Case-based Approach in Exfoliative Cytology Pranab Dey
INDEX
Page numbers followed by f refer to figure and t refer to table
A
Acid fast bacilli 291
Acinic cell carcinoma 2
Actinomyces, presence of 115
Actinomycosis 75
Adenocarcinoma 64, 79, 81, 140, 147, 175t, 189, 241, 243, 244, 245, 246, 251, 255, 266, 321
cervix 83
extrauterine 83
Adrenocortical adenoma 2
Amorphous globules 3
Anaplastic
large cell 16
lymphoma kinase 190
Anemia 308, 314
Angiomyolipoma 2
Apocrine cells 22
Artifactual nuclear vacuolation 27
Aspergillosis 327
Aspergillus infection 134, 174
Atrophic smear 38, 63, 113, 339, 348
B
Bacille calmette-guerin 276
granuloma 325
Bacilli positive 351
Back pain 306
Bacterial vaginosis 41, 75
Barrett's esophagus 255
Basal cell 93
Bethesda system 94, 31
Bile duct, adenocarcinoma of 257
Bladder
stone in 282
tumor of 266
tumors, malignant 264
Bleeding gum 308, 314
Bone marrow 312
Brain
primary tumor of 311
tumor, primary 300, 305
Breast 159
carcinoma 313
metastatic 305, 313
of left 305
Burkitt's lymphoma 141
C
Calcium crystal 25
Calretinin 127
Cancer cells 3
Candida infection 133, 173
Candidal esophagitis 245
Candidal infection 75, 134, 253, 255, 327
Carcinoid tumors 2
Cell
adequate number of 32
arrangement 1, 124
basal types of 33
cannibalism 12, 26
clusters of 35, 294
malignant 295
cohesive group of 33, 105
discrete large 298
in urine 267
intermediate 36, 93
loose clusters of 298, 313
malignant 128, 147, 243, 270, 282, 311
morphology 1
polyhedral shaped 298
reactive atypical 270
round 297
to oval 313
shape 2
typical glandular arrangement of 295
with abundant cytoplasm 297
with scanty cytoplasm 314
Central nervous system 300
lymphoma 300
tumor 301, 308
Cerebrospinal fluid 300
Cervical
cytology 31
intraepithelial neoplasia 33
lesion 108f, 353f
section of 119f, 121f
lymph nodes 277
Chemotherapy changes 267, 290
Chest pain 315
Chondroid material 3
Chondromyxoid material 25
Chondrosarcoma 6
Chordoma 6
Chromatin 3
Coarse chromatin 103
Coarse granular chromatin 265, 292, 295
Cohesive clusters 314
Colposcopy 338
Columnar appearance 350
Columnar cell 1, 22
Condensed chromatin 297
Consistent with sarcoma 289, 299
Corn flakes cell 69, 112
Cough 311, 315
Cryptococcal infection 307, 345
Crystals in gout 25
Cystitis 269, 273, 274, 276, 279, 280
Cytology
normal 340
smear, normal 320
Cytoplasm 2, 34, 35, 124, 314
moderate 354
of cells contain sperm head 298
D
Detrusor muscle invasion 296
Discrete cells 294, 297, 313
Disseminated peritoneal adenomucinosis 179
Duct papilloma 318
Ductal carcinoma, metastatic 159, 336
Dysgerminoma 137, 139, 170
infiltration by 143
Dysplasia 244, 245
mild 246
of duct epithelium 257
Dysplastic cells 321
E
Eccentric nuclei 297
Embryonal rhabdomyosarcoma 141
Empyema 129, 130, 157, 172
Endocervical adenocarcinoma 35
Endocervical cells 36, 93, 113
Endocervical component 95
Endometrial
adenocarcinoma 35
cells 34, 36, 87, 93, 102, 113
Eosinophilic effusion 130, 131
causes of 173t
Epidermal growth factor receptor 189
Epithelioid cell granuloma 291, 294, 351
Esophagus 241
Ewing's tumor 3
Eye tumor 307
F
Fat necrosis of breast 24
Fever
high 302
low-grade 304
Fiber cells 34, 69, 107, 111, 112, 359
Fine chromatin 27, 312
Flow cytometry 28
Foamy macrophages 22
Follicular carcinoma of thyroid 2
Foreign body giant cells 69, 112
Fusarium 293
Fusarium
moniliforme 293
oxysporum 293
Fusarium solani 293
G
Gastritis 252
chronic 256
Gastrointestinal
carcinoma 266
stromal tumor 242, 251, 256
tract 148, 241, 300
Genetic profile 189
Germ cell tumors 2
Giant cell 8
multinucleated 123
tumor of bone 8, 24
Glandular arrangement 1
Glandular cell 34
abnormality 34
atypical 34, 85, 89, 116
Glial fibrillary acidic protein 301
Glomeruloid body 25
Granulomatous inflammation 325
Granulosa cell tumor 2
Ground glass nuclei 123
Gum bleeding 302, 312
H
Headache 303, 304, 308, 310, 314
Hematological malignancies 126
Hemogram 312
Hepatocellular carcinoma 2, 132
Herpes simplex virus 110
Histoplasma infection 133, 169
Hodgkin lymphoma 7, 23
HPV infection 6, 23
Human immunodeficiency virus 312
Hyperchromasia 265, 294
moderate 291, 292
Hyperchromatic
enlarged nuclei 298
nuclei 290, 298
Hyper-eosinophilia 129
I
Immature cells
abundant 312
discrete 314
Inflammation
acute 129, 131, 134, 172, 306
chronic 246, 248, 254, 277, 319
Inflammatory cells 296
Intranuclear inclusion 3, 27, 123
Irregular clumped chromatin 3, 265
Irregular nuclear margin 26, 103, 290, 298, 312, 355, 359
Irregular nuclear membrane 265, 292, 295, 314
K
Koilocytes 123
Koilocytosis 33, 71, 355
L
Large cell 298
anaplastic tumor 191
carcinoma 191
neuroendocrine carcinoma 190
Leiomyoma 251
Leiomyosarcoma
case of 299
history of 296
Leishmania donovani 133
body 30
Leptomeninges, infective conditions of 300
Leucocyte common antigen 28
Leukemia 300
acute 169, 302, 304, 309, 312, 319
Lipoma, atypical 2
Liposarcoma 6
Liquid based cytology 32, 34, 96
Lobular carcinoma
