscopic features 781–782, 783f–785f, 783t
Ovaries, 852 of, 772 differential diagnoses of, 782
adenocarcinomas of, in effusions, immunoprofile of, 776 gross and microscopic features
569 cystic lesions of, 789, 794, 794t of, 781, 782f
corpus luteal cysts of, 853t–854t, differential diagnoses of, immunoprofile and ultrastruc-
855–856, 856f 795t–799t, 810 ture of, 782
cystic lesions of, 852t cystic neoplasms of, 800 source of neoplasms of, 770
cytologic features of, diagnostic considerations in cyto- specimens for cytologic diagnosis
853t–854t pathology of lesions of, 769 of lesions of, 769, 770t
dermoid cysts of, 852, 852t, FNA biopsy of, 769 contaminants in, 772t
853t–854t islet cell tumor, 782 Pancreatic aspirates, normal compo-
endometriotic cysts of, metastatic malignancy to, 810 nent of, 770
853t–854t, 859, 860f microcystic adenoma of, differen- Pancreatic duct, adenocarcinoma of,
FNA biopsy of, use of, 852 tial diagnosis of, 786t with cystic change, differen-
follicular cysts of, 852, molecular markers of, 810 tial diagnosis of, 770–773,
853t–854t, 855, 855f mucinous neoplasms of, 773t, 791t
germ cell tumors, 864, 864t 802–808, 809f–810f cytopathology of, 772–773, 773t
granulosa cell tumors of, intraductal papillary mucinous with small cell pattern, 791t
856–857, 857f–859f, 857t neoplasms, 802–807 well differentiated, adenocarcino-
mucinous cystadenomas of, mucinous cystic neoplasms, ma of, differential diagnosis
853t–854t, 862–863, 863f 807–808 of, 777t
mucinous tumors, malignant, mucinous noncystic adenocar- Pancreatitis, chronic, duct hyperpla-
853t–854t, 863, 864f cinoma, 808 sia in, differential diagnosis
neuroendocrine tumors of, 863 neuroendocrine tumors of, 767, of, 776, 777t
nonepithelial cysts and neoplasms 786t, 790t Pancreatic endocrine tumors (PET),
of, 852–859 normal components of, 770, 782–783
serous cystadenoma and cysta- 770t, 771f cytopathologic features of, 785,
denocarcinomas of, 853t– pancreatic endocrine tumors, 786t, 787, 787f–789f
854t, 860, 861f 782–783 and diagnostic difficulties, 787,
serous surface epithelial tumors, cytopathologic features of, 789
860–863 785, 786t, 787, 787f–789f differential diagnoses of, 789,
serous tumors of, malignant, and diagnostic difficulties, 790t, 791t, 792f–794f
860–862, 861f–862f 787, 789 gross and microscopic features
differential diagnoses of, 789, of, 785, 786f
P 790t, 791t, 792f–794f ultrastructure of, 786
Paget’s disease gross and microscopic features Pancreatic neuroendocrine tumors
of breast, 724t, 725, 725f of, 785, 786f (PNT). See Pancreatic
of vagina, 138–140 immunoprofile of, 787 endocrine tumors (PET)
of vulva, 138–140 ultrastructure of, 787 Pancreatic pseudocysts, 794,
Pancreas pancreatoblastomas, 789 795t–799t, 800, 800f,
acinar cell carcinomas of, 779 papillary cystic tumor of, 779 801f
cytologic pattern of, 779, pseudocysts of, 794 PAP. See Pulmonary alveolar
780f–781f, 780t cytopathologic features of, proteinosis (PAP)
differential diagnoses of, 779, 795t–799t, 800, 800f, 801f Pap cells, in sputum, 216, 218f
781f diagnostic problems with, 800 Papanicolaou stain, 5, 195, 677
gross and microscopic features gross and microscopic features Papillary adenoma, renal, 814
of, 779, 779f of, 794, 800, 800f Papillary carcinomas in serous
immunoprofile and ultrastruc- serous cystadenoma, microcystic, effusios, differential diagnosis
ture of, 779 800–801 of, 167t, 179f
1008 Index
Papillary carcinoma, of breast, diagnostic problems with, 455, diagnostic accuracy and differen-
690t–691t, 695f, 458f tial diagnoses of, 526t, 529
699t–701t, 703 nuclear grooves in, 474 gross and microscopic features
differential diagnosis of, 709t, occult carcinoma, 454–455 of, 529
710f–712f oncocytic variant of, 452–453, Parathyroid glands
Papillary serous tumors, of 452f fine needle biopsy for, use of, 528
peritoneum, 188 and pale watery nuclei, 474 imaging modalities for, 528
Papillary thyroid carcinoma (PTC), papillary Hürthle cell carcinoma normal anatomy and histology
439 with lymphocytic stroma, of, 528
architectural patterns of tissue 454 parathyroid cysts, 526t, 527f,
fragments in, 443, 443f papillary microcarcinoma, 528–529
cartwheel pattern in, 443, 444f 454–455 parathyroid hyperplasia/adenoma,
cells of, 440–445, 442f psammoma bodies in, 444, 444f 529–531, 530f, 531f, 532t
with clear cell change, 454 radiologic features of, 439 vs. follicular adenoma/carci-
columnar cell variant of, 450, risk factors for, 439 noma, 531, 532t, 533, 533t
451f, 452 with single-cell pattern, 455, 458 vs. papillary thyroid carci-
conventional, cytopathologic fea- solid variant, 449–450, 451f noma, 532t, 533, 534f
tures of, 440, 441f, 441t squamous metaplasia in, 472, PCP. See Pneumocystis pneumonia
cribriform-morular variant of, 476f (PCP)
454, 454f tall cell variant of, 448–449, Pediatric malignant tumors, 965
cystic, 455, 458, 459f–462f 449t, 450f Pemphigus vulgaris
diagnostic accuracy of, 465 typing errors in diagnosis of, 467 of cervix, 78
diagnostic difficulties in, 455, vs. follicular hyperplasia, 472, cytopathologic features of, 79t
455f, 458t 472f–474f, 475t, 476f Peptide hormone antibodies, 366
diagnostic errors, 465–467 vs. papillary hyperplasia, 468, Pericardial effusion. See Serous
diffuse follicular variant, 453 468t, 469f–471f, 472 effusion
diffuse sclerosing variant of, 453, Papillary Hürthle cell carcinoma Periorbital lesions, of head and
453f with lymphocytic stroma, neck, 391
encapsulated variant, 453–454 454 Peripheral nerve sheath tumors, 940
with exuberant nodular fasciitis- Papillary microcarcinoma, 454–455 Peripheral neuroectodermal tumor
like stroma, 453 Papillary thyroid carcinoma (PTC). (PNET), 847, 958
false-negative diagnoses of, 465 See Papillary carcinomas, Peripheral neuroepithelioma,
false-positive diagnoses of, of thyroid adrenal, 351t
