Difference between revisions of "Gastrointestinal cytopathology"

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=Liver=
=Liver=
Normal:
Brief DDx:
*Liver cells may be binucleated.
*Metastatic adenocarcinoma, usu. colorectal adenocarcinoma.
*Hepatocellular carcinoma.
 
Others:
*[[Cholangiocarcinoma]] - usu. adenocarcinoma NOS, i.e. non-specific.
*[[Epithelioid hemangioendothelioma]].
*[[Angiomyolipoma]].
 
==Normal liver==
===Cytology===
Features:
*Hepatocytes:  
*Hepatocytes:  
**Abundant cytoplasm, central nucleus.
**Abundant cytoplasm
**Bile ductules between adjacent cells.
**central nucleus +/- binucleation.
**+/-Yellow granular pigment (bile).
**+/-Yellow granular pigment (bile).
*Bile ductules between adjacent cells.


==Hepatocellular carcinoma==
==Hepatocellular carcinoma==
Line 16: Line 27:
===Cytology===
===Cytology===
Features:
Features:
*Cohesive clusters of (liver) cells surrounded by endothelial cells - '''diagnostic'''.<ref name=Ref_APBR679>{{Ref APBR|679}}</ref>
*Architecture - single cells and large clusters:
*+/-Nuclear atypia.
**Cohesive clusters of cells (hepatocytes) surrounded by endothelial cells - '''diagnostic'''.<ref name=Ref_APBR679>{{Ref APBR|679}}</ref>
*+/-Prominent nucleoli.<ref name=ouhsc_34/>
**Capillaries traversing the fragments.
*Cells:
**Central nucleus +/-prominent nucleoli,<ref name=ouhsc_34/> +/-nuclear inclusions.
**+/-Multinucleation.
**+/-Yellow cytoplasmic pigment (bile).
**+/-Nuclear atypia.
**+/-High NC ratio.


Notes:
Notes:
*Low grade [[HCC]] is composed of cytologically normal appearing cells; the arrangement is what is diagnostic of malignancy.<ref name=Ref_APBR679>{{Ref APBR|679}}</ref>
*Low grade [[HCC]] is composed of cytologically normal appearing cells; the arrangement is what is diagnostic of malignancy.<ref name=Ref_APBR679>{{Ref APBR|679}}</ref>
*[[Fibrolamellar HCC]] has very large cells.


Images:
Images:
Line 29: Line 47:
==Cholangiocarcinoma==
==Cholangiocarcinoma==
{{Main|Cholangiocarcinoma}}
{{Main|Cholangiocarcinoma}}
===Cytology===
===Cytology===
Features:
Features:
*Looks like an adenocarcinoma:  
*Looks like an adenocarcinoma:  
**Eccentric nuclei, one [[nucleolus]] per cell, abundant cytoplasm, nuclear size var. cell-to-cell, irregular nuclear membrane, irregular/uneven chromatin pattern.
**Eccentric nuclei, one [[nucleolus]] per cell, abundant cytoplasm, nuclear size var. cell-to-cell, irregular nuclear membrane, irregular/uneven chromatin pattern.
==Epithelioid hemangioendothelioma==
{{Main|Epithelioid hemangioendothelioma}}
===General===
*Rare.
===Cytology===
Features:
*Large atypical cells with:
**Nuclear inclusions
**Moderate cytoplasm.
**+/-Multinucleation.
===IHC===
*Factor VIII +ve.


=Common bile duct=
=Common bile duct=
Line 48: Line 80:
*Nuclear membrane irregularities.
*Nuclear membrane irregularities.


Images:
===Images===
*[http://commons.wikimedia.org/wiki/File:Colorectal_adenocarcinoma_cytology_low_mag.jpg Colorectal adenocarcinoma - low mag. (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Colorectal_adenocarcinoma_cytology_intermed_mag.jpg Colorectal adenocarcinoma - intermediate mag. (WC)].
Image:Colorectal_adenocarcinoma_cytology_low_mag.jpg | Colorectal adenocarcinoma - low mag. (WC)
Image:Colorectal_adenocarcinoma_cytology_intermed_mag.jpg | Colorectal adenocarcinoma - intermediate mag. (WC)
</gallery>
====www====
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418535/figure/f16/ Colonic carcinoma (nlm.nih.gov)].<ref name=pmid22943018>{{Cite journal  | last1 = Conrad | first1 = R. | last2 = Cobb | first2 = C. | last3 = Raza | first3 = A. | title = Role of cytopathology in the diagnosis and management of gastrointestinal tract cancers. | journal = J Gastrointest Oncol | volume = 3 | issue = 3 | pages = 285-98 | month = Sep | year = 2012 | doi = 10.3978/j.issn.2078-6891.2012.023 | PMID = 22943018 }}</ref>


