Cytology for the Endocrinologist. Nicole Massoll M.D
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1 Cytology for the Endocrinologist Nicole Massoll M.D
2 Objectives Discuss slide preperation Definitions of adequacy ROSE (Rapid On-Site Evaluation)
3 Thyroid Cytology Adequacy Nicole Massoll M.D. University of Arkansas for Medical Sciences
4 Supplies for Preparation Glass slides labeled with pencil Fixative for Pap Air dried slides Stains (Diff Quick) Preservative for rinse (formalin or Cytolyt) Requisition form
5 Supplies for Preparation Glass slides labeled with pencil Fixative for Pap and air dried slides Stains (Diff Quick) Preservative (formalin of Cytolyt)
6 Different Preparations Direct Smear- can be done like a peripheral blood smear or book technique. Cytospin-Centrifugation of needle washings onto a slide, to concentrate material. Cell Block-Needle washing is spun down and clotted to embed and cut like tissue.
7 Fixation Techniques Air drying- Cells tend to spread out as they air dry, introducing some distortion. This method is used for Diff-Quick and Wright- Geimsa stains. Alcohol fixed (dip or spray)- Preserves the cytomorphologic detail. Ideal for Pap or H&E stains.
8 Different Stains Diff-Quick- A simplified H&E. Similar to Wright- Geimsa in Hematology. Cytoplasm is pink; nuclei are purple. Good for nuclear size and shape. Need air-dried slides.
9 Different Stains Papanicolaou- Cytoplasm is pink-orange to green-gray; nuclei are purple to blue. Good for nuclear detail. Need alcohol fixed slides.
10 Different Stains Hematoxylin and Eosin(H&E)- Classic tissue stain for cell block material. Cytoplasm is pink; nuclei are purple. fixed or paraffin embedded material.
11 The Diff-Quick First - 95% alcohol Second - Orange G Third - Hematoxylin
12 Slide Prep Place a small drop of the sample onto the slide.
13 Slide Prep Place a second slide onto of the specimen.
14 Slide Prep Let capillary action spread the sample out over the slides.
15 Slide Prep Pull the slide apart like opening a book.
16 Slide Prep A set of mirror image slides will have created.
17 Smear Prep
18 Smear Prep
19 Smear Prep
20 Smear Prep
21 Smear Prep
22 Liquid Cytology The FNA sample is collected and it is deposited into a bottle of preservative solution The solution then gets sent to the Lab In the lab, the liquid is treated to remove other elements before a layer of cells is suctioned by a machine to transfer cells to a slide (fully automated) The slides are then stained (PAP) and evaluated under the microscope
23 Liquid base sides
24 Slides
25 Molecular vials Affirma- 2 dedicated passes Interpace 1 dedicated pass
26 Adequacy Adequacy is assessed on the air dried slides (Diff Quick). Cellularity Cell types Colloid Architecture
27 Definitions of Adequacy The Papanicolaou Society of Pathology defines an adequate thyroid FNAB as: Six to eight groups of well-preserved follicular cells (10 or more cells per group)»or Six groups of follicular cells on at least two slides from separate passes with a minimum of 10 clusters of follicular cells (20 cells/cluster) ( Papanicolaou Society of Cytopathology Task Force. Diagn Cytopathol )
28 Follicular Cells
29 Hurthle Cells
30 Colloid
31 Macrophages
32 What Is Needed for ROSE Patient sample on immediately prepared slides Diff Quick stains Microscope Ability to recognize and count follicular cell and hurthle cell clusters
33 Sample
34 Other Slide Prep
35 Other Tests
36 Diff Quik Stain
37 Cellularity Six to eight groups of well-preserved follicular cells (10 or more cells per group)
38 Microscope 4x, 10x, 20x or 40x objective No 100 or oil objectives
39 Billing for ROSE The billing code is for the first pass and for each subsequent pass in the same nodule. Documentation must exist stating what was seen on each pass an if it was adequate or not. CMS has declared that NO CLIA license is required for this procedure. CMS considers cytology in the Surveyor Interpretive Guidelines on the CMS/CLIA web site at: at