465–466, 467t Papilloma, urothelial, 328t, 343, Peripheral T-cell lymphoma, differ-
due to atypical nuclear 345t ential diagnosis of, 554t
features, 472 Papillary urothelial neoplasms, 327 Peritoneal effusion. See Serous
due to psammoma bodies, Papillary urothelial neoplasm of low effusions
475, 478f, 478t malignant potential Peritoneal/pelvic washings
follicular variant of, 446, (PUNLMP), 327, 328t, 334 cytologic presentation of, 185–186
447f–448f, 448, 448t Parabasal cells, 33 differential diagnoses of, 187t
gross and histologic features of, Paraganglia, 350 Peritoneum, female, 186
439–440 structure of, 350–351 endosalpingiosis, 186, 186t
and Hashimoto’s thyroiditis, 465, Parakeratosis, 39–40 papillary serous tumors of, 188
468t Paraganglioma-like adenoma of thy- Pheochromocytomas, 838
immunoprofile of, 445 roid (PLAT). See Hyalinizing cytologic features of, 839,
incidence of, 439 trabecular adenomas 840f–841f, 840t, 841–842
intranuclear inclusions in, Paraganglioma, in head and neck, diagnostic difficulties and dif-
474, 477f 390 ferential diagnoses of, 842,
macrofollicular variant, 449, cytopathologic features of, 390t 843t–844t
450f differential diagnoses of, 390, gross and histologic features of,
minimal criteria for cytologic 392f, 392t 839
diagnosis of, 467, 467t Parapharyngeal space, 398 and radiologic findings, 839
morphologic variants of, 440t, tumors of, 398, 399f Phyllodes tumors, of breast, 708,
445–446 Parathyroid cysts, 528–529 711f–712f
cytopathologic features of, cytopathologic features of, 526t, Physaliphorous cells, in chordoma,
456t–457t 527f, 529 912
Index 1009
Pilocytic astrocytomas, 877, 878t, Pleomorphic carcinomas, lung, differential diagnosis of, 972
879f 273–274 gross and microscopic features, 970
Pilomatrixoma, 383 Pleomorphic cell, 80 immunoprofile of, 972
cytologic features of, 383, Pleomorphic dysplasia, 54 overview, 969
384f–385f, 384t, 385 Pleomorphic sarcoma, differential ultrastructure of, 972
Pineal tumors, of central nervous diagnosis of, 947t Proliferative breast disease, 708,
system, 900 Pleomorphic squamous cells, 60 717–719
Pineoblastoma, 351t, 352t Pleomorphic xanthoastrocytoma cytopathology of, 720t
Pineocytoma, 898f, 900, 901t (PXA), 885, 886f–887f, 887 differential diagnosis of, 721t
Pituitary adenomas, 897t, 899 Pleural effusion. See Serous effusion Proplasia, 2t, 3, 3t
Plasmacytoma, 563f, 566–567 Pneumocystis carinii, 284 Prostate adenocarcinoma, 175
in thyroid, 523 Pneumocystis jiroveci pneumonia, Progesterone, 38
Pleomorphic adenomas, of 284 Progesterone receptors, 637
salivary glands, 573–588, cytologic features, 287, 288t Psammoma bodies, 195, 407, 475
575f–581f differential diagnosis of fluffy in cervical-vaginal smears,
and chronic sialadenitis, differen- exudates, 287, 288t 144–147
tiation between, 587t Pneumocystis pneumonia (PCP), in nodular goiter, 478t
cytopathologic features of, 574t, 287 in papillary carcinoma, 457t, 475
575, 581, 586 Pneumocystosis, 284 Pseudocyst, pancreatic, 794
diagnostic difficulties and dif- Pneumocytes, 193, 201f Pseudomyxoma peritonei, 172
ferential diagnoses of, 575t, differentiating features between, Pseudoparakeratosis, 216
581f–583f, 586 244t Pseudorosettes, central nervous
differentiation from acinar cell reactive/hyperplastic type II, system, 901t
carcinoma, 643t 202–203, 203t Pulmonary alveolar proteinosis
differentiation from low grade vs. adenocarcinoma, 235f–238f (PAP), 287–289
adenocarcinoma, NOS, Pollen, 195 cytopathologic features, 287, 288t
643t Polymerase chain reaction (PCR), 30 differential diagnoses, 287, 288t
differentiation from lymphoepi- Polymorphous low-grade adenocar- histologic features, 287
thelial carcinoma, 643t cinoma (PLGA), of salivary ultrastructural findings, 287
differentiation from mucoepider- glands, 644, 652 Pulmonary bacterial infections, 282,
moid carcinoma, 643t cytopathologic features, 652, 283t
differentiation from normal 653t, 653f–655f Pulmonary blastoma, 274
acinar tissue, 643t differential diagnosis, 652 Pulmonary carcinoid tumors
differentiation from oncocytoma, Polyoma virus (BK virus) effect on cytopathologic features, 255
643t urothelial cells, 338t, 341f differential diagnoses of, 255, 259
gross and microscopic features Poorly differentiated carcinoma, dif- histologic features, 254–255
of, 573–575 ferential diagnosis of, 698 overview, 254
and low-grade mucoepidermoid Postmenopausal smears, 86 Pulmonary clear cell tumors, differ-
carcinoma, differentiation Postmenopausal women, endocervi- ential diagnoses of, 274t
between, 587t cal sampling in, 32 Pulmonary mycotic infections,
pitfalls in, cytopathologic diagno- morphologically benign appearing 282–284, 285t–286t, 287
sis of, 587t endometrial cells in, 94 cytopathologic features, 287
with predominant epithelial Primary effusion lymphoma, 275 differential diagnoses of, 287
component, 587t Primary fallopian tube adenocarci- histologic features, 287
with predominant oncocytic noma, 141, 141f Pulmonary soft-tissue tumors,
metaplasia, 587t Primary pleural malignancy 274–275
with predominant small cell besa- cytopathologic features of, 276, cytopathologic features of, 275
loid pattern, 587t 277f–279f, 279, 280t types of, 275
with predominant spindle cell Primary tracheal tumors, 276 Pulmonary tuberculosis, 282
pattern, 587t Primary sclerosing cholangitis Pulmonary viral infections, 282, 284t
with predominant stromal com- (PCS), 315 Pulmonary nodule, solitary, differen-
ponent, 587t Primitive neuroectodermal tumors tial diagnosis of, 290
with predominant squamous (PNET), 255, 966 PUNLMP. See Papillary urothelial
metaplasia, 587t cytogenetic analysis, 972 neoplasm of low malignant
vs. mucoepidermoid carcinoma, cytopathologic features, 970, potential (PUNLMP)
583f–585f 971f–972f, 970t Pyknotic nuclei, 33
1010 Index
R Repair, gastric brushings, differential Retroperitoneal tumors, 851