metastatic 155, 159
of breast 2
Lung 191t, 311
left upper lobe of 311
tumors, classification of 188
Lymphoblastic lymphoma 17
Lymphocyte 302, 305, 312
rich effusion 128, 129, 130, 135, 141, 149, 158, 165, 167, 336
Lymphocytosis 303, 304, 306, 307, 308, 309, 312
Lymphoid
cells 3, 17, 294
hyperplasia, reactive 252
Lymphoma 158, 256, 300, 303, 305, 307, 310, 342
infiltration by 143
M
Mature lymphocytes 155
Medulloblastoma 301, 309, 314
Melanin containing cells 11, 25, 26
Mesothelial cell 22, 36, 93, 175t
Mesothelial proliferation, reactive 336
Metastatic adenocarcinoma 125, 128, 132, 135, 150, 152, 153, 157, 161, 164, 167, 174, 282, 296, 323, 342
Metastatic carcinoma 129, 130, 148, 158, 169, 302, 304, 306, 311, 323, 341, 345
Metastatic squamous cell carcinoma 152
Metastatic tumor 125, 300
Mitosis 3, 125
Monomorphic cells 1
Monomorphic lymphoid cells 294
Monomorphic nuclei 297
Mucinous 3
adenocarcinoma 137
carcinoma of breast 2
Mucormycosis 327
infection 134
Mucosa, normal 247
Muscle, normal smooth 251
Myeloid leukemia, acute 308, 314
Myeloma, multiple 306
N
Neoplastic causes of effusion 124
Neuroendocrine tumors 191t
Neurological symptoms 306
Non-Hodgkin lymphoma 132, 139, 145, 155, 170, 246, 252, 254, 277, 294, 300, 304, 341, 345
Nuclear
chromatin, clearing of 3
enlargement, mild 101
hyperchromasia 265, 295, 355
margin 2
pleomorphism 2, 294
Nucleocytoplasmic ratio, high 292
Nucleoli, absent 292
Nucleus 2, 125
O
Oval cells 296
P
Paget's disease 320
Painless hematuria 275, 279
Pancreas, adenocarcinoma of 254
Pancreatic adenocarcinoma 250
Pancreatic neuroendocrine tumor 250, 254
Pancreatitis, chronic 250
Papillary
clusters 2
of cells 2
neoplasm 320
Papilloma, inverted 280
Parabasal cell 93
Paraganglioma 2
Pepper 3, 27
Peripheral neuroectodermal tumor 145
Peritoneal implants 165
Peritoneal mucinous carcinomatosis 179
Plasma cell 3, 312, 313
atypical 313
neoplasm 136, 175
tumor 306, 313
Pleomorphic cell 34
Pleomorphic hyperchromatic nuclei 359
Pleomorphic lipoma 2
Pleomorphic nuclei 297, 314, 357
large moderately 313
mild to moderately 292
moderate 295
Pleomorphic nucleoli 291
Pleomorphic sarcoma 24
Pneumocystis carinii 340
Polygonal squamous cells 96
Prominent nucleoli 259, 350
Prostate specific antigen 280
Prostatic carcinoma, metastatic 161
Psammoma body 3, 26
Pseudomyxoma 168
peritonei 126, 147, 164, 331
R
Rectal carcinoma 296
Red cytoplasmic granules 97
Reinke's crystal 3
Renal cell carcinoma 2, 296
Respiratory
cytology 188
epithelial cell 22
Retinoblastoma 307, 314, 319
history of 314
Retroperitoneal lymph node 294
Rhabdomyosarcoma 7, 23, 145
Round cell tumor, metastatic 141
S
Salivary gland, carcinoma of 2
Sarcoma, metastatic 296
Schistosoma hematobium infection 266
Schwannoma, ancient 2
Seminal vesicle cells 267, 288, 290, 298
Sertoli cell tumor 3
Serum electrophoresis 306
Sex cord tumor 15
Signet ring
carcinoma, metastatic 149
cell carcinoma 163, 316
Single cells 1
Skeletal muscle 16
Small cell carcinoma 125, 190, 241, 266, 284, 297
metastatic 136, 150, 151, 153
Small immature atypical cells 102
Small inconspicuous nucleoli 291
Small nucleoli 34
Soft tissue
Ewings’ tumor 145
tumor 16
Sperm 322
head within cell 298
Spermatozoa 298
Spindle cell
abundant 296
tumor 283, 296
Spindle shaped pleomorphic nuclei 296
Squamous cell 22
abnormality 33
carcinoma, diagnosis of 294
adequacy of 94
atypical 33, 38, 42, 100, 105
insufficient 94
superficial 36, 93
carcinoma 7, 23, 34, 48, 61, 125, 189, 241, 243, 244, 245, 247, 253, 255, 266, 278, 287, 294, 298, 334, 339
Squamous intraepithelial lesion
high-grade 33, 42
low-grade 33, 42
Squamous metaplastic cells 102
Squamous pearl 71
Stomach 241
adenocarcinoma of 6, 23
Synaptophysin 266
Syncytial aggregates of cells 33
Synovial fluid 25
T
Tadpole cells 34, 107
Taenia solium 30
T-lymphoblastic lymphoma 141
Trichomonas vaginalis 30, 38, 41, 75, 95, 97, 322
Tubal metaplasia 59, 69, 112, 335
Tubal metaplastic cells 113
Tuberculosis 131, 139, 269, 291, 303, 310, 311, 315
Tuberculous effusion 163, 316
Tumor
cells 313, 314, 315
abundant dissociated 295
clusters of 34
discrete 299
diathesis 34, 71, 107, 111, 354, 359
dispersed 180
low risk 242
metastatic malignant 124
metastatic solid 300
U
Umbrella cells 267, 290
Urinary
bladder
adenocarcinoma of 285, 297
cancers of 264
fusariosis 293
Urine
cytological 277
cytology 264, 269
Urothelial carcinoma 296
Urothelial cell 22, 265, 267, 290, 295
atypia 268, 290
carcinoma
high-grade 265, 268
low-grade 265
atypical 265, 267, 278, 285, 290
cytomorphology of 294
discrete 295
high-grade 295
low-grade 295
normal 278
carcinoma 7, 23, 264, 274, 278, 280, 282, 287, 291, 292, 341
Urothelial neoplasm, classification of 264
V
Vesicular chromatin 3
Vimentin 127
Viral infection 61, 65, 243, 302, 309, 310, 312, 319
Visual inspection 338
W
World Health Organization 188
Wuchereria bancrofti, microfilaria of 30
Y
Yolk sac tumor 137, 170, 176
×
Chapter Notes

