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ThinPrep® Non-Gyn Lecture Series

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1 ThinPrep® Non-Gyn Lecture Series
Respiratory Cytology

2 Benefits of ThinPrep® Technology
Benefits of ThinPrep Non-Gyn for Respiratory (Mucoid) specimens: Control cellular density Eliminate preparation artifact Minimize number of slides per patient Eliminate mucoid glycoprotein

3 Required Materials ThinPrep® 2000 Processor or ThinPrep 5000 Processor
ThinPrep Microscope Slides ThinPrep Non-Gyn Filters (Blue) Multi-Mix™ Racked Vortexor CytoLyt® and PreservCyt® Solutions These items may be purchased through Hologic.

4 Required Materials 50 ml capacity swing arm centrifuge
50 ml centrifuge tubes Slide staining system and reagents 1 ml plastic transfer pipettes 95% alcohol Coverslips and mounting media Optional: Glacial acetic acid, DTT and saline for troubleshooting These items are those that you are likely to already have in your laboratory.

5 Recommended Collection Media
CytoLyt® Plasma-Lyte® Polysol® Balanced electrolyte solutions

6 Non-Recommended Collection Media
Sacomanno and other solutions containing carbowax Alcohol Mucollexx® Culture Media, RPMI Solution PBS Solutions containing formalin These solutions are not optimal for cell preservation and increase the chance for sub-optimal cell morphology.

7 Hologic® Solutions CytoLyt® PreservCyt®
Copyright © 2012 Hologic,  All rights reserved. Hologic has developed these two preservative solutions to work with the ThinPrep Processors as a complete system. Copyright © 2012 Hologic,  All rights reserved.

8 Hologic® Solutions CytoLyt® Solution
Methanol-based, buffered preservative solution - Lyses red blood cells - Prevents protein precipitation - Dissolves mucus - Preserves morphology for 8 days at room temperature Intended as transport medium Used in specimen preparation prior to processing CytoLyt will preserve morphology of cytology samples for 8 days at room temperature, as long as there is a minimum CytoLyt Solution to sample volume ratio of 1:3.

9 Hologic® Solutions PreservCyt® Solution
Methanol based, buffered solution Specimens must be added to PreservCyt Solution prior to processing PreservCyt Solution cannot be substituted with any other reagents Cells in PreservCyt Solution are preserved for up to 3 weeks in a temperature range between 4°-37°C

10 Specimen Types Sputum Bronchial Brushing Bronchial Washing
Bronchoalveolar Lavage Fine Needle Aspiration (FNA) Biopsy, Transbronchial FNA, Endobronchial Ultrasound (EBUS) FNA

11 Sputum Easily obtained if spontaneous
3 to 5 consecutive day, early morning, deep cough specimens preferred Can be induced if not spontaneous by inhalation of an aerosolized solution Good for detection of central tumor

12 Bronchial Brushing Collected with a small brush under visual control using a fiberoptic bronchoscopic instrument Good for detection of peripheral tumors

13 Bronchial Washing Collected by instilling 3 to 5 mL of balanced salt solution through the bronchoscope and re-aspirating the resulting material Good for detection of peripheral tumors

14 Bronchoalveolar Lavage (BAL)
Collected by infusing and re-aspirating a sterile saline solution in the distal segments of the lung using a fiberoptic bronchoscope Utilized in the therapy of diseases such as pulmonary alveolar proteinosis, cystic fibrosis, pulmonary alveolar microlithiasism and asthma Good for detection of peripheral cancers as well as opportunistic infections in immunocompromised patients

15 Transbronchial FNA (TFNA)
Transbronchial FNA is a special modification of needle aspiration used when the lung neoplasm has not invaded through the bronchial mucosa and is not accessible through sputum or bronchial brushing/washing An endobronchial aspirate may also be preformed under ultrasound guidance to reach these lesions, commonly referred to as Endobronchial Ultrasound (EBUS) Good for detection of lesions that are not visible during conventional bronchoscopy

16 Percutaneous FNA Biopsy
A fine needle attached to a syringe is passed through the chest wall into the pulmonary mass visualized either by fluoroscopy, computed tomography, or ultrasound Good as an alternative to surgery for detection of pulmonary lesions that are not accessible during conventional bronchoscopy

17 Sample Collection Mucoid Specimens
Sputum: Collect directly into 30 ml CytoLyt® solution Bronchial Brushing: Deposit collection brush directly into a 30 ml prefilled CytoLyt solution tube Bronchial Washing/Lavage: Collect with a balanced electrolyte solution

18 Sample Collection Fine Needle Aspirates
Deposit and rinse the entire sample into a centrifuge tube containing 30 ml of CytoLyt® solution or a balanced electrolyte solution, such as Polysol® or Plasma-Lyte®

19 Sample Preparation Mucoid Specimens
1. Sample Collection Optional: If DTT is being used, add stock before agitation. See next slide for stock preparation. 2. Mechanical agitation 3. Concentrate by centrifugation 4. Pour off supernatant and vortex to re-suspend cell pellet 5. Evaluate cell pellet If cell pellet is not in liquid form do a CytoLyt® wash and repeat steps 2-4 6. Add recommended # of drops of specimen to PreservCyt® Solution Vial 7. Allow to stand for 15 minutes 8. Run on ThinPrep® 2000 using Sequence 3 or ThinPrep 5000 using Sequence Non-Gyn 9. Fix, Stain, and Evaluate

20 Sample Preparation DTT Protocol for Mucoid Specimens
Preparing a DTT Stock Solution: Add 2.5g DTT to 30 ml of CytoLyt® Solution This solution is suitable for use for 1 week when stored at room temperature (15-30°C) Add 1 ml of stock solution to the sample prior to vortexing The use of DiThioThreitol (DTT) has been shown to be a reagent that is effective in reducing the amount of mucus in respiratory samples. The above procedure is a recommendation and not a requirement.

21 Sample Preparation DTT Protocol for Mucoid Specimens
Preparing a DTT Single Use Solution: Add 0.08g DTT in individual 50 ml conical tubes. Place in freezer When ready for use, add 30 ml of CytoLyt® Solution and shake/vortex to dissolve Add specimen to DTT Vortex and continue processing protocol The use of DiThioThreitol (DTT) has been shown to be a reagent that is effective in reducing the amount of mucus in respiratory samples. The above procedure is a recommendation and not a requirement.

22 Sample Preparation Fine Needle Aspiration
Collection Concentrate by centrifugation - 600g for 10 minutes Pour off supernatant and vortex to re-suspend cell pellet Evaluate cell pellet If cell pellet is not free of blood, add 30 ml of CytoLyt® Solution to cell pellet and repeat from step 2 Add recommended # of drops of specimen to PreservCyt® Solution Vial Allow to stand for 15 minutes Run on ThinPrep® 2000 Processor using Sequence 3 or ThinPrep 5000 using Sequence Non-Gyn Fix, Stain, and Evaluate If the specimen has been collected into balanced electrolyte solution (BES), first replace it with 30 ml of CytoLyt.

