Cytology for the Endocrinologist Nicole Massoll M.D
Objectives Discuss slide preperation Definitions of adequacy ROSE (Rapid On-Site Evaluation)
Thyroid Cytology Adequacy Nicole Massoll M.D. University of Arkansas for Medical Sciences
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
Supplies for Preparation Glass slides labeled with pencil Fixative for Pap and air dried slides Stains (Diff Quick) Preservative (formalin of Cytolyt)
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.
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.
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.
Different Stains Papanicolaou- Cytoplasm is pink-orange to green-gray; nuclei are purple to blue. Good for nuclear detail. Need alcohol fixed slides.
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.
The Diff-Quick First - 95% alcohol Second - Orange G Third - Hematoxylin
Slide Prep Place a small drop of the sample onto the slide.
Slide Prep Place a second slide onto of the specimen.
Slide Prep Let capillary action spread the sample out over the slides.
Slide Prep Pull the slide apart like opening a book.
Slide Prep A set of mirror image slides will have created.
Smear Prep
Smear Prep
Smear Prep
Smear Prep
Smear Prep
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
Liquid base sides
Slides
Molecular vials Affirma- 2 dedicated passes Interpace 1 dedicated pass
Adequacy Adequacy is assessed on the air dried slides (Diff Quick). Cellularity Cell types Colloid Architecture
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. 1997.)
Follicular Cells
Hurthle Cells
Colloid
Macrophages
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
Sample
Other Slide Prep
Other Tests
Diff Quik Stain
Cellularity Six to eight groups of well-preserved follicular cells (10 or more cells per group)
Microscope 4x, 10x, 20x or 40x objective No 100 or oil objectives
Billing for ROSE The billing code is 88172 for the first pass and 88177 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: www.cms.hhs.gov/clia at 493.1274
Bethesda Reporting for Thyroid Cytopathology
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
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 15-30 Surgical lobectomy Suspicious for Malignancy 60-75 Near-total thyroidectomy or surgical lobectomy Malignant 97-99 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.
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
Unsatisfactory / Non-diagnsotic Cyst fluid Acellular Blood only Foreign material
Colloid only Unsatisfactory Features Blood only Macrophages only
Benign Hyperplastic nodule Lymphocytic thyroiditis (Hashimotos or Graves) Granulomatous thyroiditis (Reidels) Acute thyroiditis
Benign Features Follicular cells Colloid
Lymphocytic Thyroiditis Flollicular cells Hurthle cells Variable colloid Lymphocytes
Lymphocytic Thyroiditis Features Lymphocytes Follicular cells Hurthle cells
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
Follicular Neoplasm or Suspicious for a Follicular Neoplasm This can include: Follicular adenoma Follicualr carcinoma Hurthle cell adenoma Hurthle cell carcinoma Rare hyperplastic nodules
Features Hurthle cells Microfollicles
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
Follicular Neoplasm or Suspicious for a Follicular Neoplasm Features
Suspicious for Malignancy Suspicious for: papillary carcinoma medullary carcinoma metastatic carcinoma lymphoma
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
Malignant Papillary thyroid carcinoma Poorly differentiated carcinoma Medullary thyroid carcinoma Undifferentiated (anaplastic) carcinoma Squamous cell carcinoma Metastatic carcinoma Non-Hodgkin lymphoma
Papillary Thyroid Carcinoma Enlarged follicular cells Nuclear pseudo-inclusions Nuclear grooves Psammoma bodies
Papillary Thyroid Carcinoma
Medullary Thyroid Carcinoma Originates from C-cells Salt and Pepper neuroendocrine nuclei Abundant granular cytoplasm Multinucleation More discohesive Plasmacytoid, follicular or spindled
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
Follicular Carcinoma
Medullary Thyroid Carcinoma
Anaplastic Thyroid Carcinoma Pleomorphic atypical cells. Differential diagnosis is metastatic carcinoma.
Lymphoma Abundant discohesive cells Flow cytometry is needed
Correlation of US, Cytology and Histology
Case 1 A 34 year-old female with a 1.2 cm complex left thyroid nodule.
Ultrasound Findings
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
Case 1 Cytology
Histologic Features case 1
Case 2 41 year-old female with a right midpole heterogeneous nodule.
Case 2
Case 2 Cytology
Histologic Features Case 2
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
Case 3 A 51 year-old female with a 2.7 cm right complex thyroid nodule.
Case 3
Case 3
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
Case 4 A 62 year-old female with a right 1.7 cm nodule with dystrophic calcifications.
Case 4
Case 4
Histology 4
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
Case 5 An 80 year-old female with a right superior 1.3 cm thyroid nodule with comet tail effect.
Case 5
Cytology 5
Histology 5 Pathology: Follicular cells, abundant colloid Benign multinodular goiter Ultrasound: Hypoechoic with bright comet tails which represent colloid
Case 6 19 year-old female with a right level IV cystic lymph node.
Case 6
Case 6
Case 6 Histology
Findings Case 6 Pathology: Follicular cells with grooves are rare pseudoinclusion and colloid Ultrasound: Rounded, cystic lymph node
Case 7 A 60 year-old female with a 1.0 cm hypoechoic left inferior thyroid nodule with microcalcifications.
Case 7
Case 7
Histologic Features Case
Findings case 7 Cytology: Elongated follicular cells with grooves and pseudoinclusions Dx: Papillary thyroid carcinoma Ultrasound: Hypoechoic, microcalcifications, irregular margins
QUESTIONS