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General CytologyCHAPTER 1

 
Introduction
A thorough cytological evaluation is needed for the proper diagnosis of any lesion. The following data should be checked:
 
Cytological Data
  1. Cellularity
  2. Cell arrangement or distribution
  3. Cell morphology
  4. Background non cellular materials
 
Cellularity
Overall assessment of cellularity is an essential requirement of the initial step of screening of the slide. Malignant lesions usually show good amount of cells in the smear.
 
Cell Arrangement
The following arrangements may be seen:
Single cells: Dissociated single cells are commonly seen in lymphoma and poorly differentiated carcinoma.
Clusters: Three dimensional clusters of cells indicate loss of polarity. Cell clustering is seen in most of the carcinomas and sarcomas.
Sheet: Flat monolayer arrangements of the cell is known as sheets and are usually seen in benign conditions such as fibroadenoma, lymphocytic thyroiditis, mesothelial cells, etc.
Follicular pattern: In this pattern, the monomorphic cells are arranged regularly forming small follicles. Occasionally the central lumen of the follicles contains colloid in the aspirate from thyroid.
Glandular arrangement: Here the cuboidal to columnar cells are arranged in gland like pattern. Complete gland like structures and fragments of glands are often seen in adenocarcinomas.
2Rosettes: The cells in pseudorosette are arranged around central fibrillary structures. Cells are not attached with any basement membrane. This arrangement is commonly seen in neuroblastoma, peripheral neuroectodermal tumor, and retinoblastoma.
Papillary clusters: The cells are arranged as papillae like structure with central fibrovascular core. The peripheral cells in papillae are arranged perpendicularly to the axis of the papillae. Papillary clusters of cells are often present in papillary carcinoma of thyroid, breast, or renal cell carcinoma.
Fascicles: The cells are arranged in interwoven bundles. This pattern is commonly seen in leiomyosarcoma, fibrosarcoma, nerve sheath tumor and fibrous histiocytoma.
 