23 Sample Preparation Protocol Summary
ThinPrep® Non-Gyn Respiratory Protocol - Sputum - Bronchial Washing - Bronchial Brushing - Bronchoalveolar Lavage ThinPrep Non-Gyn FNA Protocol - FNA, Transbronchial FNA, EBUS All sample preparation protocols can be found in T2/T5 Operator’s manual.

24 Sample Preparation Techniques
Mechanical Agitation - Mucoid specimens require vigorous agitation in CytoLyt® solution to break up the mucus. Two recommended methods: - Vortex for 5 minutes - Blend for a few seconds Note: Agitation times for both methods may vary depending on specimen consistency

25 Sample Preparation Techniques
Centrifugation - 600g for 10 minutes or 1200g for 5 minutes - Concentrates the cellular material in order to separate the cellular components from the supernatant Refer to Centrifuge Speed Chart in the ThinPrep® 2000 or ThinPrep 5000 Processor Manual, Non-Gynecologic section, to determine the correct speed for your centrifuge to obtain force of 600g or 1200g Can also centrifuge at 1200g for 5 minutes---helpful when processing bloody fluids that require 2 CytoLyt washes.

26 Sample Preparation Techniques
Pour off supernatant - Invert the centrifuge tube 180° in one smooth movement, pour off all supernatant and return tube to its original position (Note: Failure to completely pour off the supernatant may result in a sparsely cellular sample due to dilution of the cell pellet).

27 Sample Preparation Techniques
Vortex to re-suspend cell pellet - Randomizes the cell pellet and improves the results of the CytoLyt® solution washing procedure - Place the centrifuge tube onto a vortexor and agitate the cell pellet for 3 seconds or vortex manually by syringing the pellet back and forth with a plastic pipette

28 Sample Preparation Techniques
CytoLyt® Solution Wash - Preserve cellular morphology while lysing red blood cells, dissolving mucus and reducing protein precipitation - Add 30 ml of CytoLyt Solution to a cell pellet, vortex for 5 minutes (mucoid specimens only), concentrate by centrifugation, pour off the supernatant and vortex to resuspend the cell pellet

29 Sample Preparation Techniques
Evaluate cell pellet - If cell pellet is white, pale pink, tan or not visible add specimen to PreservCyt® Solution vial (# of drops added is dependant on sample volume and will be discussed on future slides) - If cell pellet is distinctly red or brown indicating the presence of blood conduct a CytoLyt® wash As previously discussed, to conduct a Cytolyt Wash simply add 30ml of Cytolyt Solution to specimen, concentrate by centrifugation, poor off supernatant, vortex to resuspend cell pellet.

30 Sample Preparation Techniques
Evaluate cell pellet - To test for liquid form, draw a small amount of sample into a pipette and deliver drops back into the tube. - If the drops appear stringy or gelatinous, the mucus must be further liquefied.

31 Sample Preparation Techniques
Calculate how many drops of specimen to add to PreservCyt® vial: - If pellet is clearly visible and the pellet volume is ≤ 1ml (if not consider the next 2 slides) Vortex pellet and transfer 2 drops to a fresh PreservCyt Solution vial The type of pipette that you use may affect the concentration of the sample that is added to the PreservCyt Solution Vial, and therefore may affect the volume of sample.

32 Sample Preparation Techniques
Calculate how many drops of specimen to add to PreservCyt® vial: - If pellet volume is ≥1ml Add 1ml of CytoLyt® Solution into the tube and vortex briefly to resuspend the cell pellet Transfer 1 drop of the specimen to a fresh PreservCyt Solution vial The type of pipette that you use may affect the concentration of the sample that is added to the PreservCyt Solution Vial, and therefore may affect the volume of sample.

33 Sample Preparation Techniques
Calculate how many drops of specimen to add to PreservCyt® vial: - If pellet is not visible or scant Add contents of a fresh PreservCyt Solution vial into the tube and vortex briefly to mix the solution Pour entire sample back into the vial The type of pipette that you use may affect the concentration of the sample that is added to the PreservCyt Solution Vial, and therefore may affect the volume of sample.

34 Sample Preparation Troubleshooting
Due to the biological variability among samples and variability in collection methods, standard processing may yield a slide that indicates further troubleshooting may be needed. Troubleshooting is described in further detail in slides

35 Sample Preparation Troubleshooting
After staining, you may observe the following irregularities: Non-uniform distribution of cells in the cell spot without a “sample is dilute” message Uneven distribution in the form of a ring or halo of cellular material and/or white blood cells A sparse cell spot lacking in cellular component and containing blood, protein and debris – may be accompanied by a “sample is dilute” message

36 Techniques Used in Troubleshooting
Diluting the Sample 20 to 1 Glacial Acetic Acid Wash for Blood and Non-Cellular Debris Saline Wash for Protein

37 Techniques Used in Troubleshooting
Diluting the Sample 20 to 1 - Add 1ml of the sample that is suspended in PreservCyt® Solution to a new PreservCyt Solution vial (20ml). This is most accurately done with a calibrated pipette. For uncalibrated plastic pipette make sure to calculate using PreservCyt Solution rather than any other liquid so the drop size will be consistent with the sample drops.

38 Techniques Used in Troubleshooting
Glacial Acetic Acid Wash for Blood and Non-Cellular Debris - If sample is bloody, it can be further washed using a solution of 9 parts CytoLyt® Solution and 1 part Glacial Acetic acid. This should only be done after a sample has been in PreservCyt Solution. Do not use directly with fresh specimens; nuclear morphology may not be adequately preserved.

39 Techniques Used in Troubleshooting
Saline Wash for Protein - If sample contains protein, it can be further washed with saline solution in place of CytoLyt® Solution. This should only be done after a sample has been in PreservCyt Solution. Do not use directly with fresh specimens; nuclear morphology may not be adequately preserved.