Radial scar, of breast, 717 diagnosis of, 302t Retroperitoneum, 851
cytologic features of, 717 Reserve cell hyperplasia in pulmo- primary malignancy of, 851
differentiation from papillary nary specimens, differential Retroplasia, 2t, 3, 3t
neoplasms, 709t diagnosis, 265t Rhabdoid tumors, in children, 976
Radiation effect on urothelial cells, Respiratory epithelial cells, 191, Rhabdomyosarcoma, 393, 393f.
344 192, 193 See also Soft tissue tumors
Radiation induced changes, in cervical- Respiratory specimens alveolar, 977, 979
vaginal smears, 83, 90t differential diagnoses of foamy in children, 184
differentiation from ASCUS, 90t histiocytes in, 245f–246f, cytogenetic analysis, 977t
Radiation induced changes, in 247t–248t cytopathologic features of, 977t,
esophagus, 295 noncellular entities in, 193, 195 978f–979f
Reactive gliosis, cell morphology of, amyloid, 195 embryonal, 977
876–877, 876t asteroid bodies, 195 in head and neck, 393
differentiation from astrocytoma, calcium oxalate crystals, 195 immunoprofile of, 980
876–877, 876t Charcot-Leyden crystals, 193 overview, 976–977
Reactive hepatocytes, differential contaminants, 195 pleomorphic, 932–933, 947t
diagnosis of, 759t corpora amylacea, 193, 195 ultrastructure of, 980
Reactive mesothelial cells Curschmann spirals, 193 Rheumatoid granulomas, character-
cytomorphology of, 150t elastin fibers, 195 istic feature of, 152
histocytologic feature of, 151 ferruginous bodies, 193 Rheumatoid lesion, 152
Reactive type II pneumocyte, hyaline cartilage, 195 Rheumatoid pleuritis, 151–152
differential diagnosis of, mucus, 193 cytopathologic features, 152
203, 230t psammoma bodies, 195 effusion fluid in, 152
Reed–Sternberg cells, 556, 566, reserve cell hyperplasia, 192 Rhodococcus equi, 282
567t Schaumann bodies, 195 Richart’s classification, of cervical
Reagen’s classification, of dysplasia, types of, 192t intraepithelial neoplasia, 31
31 sputum, 192t Romanowsky stains, 149, 973
Renal angiomyolipoma, 814, 814t bronchial brushings/washings, air-drying, 5
Renal cell carcinoma (RCC), 192t for FNA biopsy, 401–402
814–815 bronchoalveolar lavage, 192t Rosenthal fibers, 877, 878t, 879f
clinicopathologic features and percutaneous transthoracic Rosettes, in central nervous system
cytomorphology of, 816t, biopsy, 192t tumors, 888, 891t
817t, 818f–823f transbronchial aspiration types of, in CNS specimens, 891t
cromophobe type, clinicopatho- biopsy, 192t Round cell liposarcomas, 927
logic features of, 813, 815, transtracheal biopsy, 192t
816t–817t Respiratory tract S
cystic, 812–813, 824t anatomy of, 192–193 S100 protein, 26t, 27t
diagnostic difficulties and differen- bronchial brushings and washing, Salivary duct carcinoma, 635
tial diagnoses of, 815, 823f, 191, 192t cytopathologic features of, 635,
824t, 825f–827f bronchoalveolar lavage of, 191, 635f–638f, 636t
morphologic variants, 816t–817t 192t differential diagnoses of, 638
types of, 815 cytology of, 192–193, 194t gross and histologic features of,
Renal masses, fine needle aspiration diagnostic issues in, 191–192, 635
biopsy for, 830 192t immunoprofile of, 637
Renal neoplasms, in infancy and histology of, 192–193 ultrastructure of, 637
childhood, 828t, 974 noncellular entities in, 193, 195 Salivary glands, 571–687
Renal oncocytoma, cytopathology nonneoplastic epithelial altera- acinic cell carcinoma of, 638–642
of, 813–814, 813t tions, 195, 196t–197t, 202 adenocarcinoma, NOS of, 618,
Renal pelvic brushings/washings, pneumocytes, reactive/hyper- 630–634
326t, 327 plastic type II, 202–203, adenoid cystic carcinoma of,
Renal pelvis, primary carcinoma of, 203t 642–644, 645f–651f, 645t
815, 829t Retinoblastoma, 351t, 352t basal cell adenocarcinoma of,
Repair, endocervical glandular, dif- in childhood, 393, 393f 600, 601f–602f
ferentiation from adenocar- Retrograde ureteral catheterization, basal cell adenoma of, 593,
cinoma, 128, 133t–134t 343 597–600
Index 1011
classification of neoplasms & differential diagnoses of, 603, Serous cystadenocarcinoma,