Individual Cell Morphology
Shape: Cell shape, cytoplasm and nucleus provide the very important information. The shape of the cell may be round, polygonal, spindle shaped or bizarre depending on the type of the lesion.
Cytoplasm: The following information of cytoplasm is needed for the diagnosis: volume of the cytoplasm, tinctorial character, vacuolation, cytoplasmic granularity, intracytoplasmic lumina, and cytoplasmic inclusions.
Nucleus: The following information about nuclei is helpful: nuclear size, shape, pleomorphism, margin, nucleoli, chromasia and chromatin pattern.
  • Nuclear pleomorphism: Variation of nuclear shape and size is known as pleomorphism. Nuclear pleomorphism is one of the most important features of malignancy. However the following malignant tumors show minimal pleomorphism:
    • Follicular carcinoma of thyroid
    • Adenoid cystic carcinoma of salivary gland
    • Acinic cell carcinoma
    • Lobular carcinoma of breast
    • Mucinous carcinoma of breast
    • Carcinoid tumors.
      Similarly the following benign tumors may show marked pleomorphism:
    • Pleomorphic lipoma
    • Atypical lipoma
    • Ancient schwannoma
    • Paraganglioma
    • Angiomyolipoma
    • Adrenocortical adenoma.
  • Nucleoli: Multiple, enlarged and pleomorphic nuclei indicate malignancy. Macronucleoli are usually seen in malignant melanoma, hepatocellular carcinoma, and germ cell tumors. However, large nucleoli are also seen in chronic inflammation and radiation exposure or post chemotherapy.
  • Nuclear margin: Nuclear margin irregularity is seen in majority of cancer cells. Deep longitudinal nuclear groove is the characteristic feature of Langerhans cell histiocytosis, papillary carcinoma of thyroid, and granulosa cell tumor of ovary.
  • 3Chromatin pattern: Abnormal chromatin pattern is possibly one of the most important criteria of malignancy.
    • Irregular clumped chromatin: Most of the malignancy.
    • Salt and pepper like chromatin: Peripheral neuroectodermal tumor, Ewing's tumor and carcinoid.
    • Vesicular chromatin: Adenocarcinomas.
    • Fine chromatin pattern: Leukemia, adenocarcinoma and many lymphoma cases.
    • Cartwheel appearance of chromatin: Plasma cells and the neoplasm arising from the plasma cells.
    • Clearing of nuclear chromatin: Papillary carcinoma of thyroid.
  • Intranuclear inclusion: Intranuclear pseudoinclusions are the protrusion of the cytoplasm within the cell nucleus. Intranuclear inclusion is often seen in papillary carcinoma of thyroid, melanoma, and bronchoalveolar carcinoma.
  • Mitosis: Frequent mitosis is seen in majority of malignant tumors. However, increased number of mitotic activity may also be seen in reactive lymphoid hyperplasia and regenerative condition. Qualitative abnormality of mitosis such as tripolar or multipolar mitosis is the more important characteristic feature of cancer cells.
 
