Gabrijela Kocjan
Fine Needle Aspiration Cytology
Gabrijela Kocjan
Fine Needle
Aspiration Cytology
With 527 Figures
123
Diagnostic Principles and Dilemmas
Dr. Gabrijela Kocjan University College London Medical School
Dept. of Histopathology Rockefeller Building WC1E 6JJ London United Kongdom
Library of Congress Control Number: 2005937513
ISBN-10 3-540-25639-3 Springer Berlin Heidelberg New York ISBN-13 978-3-540-25639-7 Springer Berlin Heidelberg New York
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To my parents, Hilda and Franc For encouraging my independence
To Tony and Arabella, For being proud of me
Preface
The urge to write this book arose after years of storing glass slides from difficult cases into plastic folders where they have been breaking and fading. When discussing the- se cases at the weekly teaching for trainee pathologists, some of the observations that arose, made it obvious that experience cannot compensate for methodical approach, careful observation, clinical information and honest conclusion. Hence in writing this book, I had two major aims: firstly, to reiterate the importance of the approach to cytodiagnosis and, secondly, to expose diagnostic dilemmas in some of the most difficult areas of Fine Needle Aspiration Cytology (FNAC).
FNAC had become a well established diagnostic component in pathology. Within any pathology laboratory, FNAC has its dedicated proponents but also those who are practicing it occasionally, perhaps only to cover the absence of a colleague, or, alongside histopathology, as part of the subspecialty reporting. The differences in expertise often mean that the standard of reporting varies, the latter group being reluctant to ask some of the basic as well as more difficult questions for fear of ap- pearing ignorant. Cytology training is variable in different institutions, depending on the local circumstances. Trainees without any prior experience in cytology may be exposed to difficult FNAC cases early in their career.
In order to help the approach to FNAC samples for those with and without any prior experience, the first part of this book lists principles of cytological diagnosis.
The importance of a methodical approach to interpreting cytological material can- not be overstated. However, cytological interpretation is not merely a mathematical algorithm where numerical values are added up. In majority of cytology cases, the whole is more than the sum of parts: the interpretation of morphological features is complex. It needs careful observation of morphology but also, crucially, it needs to be taken in the clinical context. Without the clinical information, morphology alone may be misleading.
Chapters on diagnostic dilemmas in FNAC practice discuss potentially difficult morphological features. As well as to educate, the aim of these chapters is to expose difficult areas of diagnosis where FNAC has its limitations. To that end and in line with the developing area of medical litigation affecting all areas of practice, there is a chapter on medico-legal issues associated with FNAC. This is a growing field that has been addressed in a number of legal references but has thus far not been addressed extensively from a cytologicl standpoint.
In preparing this manuscript, I would like to thank, first of all, my patients for allowing me to use their clinical histories and photomicrographs. I would also like to thank my colleagues in the Department of Histopathology, University College Lon- don, in particular Dr. Mary Falzon for their help in sharing some of the diagnostic dilemmas presented in this manuscript. The ability to share problems with clinicians and fellow pathologists is the essential requirement for ensuring a good night’s sleep and one’s professional reputation. I would also like to thank my clinical colleagues by their supportive approach to cytology in sending their patients for FNAC. The ex-
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perience I have accumulated on these sound clinical grounds had been shared with generations of postgraduate trainee pathologists. I thank them for being a source of inspiration through curiosity and enthusiasm. Many went on to become dedicated cytopathologists and made me immensely proud of them. I would also like to give special thanks to Eva Kauerova for her help in the past five years.
I hope that you, the reader, will use this book in your daily practice, if only to find that there are no straight answers to difficult questions.
