Contents. 1. Introduction and Approach to Fine Needle Aspiration Cytology Head, Neck, Orbit and Salivary Glands... 12

Transcription

1 Contents 1. Introduction and Approach to Fine Needle Aspiration Cytology... 1 Complications 1 Fine Needle Aspiration Technique 1 Evaluation of FNAC Smear 4 Cell Morphology 4 Nucleus 4 Cytoplasm 6 Background Acellular Materials 7 Diagnostic Difficulties Head, Neck, Orbit and Salivary Glands Head and Neck 12 Non-neoplastic Lesions 12 Diagnostic Difficulties 13 Neoplastic Lesions 13 Paraganglioma 13 Nasopharyngeal Carcinoma 14 Ameloblastoma 15 Parathyroid Tumors 16 Meningioma 16 Salivary Gland 17 Clinical History 17 Aspirated Material 17 Normal Salivary Gland Cells 17 Lesions of the Salivary Gland 18 Sialadenosis 18 Cysts 19 Acute Sialadenitis 19 Chronic Sialadenitis 19 Autoimmune Sialadenitis and Benign Lymphoepithelial Lesions 19 Diagnostic Difficulties 19 Neoplasm 20 Benign 20 Warthin s Tumor 22 Basal Cell Adenoma (BCA) 23 Oncocytoma 23 Myoepithelial Tumors 24 Malignant Tumors 24 Adenoid Cystic Carcinoma (ACC) 24 Acinic Cell Carcinoma 26 Mucoepidermoid Carcinoma 27 Polymorphous Low Grade Adenocarcinoma (PLGA) 27 Other Tumors 28 Metastatic Malignancy 28 Approach to Salivary Gland Lesions 28 Orbital Lesions 29 Eyelid 29 Neoplasms 29 Retinoblastoma 29 Diagnostic Difficulty 30

2 Fine Needle Aspiration Cytology: Interpretation and Diagnostic Difficulties Malignant Melanoma 30 Lymphomas 30 Optic Glioma 30 Rhabdomyosarcoma 30 Metastatic Malignancy 30 Granulocytic Sarcoma Thyroid Approach to FNAC of the Thyroid 33 Clinical History and Physical Examination 33 Other Investigations 33 Techniques 33 Optimal Material 33 Normal Aspirated Material 33 Terminology 34 Lesions 34 Nodular Colloid Goiter 35 Diagnostic Difficulties 35 Adenomatoid Nodule/Hyperplastic Nodule 35 Diagnostic Difficulties 36 Diffuse Toxic Goiter 36 Thyroiditis 36 Acute Thyroiditis 36 Diagnostic Difficulties 36 Subacute Granulomatous Thyroiditis 36 Diagnostic Difficulties 37 Chronic Lymphocytic Thyroiditis 37 Diagnostic Difficulties 37 Follicular Neoplasm 37 Diagnostic Difficulties 39 Hurthle Cell Neoplasm 40 Diagnostic Difficulties 40 Papillary Carcinoma 40 Variants of Papillary Carcinoma of Thyroid 41 Diagnostic Difficulties of Usual PC 43 Variants of Papillary Carcinomas: Diagnostic Difficulties 43 Medullary Carcinoma (MC) 43 Immunocytochemistry 45 Diagnostic Difficulties 45 Anaplastic Carcinoma 45 Diagnostic Difficulties 46 Insular Carcinoma 46 Diagnostic Difficulties 46 Lymphomas 47 Diagnostic Difficulties 47 Metastatic Malignant Tumors 47 Diagnostic Difficulties 47 Ancillary Techniques 48 xiv 4. Breast Indications of FNAC of Breast 51 Diagnostic Accuracy 51 Overall Approach 51 Clinical History 51 Mammography 51 Triple Test 52

3 Contents Core Needle Biopsy Versus FNAC 52 Fine Needle Aspiration Techniques 52 Is this Sample Adequate? 52 Normal Breast FNAC 52 Approach to FNAC of Breast Lesions 52 Inflammatory Lesions 54 Acute Inflammation 54 Granulomatous Mastitis 54 Tuberculous Mastitis 54 Fat Necrosis 55 Benign Lesions 55 Fibroadenoma 55 Fibrocystic Disease 57 Diagnostic Difficulties 58 Galactocele 58 Lactating Adenoma 58 Diagnostic Difficulty 59 Proliferative Breast Disease with Atypia 59 Diagnostic Difficulties 59 Ductal Carcinoma In Situ 60 Diagnostic Difficulty 60 Phyllodes Tumor 60 Diagnostic Difficulties 61 Papillary Lesions of the Breast 62 Diagnostic Difficulties 62 Carcinoma 62 Diagnostic Difficulties 63 Other Types 63 Medullary Carcinoma 63 Diagnostic Difficulties 64 Mucinous Carcinoma (Colloid Carcinoma) 64 Diagnostic Difficulties 64 Apocrine Carcinoma 65 Diagnostic Difficulties 65 Tubular Carcinoma 65 Diagnostic Difficulties 66 Metaplastic Carcinoma 66 Lobular Carcinoma 66 Diagnostic Difficulties 67 Paget s Disease 67 Diagnostic Challenges 67 Other Uncommon Malignancies 67 Male Breast Lesions 68 Diagnostic Difficulties 68 Carcinoma in Male Breast 68 Ancillary Investigations on Breast Aspiration Material 68 Immunocytochemistry 68 Reporting of Breast FNAC 69 Cytological Grade 69 Diagnostic Pitfalls in Breast FNAC Lung Normal and Benign Cells 72 Inflammatory Lesions 73 Acute Inflammation 73 Diagnostic Difficulties 73 Specific Infections 73 xv