Background of the Smear
The following background information is helpful in diagnosis:
  • Mucinous: Mucinous adenocarcinoma
  • Tigroid: Seminoma/dysgerminoma, rhabdomyosarcoma
  • Fat: Lipomatous tumor, fat necrosis
  • Myxoid: Myxoma, pleomorphic adenoma, chordoma
  • Chondroid material: Cartilaginous tumor
  • Colloid: Colloid goitre
  • Necrosis: Tumor necrosis, inflammation
  • Lymphoglandular bodies: Lymphoid cells
  • Psammoma body: Papillary carcinoma of thyroid, meningioma, serous adenocarcinoma of ovary
  • Amorphous globules: Collagenous spherulosis
  • Reinke's crystal: Sertoli cell tumor.
4QUESTIONS
Problem 1.1
Match the following (Fig. 1.1)
A.
1. Squamous cell
B.
2. Respiratory epithelial cells
C.
3. Columnar cell
D.
4. Urothelial cell
zoom view
Figures 1.1A to D:
5Problem 1.2
Match the following (Fig. 1.2)
A.
1. Apocrine cell
B.
2. Foamy macrophages
C.
3. Hepatocytes
D.
4. Mesothelial cell
zoom view
Figures 1.2A to D:
6Problem 1.3
Match the following (Fig. 1.3)
A.
1. Adenocarcinoma of stomach
B.
2. Chordoma
C.
3. Liposarcoma
D.
4. Chondrosarcoma
E.
5. HPV infection
zoom view
Figures 1.3A to E:
7Problem 1.4
Match the following (Fig. 1.4)
A.
1. Hodgkin lymphoma
B.
2. Squamous cell carcinoma
C.
3. Urothelial cell carcinoma
D.
4. Rhabdomyosarcoma
zoom view
Figures 1.4A to D:
8Problem 1.5
Match the following (Fig. 1.5)
A.
1. Fat necrosis of breast
B.
2. Megakaryocyte in normal bone marrow
C.
3. Giant cell tumor of bone
D.
4. Pleomorphic sarcoma with tumor giant cell
zoom view
Figures 1.5A to D:
9Problem 1.6
Match the following (Fig. 1.6)
A.
1. Rosettes
B.
2. Glomeruloid body
C.
3. Microfollicles
D.
4. Papillae
E.
5. Vertebroid appearance
zoom view
Figures 1.6A to E:
10Problem 1.7
Match the following (Fig. 1.7)
A.
1. Calcium crystal
B.
2. Necrosis
C.
3. Chondromyxoid material
D.
4. Mucinous material
E.
5. Synovial fluid
zoom view
Figures 1.7A to E:
11Problem 1.8
Match the following (Fig. 1.8)
A.
1. Psammoma body
B.
2. Crystals in gout
C.
3. Melanin containing cells in dermatopathic lymphadenitis
D.
4. Melanin containing cells in melanoma
zoom view
Figures 1.8A to D:
12Problem 1.9
Match the following (Fig. 1.9)
A.
1. Micronucleus
B.
2. Emperipolesis
C.
3. Cell cannibalism
zoom view
Figures 1.9A to C:
13Problem 1.10
Match the following (Fig. 1.10)
A.
1. Artifactual nuclear vacuolation
B.
2. Irregular nuclear margin
C.
3. Intranuclear inclusion
zoom view
Figures 1.10A to C:
14Problem 1.11
Match the following (Fig. 1.11)
A.
1. Clumped chromatin
B.
2. Cartwheel
C.
3. Fine chromatin
D.
4. Salt and pepper
zoom view
Figures 1.11A to D:
15Problem 1.12
Match the following (Fig. 1.12)
A. Inhibin
1. Adenocarcinoma of lung
B. Mic 2
2. Carcinoma of colon
C. Napsin
3. Peripheral neuroectodermal tumor
D. CK 20
4. Sex cord tumor of ovary
zoom view
Figures 1.12A to D:
16Problem 1.13
Match the following (Fig. 1.13)
A. Desmin
1. Anaplastic large cell lymphoma
B. Vimentin
2. Hodgkin's lymphoma
C. CD 15
3. Histiocyte
D. ALK
4. Any soft tissue tumor
E. CD 68
5. Adenocarcinoma lung
F. CK 7
6. Skeletal muscle
zoom view
Figures 1.13A to F:
17Problem 1.14
Match the following (Fig. 1.14)
A.
1. B cell lymphoma
B.
2. All lymphoid cells express
C.
3. Lymphoblastic lymphoma
D.
4. Light chain restriction
zoom view
Figures 1.14A to D:
18Problem 1.15
Match the following (Fig. 1.15)
1.
A. Heterochromatin
2.
B. Mitochondria
3.
C. Euchromatin
4.
D. Rough endoplasmic reticulum
5.
E. Nuclear pore
zoom view
Figure 1.15:
19Problem 1.16
Match the following (Fig. 1.16)
A.
1. Nocardia
B.
2. Candia
C.
3. Aspergillosis
D.
4. Mucormycosis
zoom view
Figures 1.16A to D:
20Problem 1.17
Match the following (Fig. 1.17)
A.
1. Trichomonas vaginalis
B.
2. Leishmania donovani body
C.
3. Cryptococci
D.
4. Histoplasma
zoom view
Figures 1.17A to D:
21Problem 1.18
Match the following (Fig. 1.18)
A.
1. Microfilaria
B.
2. Hydatid
C.
3. Actinomycosis
D.
4. Cysticercosis
zoom view
Figures 1.18A to D:
22ANSWERS
Problem 1.1
A.
2. Respiratory epithelial cells
B.
3. Columnar cell
C.
1. Squamous cell
D.
4. Urothelial cell
 
Discussion
Respiratory epithelial cell: These are ciliated columnar epithelial cells. The cilia are usually shredded out in neoplastic cells and therefore the presence of cilia eliminates the possibility of neoplastic pathology.
Columnar cell: Tall columnar cell is characterized by basally placed nuclei.
Squamous cell: These are polyhedral cells with centrally placed nuclei.
Urothelial cell: These are also stratified columnar cells and form the transitional epithelial cell layer of the urinary tract.
Problem 1.2
A.
3. Hepatocytes
B.
4. Mesothelial cell
C.
1. Apocrine cell
D.
2. Foamy macrophages
 
Discussion
Hepatocytes: Polygonal cells with central round nuclei. The presence of bile pigments indicates the cell as hepatocyte.
Mesothelial cell: This cell is characterized by monolayer sheet of cells with window pattern in between the cells.
Apocrine cells: The cells show abundant eosinophilic cytoplasm with central monomorphic nuclei.
Foamy macrophages: The cell contains abundant cytoplasm with phagocytosed material that often obscures the nuclear details.
Problem 1.3
A.
2. Chordoma
B.
3. Liposarcoma
C.
5. HPV infection23
D.
1. Adenocarcinoma of stomach
E.
4. Chondrosarcoma
 
Discussion
Chordoma: The Figure 1.3A shows physaliferous cells of chordoma. The cells contain abundant bubbly cytoplasm with centrally placed round nuclei.
Liposarcoma: The Figure 1.3B shows lipoblast of liposarcoma. The cells show vacuolated cytoplasm with central nuclei. The vacuoles often indent the nuclear margin.
HPV infection: The Figure 1.3C shows classical koilocytes of low grade squamous intraepithelial lesion (LSIL) case. The cells show enlarged central nuclei with perinuclear halo. The cytoplasmic margin of the halo is thick. Koilocytes is seen in HPV infection.
Adenocarcinoma of stomach: The Figure 1.3D shows signet ring cell of adenocarcinoma of stomach. The cell shows abundant vacuolated cytoplasm with eccentric enlarged nuclei.
Chondrosarcoma: The Figure 1.3E shows chondrocytes of chondrosarcoma. The cell is large with abundant reddish blue cytoplasm and enlarged nucleus.
Problem 1.4
A.
3. Urothelial cell carcinoma
B.
4. Rhabdomyosarcoma
C.
1. Hodgkin lymphoma
D.
2. Squamous cell carcinoma
 