nonneoplastic disorders of, 605f–607f, 607–608, 607t ovarian, differential
686–687 diagnostic pitfalls in, 603f– diagnosis of, 853t–854t
clear cell carcinomas, 605f, 605t Serous cystadenoma, 800–801
667–668, 668f, 669t, gross and histologic features cytopathologic features of, 802,
670f–671f of, 600 802f–804f
cystic lesions, 672t use of cell block in, 605–606 gross and microscopic features
epithelial–myoepithelial carci- “Salt & pepper” chromatin, 352 of, 801–802, 802f
noma of, 652, 656, 657f, Sarcoidosis of ovaries, 853t–854t, 860,
658, 658f cytopathologic features, 289, 861f
cytopathologic features of, 544t Serous effusions
656–657, 656t, 657f differential diagnoses, 289 cytologic evaluation of, 149
differential diagnosis of, 658 histologic features, 289 cytopreparatory techniques in,
FNA of, major and minor, 571 Sarcomas 149
lymphoepithelial carcinomas, 667 alveolar soft part, 948 diagnostic problem, overview of,
lymphoepithelial cysts, 671 clear cell, 948 149
HIV associated, 671–672 endometrial stromal, 112, 944t differential diagnoses of single
lymphoepithelial lesions, benign, epithelioid, 942, 949t small to medium cells in,
671 Ewing’s, 27t, 367, 958, 969–970 177f–178f
lymphoepithelial sialadenitis, granulocytic, 967–968 histology of, 149
682 Kaposi’s, 934 malignant mesothelioma of, 152,
lymphoid proliferations of, 682, with large round and polygonal 153t
682t cells, differential diagnosis mechanism of, 149, 151
malignant lymphomas of, of, 949t mesothelial cells normal,
682–685 pleomorphic, differential diagno- histology and cytology of,
malignant mixed tumors of, 667 ses of, 947t 149, 150t
metastatic malignancy to, 668 of smooth muscles. See mesothelial hyperplasia, cells of,
mucoepidermoid carcinoma of, Leiomyosarcomas 150t, 151
612–618, 617t soft tissue, differential diagnoses metastatic cancer in, 167–185
myoepithelial carcinomas of, of, 947t breast adenocarcinoma, 167,
589–593 synovial, cytopathology of, 168t, 170
myoepitheliomas of, 588–589 943t–944t differential diagnosis of, single
nonneoplastic lesions of, of urinary bladder, 338 malignant cells, 176t
668–682 Sarcomatoid carcinoma, 273–274 extramedullary hematopoiesis,
normal constituents of, cytology Schaumann bodies, 195 182
of, 572–573 Schwann cells, spindle cell matrix female genital tract malignancy
oncocytic carcinoma of, of, 968 in, 172
610–612 Schwannomas (neurilemmoma), gastric carcinoma, cells
oncocytoma of, 608–610 901, 903, 906t, 940 in, 172
pleomorphic adenomas of, cytologic features of, 940, 940f– germ cell tumors, cells in, 181
573–588 941f, 940t lung adenocarcinoma, 170,
polymorphous low-grade adeno- Sclerosing hemangioma, pulmonary, 171t
carcinoma of, 644, 652, 230t, 243, 272t lymphoma-leukemia, cells in,
653f–655f, 653t cytologic features of, 272t 182
salivary duct carcinomas, differential diagnosis of, 230 malignant melanoma,
635–638 Sebaceous carcinomas, 396, 396f 181–182
small cell (neuroendocrine) Secretory carcinoma, of breast, neuroendocrine tumors, cells
carcinomas of, 658–660, 705 in, 181
659f, 660t, 661t, 662f Seminoma of testes, 865–866, renal carcinoma, cells in, 175
tumors of, 274 865f–866f, 865t sarcomas, 184
undifferentiated carcinomas of, differential diagnoses of, 866, small round cell tumors, of
660, 664–667, 664t 867t childhood, cells in, 184
Warthin’s tumors of, 600, Sepsis, 202 squamous cell carcinoma, cells
603–608 Serous borderline tumors (SBT), in, 177
cytopathologic features of, ovarian, in peritoneal/pelvic Serous fluids, cytopathologic
600, 603, 603f–605f, 603t washings, 187t features of, 167t
1012 Index
Serous membranes, 149 differential diagnoses of, 979f, synovial sarcoma, 937–938,
primary neoplasms of, 152–153 980t–982t, 982f–983f 938f, 939f
Serous papillary adenocarcinoma, Smear preparation, technique of, tumors of vascular origin, 933
ovarian, 147, 172f 873, 915–916 angiosarcoma, 933–934, 935f
Serous papillary tumors, differentia- Smooth muscle tumors, of gastroin- epithelioid hemangioendothe-
tion from malignant meso- testinal tract, 311 lioma, 933, 933f, 934f
thelioma, 161, 166 Soft tissues, 919–951 hemangiopericytoma, 936–
Severe dysplasia. See High grade adipose tissue tumors 937, 937f
squamous intraepithelial lipomas, 926–927 Kaposi’s sarcoma, 934, 936f
lesions liposarcomas, 927–930 Soft tissue tumors, 569
Severe keratinizing dysplasia, HSIL, alveolar soft part sarcomas, 948, differential diagnosis of, with
59–60 949t mucoid, 959t
cytopathologic features of, clear cell carcinomas, 948, 949t, differential diagnosis of, with
56f–59f, 60 951, 951f myxoid stroma, 959t
histologic features of, 60 epithelioid sarcoma of, 942, 949t differential diagnosis of, with
Sialadenitis, chronic, differentiation extraskeletal chondrosarcomas spindle cell pattern, 337,
from pleomorphic adeno- of, 951 378t
ma, 581f–582f, 587t fibroblastic/myofibroblastic Solitary fibrous tumor (SFT),
Signet-ring carcinomas, of breast, tumors of 920–921
705 fibromatosis, 922, 922f Solitary pulmonary nodules, differ-
SIL. See Squamous intraepithelial fibrosarcoma, 922–923, 923f ential diagnoses, 290
lesions fibrous histiocytic tumors, Southern blot (SB) analysis, 367
Simple follicular adenoma, differen- 923–926 Specimens for cytologic evaluation
tial diagnosis of, 472, 475t myofibroblastoma, 921–922, adequacy of, 6
Sinonasal undifferentiated 922f background of, 23
carcinoma (SNUC), myxofibrosarcoma, 923 cellular morphology, 11–23
396–397, 398f nodular fasciitis, 920, fixative selection, 5
differential diagnoses of, 397 920f–921f general aspects of, 6
Skeletal muscle tumors, 919 solitary fibrous tumor, right scan, 5–6
Small cell glioblastoma, 897t 920–921 specimen collection and, 5