40 Troubleshooting Mucoid Specimens “Sample is Dilute” message Yes
Check to see if cellularity is adequate. If not, use more of the pellet, if available and prepare new slide. “Sample is Dilute” message Yes Re-evaluate pellet to determine how many drops of residual pellet are to be added to the PreservCyt specimen vial. Top off vial with PreservCyt to reach a total volume of 30ml. No, continue to next slide

41 No, continue to next slide
Troubleshooting Mucoid Specimens Dilute the sample 20:1 by adding 1ml of sample to a new PreservCyt® Solution vial. Prepare new slide. If halo is present on the new slide, contact Hologic® Technical Service. Does the slide have a “halo” of cellular material and/or white blood cells? Yes No, continue to next slide

42 Troubleshooting Mucoid Specimens Yes No
Centrifuge remaining specimen from PreservCyt® vial, pour off and vortex. Perform CytoLyt® wash and evaluate cell pellet appearance. If pellet contains mucus repeat CytoLyt wash. Add to PreservCyt vial and prepare new slide. If resulting slide is sparse, contact Hologic Technical Service. Is the slide sparse and does it contain mucus? Yes If “Yes”, pour the contents of the PreservCyt Vial into a centrifuge tube. Concentrate by centrifugation. Pour off supernatant and Vortex to resuspend cell pellet. Perform CytoLyt Solution wash and evaluate cell pellet appearance. If pellet contains mucus, repeat CytoLyt Solution wash for mucoid specimens. Add the specimen to the PreservCyt vial. No Contact Hologic® Technical Service

43 Bloody or Proteinaceous Specimens
Troubleshooting Bloody or Proteinaceous Specimens Check to see if cellularity is adequate. If not, use more of the pellet, if available and prepare new slide. “Sample is Dilute” message Yes Re-evaluate pellet to determine how many drops of residual pellet are to be added to the PreservCyt specimen vial. Top off vial with PreservCyt to reach a total volume of 30ml. No, continue to next slide

44 Bloody or Proteinaceous Specimens
Troubleshooting Bloody or Proteinaceous Specimens Dilute the sample 20:1 by adding 1ml of residual sample to a new PreservCyt® Solution vial and prepare new slide. If halo is present on the new slide, contact Hologic® Technical Service. Does the slide have a “halo” of cellular material and/or white blood cells? Yes “Yes”: Dilute the sample 20:1. Add 1 ml of sample to a new PreservCyt Solution Vial. No, continue to next slide

45 Bloody or Proteinaceous Specimens
Troubleshooting Bloody or Proteinaceous Specimens Centrifuge remaining specimen from PreservCyt® vial, pour off. Add 30ml of a 9:1 CytoLyt® to glacial acetic acid solution to the sample, centrifuge, pour off and vortex. Add to PreservCyt vial and prepare new slide. If the resulting slide is sparse, contact Hologic Technical Service. Is the slide sparse and does it contain blood, protein or non-cellular debris? Yes-blood or non-cellular debris “Yes”: Pour contents of PreservCyt vial into a centrifuge tube. Concentrate by centrifugation. Pour off supernatant and vortex to resuspend cell pellet. If sample contains blood or non-cellular debris, mix 9 parts CytoLyt Solution to 1 part Glacial acetic acid and add 30 ml of this solution to the sample centrifuge tube. If sample contains protein, add 30 ml of saline to the centrifuge tube, concentrate, pour off and resuspend. (Repeat steps if pellet still contains blood or protein.) Add to PreservCyt vial and prepare a new slide. No Centrifuge remaining specimen from PreservCyt vial, pour off. Add 30 ml of saline to sample, centrifuge, pour off and vortex. Add to PreservCyt vial and prepare new slide. If resulting slide is sparse, contact Hologic Technical Service. Yes-protein Contact Hologic® Technical Service

46 Troubleshooting Common Artifacts
Smudged Nuclear Detail Compression Artifact Staining Artifact Edge of the Cylinder Artifact

47 Troubleshooting Common Artifacts
Smudged Nuclear Detail May occur if specimen is collected in saline, PBS or RPMI To avoid this, collect the sample either fresh, in CytoLyt® or in PreservCyt® solution

48 Troubleshooting Common Artifacts
Compression Artifact Appears as “air dry” artifact on the perimeter of the cell spot Due to the compression of cells between the edge of the filter and the glass of the slide

49 Troubleshooting Common Artifacts
Staining Artifact Mimics air-drying Appears as a red or orange central staining primarily in cell clusters or groups Due to the incomplete rinsing of counterstains. To eliminate this artifact, fresh alcohol baths or an additional rinse step after the cytoplasmic stains is required

50 Troubleshooting Common Artifacts
Edge of the Cylinder Artifact Narrow rim of cellular material just beyond the circumference of the cell spot Result of cells from the outer edge of the wet filter cylinder being transferred to the glass slide This may be more evident on highly cellular samples.

51 Anatomy The respiratory system is divided into upper and lower portions. The upper respiratory system consists of the nasal cavities, sinuses, mouth, pharynx, and larynx. The lower respiratory system consists of the trachea, bronchi, bronchioles, and alveoli. The left lung is made up of two lobes and the right is made up of three lobes.

52 Histology of the Epithelium
Respiratory system is lined by two types of epithelium: Non-Cornified Stratified Squamous Epithelium Pseudostratified Ciliated Columnar Epithelium Other Cell Types Include: Goblet cells Clara cells Kulchitsky cells Pneumocytes The nasal passages, oral cavity, pharynx, anterior surface of epiglottis and larynx are all lined by non-cornified stratified squamous epithelium. Whereas the nasopharynx, laryngopharynx, trachea, bronchi and bronchioles are all lined by pseudostratified ciliated columnar epithelium. Courtesy of Brian Bich at Lake Superior College

53 Specimen Adequacy Sputum- presence of numerous alveolar macrophages
Bronchial Brushing- presence of numerous bronchial cells BAL/Bronchial Washing- presence of bronchial cells and alveolar macrophages FNA- presence of diagnostic material

54 Normal Components and Findings
Ciliated columnar epithelial cells Nuclei: - Basally oriented - Round to oval with smooth nuclear membranes - May contain a nucleolus - Fine to mildly coarse chromatin - Variable in size Cytoplasm: - Homogenous and basophilic

55 Ciliated Columnar Epithelial Cells
Group of benign ciliated glandular bronchial cells in a bronchial washing. 40x Copyright © 2012 Hologic,  All rights reserved.

56 Normal Components and Findings
Goblet Cells - Commonly seen in bronchial washing and brushing specimens - Often in clusters or sheets - Usually one for every 5-10 ciliated epithelial cell - Abundant finely vacuolated cytoplasm filled with mucus Goblet cells are commonly observed in bronchial washing/brushings and are more abundant in asthma, bronchitis, bronchiectasis, and allergies

57 Goblet Cells Bronchial washing: Goblet cells have abundant, finely vacuolated, slightly basophilic, delicate cytoplasm that is filled with mucin. Nuclei are uniform and basally located. Stripped nuclei are common due to the degenerative nature of these cells. 60x Copyright © 2012 Hologic,  All rights reserved.