Discussion
Urothelial cell carcinoma: Figure 1.4A shows cercariform cells. It is seen in urothelial cell carcinoma. The particular word “cercaria” is derived from Greek word “kerkos” that means tail. The cell has a globular nucleus in one end with long cytoplasmic tail like process. This is not an artefact due to the smear preparation. These cells are not specific for urothelial cell carcinoma; however the presence of more than 20 cercariform cells in a single case indicates urothelial cell carcinoma.
Rhabdomyosarcoma: The (Fig. 1.4B) strap cell is noted in rhabdomyosarcoma. The cell has eccentric nuclei with abundant eosinophilic cytoplasm with striation that can be seen in careful examination.
Hodgkin lymphoma: The Figure 1.4C shows classical Reed Sternberg (R-S) cell. The cell has two enlarged nuclei which are mirror image of each other. Each nucleus contains a large prominent nucleoli. Many cells may simulate R-S cells such as cells in melanoma, nasopharyngeal carcinoma, anaplastic large cell lymphoma, etc.
Squamous cell carcinoma: The Figure 1.4D shows tadpole cells which is seen in squamous cell carcinoma. The cell is elongated with a hyperchromatic nucleus in one end and elongated orangeophilic cytoplasm in the other end.
 
24Further Reading
  1. Dey P, Amir T, Jogai S, Al Jussar A. Fine needle aspiration cytology of metastatic transitional cell carcinoma. Diagn Cytopathol. 2005;32:226–8.
  1. Hida CA, Gupta PK. Cercariform cells: are they specific for transitional cell carcinoma? Cancer. 1999;87:69–74.
 
Problem 1.5
A.
3. Giant cell tumor of bone
B.
4. Pleomorphic sarcoma with tumor giant cell
C.
2. Megakaryocyte in normal bone marrow
D.
1. Fat necrosis of breast
 
Discussion
Giant cell tumor of bone: Figure 1.5A shows multiple multinucleated giant cells in a case of giant cell tumor of bone. The giant cell contain 30 to 50 round monomorphic nuclei.
Pleomorphic sarcoma with tumor giant cell: Figure 1.5B shows multinucleated tumor giant cells in a case of pleomorphic sarcoma. The nuclei are 5 to 15 in number and show considerable pleomorphism.
Megakaryocyte in normal bone marrow: Figure 1.5C shows a megakaryocyte in the bone marrow. The nuclei are fused together. Background normal marrow elements help to recognize the megakaryocyte. At times platelets may be attached with the megakaryocyte.
Fat necrosis of breast: Figure 1.5D shows the foreign body giant cell in a fat necrosis of breast. The nuclei of the foreign body giant cells are usually variable form 5 to 20. The cytoplasm of the cell often contains foreign body material.
Problem 1.6
A.
3. Microfollicles
B.
4. Papillae
C.
1. Rosettes
D.
2. Glomeruloid body
E.
5. Vertebroid appearance
 
Discussion
Microfollicles: Figure 1.6A shows microfollicular arrangement of the cells. This is characterized by the circular arrangement of 12 to 15 thyroid follicular cells around a central clear space or colloid.
Papillae: Figure 1.6B shows papillae. These are finger like arrangement of cells. The peripheral layer of cells is often placed horizontally and the long axis of these cells is perpendicular to the long axis of the underlying cells. Papillae may be avascular or they may show central core of vessels.
25Rosettes: The cells in the rosettes are arranged around central fibrillary structures. Cells are not attached with any basement membrane. Rosettes like arrangement are often seen in neuroblastoma, peripheral neuroectodermal tumor, and retinoblastoma.
Glomeruloid body: This is a tight cluster of cells resembling glomeruloid structure of kidney. Glomeruloid body is seen in Wilms’ tumor.
Vertebroid appearance: This arrangement is characterized by row of single cells that compress each other. This is commonly seen in small cell carcinoma and lobular carcinoma.
Problem 1.7
A.
5. Synovial fluid
B.
4. Mucinous material
C.
3. Chondromyxoid material
D.
2. Necrosis
E.
1. Calcium crystal
 
Discussion
Synovial fluid (Fig. 1.7A): Mossy proteinaceous background is typical for synovial fluid.
Mucinous material (Fig. 1.7B): This is readily recognized as bluish material in May Grunwald Giemsa stain.
Chondromyxoid material (Fig. 1.7C): It is seen as deep red homogenous material.
Necrosis (Fig. 1.7D): It is characterized by bluish granular material with intermingled nuclear debris.
Calcium crystal (Fig. 1.7E): This is seen as variable sized dark blackish acellular material. This may be mistaken as collection of bacterial organisms. However the calcified material is homogenous and bacteria are granular.
Problem 1.8
A.
2. Crystals in gout
B.
4. Melanin containing cells in melanoma
C.
1. Psammoma body
D.
3. Melanin containing cells in dermatopathic lymphadenitis
 