Small cell carcinoma, 243 FNA biopsy of, use of, 919 stain selection, 5–6
combined, 266 granular cell tumors of, 942, tissue fragments in, 5
cytopathologic features, 262f– 949t, 950f Spindle cell carcinoid, 255, 256t
263f, 264, 265t–266t peripheral nerves, tumors of, Spindle cell lesions
differential diagnoses of, 264, 940 in breast aspirates, differential
265t–266t, 266, 267f–270f malignant peripheral nerve diagnosis of, 708, 713t
histologic features, 261 sheath tumors, 941–942, in salivary gland aspirates, differ-
overview, 261 941f ential diagnosis of, 594t
Small cell (neuroendocrine) carci- schwannomas, 940, 940f, in soft tissues, differential
nomas, of salivary glands, 940t, 941f diagnosis of, 943t
658–660, 659f, 660t, 661t, pleomorphic sarcoma of, 942 Spindle cell lipomas, 927, 928f
662f differential diagnoses of, Spindle cell neoplasm, in mediasti-
Small cell carcinoma. See Neuroen- 947f–948f, 947t nal aspirates, 732, 734t
docrine tumors skeletal muscle, tumors of Spindle cell pattern, in anaplastic
metastatic to adrenal glands, rhabdomyosarcomas, 932–933 thyroid carcinoma, 505t
832 smooth muscle, tumors of Spindle cell thymomas, 732–736,
metastatic in effusion, 168t gastrointestinal stromal tu- 733f, 734f
metastatic to lymphnode, 569 mors, 932, 932f cytopathologic features of, 733t
Small cleaved cell lymphoma, differ- leiomyomas, 930 differential diagnoses of, 734t,
ential diagnosis of, 549t leiomyosarcomas, 930, 931f– 735f–736f
Small lymphocytic lymphoma, dif- 932f, 931t Spindle cells, 970
ferential diagnosis of, 547t, spindle cell lesions of, 942 carcinoid tumors, 255
549t differential diagnoses of, 943t– multinucleation of, 152
Small noncleaved cells, 543, 747 944t, 945f–946f Sputum, 191, 198f
Small round cell tumors synovium tumors of Charcot-Leyden crystals, 193
of childhood, 184, 184f–185f giant cell tumors, 937, 938f Curschmann spirals, 193
Index 1013
cytologic evaluation of, 290 Squamous metaplasia, 36, 38, 152, T-cell, 965
ferruginous bodies, 193 217 Tendon sheath, giant cell tumors of,
metaplastic squamous cells in, 218 in nodular goiter, 407, 407f 937
mucus, 193 Stains, 5 Teratomas, 867–868, 868f
Squamous cell carcinoma, 48, 177, histochemical, 25, 25t in children, 985
180, 565f, 568–569 immunochemical, 25, 26t Testes
of esophagus, 296–297, 296f, Papanicolaou, 27 choriocarcinoma of, 868, 869f
297f Romanowsky, 5, 6, 19f, 22f, 149 embryonal carcinoma of, 866,
of skin, 383, 383f selection of, specimen evaluation, 868f
cytopathologic features of, 209, 5–6 endodermal sinus tumor of,
210t, 211f–212f Stereotactic CT guidance, of 866–867
differential diagnoses of, 78, 78t, aspiration biopsy, of central FNA biopsy of, use of, 863–864
213, 213t, 214f, 218f–223f nervous system lesions, germ cell tumors of, 864–869
false-negative diagnosis, 75, 78 873 classification of, 864t
histologic features of, 208–209 Starch granules, 195 seminoma of, 865–866, 865f–
invasive, 208 Stroma, 22 866f, 865t
morphologic variants of, 209, Stomach differential diagnoses of, 866,
212–213 adenocarcinoma of, 300–301, 867t
basaloid type, 209, 212–213 301f–305f, 301t teratomas of, 867–868, 868f
with clear cell change, 213 gastric lesions, cytologic evalua- Thiotepa effect on urothelial cells,
small cell variant, 209 tion of, 300 338t, 344
well-differentiated papillary or malignant lymphomas of, 301, Thymoma, 732–733
verrucous type, 209 305, 306f cytopathology of, 733t
overview, 208 nonneoplastic lesions of, 300 epithelial predominant, 738t
of uterine cervix, 68–69 normal gastric mucosa of, 300 malignant, 732
incidence of, 68 Stratified squamous epithelium spindle cell type, 733t
prognosis and biologic benign cellular changes in, 40, lymphocyte predominant, 735t
behavior of, 69 42t–43t Thymic carcinoid, differential diag-
vs. poorly differentiated endocer- characteristics of, 33 nosis of, 739t
vical and endometrial Stromal foam cells Thymus
carcinoma, 70t, 81 polygonal shape of, 96 and diagnostic challenges, 731
Squamous cells, abnormalities of, Stromal tumors, 568 germ cell tumors of, 747–748,
in Bethesda system, 4, 79 Submesothelial collagenous tissue, 747f
atypical function of, 3 149 Hodgkin lymphoma of, 746
immature metaplastic, differen- Submucosal lesions, in bronchi, lesions of, 732t
tiation from HSIL, 36 191 lymphoblastic lymphoma,
intermediate type, 33 Superficial squamous cells, 33 746–747
metaplastic, of endocervical glan- Surface epithelial inclusion cyst, lymphocyte predominant thymo-
dular epithelium, 34 ovarian, 852t, 859, 860f mas, 737f–738f
morphologic features of, 34t Synaptophysin, 366 cytopathologic features of,
parabasal, 33 Syncytial meningioma, cytopathol- 735t
primitive, 33 ogy of, 897t differential diagnoses of, 737t,
superficial, 33 Syncytiotrophoblasts, in cervical– 740f, 741f–744f
Squamous intraepithelial lesions vaginal smear, 40, 43 Type B1 thymoma, 736
(SIL), 48 Syncytial tissue fragments, 59, 967 Type B2 thymoma, 736,
Bethesda System categorization, Synovial sarcoma, 937–938, 939f 739–740
46–47 cytogenetic and molecular Type B3 thymoma, 738t, 740
defined, 48 studies, 938 malignant lymphomas of,
differentiating low-grade from cytologic features of, 938 746–747
high-grade, 68 differential diagnosis, 938 neuroendocrine tumors of, 739t,
grading for, 49 immunoprofile, 938 743, 745, 745f
Squamous keratinizing lesions, dif- non-Hodgkin lymphoma of, 746
ferential diagnoses of, 80t T normal, 731–732
Squamous lesions TBFNA. See Transbronchial fine primary neoplasms of, 732–746
overview, 48 needle biopsy (TBFNA) spindle cell thymomas, 732–736,
TBS 2001, classification of, 48 TBS. See The Bethesda System (TBS) 733f, 734f
1014 Index
Thymus (Cont.) parathyroid cysts and thyroid classification of, 507t