58 Normal Components and Findings
Squamous cells - More common in sputum than in washings/brushings - Similar to those seen in Gyn samples - Predominantly superficial - Anucleated squames, intermediate cells and benign squamous pearls may also be present

59 Normal Components and Findings
Squamous Metaplasia - Similar to metaplasia seen in Gyn samples - Uniform in size and shape - Appear in loose sheets, in a cobblestone arrangement - Nuclei are round - Chromatin ranges from granular to coarse or pyknotic - No nucleoli, unless cells are reactive

60 Squamous Metaplasia 60x 60x
Bronchial washing: Metaplasia cells are uniform in size and shape. They appear in cobblestone arrangements or loose sheets, cytoplasm is dense with distinct cellular borders. Nuclei are round, with granular to coarse or pyknotic chromatin. Nucleoli are only present if the cells are irritated or reactive. 60x 60x Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

61 Normal Components and Findings
Clara cells - Non-ciliated bronchiolar cells - Secrete a protein that acts as a clarificant, a function similar to mucus Kulchitsky cells - Scattered basal epithelial cells - Contain neurosecretory granules - Parent cells of carcinoid tumors Clara cells are more numerous deeper in the bronchi whereas goblet cells decrease in number.

62 Normal Components and Findings
Reserve cells - Small, round, lymphocyte-like cells - Nuclei are centrally located, uniform and hyperchromatic - Can only be specifically identified in clusters Pneumocytes - Type I Pneumocytes - Type II Pneumocytes: (Bronchoalveolar cells) Reserve cells are usually sparse in sputum, but may be present in reserve cell hyperplasia. In brushings, reserve cells can be seen with ulceration associated with acute bronchitis or due to damage to the mucosa with the brush. Type I Pneumocytes are metabolically inactive, Type II Pneumocytes secrete surfactant and are often interpreted as macrophages because of the similar features.

63 Reserve cells Tight cohesive group of reserve cells.
Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

64 Normal Components and Findings
Pulmonary macrophages - Cells may appear singly or in clusters - Nuclei may be round, oval, reniform or other shape - Multinucleation may be present - Cytoplasm is foamy and may be abundant - May contain ingested debris 3 Examples of Macrophages: 1.Carbon histiocytes 2.Hemosiderin-laden macrophages 3.Lipophages

65 Macrophages Carbon-laden Hemosiderin-laden
Carbon histiocytes are more common in smokers, urban dwellers, and in anthracosis (Coal Miners disease); also known as “Dust cells” Hemosiderin-laden macrophages may be present due to infarcts, heart failure, hemosiderosis or malignancy Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

66 Macrophages Lipophages
Lipophages can be exogenous (oily nose drops) or endogenous (tissue destruction). Seen in lipid pneumonia, fat embolism, aspiration pneumonia or malignancy. Copyright © 2012 Hologic,  All rights reserved

67 Normal Components and Findings
Ciliocytophthoria - Small ciliated tufts Inflammatory cells - PMN’s - Lymphocytes - Plasma cells - Eosinophils Ciliocytophthoria is a cytopathic effect related to nonspecific injury/insults, including exposure to air pollution, hot or dry air, and viral infections, particularly adenovirus. Polymorphonuclear neutrophils (PMN) - an increase may indicate or be associated with necrosis and smoking, cancer, bronchitis, abscess, pneumonia (including fungal), and drug toxicity. Lymphocytes-an increase in the presence of lymphocytes may indicate any of the following: chronic bronchitis, TB, atelectasis, follicular bronchitis, hypersensitivity or cancer. Plasma cells-these cells usually originate from the mouth but may indicate chronic pulmonary inflammation, including asthma Eosinophils-presence of eosinophils may indicate allergies, asthma, eosinophilic pneumonia, Wegener’s granulomatosis, drug toxicity, or environmental toxicity

68 Ciliocytophthoria In the presence of ciliocytophthoria it is common to see reactive atypia within the bronchial cells. Copyright © 2012 Hologic,  All rights reserved

69 Normal Components and Findings
Infectious agents that may be seen: Bacteria/Fungus Actinomyces M. tuberculosis Aspergillus spp. Candida spp. Pneumocystis carinii Cryptococcus Histoplasma Blastomyces Coccidioides Zygomyces

70 Actinomyces Sputum: This fungal like bacteria is typically an oral contaminant but may also indicate a true infection. Actinomyces bacteria are large blue filamentous “ cotton balls”. True thoracopulmonary actinomycosis should be considered if the bacterial is associated with abundant neutrophils. 60x Copyright © 2012 Hologic,  All rights reserved

71 Tuberculosis Caused by infection with Mycobacterium tuberculosis and commonly results in granulomatous inflammation Cytologic features: - Aggregates of epithelioid histiocytes, lymphocytes, and Langhans giant cells Necrosis may or may not be present Definitive diagnosis can be made with help from special stains or microbiologic culture

72 Aspergillus spp. Left Image-Bronchial Wash: Characterized by 45 degree angle branching. Right Image- BAL: Fruiting heads may also be identified. 40x 40x Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

73 Candida spp. Sputum: The presence of Candida is commonly due to oral contamination. It is characterized by its pseudohyphae and yeast spores. 40x Copyright © 2012 Hologic,  All rights reserved

74 Pneumocystis carinii 60x
This fungus is commonly associated with AIDS patients. 60x Copyright © 2012 Hologic,  All rights reserved

75 Cryptococcus This fungus characterized by single, teardrop-shaped budding. Referred to as “Crying Crypto”. Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

76 Histoplasma Contracted by inhalation of spores of Histoplasma capsulatum More commonly affects patients who are immunocompromised Organism often presents within cytoplasm of macrophages Is very small and may be overlooked if silver stains are not used

77 Blastomyces This fungus is characterized by broad based budding. Note the thick, refractile cell wall is double contoured. 60x Copyright © 2012 Hologic,  All rights reserved

78 Coccidioides This fungal organism appears as well-defined spherules with encapsulated endospores. 60x Copyright © 2012 Hologic,  All rights reserved

79 Zygomyces Mucor and Rhizopus are examples of zygomyces. These fungi are characterized by broad, irregular, thin-walled, ribbon-like, and pauciseptate hyphae that branch at irregular intervals, often 90 degree angles. 40x Copyright © 2012 Hologic,  All rights reserved

80 Normal Components and Findings
Infectious agents that may be seen: Viral Herpes CMV Adenovirus Measles Respiratory Syncytial Virus (RSV) Nematode Strongyloides

81 Herpes (HSV) Image 1: (Bronchial washing) a cluster of bronchial cells infected with herpes virus exhibiting the classic “ground glass” appearance, nuclear molding and chromatin margination. Image 2: (Bronchial washing) the eosinophilic intranuclear viral inclusions may also be seen with a herpes infection. These inclusions are said to indicate a secondary infection. 60x 60x Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

82 Cytomegalovirus (CMV)
Bronchial wash specimen This virus usually appears in patients with compromised immune systems or it may be transmitted from a mother to her fetus at birth. CMV infected cells typically have a large eosinophilic or basophilic intranuclear inclusion that causes margination of the nuclear chromatin, resulting in a “bull’s eye” appearance. 60x Copyright © 2012 Hologic,  All rights reserved