Discussion
Crystals in gout (Fig. 1.8A): There are abundant crystals in the background. In gout these crystal are monosodium urate monohydrate crystals.
Melanin containing cells in melanoma (Fig. 1.8B): The figure shows abundant melanin containing pigments within the tumor cells in a case of melanoma. These cells are HMB 45 positive.
26Psammoma body (Fig. 1.8C): The concentric laminated calcified material is known as psammoma body. This is commonly seen in papillary carcinoma of thyroid, meningioma, and serous cyst adenocarcinoma of ovary.
Melanin containing cells in dermatopathic lymphadenitis (Fig. 1.8D): The melanin containing benign cells are often seen in dermatopathic lymphadenitis. This is a benign condition and is usually seen in the drainage lymph node of dermatitis.
 
Further Reading
  1. Johannessen JV, Sobrinho-Simões M. The origin and significance of thyroid psammoma bodies. Lab Invest. 1980;43(3):287–96.
  1. Das DK, Mallik MK, Haji BE, Ahmed MS, Al-Shama'a M, et al. Psammoma body and its precursors in papillary thyroid carcinoma: a study by fine-needle aspiration cytology. Diagn Cytopathol. 2004;31(6):380–6.
 
Problem 1.9
A.
3. Cell cannibalism
B.
1. Micronucleus
C.
2. Emperipolesis
 
Discussion
Cell cannibalism (Fig. 1.9A): The cell cannibalism is an active killing of one cell by the other. The cannibalistic cell phagocytoses the victim cell and actively kills it. The cell cannibalism is usually seen in malignancy.
Micronucleus (Fig. 1.9B): This is the nuclear fragment. The micronucleus is always near the main nucleus and not attached with it. The size of the micronucleus is 2 to 4 micron. The excess number of micronucleus indicates chromosomal damage.
Emperipolesis (Fig. 1.9C): In emperipolesis the histiocyte phagocytose large number of lymphocytes. Emperipolesis is commonly seen in Rosai-Dorfman disease.
 
Further Reading
  1. Samanta S, Dey P. Micronucleus and its applications. Diagn Cytopathol. 2012;40(1):84–90.
  1. Sharma N, Dey P. Cell cannibalism and cancer. Diagn Cytopathol. 2011;39(3):229–33.
 
Problem 1.10
A.
2. Irregular nuclear margin
B.
1. Artifactual nuclear vacuolation
C.
3. Intranuclear inclusion
 
Discussion
Irregular nuclear margin (Fig. 1.10A): The nucleus show markedly irregular margin. This type of irregular margin is usually seen in malignant cells.
27Artifactual nuclear vacuolation (Fig. 1.10B): This type of artifact is commonly mistaken as intranuclear inclusion.
Intranuclear inclusion (Fig. 1.10C): Intranuclear inclusion shows round shaped cytoplasmic invagination within the nucleus. The color of the inclusion is same as cytoplasmic color. This is commonly seen in papillary carcinoma of thyroid, bronchoalveolar carcinoma, melanoma, and meningioma.
 
Further Reading
  1. Arora SK, Dey P. Intranuclear peudoinclusions: morphology, pathogenesis, and significance. Diagn Cytopathol. 2012;40(8):741–4.
 
Problem 1.11
A.
2. Cartwheel
B.
4. Salt and pepper
C.
1. Clumped chromatin
D.
3. Fine chromatin
 
Discussion
Cartwheel (Fig. 1.11A): This is characterized by peripheral clumped chromatin in a cartwheel like fashion. Plasma cells show cartwheel chromatin.
Salt and pepper (Fig. 1.11B): The chromatin is granular and gives the salt and pepper appearance. This pattern is typically seen in neuroendocrine tumor.
Clumped chromatin (Fig. 1.11C): Coarsely clumped chromatin is usually seen in malignant nucleus.
Fine chromatin (Fig. 1.11D): Fine chromatin is seen mainly in leukemia, adenocarcinoma and many lymphomas.
Problem 1.12
A. Inhibin
4. Sex cord tumor of ovary
B. Mic 2
3. Peripheral neuroectodermal tumor
C. Napsin
1. Adenocarcinoma of lung
D. CK 20
2. Carcinoma of colon
 
Discussion
Inhibin: It is one of the markers of sex cord tumor of ovary.
Mic 2: Ewing's tumor and peripheral neuroectodermal tumors are all positive for Mic 2.
Napsin: It shows granular cytoplasmic positivity. Napsin is positive in adenocarcinoma of lung.
28CK 20: Carcinoma of colon is positive for CK 20. In addition focal CK 20 positivity is also seen in urothelial cell carcinoma, pancreatic and biliary carcinoma.
Problem 1.13
A. Desmin
6. Skeletal muscle
B. Vimentin
4. Any soft tissue tumor
C. CD15
2. Hodgkin's lymphoma
D. ALK
1. Anaplastic large cell lymphoma
E. CD 68
3. Histiocyte
F. CK 7
5. Adenocarcinoma lung
 
