FNA cytology of lymphomas: useless or useful? Edneia Tani

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1 FNA cytology of lymphomas: useless or useful? Edneia Tani Karolinska University Hospital Stockholm Sweden

2 FNAC LYMPH NODE First report:

3 FNAC LYMPH NODE Pioneers Sixten Franzén Lopez Cardoso

4

5

6 FNAC LYMPH NODE Zajicek (1974): 20% of cases of well differentiated lymphomas can not at present be recognized. Koss (1984): often possible and accurate, requires considerable caution and experience. Franzén (1983): there is no question that the diagnosis can be made with ease by FNA.

7 FNAC LYMPHOMAS PROBLEMS Cytomorphology: low grade lymphomas reactive high grade lymphomas metastasis Growth pattern

8 benign reactive x lymphoma

9 LYMPHOMA X CARCINOMA

10 FNAC LYMPH NODE Accepted for metastasis Not accepted for primary lymphomas but for recurrences and deep seated lymphomas

11 FNAC - LYMPHOMAS IMMUNOCYTOCHEMISTRY

12 Acta Cytol 1988 FNAC LYMPH NODE

13 FNAC LYMPHOMAS Classifications Cyto morphol Immuno Growth pattern Cyto genetics Kiel REAL WHO

14 FNAC LYMPHOMAS TODAY Quick stain cytomorphology Flow/immunocytochemistry Proliferation Cytogenetics

15 benign reactive x lymphoma

16 B T B T K L K L

17 lymphoma benign reactive

18 LYMPHOMA X CARCINOMA

19 LCA CK CD3 CD20 Cytokeratin

20 CARCINOMA LYMPHOMA

21 ENLARGED LYMPH NODE reactive hyperplasia lymphoma metastasis

22 27G 0.4 mm 23G 0.6 mm

23 Smear Cell suspension

24 FNA lymph node smears MGG, Pap Mib 1 ER, PR, AR cell susp cytospin (immuno, FISH) flow cytometry gene rearrangement bacteriology

25 Cell suspension cytospin immunostaining Cell concentration: 1 2 million cells/ml volume / cytospin: 100 ul 700 rpm 3 min air dried (up to 5 days) cold aceton fixed (10 min) three step alkaline phosphatase immunostaining technique

26

27

28 Four colour flow cytometry FITC PE PerCP alt. PE/Cy5/ APC Lambda kappa CD19 CD5 CD23 CD10 CD20 CD19 CD4 CD7 CD8 CD3 Bcl 2 CD10 CD3 CD19

29 Flow cytometry Lambda/ kappa/ CD19/ CD5 2. Gating on CD19/SSC and analysis of kappa/lambda Gate on CD19/SSC Reactive population Kappa:lambda 1,5 Lambda positive NHL

30 FNA lymph node ENLARGED LYMPH NODE Benign Unspecific reactive hyperplasia Specific infection Malignant lymphoma metastasis

31

32 CD3 kappa CD20 lambda

33

34 CD20 CD3

35 FNA lymph node ENLARGED LYMPH NODE Benign Unspecific reactive hyperplasia Specific infection Malignant lymphoma metastasis

36

37 Childhood suppurative lymphadenitis (non tuberculous mycobacterial lymphadenitis) Mycobacterium avium 7 (39%) Mycobacterium malmoense 4 (22%) Negative mycobact culture 7 (39%) Total: 18 cases

38

39 FNA lymph node ENLARGED LYMPH NODE Benign Unspecific reactive hyperplasia Specific infection Malignant lymphoma metastasis

40 FNA lymph node LYMPHOMAS Hodgkin s lymphoma Non Hodgkin s lymphoma T cell B cell

41

42 CD15 CD30

43 FNA lymph node LYMPHOMAS Hodgkin s lymphoma Non Hodgkin s lymphoma T cell B cell

44

45

46 CD3 kappa CD20 lambda

47 Lymphoma subclassification B cell lymphomas WHO Lymphoma subtype CD5 CD10 CD23 CD43 CLL lymphoplasmacytic +/ Mantel cell lymphoma + /+ +/ Follicular lymphoma + /+ Marginal zone

48 CD10 CD5 Mib 1

49

50 Lymphomas cytogenetics B cell tumors Small cell lymphocytic trisomy 12 Mantle cell t (11;14) Marginal zone trisomy 3 t(11;18) Follicular t (14;18) Burkitt/Burkitt like t (8;14), t (2;8) or t (8;22) T cell tumors Anaplastic large cell t (2;5)

51 Lymph node FNA: Mantel cell lymphoma?

52

53 Follicular lymphoma: Monoclonal kappa CD20+/CD10

54 26 year old HIV +

55 CD20 CD3 kappa lambda

56 Lymph node FNA: Burkitt like lymphoma?

57

58 CD20 CD4 CD3 C CD8

59

60

61 CD3 CD8 CD20 CD4

62

63 CD30 CD45

64 FNA lymph node ENLARGED LYMPH NODE Benign Unspecific reactive hyperplasia Specific infection Malignant lymphoma metastasis

65 Metastasis Carcinoma Squamous cell carcinoma Adenocarcinoma Poorly differentiated ca Undifferentiated ca Melanoma Sarcoma

66 Metastasis of adenocarcinoma

67 Metastasis of adenocarcinoma CK subtyping ER, PGR, AR TTF 1 CA125, CEA, CDX 2 PSA, PSAP Thyroglobulin, calcitonin Uroplakin CD10

68 CK subtyping CK7+ CK20+ urothelial, pancreas, ovarium (mucinous) CK7+ CK20 lung, breast, mesothel ovarium, endometrial CK7 CK20+ colon CK7 CK20 prostate, hepatoma, renal, squamous ca

69 CK7 CK20 TTF 1 adenocarcinoma

70 ER PGR

71 Enlarged lymph node: metastasis of adenocarcinoma

72 CK7 CK20 AR PSA

73 Metastasis Carcinoma Squamous cell carcinoma Adenocarcinoma Poorly differentiated ca Undifferentiated ca Melanoma Sarcoma

74 LCA CK

75 Metastasis Carcinoma Squamous cell carcinoma Adenocarcinoma Poorly differentiated ca Undifferentiated ca Melanoma Sarcoma

76

77 LCA HMB45

78 Metastasis Carcinoma Squamous cell carcinoma Adenocarcinoma Poorly differentiated ca Undifferentiated ca Melanoma Sarcoma

79 desm myoglob

80 FNA lymph node FINAL DIAGNOSIS cytomorphology immunocytochemistry cytogenetics clinical presentation

81 Cancer Lymphadenitis Lymphoma Sarcoma Melanoma Unclear Others Total Cancer Benign l. Lymph. Sarcoma Melanoma Unclear Others

82 How to succeed? Interested clinicians Surgical biopsy not the primary diagnostic technique Interested cytopathologists Training Quick staining triage Conferences (hemathologists, pathologists, cytologists, radiologists, oncologists )

83 FNA cytology of lymphomas: useless or useful? Edneia Tani Karolinska University Hospital Stockholm Sweden

84 FNA cytology of lymphomas: useful! Thank you for your attention!

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