Gabrijela Kocjan. Fine Needle Aspiration Cytology

Transcription

1 Gabrijela Kocjan Fine Needle Aspiration Cytology

2 Gabrijela Kocjan Fine Needle Aspiration Cytology Diagnostic Principles and Dilemmas With 527 Figures 123

3 Dr. Gabrijela Kocjan University College London Medical School Dept. of Histopathology Rockefeller Building WC1E 6JJ London United Kongdom Library of Congress Control Number: ISBN Springer Berlin Heidelberg New York ISBN Springer Berlin Heidelberg New York This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable for prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springeronline.com Springer-Verlag Berlin Heidelberg 2006 Printed in Germany The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: the publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editor: Gabriele Schröder Desk Editor: Ellen Blasig Typesetting and Production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig Cover design: estudio calamar, Frido Steinen-Broo, Calamar, Spain Printed on acid-free paper 24/3100/YL

4 To my parents, Hilda and Franc For encouraging my independence To Tony and Arabella, For being proud of me

5 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 these 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 appearing 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 cannot 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 London, 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-

6 VIII 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

7 Contents Preface VII Contents...IX Introduction and Historical Perspective... 1 References...3 FNAC Technique and Slide Preparation Informed Consent Location of the FNAC Procedure The FNAC Clinic Inpatient FNAC Image-Guided and Other FNAC Procedure Locations The Importance of the Aspirator Aspiration Techniques Suction FNAC The Capillary Method Slide Preparation Conventional Preparations Liquid-Based Preparations Cell Block Fixation Techniques Air Drying Alcohol Fixation Transport Medium Staining Methods Papanicolaou Staining Romanowsky Staining Other Stains Ancillary Techniques Cytochemistry Immunocytochemistry Molecular Markers in Cytology Safety...27 References...28 Diagnostic interpretation of FNAC material Slide Background Cystic Background Inflammatory Background Necrotic Background Myxoid and Mucinous Background Lymphoid Background Other Background Features Cell Arrangement Clusters Sheets Single Cells Papillary Arrangement Other Features Cellular Features: the Nucleus Nuclear Size Nuclear Shape Position of the Nucleus Chromatin Pattern Number of Nuclei Nucleoli Mitoses...55

8 X 3.4 Cellular Features: Cytoplasm Relative Amount Quality and Contents Shape and Definition Criteria of Malignancy Cytology Report...57 References...58 Diagnostic Dilemmas in FNAC Practice: Cystic Lesions Cysts in the Neck Thyroglossal Duct Carcinoma Branchial Cleft Cysts Salivary Gland Lesions Lymphoepithelial Cysts Cystadenolymphoma Acinic Cell Carcinoma Pleomorphic Adenoma Dermoid Cyst Thyroid Cysts The Lymph Nodes Parathyroid Cysts Cysts of the Jaw Teratoid Cyst Cysts in the Abdomen Cystic Lesions of the Pancreas Cystic Lesions of the Liver Adrenal and Renal Cystic Lesions Cystic Lesions of the Peritoneum Thoracic Cysts Breast Cysts Other Cysts and Artefacts...82 References...85 Diagnostic Dilemmas in FNAC Practice: Lymphoid Infiltrates Granulomatous Infiltrates Tuberculous Lymphadenitis Sarcoidosis Kikuchi-Fujimoto Disease Cat-Scratch Disease Leishmania Lymphadenitis Kimura s disease Sinus Histiocytosis with Massive Lymphadenopathy Foreign-Body Granulomatous Inflammatory Response Malignant Lymphomas Lymphoid Infiltrates in Extranodal Sites Lymphoid Infiltrates in the Thyroid Lymphoid Processes in the Salivary Gland Lymphoid Infiltrates of the Orbit Lymphoid Lesions in the Breast Neoplasms Containing Lymphocytes Dilemmas in the Cytological Diagnosis of Lymphomas Solid Neoplasms Containing Lymphocytes References Diagnostic Dilemmas in FNAC Practice: Metastatic Tumours Metastatic Carcinomas Establishing the Diagnosis of Malignancy Determining the Nature of the Tumour Finding the Primary Tumour The Role of Imaging in the FNAC of Metastases Metastases of Non-Epithelial Tumours References Diagnostic Dilemmas in FNAC Cytology: Small Round Cell Tumours Small Round Cell Tumours of Childhood Ewing s Sarcoma/Primitive Neuroectodermal Tumour Neuroblastoma Ganglioneuroblastomas...136