G Kocjan September 2005 London
Preface. . . .VII
Contents . . . .IX
Introduction and Historical Perspective . . . . 1
References. . . 3
FNAC Technique and Slide Preparation . . . . 7
2.1 Informed Consent. . . 7
2.2 Location of the FNAC Procedure . . . 8
2.2.1 The FNAC Clinic. . . 9
2.2.2 Inpatient FNAC. . . 12
2.2.3 Image-Guided and Other FNAC Procedure Locations. . . 12
2.3 The Importance of the Aspirator . . . 14
2.4 Aspiration Techniques . . . 15
2.4.1 Suction FNAC . . . 15
2.4.2 The Capillary Method . . . 16
2.5 Slide Preparation. . . 17
2.5.1 Conventional Preparations . . . 17
2.5.2 Liquid-Based Preparations . . . 18
2.5.3 Cell Block . . . 18
2.6 Fixation Techniques . . . 19
2.6.1 Air Drying . . . 19
2.6.2. Alcohol Fixation .. . . 20
2.6.3 Transport Medium . . . 20
2.7 Staining Methods . . . 20
2.7.1 Papanicolaou Staining . . . 20
2.7.2 Romanowsky Staining . . . 22
2.7.3 Other Stains . . . 23
2.8 Ancillary Techniques . . . 23
2.8.1 Cytochemistry . . . 23
2.8.2 Immunocytochemistry . . . 24
2.8.3 Molecular Markers in Cytology . . . 26
2.9 Safety. . . 27
References. . . 28
Diagnostic interpretation of FNAC material . . . 35
3.1 Slide Background . . . 35
3.1.1 Cystic Background . . . 39
3.1.2 Inflammatory Background . . . 40
3.1.3 Necrotic Background . . . 42
3.1.4 Myxoid and Mucinous Background. . . 42
3.1.5 Lymphoid Background. . . 43
3.1.6 Other Background Features . . . 43
3.2 Cell Arrangement . . . 44
3.2.1 Clusters. . . 46
3.2.2 Sheets . . . 46
3.2.3 Single Cells. . . 47
3.2.4 Papillary Arrangement. . . 47
3.2.5 Other Features. . . 48
3.3 Cellular Features: the Nucleus. . . 49
3.3.1 Nuclear Size . . . 50
3.3.2 Nuclear Shape . . . 51
3.3.3 Position of the Nucleus . . . 52
3.3.4 Chromatin Pattern . . . 53
3.3.5 Number of Nuclei . . . 54
3.3.6 Nucleoli . . . 54
3.3.7 Mitoses . . . 55
Contents
X
3.4 Cellular Features: Cytoplasm . . . 55
3.4.1 Relative Amount . . . 55
3.4.2 Quality and Contents . . . 55
3.4.3 Shape and Definition . . . 56
3.5 Criteria of Malignancy . . . 57
3.6 Cytology Report . . . 57
References. . . 58
Diagnostic Dilemmas in FNAC Practice: Cystic Lesions . . . 59
4.1 Cysts in the Neck. . . 59
4.1.1 Thyroglossal Duct Carcinoma. . . 60
4.1.2 Branchial Cleft Cysts . . . 61
4.1.3 Salivary Gland Lesions . . . 62
4.1.4 Lymphoepithelial Cysts . . . 63
4.1.5 Cystadenolymphoma . . . 64
4.1.6 Acinic Cell Carcinoma . . . 66
4.1.7 Pleomorphic Adenoma . . . 67
4.1.8 Dermoid Cyst . . . 68
4.1.9 Thyroid Cysts. . . 68
4.1.10 The Lymph Nodes. . . 70
4.1.11 Parathyroid Cysts . . . 71
4.1.12 Cysts of the Jaw . . . 72
4.1.13 Teratoid Cyst . . . 72
4.2 Cysts in the Abdomen . . . 73
4.2.1 Cystic Lesions of the Pancreas . . . 73
4.2.2 Cystic Lesions of the Liver. . . 77
4.2.3 Adrenal and Renal Cystic Lesions . . . 78
4.2.4 Cystic Lesions of the Peritoneum . . . 79
4.3 Thoracic Cysts . . . 79
4.4 Breast Cysts . . . 80
4.5 Other Cysts and Artefacts . . . 82
References. . . 85
Diagnostic Dilemmas in FNAC Practice: Lymphoid Infiltrates . . . 91
5.1. Granulomatous Infiltrates . . . 91
5.1.1 Tuberculous Lymphadenitis . . . 91