cytopathologic features of, cysts in nodular goiter, subacute (granulomatous)
733t differential diagnosis, 525, thyroiditis, 504, 507
differential diagnoses of, 734t, 526t cytopathologic features of,
735f–736f primary malignant lymphomas 507, 508t
thymic carcinomas, 741, 743 of, 514 differential diagnoses of, 508
differential diagnoses of, 739t, diagnostic accuracy of, Thyroid nodules, 401
744f–745f 519–521 Thyroid transcription factor 1
Thyroglobulin, 243 differential diagnosis of, 521, (TTF-1), 208, 366
Thyroid 522t, 523t Tissue fragments, 6
adenoma. See Follicular adenoma diffuse large B-cell lymphoma, architectural patterns in, 6
anaplastic carcinomas. See 518–519, 519t differentiation from atrophic
Anaplastic thyroid marginal zone B-cell lympho- epithelium, 39t
carcinoma (ATC) ma, 514, 517–518, 518f, endocervical epithelium, 34
cystic lesions of, 522f, 523–525, 519t of HSIL, 55t, 61t
524t, 525f, 526f plasmacytomas, 523 in papillary hyperplasia, 468
differential diagnosis, 524t vs. anaplastic carcinoma, 521, in thyroid aspirates, 475t
cystic papillary carcinoma, 523 TKI. See Tyrosine kinase inhibitor
458–459, 459f–464f vs. Hashimoto’s thyroiditis, (TKI)
cytopathology of lesions of 521 Torulosis, pulmonary, 284
nodular goiter, 402–408 vs. metastatic small cell carci- Toxoplasma, of lymph node, cyto-
cytopreparations for, 401 noma, 523 pathology of, 544t
fine needle biopsy of specimen adequacy and reporting Trabecular adenoma (embryonal
development of, 401 system for thyroid aspirates, adenoma), 411. See also
and diagnostic problems, 401 533–540 Cellular follicular adenomas
follicular adenomas, 409–417 reporting scheme for thyroid Trachea, 192
follicular carcinomas, 417–423 aspirates, 534t, 540t lesions of, 275
Hürthle cell adenomas, 423, specimen adequacy, 535f, primary tumors, 276
426–430 537f–539f Transbronchial fine needle biopsy
Hürthle cell carcinomas, 430, 432 unsatisfactory/inadequate (TBFNA), 291
Hürthle cell metaplasia specimen, guidelines for, Transitional cell carcinoma, urinary
in nodular goiter, 436–438 536t–537t bladder, 327, 333
in Hashimoto’s thyroiditis, spindle cells in thyroid aspirates, Transitional cell neoplasm, of
438 486, 488, 488t, 489f–493f, urinary bladder, 327
Hürthle cell neoplasms, 423 495f Transitional epithelium, normal
immunoprofile of, 402 benign and malignant spindle histology of, 325
insular carcinomas, 477, cells, differentiation be- Transitional zone (squamo-columnar
479–481 (See also Insular tween, 489t junction), of cervix sam-
carcinomas) neoplastic spindle cells of epi- pling, 32
and malignancies of lymphoid thelial origin, 494 Transudates, 151
tissue, 523 neoplastic spindle cells of Trichomonas infection, in cervical-
medullary carcinoma of, stromal origin, 493 vaginal smears, 41t
494–500 nonneoplastic spindle cells of Trophoblasts,in pregnancy, 40
metastatic malignancy to, 500, epithelial origin, 494 TTF-1. See Thyroid transcription
504, 505f–506f, 505t nonneoplastic spindle cells of factor-1 (TTF-1)
modified histological classifica- stromal origin, 488–493 TTFNA. See Transthoracic fine
tion of tumors of, 541 staining methods for, 401–402 needle biopsy (TTFNA)
molecular testing of FNA samples thyroiditis, 504–514 Tubal metaplasia, of endocervix,
of, 526–527s WHO histological classification 114–115, 115t, 116f–117f
normal histology and cytology of tumors of, 541 Tuberculosis, 152, 158t
of, 402 Thyroglossal duct cysts, 380, 523 Tubular carcinoma, of breast, 700t–
papillary carcinomas, 432–477. Thyroiditis, 504 691t, 694f, 699t–701t, 703
See also Papillary carcino- chronic lymphocytic Tumor-like lesions, of lungs, 271t
mas, of thyroid (Hashimoto’s) thyroiditis, Tyrosine crystals in pleomorphic
papillary variant of Hürthle cell 508–514 (See also adenomas, 586, 587t
carcinoma, 432 Hashimoto’s thyroiditis) Tyrosine kinase inhibitor (TKI), 208
Index 1015
U normal histology and cytology Virus-induced infection, of lymph