4 Fine Needle Aspiration Cytology: Interpretation and Diagnostic Difficulties Granulomatous Inflammation 74 Diagnostic Difficulties 74 Lung Carcinomas 75 Squamous Cell Carcinoma 75 Diagnostic Difficulties 76 Bronchogenic Adenocarcinoma 76 Diagnostic Difficulties 76 Bronchioloalveolar Carcinoma (BAC) 76 Diagnostic Difficulties 77 Small Cell Carcinoma 78 Immunocytochemistry 78 Diagnostic Difficulties 78 Undifferentiated Large Cell Carcinoma 79 Diagnostic Difficulties 79 Carcinoid 79 Diagnostic Difficulties 81 Pulmonary Blastoma 81 Diagnostic Difficulties 81 Metastatic Malignancies 82 Pleura 82 Mesothelioma 82 Immunocytochemistry 83 Diagnostic Difficulties 83 xvi 6. Mediastinum Clinical History 85 Radiological Localization 85 Techniques 85 Lesions 85 Thymoma 85 Malignant Thymoma 87 Diagnostic Difficulties 87 Thymic Carcinoid 87 Atypical Carcinoid 87 Diagnostic Difficulty 87 Germ Cell Tumors 87 Mature Cystic Teratoma 88 Diagnostic Difficulties 88 Immature Teratoma 88 Germinomas 88 Diagnostic Difficulty 88 Embryonal Carcinoma 89 Diagnostic Difficulty 89 Endodermal Sinus Tumor 89 Lymphomas 89 Non-Hodgkin s Lymphoma (NHL) 89 Large Cell NHL 89 Diagnostic Difficulty 89 Lymphoblastic Lymphoma 90 Diagnostic Difficulty 90 Hodgkin s Lymphoma 90 Diagnostic Difficulty 90 Neurogenic Tumor 90 Neuroblastoma 91 Diagnostic Difficulty 91 Ganglioneuroblastoma 91 Peripheral Nerve Sheath Tumor 91 Neurofibroma and Schwannoma 91

5 Contents Malignant Peripheral Nerve Sheath Tumors 91 Diagnostic Difficulties 92 Paraganglioma 92 Metastatic Carcinoma 92 Approach to the Diagnosis of Mediastinal Tumors Lymph Node Approach 96 Clinical History 96 Physical Findings 96 Aspiration 96 Normal Component of a Lymph Node 97 Follicular Center Cells 97 Reactive Lymphoid Hyperplasia 98 Diagnostic Difficulties 98 Acute Lymphadenitis 99 Cytology 99 Granulomatous Lymphadenitis 99 Diagnostic Difficulties 101 Rosai-Dorfman Disease 101 Diagnostic Difficulties 101 Kimura s Disease 102 Diagnostic Difficulties 102 Kikuchi s Disease 102 Diagnostic Difficulties 102 HIV Lymphadenopathy 102 Langerhans Cell Histiocytosis (LCH) 102 Diagnostic Difficulties 103 Dermatopathic Lymphadenitis 103 Diagnostic Difficulties 104 Metastatic Malignant Tumor 104 Diagnostic Difficulties 105 Lymphomas 105 Lymphoma Classification 105 B Cell Small Lymphocytic Lymphoma (SLL) 106 Mantle Cell Lymphoma (MCL) 107 Follicular Center Cell (FCC) Lymphoma 107 Marginal Zone Lymphoma 108 Diffuse Large B Cell Lymphoma 108 Centroblastic 109 Immunoblastic 109 T Cell/Histiocytes Rich 109 Anaplastic 109 B Lymphoblastic Lymphoma 110 Burkitt Lymphoma 111 T Cell Chronic Lymphocytic Lymphoma 111 T Lymphoblastic Lymphoma 112 Anaplastic Large Cell Lymphoma (ALCL) 112 Hodgkin s Lymphoma (HL) 112 Diagnostic Difficulties 114 Leukemic Infiltration 114 Diagnostic Difficulty Liver, Spleen, Pancreas and Gastrointestinal Tract Liver 118 Normal Cells 118 Liver Lesions 119 xvii