83 Adenovirus Usually causes minor illness but adenovirus pneumonia can be severe and fatal, especially for those who are immunocompromised Causes two types of nuclear inclusions - “The smudge cell”- large basophilic inclusions fill the entire nucleus and obscure chromatin detail - Eosinophilic inclusion that resembles the Cowdry A inclusion of herpes simplex virus Ciliocytophthoria can be prominent

84 Measles and Respiratory Syncytial Virus (RSV)
Measles is highly contagious Caused by the rubeola virus Incidence limited because of vaccination Measles pneumonia occurs as an opportunistic complication in children who are immunocompromised Cytologic features: - Enormous multinucleated cells with cytoplasmic and nuclear inclusions RSV has similar findings and is usually confirmed by detecting RSV antigen in BAL specimens

85 Strongyloides Bronchial wash: Strongyloides is most commonly seen in patients who are immunosuppressed and presents as a pneumonitis with hemoptysis. Infection of the lungs is caused by the hematogenous migration of the infective larva from the gut or skin. This organism is identified by their large size and its notched tail with short buccal cavity. 20x Copyright © 2012 Hologic,  All rights reserved

86 Normal Components and Findings
Acellular Material: Other Findings/Contaminants: Curshmann’s spirals Amorphous mucus Corpora Amylacea Amyloid Psammoma bodies Charcot-Leyden Crystals Ferruginous bodies Undigested food particles Plant material Vegetable cells Pollen

87 Curshmann’s spirals Curshmann’s spirals usually come from the deep lung and are associated with conditions that produce excess mucus, as in patients with asthma and in smokers. 20x Copyright © 2012 Hologic,  All rights reserved

88 Amorphous Mucus Also known as mucus bodies or blue blobs
Can mimic naked malignant nuclei, lacking distinct chromatin pattern or cytoplasm Can be round or ring shaped

89 Corpora Amylacea Spherical structures with circumferential
and radiating lines Measure between 30 and 200 µm Indistinguishable from those seen in the prostate No known clinical significance More commonly seen in older patients

90 Amyloid Occurs as multiple, irregular, dense, acellular fragments of eosinophilic material Waxy, homogenous appearance, with sharp often scalloped margins Characteristic apple green birefringence is seen under polarized light with Congo red staining

91 Psammoma Bodies Concentrically laminated, calcified, basophilic bodies surrounded by cells May be associated with cancers such as bronchioloalveolar carcinoma or metastatic papillary carcinoma May also be seen in benign conditions such as alveolar microlithiasis

92 Charcot-Leyden Crystals
Rhomboid-shaped, orangeophilic structures derived from degenerating eosinophils Can be seen in patients with severe allergic disorders like asthma

93 Ferruginous bodies Ferruginous bodies are golden brown, beaded and have bulbous tips. They are formed when iron salts precipitate onto tiny rounded or fibrous inhaled dust. Seen in patient who have had exposure to asbestos. Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

94 Undigested Food/Plant Material
Food particles are common in sputum Meat is characterized by cross striations Plant cells may have very dark, smudgy nuclei with translucent refractile cell walls May mimic adenocarcinoma or squamous cell carcinoma

95 Vegetable cell Plant cells can have very dark nuclei and can mimic adenocarcinoma or squamous cell carcinoma. However, plant cells have translucent, refractile cell walls. 60x Copyright © 2012 Hologic,  All rights reserved

96 Pollen Colorful bodies with cell walls and spikes.
Copyright © 2012 Hologic,  All rights reserved

97 Benign Entities and Changes
Reactive changes are common and may be due to: - Instrumentation - Infection or toxins (including smoking or tracheobronchial disease)

98 Reactive Changes Features of reactive bronchial cells may include:
- Enlarged pleomorphic nuclei - Prominent nucleoli - Coarse, hyperchromatic chromatin - Multinucleation - Abundant cytoplasm Reactive changes are more frequently seen in washing and brushing specimens rather than in sputum.

99 Bronchial washing with cluster of reactive bronchial cells
Bronchial washing with cluster of reactive bronchial cells. Note the enlarged nuclei with coarser chromatin and prominent nucleoli. Terminal bars and cilia are also identified which helps categorize this group as being part of a benign process. 60x Copyright © 2012 Hologic,  All rights reserved

100 Reactive/atypical terminal bronchiolar cells from a bronchoalveolar lavage. Note the enlarged, slightly hyperchromatic nuclei, with prominent nucleoli and multinucleation. 60x Copyright © 2012 Hologic,  All rights reserved

101 Bronchial Brushing: Mildly reactive bronchial epithelium
Bronchial Brushing: Mildly reactive bronchial epithelium. Note the presence of terminal bars and cilia, favoring a benign process. 60x Copyright © 2012 Hologic,  All rights reserved

102 Reparative Changes Similar to that seen in Gyn samples
Atypia can range from mild to severe, and may mimic cancer Unlike with cancer, both the nucleus and cytoplasm of reparative cells increase in size, maintaining a benign N/C ratio

103 40x Bronchial wash: Repair
Copyright © 2012 Hologic,  All rights reserved

104 40x Bronchial wash: Repair
Copyright © 2012 Hologic,  All rights reserved

105 40x Bronchial wash: Repair
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106 Benign Proliferation The bronchial epithelium can undergo
a series of changes due to chronic irritation: Reserve Cell Hyperplasia Squamous Metaplasia Parakeratosis, Atypical Parakeratosis Bronchial Hyperplasia

107 Benign Proliferation Reserve Cell Hyperplasia (RCH) - Tightly cohesive groups of reserve cells - Nuclear molding may identified - Differential diagnoses include lymphocytes and small cell carcinoma Reserve cell hyperplasia is commonly observed in bronchial brushings.

108 Reserve Cell Hyperplasia
Tight cohesive group of reserve cells. Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

109 Benign Proliferation Squamous Metaplasia - Very common, occurring in 20% to 80% of all patients - May be present due to irritation but may also be associated with cancer - Frequently occurs with RCH - Immature respiratory metaplasia is smaller with more polygonal cytoplasm Respiratory metaplasia may be difficult to distinguish from small parabasal cells, oral cells, or groups of macrophages. Smaller metaplasia that has more angulated, orange cytoplasm with pyknotic nuclei may be challenging to differentiate from parakeratosis. Atypical squamous metaplasia, often associated with necrotizing pneumonia, is a common source for false-positive diagnoses.