5.1.2 Sarcoidosis . . . 92
5.1.3 Kikuchi-Fujimoto Disease . . . 92
5.1.4 Cat-Scratch Disease . . . 94
5.1.5 Leishmania Lymphadenitis . . . 94
5.1.6 Kimura’s disease . . . 95
5.1.7 Sinus Histiocytosis with Massive Lymphadenopathy . . . 96
5.1.8 Foreign-Body Granulomatous Inflammatory Response . . . 96
5.1.9 Malignant Lymphomas . . . 97
5.2 Lymphoid Infiltrates in Extranodal Sites. . . 99
5.2.1 Lymphoid Infiltrates in the Thyroid . . . 99
5.2.2 Lymphoid Processes in the Salivary Gland . . . 103
5.2.3 Lymphoid Infiltrates of the Orbit . . . 105
5.2.4 Lymphoid Lesions in the Breast . . . 107
5.3 Neoplasms Containing Lymphocytes. . . 107
5.3.1 Dilemmas in the Cytological Diagnosis of Lymphomas . . . 108
5.3.2 Solid Neoplasms Containing Lymphocytes . . 109
References. . . 110
Diagnostic Dilemmas in FNAC Practice: Metastatic Tumours . . . 117
6.1 Metastatic Carcinomas. . . 118
6.1.1 Establishing the Diagnosis of Malignancy . . . 118
6.1.2 Determining the Nature of the Tumour . . . 120
6.1.3 Finding the Primary Tumour . . . 124
6.1.4 The Role of Imaging in the FNAC of Metastases . . . 129
6.2 Metastases of Non-Epithelial Tumours . . . 129
References. . . 130
Diagnostic Dilemmas in FNAC Cytology: Small Round Cell Tumours . . . 133
7.1 Small Round Cell Tumours of Childhood. . . 133
7.1.1 Ewing’s Sarcoma/Primitive Neuroectodermal Tumour. . . 134
7.1.2 Neuroblastoma . . . 136
7.1.3 Ganglioneuroblastomas . . . 136
XI
7.1.4 Rhabdomyosarcoma. . . 137
7.1.5 Acute Lymphoblastic Leukaemia and LBL . . . 139
7.1.6 Small Round Cell Tumours of Kidney . . . 141
7.1.7 Hepatoblastoma . . . 141
7.1.8 Pleuropulmonary Blastoma. . . 142
7.1.9 Small-Cell Synovial Sarcoma. . . 142
7.2 Small Round Cell Tumours in Adults . . . 142
7.2.1 Desmoplastic Small Round Cell Tumour . . . . 143
7.2.2 Small-Cell Carcinoma of the Lung. . . 144
7.2.3 Burkitt’s Lymphoma . . . 144
7.2.4 Lymphoglandular Bodies. . . 145
7.2.5 Merkel Cell Carcinoma . . . 146
7.2.6 Olfactory Neuroblastoma . . . 147
References. . . 148
Diagnostic Dilemmas in FNAC Cytology: Soft-Tissue Lesions . . . 151
8.1 Introduction . . . 151
8.2 Spindle-Cell Lesions . . . 153
8.2.1 Spindle-Cell Lesions of the Lung . . . 156
8.2.2 Spindle-Cell Lesions of the Salivary Gland . . . 156
8.2.3 Spindle-Cell Lesions of the Breast . . . 157
8.2.4 Myofibrosarcoma . . . 157
8.3 Myxoid and Chondroid Lesions . . . 157
8.3.1 Low-Grade Fibromyxoid Sarcoma . . . 159
8.3.2 Leiomyosarcoma . . . 160
8.3.3 Ossifying Fibromyxoid Tumour . . . 161
8.3.4 Myxoid Mucinous Neoplasms. . . 161
8.3.5 Intramuscular Myxoma . . . 162
8.3.6 Chondrosarcoma . . . 162
8.3.7 Chondroblastoma . . . 162
8.4 Pseudosarcomatous Lesions . . . 162
8.4.1 Nodular Fasciitis . . . 165
8.4.2 Nodular Myositis. . . 165
8.4.3 Proliferative Fasciitis and Myositis . . . 165
8.4.4 Fibromatoses . . . 166
8.4.5 Fibrous histiocytoma . . . 167
8.4.6 Pseudoangiomatous Stromal Hyperplasia. . . . 167
8.4.7 Pleomorphic Lipoma . . . 168
8.4.8 Atypical Lipoma . . . 168
8.4.9 Spindle-Cell Lipoma. . . 169
8.4.10 Ancient Schwannoma . . . 169