9 XI Rhabdomyosarcoma Acute Lymphoblastic Leukaemia and LBL Small Round Cell Tumours of Kidney Hepatoblastoma Pleuropulmonary Blastoma Small-Cell Synovial Sarcoma Small Round Cell Tumours in Adults Desmoplastic Small Round Cell Tumour Small-Cell Carcinoma of the Lung Burkitt s Lymphoma Lymphoglandular Bodies Merkel Cell Carcinoma Olfactory Neuroblastoma References Diagnostic Dilemmas in FNAC Cytology: Soft-Tissue Lesions Introduction Spindle-Cell Lesions Spindle-Cell Lesions of the Lung Spindle-Cell Lesions of the Salivary Gland Spindle-Cell Lesions of the Breast Myofibrosarcoma Myxoid and Chondroid Lesions Low-Grade Fibromyxoid Sarcoma Leiomyosarcoma Ossifying Fibromyxoid Tumour Myxoid Mucinous Neoplasms Intramuscular Myxoma Chondrosarcoma Chondroblastoma Pseudosarcomatous Lesions Nodular Fasciitis Nodular Myositis Proliferative Fasciitis and Myositis Fibromatoses Fibrous histiocytoma Pseudoangiomatous Stromal Hyperplasia Pleomorphic Lipoma Atypical Lipoma Spindle-Cell Lipoma Ancient Schwannoma Angioleiomyoma Calcifying Aponeurotic Fibroma Lipomatous Haemangiopericytoma Tumours of Low or Borderline Malignancy Dermatofibrosarcoma Protuberans Haemangiopericytoma Acral Myxoinflammatory Fibroblastic Sarcoma Soft-Tissue Deposits of Non-Sarcomatous Lesions Malignant Lymphoma and Leukaemia Calcinosis Cutis Sarcomas Mimicking Other Lesions Epithelioid Sarcoma Metastatic Soft-Tissue Sarcomas Well-Differentiated Liposarcoma Rare and Difficult Sarcomas Alveolar Soft-Part Sarcoma Angiosarcoma Kaposi s Sarcoma Clear-Cell Sarcoma of Soft Parts Haemangioendothelioma Giant-Cell Fibroblastoma Rhabdomyosarcoma Synovial Sarcoma References Diagnostic Dilemmas in FNAC Cytology: Difficult Breast Lesions Fibroadenoma Papillary Lesions Apocrine Changes Mucinous Lesions Lobular Carcinoma In Situ or Invasive Carcinoma? Rare Lesions...202

10 XII Radial Scar/Complex Sclerosing Lesion Collagenous Spherulosis Ductal Adenoma Gynaecomastia Spindle-Cell and Mesenchymal Lesions of the Breast Pseudoangiomatous Stromal Hyperplasia Metaplastic Tumours Secretory Carcinoma Tumoral Calcinosis Clear-Cell Hidradenoma Tubular Adenoma Adenomyoepithelioma Squamous Cells Inflammatory Myofibroblastic Tumour FNAC or core biopsy? Radiation Changes References Principles of Safe Practice: the Role of FNAC in Clinical Management FNAC Breast Lesions FNAC Thyroid FNAC Head and Neck Conditions FNAC Lymph Nodes FNAC Adrenal and Kidney FNAC Gastrointestinal Tract FNAC Soft Tissue FNAC Bone FNAC in Children Transrectal Digitally Guided FNAC FNAC in Gynaecology Diagnostic Accuracy and Cost-Effectiveness of FNAC References Principles of Safe FNAC Practice: FNAC versus Core Biopsy Breast Lesions Lung Lesions Hepatic Lesions Abdominal Lesions Prostate Cancer Thyroid Lesions Gynaecological Lesions Soft-Tissue Lesions Skeletal Lesions Summary References Principles of Safe FNAC Practice: Medicolegal Issues References Subject Index FNAC for HIV-Related Lesions...219