110 Squamous Metaplasia 60x 60x
Bronchial washing: Metaplasia cells are uniform in size and shape. They appear in cobblestone arrangements or loose sheets, cytoplasm is dense with distinct cellular borders. Nuclei are round, with granular to coarse or pyknotic chromatin. Nucleoli may be present in reactive metaplastic cells. 60x 60x Copyright © 2012 Hologic,  All rights reserved Copyright © 2012 Hologic,  All rights reserved

111 Benign Proliferation Parakeratosis/Atypical Parakeratosis - Similar to parakeratosis seen in Gyn samples - Associated with irritation/inflammation or dysplasia/cancer - Usually arises in the mouth or in the tracheobronchial tree - May be difficult to distinguish from keratinizing squamous cell carcinoma Helpful hint to distinguish between atypical parakeratosis and keratinizing squamous cell carcinoma is the small size of the parakeratotic cells and the absence of larger, unequivocally malignant cells.

112 Benign Proliferation Bronchial Hyperplasia
- Pseudopapillary, 3-dimensional groups of reactive/atypical bronchial cells - Reactive nuclei are uniform in size and shape - Fine to coarse, evenly distributed chromatin - Nucleoli are uniform but prominent - Cytoplasm is variable and may have vacuoles of varying sizes Bronchial hyperplasia may occur in response to a variety of acute or chronic pulmonary disorders like asthma, bronchiectasis, chronic bronchitis, viral pneumonia, Wegner’s granulomatosis, and respiratory distress syndrome. These 3-D groups of reactive/atypical bronchial cells are also referred to as “Creola bodies”. The common differential diagnosis is primary or metastatic adenocarcinoma.

113 Pneumoconioses Pneumoconiosis
- name given to the occupational and restrictive lung disease caused by inhalation of dust - the type of dust gives each disease its name Silicosis (silica) Asbestosis (asbestos) Berylliosis (beryllium) Anthracosis (coal, carbon) Byssinosis (cotton) Hemosiderosis (iron) Silicosis: caused by the inhalation of crystalline silica dust, associated with the presence of weakly birefringent, silvery particles. Also known as Potter’s rot. Asbestosis: caused by the inhalation and retention of asbestos fibers, associated with the presence of ferruginous bodies. Berylliosis: caused by the inhalation of beryllium oxide dust, beryllium oxide crystals may be identified inside macrophages and foreign body giant cells. Anthracosis: caused by the inhalation of carbon, also known as “Black Lung”, associated with the presence of abundant amounts of carbon ingested macrophages. Byssinosis: caused by the inhalation of cotton, flax or hemp dust, cytologic findings are similar to chronic bronchitis. Hemosiderosis: accumulation of iron, associated with the presence of a marked increase in hemosiderin-laden macrophages.

114 Miscellaneous Conditions
Eosinophilic Pneumonia- presence of marked increase in eosinophils -Also known as Löffler’s Pneumonia Giant Cell Interstitial Pneumonia- often caused by exposure to hard metals - Benign multinucleated giant cell histiocytes which may contain phagocytosed debris or cells Atelectasis- collapse of all or part of lung - Cytology presence with atypical squamous cells and foreign body macrophages

115 Noninfectious Diseases
Sarcoidosis-common disease, characterized by noncaseating granulomas in many organs, commonly the lung Cytologic features: - Aggregates of epithelioid histiocytes - Multinucleated giant cells - Lymphocytes

116 Sarcoidosis Patients with sarcoidosis typically have an interstitial lymphocytosis. Copyright © 2012 Hologic,  All rights reserved

117 Noninfectious Diseases Continued
Wegener Granulomatosis- presents as a lung mass with or without involvement of other organs Cytologic features: non specific - Necrotic collagen, giant cells, granulomas, and neutrophils

118 Benign Neoplasms Pulmonary Hamartoma
Inflammatory Myofibroblastic Tumor (IMT) Endobronchial Granular Cell Tumor

119 Pulmonary Hamartoma Cytologic features: - Benign glandular cells - Immature fibromyxoid matrix and bland spindle cells - Mature cartilage with chondrocytes - Adipocytes

120 Inflammatory Myofibroblastic Tumor (IMT)
Cytologic features: - Spindle cells - Arranged in fascicles or storiform pattern - Abundant polymorphous inflammatory cells - Minimal if any necrosis

121 Endobronchial Granular Cell Tumor
Cytologic features: - Small clusters of macrophage-like cells - Nuclei are small, uniform and round to oval - Abundant granular cytoplasm

122 Abnormal Findings Squamous Cell Carcinoma Adenocarcinoma
Large Cell Undifferentiated Carcinoma Small Cell Undifferentiated Carcinoma Metastatic Carcinomas

123 Squamous Cell Carcinoma
Most common sub-type Range from poorly to well differentiated Tumors tend to arise centrally Can be diagnosed with sputum cytology and bronchial brushing/washing Sputum specimens usually contain more differentiated keratinized cells with denser cytoplasm, more pyknotic nuclei and fewer nucleoli compared to bronchial cytology which tends to collect less differentiated, non-keratinized cells with more open chromatin and more prominent nucleoli. Brushing specimens may contain large tissue fragments of malignant cells.

124 Keratinizing Squamous Cell Carcinoma
Cytologic features: - Bizarre cell shapes - Numerous single cells - Nuclei are pleomorphic - Chromatin ranges from coarse and dark to pyknotic or ink dot-like - Cytoplasm is dense, waxy, or “hard” with well defined cell borders, ranges from scant to abundant - Extensive necrosis

125 Bronchial wash: group of atypical squamous cells suggestive of SCCA.
20x Copyright © 2012 Hologic,  All rights reserved

126 Bronchial wash: Bizarre caudate shaped cells with sharply angulated cytoplasm.
60x Copyright © 2012 Hologic,  All rights reserved

127 Bronchial wash: group of malignant spindle cells with ink-black nuclei.
40x Copyright © 2012 Hologic,  All rights reserved

128 Bronchial wash: deeply keratinized cells with increase in N/C ratio and parachromatin clearing.
60x Copyright © 2012 Hologic,  All rights reserved

129 Non-Keratinizing Squamous Cell Carcinoma
Cytologic features: - Sheets and single cells, bizarre forms usually absent - Nuclei are enlarged and hyperchromatic - Chromatin is coarse and irregular but more open than Keratinizing Squamous Cell Carcinoma - Nucleoli are usually prominent - Cytoplasm is dense and often cyanophilic with distinct cell borders Cells of Non-Keratinizing Squamous Cell Carcinoma are more cohesive and uniform than those of Keratinizing Squamous Cell Carcinoma

130 Bronchial washing: cell borders of poorly differentiated squamous cell carcinoma are sharper than that of adenocarcinoma. Notice multiple prominent, eccentrically placed nucleoli. Parachromatin clearing is also prominent in this image. 40x Copyright © 2012 Hologic,  All rights reserved

131 Bronchial brushing: The cell on the right shows irregular nuclear shape, clumped chromatin and multiple irregularly shaped nucleoli. 60x Copyright © 2012 Hologic,  All rights reserved