6 Fine Needle Aspiration Cytology: Interpretation and Diagnostic Difficulties Non-neoplastic Lesions 119 Cysts 119 Benign Neoplastic Lesion 119 Liver Cell Adenomas 119 Malignant Tumors 120 Hepatocellular Carcinoma (HCC) 120 Fibrolamellar Variant of HCC 122 Clear Cell Variant 122 Giant Cell Variant of HCC 122 Small Cell Variant 122 Spindle Cell Variant 122 Diagnostic Difficulties 122 Cholangiocarcinoma 122 Diagnostic Difficulties 123 Hepatoblastoma 123 Diagnostic Difficulties 123 Metastatic Malignancies 123 Diagnostic Difficulties 124 Spleen 124 Non-neoplastic Process 125 Granulomatous Infection 125 Storage Disorders 125 Neoplasm 125 Lymphoma 125 Pancreas 125 Normal Cells 125 Lesions 126 Cystic Lesions of Pancreas 126 Mucinous Neoplasia 126 Pancreatic Pseudocyst 126 Carcinoma 126 Ductal Adenocarcinoma 126 Other Types of Carcinoma 127 Pancreatic Acinar Carcinoma 127 Neuroendocrine Tumor 128 Islet Cell Tumor of Pancreas 128 Solid and Cystic Papillary Neoplasm (SCPN) of Pancreas 129 Diagnostic Difficulties 130 Gastrointestinal Tumors 130 Adenocarcinoma 130 Signet Ring Cell Adenocarcinoma 130 Carcinoid Tumors of the Small Intestine 131 Diagnostic Difficulties 131 Gastrointestinal Stromal Tumor (GIST) 132 Diagnostic Difficulties 132 Primary Small Intestinal Lymphomas 132 xviii 9. Kidney and Adrenal Normal Cells 134 Renal Lesions 134 Diagnostic Difficulty 135 Xanthogranulomatous Inflammation 135 Angiomyolipoma 135 Renal Cell Carcinoma (RCC) 136 The Other Variants of RCC 137 Oncocytoma 138 Transitional Cell Carcinoma (TCC) 139

7 Contents Pediatric Renal Tumors 139 Wilms Tumor 139 Mesoblastic Nephroma 140 Rhabdoid Tumor 140 Diagnostic Difficulty 141 Clear Cell Sarcoma 141 Lesions 141 Adrenocortical Carcinoma 141 Pheochromocytoma 141 Metastatic Tumors Gonads and Prostate Testis 145 Peritesticular Lesions 145 Hydrocele 145 Spermatocele 145 Inflammation 145 Spermatocytic Granuloma 145 Other Tumors 146 Neoplasms of Testis 146 Seminoma 146 Embryonal Carcinoma 147 Yolk Sac Tumor 147 Choriocarcinoma 148 Other Tumors of Testis 148 Evaluation of Male Infertility 148 Female Genital System 149 Ovarian Tumor 149 Serous and Mucinous Adenocarcinoma 149 Clear Cell Carcinoma 149 Diagnostic Difficulties 149 Germ Cell Tumor 150 Immature Teratoma 150 Granulosa Cell Tumor 150 Prostate 151 Benign Prostatic Hyperplasia 151 Carcinoma 152 Diagnostic Difficulties Soft Tissue Lesions and Skin Different Lesions 155 Lipoma and its Variants 155 Fibromatosis 156 Nodular Fasciitis 157 Benign Peripheral Nerve Sheath Tumor 157 Myositis Ossificans 157 Giant Cell Tumor of Tendon Sheath 158 Malignant Tumor 158 Liposarcomas 158 Well-differentiated Liposarcoma 158 Malignant Peripheral Nerve Sheath Tumor (MPNST) 160 Fibrosarcoma 160 Malignant Fibrous Histiocytoma 162 Synovial Sarcoma 163 Cytology 163 Rhabdomyosarcoma 164 Leiomyosarcomas 165 xix

8 Fine Needle Aspiration Cytology: Interpretation and Diagnostic Difficulties Clear Cell Sarcoma 165 Epithelioid Sarcomas 166 Alveolar Soft Part Sarcomas 166 Hemangiopericytoma 166 Skin 166 Inflammation 166 Pilomatrixoma 167 Basal Cell Carcinoma 167 Granular Cell Tumor 168 Meibomian Carcinoma 168 Malignant Melanoma 169 Malignant Sweat Gland Tumor 170 Markel Cell Tumor 170 Metastasis 170 Diagnostic Difficulties 170 Miscellaneous Bone Normal Cells 173 Osteosarcoma 173 Diagnostic Difficulties 174 Chondrosarcoma 175 Diagnostic Difficulty 176 Giant Cell Tumor of Bone (GCT) 176 Diagnostic Difficulty 176 Chondroblastoma 177 Diagnostic Difficulty 177 Chordoma 177 Diagnostic Difficulties 178 Ewing s Sarcoma 178 Diagnostic Difficulty 179 Non-Hodgkin s Lymphoma 179 Metastatic Carcinoma 179 Plasma Cell Neoplasm 179 Diagnostic Difficulty 180 Langerhans Cell Histiocytosis 180 Diagnostic Difficulty Round Cell Tumor Fine Needle Aspiration 182 Cytomorphology 182 Neuroblastoma 184 Ewing s Sarcoma (EWS) and Peripheral Neuroectodermal Tumor (PNET) 185 Wilms Tumor (WT) 185 Rhabdomyosarcoma (RMS) 185 Desmoplastic Small Round Cell Tumor (DSRCT) 185 Index xx