40 Bethesda Reporting for Thyroid Cytopathology
41 The Bethesda System for Reporting Thyroid Cytopathology: Recommended Diagnostic Categories* I. Nondiagnostic or Unsatisfactory Cyst fluid only, Virtually acellular specimen, Other (obscuring blood, clotting artifact, etc) II. Benign Consistent with a benign follicular nodule (includes adenomatoid nodule, colloid nodule, etc) Consistent with lymphocytic (Hashimoto) thyroiditis in the proper clinical context Consistent with granulomatous (subacute) thyroiditis III. Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance IV. Follicular Neoplasm or Suspicious for a Follicular Neoplasm Specify if Hürthle cell (oncocytic) type V. Suspicious for Malignancy Suspicious for papillary carcinoma Suspicious for medullary carcinoma Suspicious for metastatic carcinoma Suspicious for lymphoma VI. Malignant Papillary thyroid carcinoma Poorly differentiated carcinoma Medullary thyroid carcinoma Undifferentiated (anaplastic) carcinoma Squamous cell carcinoma Carcinoma with mixed features (specify) Metastatic carcinoma Non-Hodgkin lymphoma * Adapted with permission from Ali and Cibas.3
42 The Bethesda System for Reporting Thyroid Cytopathology: Implied Risk of Malignancy and Recommended Clinical Management Diagnostic Category Risk of Malignancy (%) Usual Management Nondiagnostic or Unsatisfactory 1-4 Repeat FNA with ultrasound Benign 0-3 Clinical follow-up Atypia of Undetermined Significance or Follicular Lesion ~5-15 Repeat FNA of Undetermined Significance Follicular Neoplasm or Suspicious for a Follicular Neoplasm Surgical lobectomy Suspicious for Malignancy Near-total thyroidectomy or surgical lobectomy Malignant Near-total thyroidectomy FNA, fine-needle aspiration. * Adapted with permission from Ali and Cibas.3 Actual management may depend on other factors (eg, clinical, sonographic) besides the FNA interpreta on. Es mate extrapolated from histopathologic data from pa ents with repeated atypicals. In the case of Suspicious for metastatic tumor or a Malignant interpretation indicating metastatic tumor rather than a primary thyroid malignancy, surgery may not be indicated.
43 Other Diagnostic Schemes Diagnostic Category Diagnostic Category Nondiagnostic or Unsatisfactory Benign Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance Follicular Neoplasm or Suspicious for a Follicular Neoplasm Suspicious for Malignancy Malignant Nondiagnostic or Unsatisfactory Benign Indeterminate Suspicious for Malignancy Malignant
44 Unsatisfactory / Non-diagnsotic Cyst fluid Acellular Blood only Foreign material
45 Colloid only Unsatisfactory Features Blood only Macrophages only
46 Benign Hyperplastic nodule Lymphocytic thyroiditis (Hashimotos or Graves) Granulomatous thyroiditis (Reidels) Acute thyroiditis
47 Benign Features Follicular cells Colloid
48 Lymphocytic Thyroiditis Flollicular cells Hurthle cells Variable colloid Lymphocytes
49 Lymphocytic Thyroiditis Features Lymphocytes Follicular cells Hurthle cells
50 Atypia of Undetermined Significance or Follicular of Undetermined Significance Too few cells to make a definitive diagnosis Only a single feature of a diagnosis Ex: rare grooves only Ex: cyst lining cells Ex: Hurthle cell atypia
51 Follicular Neoplasm or Suspicious for a Follicular Neoplasm This can include: Follicular adenoma Follicualr carcinoma Hurthle cell adenoma Hurthle cell carcinoma Rare hyperplastic nodules
52 Features Hurthle cells Microfollicles
53 Follicular Neoplasm or Suspicious for a Follicular Neoplasm Cellular follicular lesion Cellular hurthle cell lesion Both can have nuclear pleomorphism Over lapping nuclei Microfollicular pattern Scant colloid