8.4.11 Angioleiomyoma. . . 169
8.4.12 Calcifying Aponeurotic Fibroma . . . 169
8.4.13 Lipomatous Haemangiopericytoma. . . 169
8.5 Tumours of Low or Borderline Malignancy . 169 8.5.1 Dermatofibrosarcoma Protuberans . . . 170
8.5.2 Haemangiopericytoma. . . 170
8.5.3 Acral Myxoinflammatory Fibroblastic Sarcoma . . . 171
8.6 Soft-Tissue Deposits of Non-Sarcomatous Lesions. . . 171
8.6.1 Malignant Lymphoma and Leukaemia . . . 171
8.6.2 Calcinosis Cutis. . . 171
8.7 Sarcomas Mimicking Other Lesions . . . 171
8.7.1 Epithelioid Sarcoma . . . 171
8.7.2 Metastatic Soft-Tissue Sarcomas. . . 172
8.7.3 Well-Differentiated Liposarcoma . . . 172
8.8 Rare and Difficult Sarcomas . . . 172
8.8.1 Alveolar Soft-Part Sarcoma . . . 172
8.8.2 Angiosarcoma . . . 172
8.8.3 Kaposi’s Sarcoma. . . 174
8.8.4 Clear-Cell Sarcoma of Soft Parts. . . 175
8.8.5 Haemangioendothelioma . . . 175
8.8.6 Giant-Cell Fibroblastoma . . . 175
8.8.7 Rhabdomyosarcoma. . . 175
8.8.8 Synovial Sarcoma . . . 176
References. . . 177
Diagnostic Dilemmas in FNAC Cytology: Difficult Breast Lesions . . . 181
9.1 Fibroadenoma . . . 182
9.2 Papillary Lesions . . . 188
9.3 Apocrine Changes. . . 193
9.4 Mucinous Lesions . . . 195
9.5 Lobular Carcinoma. . . 196
9.6 In Situ or Invasive Carcinoma? . . . 198
9.7 Rare Lesions. . . 202
XII
9.7.1 Radial Scar/Complex Sclerosing Lesion . . . 202
9.7.2 Collagenous Spherulosis . . . 203
9.7.2 Ductal Adenoma . . . 203
9.7.3 Gynaecomastia . . . 203
9.7.5 Spindle-Cell and Mesenchymal Lesions of the Breast . . . 204
9.7.6 Pseudoangiomatous Stromal Hyperplasia. . . . 205
9.7.7 Metaplastic Tumours . . . 205
9.7.8 Secretory Carcinoma . . . 205
9.7.9 Tumoral Calcinosis. . . 205
9.7.10 Clear-Cell Hidradenoma . . . 206
9.7.11 Tubular Adenoma . . . 206
9.7.12 Adenomyoepithelioma. . . 206
9.7.13 Squamous Cells . . . 206
9.7.14 Inflammatory Myofibroblastic Tumour. . . 207
9.8 FNAC or core biopsy?. . . 207
9.9 Radiation Changes . . . 207
References. . . 207
Principles of Safe Practice: the Role of FNAC in Clinical Management . . . 213
10.1 FNAC Breast Lesions . . . 214
10.2 FNAC Thyroid . . . 215
10.3 FNAC Head and Neck Conditions . . . 216
10.4 FNAC Lymph Nodes. . . 216
10.5 FNAC Adrenal and Kidney . . . 217
10.6 FNAC Gastrointestinal Tract. . . 217
10.7 FNAC Soft Tissue . . . 218
10.8 FNAC Bone . . . 218
10.9 FNAC in Children. . . 218
10.10 FNAC for HIV-Related Lesions . . . 219
10.11 Transrectal Digitally Guided FNAC. . . 219
10.12 FNAC in Gynaecology . . . 219
10.13 Diagnostic Accuracy and Cost-Effectiveness of FNAC . . . 219
References. . . 220
Principles of Safe FNAC Practice: FNAC versus Core Biopsy . . . 225
11.1 Breast Lesions . . . 225
11.2 Lung Lesions . . . 227
11.3 Hepatic Lesions . . . 227
11.4 Abdominal Lesions . . . 227
11.5 Prostate Cancer . . . 228
11.6 Thyroid Lesions . . . 228
11.7 Gynaecological Lesions . . . 228
11.8 Soft-Tissue Lesions . . . 228
11.9 Skeletal Lesions . . . 228
11.10 Summary . . . 229
References. . . 229
Principles of Safe FNAC Practice: Medicolegal Issues . . . 231
References. . . 235
Subject Index . . . 237