Discussion
Desmin: Desmin is expressed in smooth muscle, skeletal muscle and cardiac muscle. Desmin expression is a reliable marker of rhabdomyosarcoma and leiomyosarcoma.
Vimentin: Vimentin is positive in mesenchymal cells such as fibroblast, endothelial cells and smooth muscle. It is not a specific marker of mesenchymal cells and has also been demonstrated in epithelial neoplasms such as in renal cell carcinoma, lymphomas and mesothelial cells.
CD15: Positive in Hodgkin's lymphoma.
ALK: It is commonly expressed in anaplastic large cell lymphoma. It is also positive in non- small cell lung carcinoma.
CD 68: It is a marker of histiocyte.
CK 7: Adenocarcinomas of lung, breast carcinoma, and ovarian carcinomas are positive for CK 7.
 
Further Reading
  1. Dey P, Togra J, Mitra S. Intermediate filament: structure, function, and applications in cytology. Diagn Cytopathol. 2014;42(7):628–35.
 
Problem 1.14
A.
2. All lymphoid cells express
B.
1. B cell lymphoma
C.
4. Light chain restriction
D.
3. Lymphoblastic lymphoma
 
Discussion
CD 45: It is also known as leucocyte common antigen (LCA) and it is expressed in all types of lymphocytes.
CD 19: It is a B cell marker. Flow cytometry (FCM) shows predominant CD 19 expression.
29Kappa chain expression: The present FCM graph shows predominant kappa light chain expression. This is also known as light chain restriction. It indicates monoclonality of B cell lymphoma.
Tdt: It is positive in lymphoblastic lymphoma.
Problem 1.15
1.
a. Heterochromatin
2.
c. Euchromatin
3.
e. Nuclear pore
4.
b. Mitochondria
5.
d. Rough endoplasmic reticulum
 
Discussion
Heterochromatin and euchromatin: Chromatin is the uncoiled condensed chromosome in the interphase nuclei. Chromatin is classified as heterochromatin and euchromatin. Heterochromatin is condensed part of chromatin and is located on the nuclear membrane where genes are usually inactive. Uncoiled lightly stained chromatin is known as euchromatin.
Nuclear pore: In certain places in the nucleus the outer and inner nuclear membrane fuses and make the hole in the nuclear membrane known as nuclear pore. This nuclear pore selectively allows the passage of the macromolecules from the nucleus to cytoplasm and vice versa.
Mitochondria: Mitochondria are 0.5 to 1 micron diameter organelle and act as the power house of the cell. Mitochondria are double membrane-bound structures and consist of outer membrane, inner membrane, intermembranous space, cristae and mitochondrial matrix.
Endoplasmic reticulum: These are tubular and cistern like spaces and vesicular structures folded within the cytoplasm. They are involved with synthesis of secretary protein and lysosomal enzymes.
Problem 1.16
A.
2. Candida
B.
3. Aspergillosis
C.
4. Mucormycosis
D.
1. Nocardia
 
Discussion
Candida: Multiple spores of candida are seen. This is an opportunistic fungus and is seen in diabetes or other immunocompromised condition. The candida spore is 3 to 4 micron in size and is easily recognizable.
Aspergillosis: Thin slender fungi with acute angle branching is characteristic of aspergillus.
30Mucormycosis: Mucormycosis shows non-septate broad fungal hyphae with wide angle branching.
Nocardia: Thin slender nocardia is demonstrated by modified Ziehl-Neelsen stain.
Problem 1.17
A.
3. Cryptococci
B.
4. Histoplasma
C.
1. Trichomonas vaginalis
D.
2. Leishmania donovani body
 
Discussion
Cryptococci: Small round predominantly intracellular organism 5–8 µ in diameter. This is stained by PAS or India ink stain.
Histoplasma: Small round 2–5 µ in diameter, narrow budding, usually remains inside the macrophages.
Trichomonas vaginalis: It is well visualized in Papanicolaou's stained cervical smear as 15–30 µ long, round-to-oval “pear-shaped” organisms with an indistinct eccentric vesicular nucleus and red cytoplasmic granules.
Leishmania donovani body (LD body): These are amastigote form of leishmania and 3–5 µ in diameter. It consists of a kinetoplast and basal body. LD body usually remains within the histiocytes.
Problem 1.18
A.
2. Hydatid
B.
1. Microfilaria
C.
4. Cysticercosis
D.
3. Actinomycosis
 
Discussion
Hydatid: The smear shows characteristic hooklets of hydatid cyst. The disease is caused by Echinococcus granulosis. The smear from hydatid cyst aspirate may contain laminated membrane, scolex or hooklet.
Microfilaria: The smear shows microfilaria of Wuchereria bancrofti.
Cysticercosis: The microphotograph shows tegumentum layer of cysticercosis. This infection is caused by Taenia solium.
Actinomycosis: The slender filamentous organism arranged as sun ray like fashion.