54 Follicular Neoplasm or Suspicious for a Follicular Neoplasm Features
55 Suspicious for Malignancy Suspicious for: papillary carcinoma medullary carcinoma metastatic carcinoma lymphoma
56 Suspicious for Malignancy Insufficient features to be definitive Some times can be confirmed with flow cytometry, immunohistochemistry Ex: Calcitonin for medullary Ex: Flow for lymphoma
57 Malignant Papillary thyroid carcinoma Poorly differentiated carcinoma Medullary thyroid carcinoma Undifferentiated (anaplastic) carcinoma Squamous cell carcinoma Metastatic carcinoma Non-Hodgkin lymphoma
58 Papillary Thyroid Carcinoma Enlarged follicular cells Nuclear pseudo-inclusions Nuclear grooves Psammoma bodies
59 Papillary Thyroid Carcinoma
60 Medullary Thyroid Carcinoma Originates from C-cells Salt and Pepper neuroendocrine nuclei Abundant granular cytoplasm Multinucleation More discohesive Plasmacytoid, follicular or spindled
61 Follicular carcinoma Back to back follicles Overlapping nuclei Scant colloid Invasion through capsule Lymphovascular space involvement Hurthle or follicular type CAN ONLY BE DIAGNOSED ON SURGICAL PATHOLOGY
62 Follicular Carcinoma
63 Medullary Thyroid Carcinoma
64 Anaplastic Thyroid Carcinoma Pleomorphic atypical cells. Differential diagnosis is metastatic carcinoma.
65 Lymphoma Abundant discohesive cells Flow cytometry is needed
66 Correlation of US, Cytology and Histology
67 Case 1 A 34 year-old female with a 1.2 cm complex left thyroid nodule.
68 Ultrasound Findings
69 Findings Case 1 Pathology: Abundant thin watery colloid, sheets of bland follicular cells with round nuclei Dx: Colloid nodule Ultrasound: Centrally isoechoic with a hypoechoic periphery; areas suggestive of comet tails and minimal posterior enhancement
70 Case 1 Cytology
71 Histologic Features case 1
72 Case 2 41 year-old female with a right midpole heterogeneous nodule.
73 Case 2
74 Case 2 Cytology
75 Histologic Features Case 2
76 Findings Case Pathology: Follicular cells, hurthle cells, lymphocytes, variable colloid Dx Hashimoto s Thyroiditis Ultrasound: Looks like smudgy finger prints (hypo and hyperechoic), hyperechoic septae
77 Case 3 A 51 year-old female with a 2.7 cm right complex thyroid nodule.
78 Case 3
79 Case 3
80 Findings Case 3 Pathology: Follicular cells, macrophages and colloid Dx: Cystic degeneration of a benign nodule Ultrasound: Hypoechoic center, isoechoic lesion, smooth margins, peripheral blood flow, posterior enhancement
81 Case 4 A 62 year-old female with a right 1.7 cm nodule with dystrophic calcifications.
82 Case 4
83 Case 4
84 Histology 4
85 Findings Case 4 Pathology Scant colloid Bland follicular cells in a microfollicular pattern Dx Indeterminate cytology Surgical pathology: Follicular adenoma Ultrasound Isoechoic, halo, thick band of calcifications in fibrotic areas, demonstrates posterior shadowing
86 Case 5 An 80 year-old female with a right superior 1.3 cm thyroid nodule with comet tail effect.
87 Case 5
88 Cytology 5
89 Histology 5 Pathology: Follicular cells, abundant colloid Benign multinodular goiter Ultrasound: Hypoechoic with bright comet tails which represent colloid
90 Case 6 19 year-old female with a right level IV cystic lymph node.
91 Case 6
92 Case 6
93 Case 6 Histology
94 Findings Case 6 Pathology: Follicular cells with grooves are rare pseudoinclusion and colloid Ultrasound: Rounded, cystic lymph node
95 Case 7 A 60 year-old female with a 1.0 cm hypoechoic left inferior thyroid nodule with microcalcifications.
96 Case 7
97 Case 7
98 Histologic Features Case
99 Findings case 7 Cytology: Elongated follicular cells with grooves and pseudoinclusions Dx: Papillary thyroid carcinoma Ultrasound: Hypoechoic, microcalcifications, irregular margins
100 QUESTIONS
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