132 Bronchial washing: Bizarre malignant cells with nuclear enlargement, coarse clumped chromatin, and parachromatin clearing. The dense, hard cytoplasm indicated squamous differentiation. 60x Copyright © 2012 Hologic,  All rights reserved

133 Bronchial washing: scattered keratinization may be seen in a poorly differentiate squamous cell carcinoma. 40x Copyright © 2012 Hologic,  All rights reserved

134 Adenocarcinoma Tumors tend to arise in the periphery of the lungs
Two Types: - Bronchogenic Adenocarcinoma - Bronchioloalveolar Carcinoma (BAC) Detected more readily by bronchial cytology than by sputum cytology

135 Bronchogenic Adenocarcinoma
Up to 30% of lung tumors 50% of all lung tumors in females Not always associated with smoking

136 Bronchogenic Adenocarcinoma
Cytologic features: - Papillary, cell balls or acinar structures - Nuclei are enlarged with irregular nuclear borders - Chromatin ranges from fine to coarse - Prominent macronucleoli - Cytoplasm may range from homogenous to foamy

137 Bronchial washing: 3-D cell group with prominent centrally placed nucleoli.
40x Copyright © 2012 Hologic,  All rights reserved

138 Bronchial washing: Group of malignant cells forming an acinar structure.
60x Copyright © 2012 Hologic,  All rights reserved

139 Bronchoalveolar Lavage: The nuclei of this poorly-differentiated adenocarcinoma are variable in shape and have coarse clumped chromatin. Blood and necrosis may be present in the background. 60x Copyright © 2012 Hologic,  All rights reserved

140 Sputum: cytoplasm of bronchogenic adenocarcinoma may contain abundant vacuoles.
60x Copyright © 2012 Hologic,  All rights reserved

141 Bronchioloalveolar Carcinoma
Peripheral lesion, rare in pure form 1% of lung tumors May arise from different cell types, including ciliated terminal bronchiolar cells, Clara cells, or type II alveolar pneumocytes More often well-differentiated Two types: mucinous or non-mucinous

142 Bronchioloalveolar Carcinoma
Cytologic features: - Sheets, cell balls with hobnail outlines, papillary groups, acini and single cells - Nucleoli may be multiple, inconspicuous or prominent - Chromatin is pale and fine but can be moderately hyperchromatic - Cytoplasm varies from scant to abundant and finely granular to clear - Mucus may be present in background Mucinous tumors are large and columnar and resemble goblet cells, but frequently have prominent nucleoli. Non-mucinous tumors are smaller and cuboidal and are reminiscent of mesothelial cells. They can also resemble reactive alveolar pneumocytes or macrophages.

143 Bronchial washing: group of malignant cells with pale chromatin and prominent single or multiple nucleoli, finely granular cytoplasm. 60x Copyright © 2012 Hologic,  All rights reserved

144 Bronchial washing: small ball of malignant cells with increased N/C ratio and relatively bland nuclear features. 60x Copyright © 2012 Hologic,  All rights reserved

145 Bronchial washing: sheet of malignant cells with increased N/C, prominent nucleoli and clear cytoplasm. 60x Copyright © 2012 Hologic,  All rights reserved

146 Bronchial washing: another grouping showing similar criteria as the previous images.
20x Copyright © 2012 Hologic,  All rights reserved

147 Bronchial washing: malignant cell groups may be identified amongst diathesis and/or necrosis.
20x Copyright © 2012 Hologic,  All rights reserved

148 Pulmonary Neuroendocrine Neoplasms
Divided by the World Health Organization into four distinct categories - Typical Carcinoid - Atypical Carcinoid - Large Cell Undifferentiated Carcinoma - Small Cell Undifferentiated Carcinoma

149 Typical Carcinoid Accounts for 2-3% of all pulmonary tumors
Low metastatic rate, 5-year survival: 90-98% Cytologic features: - Loosely cohesive groups and single cells - Cells are round, oval or elongated - Nuclei are uniform with “salt and pepper” chromatin - Inconspicuous nucleoli - Moderate to abundant granular cytoplasm - Mitoses is uncommon - Necrosis is absent

150 Atypical Carcinoid More aggressive than Typical Carcinoid
5-year survival rate: 61-73% Cells and architecture similar to Typical Carcinoid Cytologic differences from Typical Carcinoid: - Focal necrosis - Mitoses are moderate in number - Prominent nucleoli

151 Large Cell Undifferentiated Carcinoma
Non-small cell tumor, no definite differentiation Readily exfoliates May have squamous or glandular features, or both (commonly demonstrable by using electron microscope or immunocytochemistry)

152 Large Cell Undifferentiated Carcinoma
Cytologic features: - Large malignant cells ranging from fairly uniform to bizarre - Nuclei are large and round to pleomorphic with irregular to lobulated membranes - Chromatin is fine to coarse and irregularly distributed - Nucleoli can be prominent, multiple and irregular - Cytoplasm is abundant and varies from delicate to dense to granular - Diathesis is usually present

153 Bronchial brushing: Group of dyshesive cells, with variation in nuclear size and shape, prominent irregular nucleoli and delicate cytoplasm. 40x Copyright © 2012 Hologic,  All rights reserved

154 Bronchial brushing: Large obviously malignant cells, with irregularly distributed, coarse chromatin and prominent nucleoli. 60x Copyright © 2012 Hologic,  All rights reserved

155 Bronchial brushing: Large malignant cells with, coarse chromatin, prominent nucleoli, and granular cytoplasm. 60x Copyright © 2012 Hologic,  All rights reserved

156 Bronchial washing: Sheet of Large Cell Undifferentiated Carcinoma, with coarse, irregularly distributed chromatin and prominent irregular, multiple nucleoli. 40x Copyright © 2012 Hologic,  All rights reserved

157 Small Cell Undifferentiated Carcinoma
Aggressive tumor Arises in the major bronchi Central tumor Derived from or mimics Kulchitsky cells Capable of producing a variety of hormones Small Cell Carcinoma can be divided into different categories such as: Pure small cell carcinoma (“oat cell type”, intermediate type), mixed small/large cell carcinoma or combined small cell carcinoma (shows adenocarcinoma or squamous cell carcinoma features)

158 Small Cell Undifferentiated Carcinoma
Cytologic features: - Small, 1-4x size of lymphocytes - Nuclear molding is prominent - Nuclei are hyperchromatic to pyknotic - Nucleoli are inconspicuous - Cytoplasm is scant and delicate - Presence of diathesis and crush artifact

159 Sputum: Nuclear staining ranges from dark to pale, reflecting pyknosis and cell necrosis respectfully. 40x Copyright © 2012 Hologic,  All rights reserved

160 Sputum: Notice the nuclear molding at the center of this group of small cell undifferentiated carcinoma. 60x Copyright © 2012 Hologic,  All rights reserved

