1. KCP 797 강남세브란스병원박혜성

2. 33/M, Cervical lymphadenopathy: R/O TB, R/O nonspecific lymphadenopathy R/O TB, R/O nonspecific lymphadenopathy

3. YC13-53716

7. Differential Diagnosis: Epithelioid cells Chronic granulomatous inflammation Metastatic tumors –Carcinomas from head and neck (common)  Nasopharynx: nasopharyngeal carcinoma, undifferentiated  Thyroid: anaplastic carcinoma –Sarcomas (rare): rhabdomyosarcoma, epithelioid sarcoma, angiosarcoma, synovial sarcoma Malignant melanoma: “the great mimicker” Malignant lymphoma –Diffuse large B cell lymphoma, anaplastic variant –Anaplastic large cell lymphoma –Peripheral T cell lymphoma, lymphoepithelioid variant

8. In Reality… Atypical? Mannerism in daily practice Yong male patient, R/O TB lymphadenitis Original cytodiagnosis (YC13-53716) Lymph node, neck, left, aspiration cytology: Chronic granulomatous inflammation with necrosis TB-PCR: negative Core needle biopsy was performed.

9. YS13-30234

11. P63 CK20 CK7 CK(AE1/3)

12. EBV ISH

13. Histologic Diagnosis YS13-30234 Lymph node, neck, left, biopsy: Metastatic poorly differentiated carcinoma, see note. Note) 1.Immunohistochemical results: CK (AE1/3) and p63: diffuse positive EBV ISH: positive CK7, CK20, CD56, synaptophysin, CDX-2: negative 2. 이상의 결과를 종합하여 볼 때 원발 장기로는 Head and neck (nasopharyx) 의 가능성이 가장 높습니다. Clinical correlation 하시 기 바랍니다.

14. Clinical Course 환자는 외부병원 ( 분당서울대 ) 으로 전원 Nasopharyngeal mass biopsy: Nasopharyngeal carcinoma CCRT 시행 Baseline After CCRT 분당서울대 김효진 선생님 제공

15. Final Diagnosis Lymph node, neck, left: Metastatic nasopharyngeal carcinoma, undifferentiated type

16. Nasopharyngeal Carcinoma (NPC) The most common initial presentation: cervical lymphadenopathy Age: 30-50, pediatric WHO subtype –Keratinizing: 25% –Nonkeratinizing, differentiated: < 15% –Nonkeratinizing, undifferentiated: 60% (a.k.a. lymphoepithelioma)

17. Cytology of NPC, undifferentiated Large cancer cells with scanty cytoplasm Hyperchromatic, oval-to spindle nuclei with irregular borders Stripped, bizarre, dark nuclei Often, multiple macronucleoli Pale, fragile, and indistinct cytoplasm Lymphocytes Koss’ Diagnostic Cytology and Its Histopatholgic Bases Sambit et al. Diagn Cytopathol 2002; 27:340-342 Sharanamma et al. Diagn Cytopathol 2003;28:18-22 Viguer et al. Diagn Cytopathol 2005; 32:233-237

18. Differential Diagnosis Hodgkin lymphoma –Always scattered cells –Bulky, vacuolated cytoplasm –Vesicular nuclei Metastatic carcinoma from other primary site NPC –Loose clusters + single cells –Naked nuclei –Fragile cytoplasm –Basophilic nuclei

19. Malignant Neoplasm Mimicking Granuloma in Aspiration Cytology (1) Kamal et al. Cancer cytopathol 1998; 84:84-91

20. Malignant Neoplasm Mimicking Granuloma in Aspiration Cytology (2) Ulster Med J 2006; 75 (1):59-64

21. Malignant Neoplasm Mimicking Granuloma in Aspiration Cytology (3)

22. Morphologic Features of Active Histiocytes Cytoplasmic border: sharp, distinct, pale, or fuzzy Nucleus: round, oval, one side flattened, intended, infolded, or lobulation Chromatin clumping with prominent nuclei: rounded and smudged (vs “cookie-cutter” borders in malignancy) Possible extremely prominent nucleoli: –Pulmonary infarct, thyroid nodule following FNA, reactive lymph node following therapy Mitotic activity (cells bathing in cystic spaces) –Generally normal and rarely abnormal in appearance May resemble both benign and neoplastic epithelial and mesenchymal cells -> immuno-markers are necessary. Prabodh et al. Cytohistology: Essentials and Basic concepts, Cambridge University Press

26. Take Home Massage Cytology of epithelioid cells in granuloma –Voluminous cytoplasm, Low N/C ratio –Naked nuclei: a few –Round, smudged micronucleoli in general Atypical epithelioid cells –Clinical correlation –Immunohistochemical study, if possible

27. 감사합니다.