Case year female. Routine Pap smear

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2 Case 1 57 year female Routine Pap smear

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6 Diagnosis? 1. Atypical glandular cells of unknown significance (AGUS) 2. Endocervical AIS 3. Endocervical adenocarcinoma 4. Endometrial adenocarcinoma 5. Adenocarcinoma NOS

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8 Atypical glandular cells No diathesis

9 Adenocarcinoma NOS? Extra-uterine

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11 Serous papillary ovarian carcinoma

12 Psammoma body in cervical smear Adenoca ovary with stromal invasion Psammoma body in cervical smear Serous cystadenofibroma ovary Cytojournal 2008

13 Extrauterine adenocarcinomas Usually from ovary, rarely from tube Exfoliated ca cells from ovarian tumor or malig ascites may pass through tube, endometrial cavity and os and reach the cervical sample No diathesis, unless they are metastatic to vagina or cervix Adenoca with psammoma bodies is highly suggestive of ovarian ca Direct extension from rectal or bladder ca Lymphatic or hematogenous spread of GIT ca, breast ca, ovary

14 38 year old female with neck swelling On examination: 3.5 cm, firm left thyroid nodule

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17 Case 3 40 year old female White discharge PV - 3 months Irregular bleeding PV - 3 months

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19 Cytologic features Spindle and plump cells, some with fibrillary cytoplasmic processes, no atypia Atypical squamous cells Smear background clean, no diathesis

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23 Langerhan cell histiocytosis Occasionally involves the thyroid as part of multi-organ disease Patient presents with hypothyroid or euthyroid, diffuse/ nodular goiter Accompanying symptoms relate to other organ involvement

24 Case 5 62 year female Foul smelling discharge PV Previous year Pap smear within normal limits

25 Diagnosis? HSIL Keratinizing SCC Atrophic pattern Leiomyoma

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33 Papillary lesion with oncocytes Oncocytic focus in Papillary ca Papillary Hurthle cell tumor? variant of Papillary carcinoma: Oncocytic (oxyphilic) variant Tall cell variant? Warthin tumor-like variant (lymphoplasmacytic cells in papillary cores and ants at a picnic appearance)

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37 Oncocytic variant of PC Papillary & follicular structures populated by oncocytes. Abundant, coarsely granular cytoplasm Nuclear features of PC Macronucleoli absent, (distinguishing feature from papillary HCT). Local invasion common, so more extensive surgery than classic PC. Tall cell variant: oxyphilic cells twice as tall as they are wide, frequent nuclear grooves and inclusions. septated, or vacuolated cytoplasm, lymphocytes often present.

38 Case 3 40 year old female White discharge PV - 3 months Irregular bleeding PV - 3 months

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45 TBS atlas-hsil

46 Cytologic features Spindle and plump cells, some with fibrillary cytoplasmic processes, no atypia Atypical squamous cells Smear background clean, no diathesis

47 Questions/ clarifications?

48 On per speculum examination there was a 4x3 cm polypoid ulcerated mass in the cervix and the os could not be visualized. The smear was a scrape smear taken from the mass

49 Cytologic diagnosis given ASCUS with spindle cell lesion, possibly a leiomyomatous polyp Advised excision for histological examination

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52 Leiomyomatous cervical polyp with overlying epithelium showing reparative atypia

53 6 year old male Soft left lobe thyroid swelling Generalized weakness and malaise

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59 Medium to large cells with low to medium N:C ratio Eccentric nuclei, nuclear indentations in some Dendrite-like cytoplasmic processes Admixture with neutrophils, eosinophils, lymphocytes No thyroid follicular cells? Langerhans cell histiocytosis No additional smears for immunophenotyping

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61 S100

62 Langerhan cell histiocytosis Occasionally involves the thyroid as part of multi-organ disease Patient presents with hypothyroid or euthyroid, diffuse/ nodular goiter Accompanying symptoms relate to other organ involvement

63 Cytological smears show a polymorphous cell population composed of varying proportions of Langerhans cells (LCs), eosinophils, lymphocytes, plasma cells and MNGs. LCs show nuclear indentations or grooves and dendrite-like cytoplasmic processes

64 LCs may manifest plump nuclei and increased mitotic activity - may be mistaken cytologically for lymphoma.

65 Differential diagnosis includes benign infective or non-infective granulomatous lesions. Examination of a quick-stained bedside smear can raise the possibility of LCH and allow additional smears to be wetfixed in ethanol for S100 staining and other lymphoid markers.

66 Case 5 62 year female Foul smelling discharge PV Previous year Pap smear within normal limits

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70 Diagnosis? HSIL Keratinizing SCC Atrophic pattern Leiomyoma

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75 TBS atlas-atrophy Diagnosis? Atrophy mimicking spindle cell lesion

76 Case 6 32 years female Left breast lump 3 years O/E: 5 cm, firm, mobile lump in the central and adjacent medial quadrants of left breast, partly retro-areolar

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90 Diagnosis given Spindle cell mesenchymal malignancy; possibilities of malignant phyllodes tumor and metaplastic carcinoma are suggested

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93 Final diagnosis Malignant phyllodes tumor

94 Spindle cell lesions of breast Breast lesions with a significant spindle cell or mesenchymal component are rarely encountered in FNA and constitute a heterogeneous group that may pose a diagnostic dilemma. Reactive conditions: diabetic mastopathy, granulation tissue, granulomatous lesions Benign neoplastic conditions: mammary hamartoma, dermatofibroma, fibromatosis, angiolipomas Low grade malignant neoplastic lesions, low grade phyllodes tumors High grade malignant neoplastic lesions: metaplastic carcinoma, leiomyosarcoma, malignant fibrous histiocytoma, metastatic melanoma. Diabetic mastopathy: dense keloid-like fibrosis, lymphocytic lobulitis and ductitis, lymphocytic perivascular inflammation, epithelioid-like fibroblasts

95 Fibromatoses

96 Leiomyosarcoma breast

97 Metaplastic Ca

98 Metaplastic Ca

99 Metastatic sarcoma from bone

100 Dual cell population with benign phyllodes fragments along with markedly atypical and mitotic spindle cells: suggestive of malignant PT Dual cell population (or more than two types of cells) with atypia of spindle and epithelioid cells: suggestive of metaplastic carcinoma Malignant squamous cells and chondroid stroma: suggestive of metaplastic ca Spindle cell sarcomas: usually one type of cell Pleomorphic sarcomas: varied cell morphology, polymorphism of cells

101 Stop cutting trees this is serious!