Ungraded squamous intraepithelial of, 345t node, cytopathology of,
lesion, 68 specimen types, 347 544t
UPSC. See Uterine papillary serous Urine, catheterized, 327 Vitreous fluid, use of cytologic
carcinoma Urine, voided, 326 examination, 391
Ureteral brushings/washings, 339f, Urothelial dysplasia, 333–335, Voided urine, 326
344f 336t Von Hippel–Lindau (VHL)
Ureters, primary carcinoma of, 815 Urovysion, 346, 346t syndrome, 907
Urinary bladder Uterine cervix, adenocarcinomas of, Vulva
high-grade papillary urothelial 115 Paget’s disease of, 138–140
carcinoma, 332t Uterine papillary serous carcinoma viral infections in, 138
cytologic features, 331f–333f (UPSC), 102–104 Vulvar cancers, 138
intraepithelial noninvasive lesions architecture of, 102 Vulvar scrapings, 138, 139f
of, 333–336 cytopathologic features of, 102,
urothelial carcinoma in situ, 103f, 104t W
333, 336t immunoprofile of, 103 Warthin’s tumor, 454, 600
urothelial dysplasia, 333, Uterine sarcomas, 109 cytopathologic features of, 600,
334f–335f, 335, 336t endometrial stromal sarcomas, 112 603, 603f–605f,
low-grade papillary urothelial mesodermal tumors of, 111f–112f 603t
carcinoma, 328t differential diagnoses of, 603,
cytologic features, 330f–331f V 605f–607f, 607–608,
metastatic carcinoma, 340 Vagina 607t
neoplasm of, 327–332, flora and common infections, gross and histologic features of,
336–340 40, 41t 600
adenocarcinoma of, 336 malignant melanoma in, 140 Well-differentiated papillary or
neuroendocrine carcinoma of, Paget’s disease of, 138–140 verrucous type, 209
336 squamous epithelium of, 38 Wilms’ tumor, 184
spindle cell lesions of, 338 viral infections in, 138 cytopathologic features of, 974–
squamous cell carcinoma Vaginal adenosis, 138 975, 975f–976f, 974t
of, 336 Vaginal cysts, 138 WT1 (Wilm’s tumor gene), 974
urothelial neoplasm of, 327– Vaginal endometriosis, 138
332, 332t X
Vaginal flora, in cervical-vaginal
Urinary cytology, diagnostic pitfalls Xanthoastrocytoma, pleomorphic,
smears, 41t
in, 338–345 875, 882, 883
Vaginal intraepithelial neoplasia
cellular changes from intravesical cytopathology of, 876tof, 876t
(VAIN), 138
therapy, 344 Xanthogranulomatous pyelonephritis,
Vaginal lesions, 138–140. See also
cellular changes from systemic 814
Vagina
therapy, 344 Vaginal pool specimens, 94 Y
instrumentation effect, 343 Vaginal smears, 138, 140f Yolk sac tumors, 26t, 866
nephrogenic adenoma, 344 VAIN. See Vaginal intraepithelial cytopathology of, 865t, 984t
radiation-induced changes, 344 neoplasia differential diagnosis, 867
reactive/regenerative urothelial Vascular tumors, 275 testicular, 864t
cells, 343–344 Vegetable cells, 195
virus-induced changes, 344 Verocay bodies, 903, 940, 940t Z
Urinary tract, 325–326 Viral infections, in effusion fluids, 152 Zona reticularis, in adrenals, 832