161 Sputum: Tumor cells of Small Cell Undifferentiated Carcinoma may be seen in a linear configuration.
60x Copyright © 2012 Hologic,  All rights reserved

162 TBA-Wang needle: The cells of this loose aggregate show better preservation and less nuclear molding. 60x Copyright © 2012 Hologic,  All rights reserved

163 Bronchial brushing: Cells are tightly clustered and show nuclear molding and individual cell necrosis. 60x Copyright © 2012 Hologic,  All rights reserved

164 Uncommon Pulmonary Tumors
Adenoid Cystic Carcinoma Mucoepidermoid Carcinoma Clear Cell Tumor (“Sugar Tumor”) Sarcomas Lymphomas/Leukemias

165 Adenoid Cystic Carcinoma
Account for 20-30% of all cancers in the trachea but also occur in the bronchi Symptoms include: cough, dyspnea and hemoptysis Poor long-term prognosis Most often diagnosed by bronchial brushings or transbronchial needle aspiration Cytologic features: - Cylinders or spheres of small, benign-appearing epithelial cells that surround basal lamina material

166 Mucoepidermoid Carcinoma
Uncommon, representing only 0.2% of lung tumors Develop in persons of all ages, including children A recurrent and tumor specific genetic aberration is present: t (11; 19), forming the MECT1-MAML2 fusion transcription Cytologic features: - Presence of squamous, intermediate and mucinous cells - High-grade tumors show marker nuclear atypia

167 Clear Cell Tumor (“Sugar Tumor”)
Extremely rare, can occur in persons of all ages Typically presents as a peripheral mass ranging from 1 to 7 cm in greatest diameter Cytologic features: - Bland polygonal and spindle-shaped cells with a central oval or elongated nucleus - Cytoplasm is clear and glycogenated Differentials include: clear cell variant of adenocarcinoma or Squamous Cell of the lung, granular cell tumor, and metastatic tumors with clear-cell features

168 Sarcomas Primary malignant mesenchymal tumors of the lung are rare
Occur in adults of either sex One of the most common primary sarcomas is leiomyosarcoma Can be large masses or small endobronchial lesions Cytologic features: - Sheet-like cellular aggregates - Malignant spindle cells are single and highly atypical

169 Lymphomas Primary Hodgkin and non-Hodgkin lymphomas can occur but metastatic lymphomas are more common Primary pulmonary non-Hodgkin lymphoma represents less than 10% of all extranodal lymphomas Most common primary non-Hodgkin lymphoma of the lung (70-90%) is MALT lymphoma, followed by diffuse large B-cell lymphoma Primary pulmonary Hodgkin lymphoma is exceptionally rare Cytologic features of Hodgkin and non-Hodgkin lymphomas are similar to those seen in other body sites

170 Leukemias 10% of diffuse pulmonary infiltrates in patients with leukemia result from leukemic involvement of the lung Leukemic involvement of the lung may present as a mass Cytologic features: - Cells are dispersed as isolated cells, as with lymphomas, and cellular monomorphism is characteristic BAL is useful for demonstrating leukemic involvement, especially when biopsy is contraindicated because of coagulopathy

171 Metastatic Disease Three times more common than primary Adenocarcinoma of the lung Most common sites of origin are GI, Breast, Lymphoma/Leukemia, Melanoma and Sarcoma Multiple nodules favor metastatic disease In addition to clinical history, cytomorphologic features and immunochemistry studies may help determine primary tumor site

172 FNA lung: Metastatic Renal Cell Carcinoma
FNA lung: Metastatic Renal Cell Carcinoma. Note the abundant, lacy cytoplasm and nuclei with fine chromatin and prominent nucleoli. 60x Copyright © 2012 Hologic,  All rights reserved

173 Bronchial washing: Metastatic Apocrine Cell Carcinoma of the Breast- large nuclei with malignant features, prominent nucleoli. Cytoplasm is abundant, finely granular. Clean background which helps support a metastatic lesion vs. a primary. 60x Copyright © 2012 Hologic,  All rights reserved

174 Bronchial brushing: Metastatic Colon Carcinoma- cells of this metastatic colon carcinoma are tall and columnar with elongated, cigar shaped nuclei. Chromatin is coarse and dark with prominent nucleoli. Cytoplasm is finely granular. 60x Copyright © 2012 Hologic,  All rights reserved

175 Lung FNA: Poorly Differentiated Sarcoma- malignant spindle cells with enlarged, obviously malignant nuclei, prominent nucleoli and coarse, clumped chromatin. 60x Copyright © 2012 Hologic,  All rights reserved

176 Bronchial washing: metastatic B-cell lymphoma
Bronchial washing: metastatic B-cell lymphoma. Atypical lymphocytes of varying size and shape are present and exhibit coarse chromatin, nuclear clefts and prominent nucleoli. 60x Copyright © 2012 Hologic,  All rights reserved

177 Trademark Statement CytoLyt, Hologic, PreservCyt, ThinPrep, and UroCyte are registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States.  CytoLyt, Hologic, PreservCyt, ThinPrep, UroCyte and associated logos are trademarks of Hologic, Inc. and/or its subsidiaries in other countries. All other trademarks are the property of their respective owners.

178 For more information… Visit our websites: - Product Catalog - Contact Information - Complete Gynecologic and Non-gynecologic Bibliographies - Cytology Case Presentations and Unknowns - Slide Library Request Form

179 Bibliography ThinPrep® 2000 Processor Operator’s Manual ThinPrep 5000 Processor Operator’s Manual DeMay, Richard M.: Arts & Science of Cytopathology Exfoliative Cytology. 1996: DeMay, Richard M.: Practical Principles of Cytopathology.1999: Cibas, E., Ducatman, B.: Cytology: Diagnostic Principles and Clinical Correlates. 3rd edition, 2009: Keebler, C., Somrak, T. The Manual of Cytotechnology. 7th edition, 1993: McKee, Grace T: Cytopathology. 1997:

180 Bibliography Images: Bich, Brian. Bronchus Photograph. Lake Superior College, Duluth, MN. Web. Lake Superior College. [http://employee.lsc.edu/faculty/BrianBich/Picture%20Library/Forms/AllItems.aspx?RootFolder=%2Ffaculty%2FBrianBich%2FPicture%20Library%2FAnat%2DPhys%20II%20%28Biol%201141%29%2FRespiratory%20System%20Tissues%2FBronchi%20and%20Bronchioles%20%2D%20Tutorial&View=%7b997D B-48F0-A9FE-07741C9C8B65%7d] 3 Feb 2012. SmartDraw® (Standard Edition) [Software]. (2011). Retrieved from ThinPrep® Non-Gyn Morphology Reference Atlas: Respiratory: ADS Rev. 001


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