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COLOR ATLAS OF

351 West Camden Street Two Commerce Square

Library of Congress Cataloging-in-Publication Data

Dhananjay Chitale, MD Mariza de Peralta-Venturina, MD

Kedar Inamdar, MD, PhD Aditya Raghunathan, MD, MPH

SECTION I: GYNECOLOGIC CYTOPATHOLOGY

CHAPTER 2 General Aspects of Gynecologic Cytopathology, Reporting System,

SECTION II: NONGYNECOLOGIC CYTOPATHOLOGY

CHAPTER 6 Serous Effusions 149

SECTION III: FINE-NEEDLE ASPIRATION CYTOPATHOLOGY

CHAPTER 10 Neuroendocrine System and Neuroendocrine Neoplasia 349

CHAPTER 16 Breast 688

ACOG American College of Obstetrics and EM Electron microscopy

AIDS Auto immune deficiency syndrome EUS Endoscopic ultrasound

AIS Adenocarcinoma in situ FIGO International Federation of Gynecology and

ASR Arias-Stella reaction H&E Hematoxylin and Eosin

BAC Bronchioloalveolar carcinoma HCC Hepatocellular carcinoma

BAL Bronchoalveolar lavage HIV Human immunodeficiency virus

BCG Bacillus Calmette-Guérin HPV Human papilloma virus

CIN Cervical intraepithelial neoplasia HRT Hormone replacement therapy

CIS Carcinoma in situ HSIL High-grade intraepithelial lesion

CK Cytokeratin IUD Intrauterine device

CNS Central nervous system ISUP International Society of Urologic Pathologists

CSF Cerebrospinal fluid LBP Liquid-bases preparation

CT Computed tomography LCA Leukocyte common antigen

DES Diethylstilbestrol LGNEC Large cell neuroendocrine carcinoma

EBUS Endoscopic bronchial ultrasound LSIL Low-grade squamous intraepithelial lesion

LUS Lower uterine segment PTC Papillary thyroid carcinoma

MALT Mucosa-associated lymphoid tissue PUN-LMP Papillary urothelial neoplasm of low

Working up a diffi cult case is very challenging and

TABLE 1.1 MORPHOLOGIC CHARACTERISTICS OF DIFFERENT TYPES OF GENERAL ACTIVITY OF CELLS

Etiology — Known factors: viruses, Physiologic (growth); Physiologic—aging;

Key Features Roundness; Sharp angularity Roundness; uniformity; Extreme variations in

Shape Round Extremes in size and Round Variable

Parachromatin Delicate, uniform, Excessive clearing; Uniform clearing Clearing ⫹/⫺

Chromatin/ Not observed due Sharp Sharp Blurred

TABLE 1.1 (continued)

Number When present, Marked variation in Vary in number Present ⫹/⫺

Size Small Variable: micro/macro/ May be variable Small and inconspicuous

Shape Round Round to irregular with Generally round Generally round

Mitoses — When present, normal When present, normal None

Multinucleation — Frequent, nuclei irregular Frequent, nuclei benign, ⫹/⫺

Bare Nuclei None Frequent None Frequent

GENERAL ASPECTS OF SPECIMEN EVALUATION SPECIMEN COLLECTION AND

and nuclear structure; other nuclear characteristics; and

Figs. 1.4G to I. (continued) G: Triphasic. FNA of a Wilms’ tumor

stromal, and blastemal) is triphasic. Synovial sarcoma is

Figs. 1.5I to M. (continued) I: Triangular cell; three sided. J: Cau-

Nuclear Characteristics Cytoplasmic Qualities

Figs. 1.7I to O. (continued) I: Microvilli, cytoplasmic brush bor-

Background epithelial hyperplasia versus adenocarcinoma; and meso-

Figs. 1.9A to C. A, B: Diathesis. Background characterized by old

TABLE 1.2 COMMONLY USED HISTOCHEMICAL STAINS IN DIFFERENTIAL DIAGNOSES OF NEOPLASMS

Tissue Component Method Tissue Fixation Substance Identification Diagnostic Application

PAS, diastase Routine Neutral Adenocarcinomas; B-cell

Alcian blue at Routine Acid mucopolysaccharide Adenocarcinoma

Mucicarmine Routine Acid mucopolysaccharide Adenocarcinoma

Fibrillar Proteins Congo red Routine Amyloid Medullary thyroid carcinoma;

Thioflavin T Routine Amyloid Medullary thyroid carcinoma;

Neuroendocrine Grimelius Routine Argyrophil granules Neuroendocrine tumors

Granules Masson-Fontana Routine Argentaffin and Neuroendocrine tumors

Formaldehyde Fresh frozen Catecholamines Neuroendocrine tumors

Nucleic Acids Methyl Frozen; fresh; RNA/DNA B-cell lymphoma; plasmacytoma

TABLE 1.3 IMMUNOCYTOHISTOCHEMICAL STAINS’ DIAGNOSTIC MARKERS