=Stomach=
=Stomach=
==Normal stomach==
===General===
*Important as it may be a contaminant in a pancreatic FNA.
===Cytology===
Features:
*Bland cells with round nuclei.
*Granular cells with red cytoplasm (on Pap stain) - parietal cells - distinctive.
Note:
*May be difficult to distinguish from pancreas ductal epithelium.<ref name=Ref_APBR680>{{Ref APBR|680 (Q23)}}</ref>
*May be difficult to distinguish from pancreas ductal epithelium.<ref name=Ref_APBR680>{{Ref APBR|680 (Q23)}}</ref>


=Small bowel=
=Small bowel=
Epithelium:<ref name=Ref_APBR680>{{Ref APBR|680 (Q23)}}</ref>
Epithelium:<ref name=Ref_APBR680>{{Ref APBR|680 (Q23)}}</ref>
*Small blue cells.
*Orderly flat sheets of smaller (blue) cells without atypia.<ref name=pmid22943018/>
**"Orderly" = nuclei do not overlapped.
*Goblet cells - '''key feature'''.
*Goblet cells - '''key feature'''.


Notes:
Notes:
*May appear to be similar to stomach and pancreatic duct.<ref name=Ref_APBR680>{{Ref APBR|680 (Q23)}}</ref>
*May appear to be similar to stomach and pancreatic duct.<ref name=Ref_APBR680>{{Ref APBR|680 (Q23)}}</ref>
===Images===
====www====
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418535/figure/f15/ Normal duodenal mucosa and duodenal adenocarcinoma (nlm.nih.gov)].<ref name=pmid22943018>{{Cite journal  | last1 = Conrad | first1 = R. | last2 = Cobb | first2 = C. | last3 = Raza | first3 = A. | title = Role of cytopathology in the diagnosis and management of gastrointestinal tract cancers. | journal = J Gastrointest Oncol | volume = 3 | issue = 3 | pages = 285-98 | month = Sep | year = 2012 | doi = 10.3978/j.issn.2078-6891.2012.023 | PMID = 22943018 }}</ref>


=Esophagus=
=Esophagus=
Line 75: Line 126:
=Pancreas=
=Pancreas=
A short DDx:
A short DDx:
*Normal:
**Duct.
**Acini.
*Cystic lesions:
*Cystic lesions:
**[[Serous cystadenoma of the pancreas]].
**[[Serous cystadenoma of the pancreas]].
Line 84: Line 138:
**[[Pancreatic neuroendocrine tumour]].
**[[Pancreatic neuroendocrine tumour]].


==Mucinous tumours==
==Normal pancreas==
===Cytology===
Features - duct:
*2-D sheet of cells - equally spaced.
*Moderate-to-abundant cytoplasm.
 
Features - acini:
*Clustered cells +/- nuclear overlap.
*Round bland nuclei.
**Small nucleoli.
*Moderate cytoplasm.
 
==Pancreatic pseudocyst==
===General===
*Symptomatic, e.g. abdominal pain.
**Asymptomatic pseudocysts are typically observed, as a large number resolve spontaneously.<ref name=pmid20142757>{{Cite journal  | last1 = Gumaste | first1 = VV. | last2 = Aron | first2 = J. | title = Pseudocyst management: endoscopic drainage and other emerging techniques. | journal = J Clin Gastroenterol | volume = 44 | issue = 5 | pages = 326-31 | month =  | year =  | doi = 10.1097/MCG.0b013e3181cd9d2f | PMID = 20142757 }}</ref>
*Classically associated with [[pancreatitis]] secondary to [[alcohol]].<ref name=pmid14730118>{{Cite journal  | last1 = Andrén-Sandberg | first1 = A. | last2 = Dervenis | first2 = C. | title = Pancreatic pseudocysts in the 21st century. Part I: classification, pathophysiology, anatomic considerations and treatment. | journal = JOP | volume = 5 | issue = 1 | pages = 8-24 | month = Jan | year = 2004 | doi =  | PMID = 14730118 |URL = http://www.joplink.net/prev/200401/08.html }}</ref>
*Pathologic diagnosis of exclusion.
 
===Cytology===
Features:
Features:
*Mucin.
*Histiocytes.
**Should be paucicellular otherwise.
*Necrotic debris - granular.
 
Note:
*Pseudocysts, by definition, do '''not''' have an epithelial lining.
*Luminal GI tract contamination - may lead to confusion with mucinous neoplasm.
 
DDx:
*Mucinous neoplasm.
*Serous neoplasm.
 
==Serous neoplasm==
===General===
*May be associated with [[von Hippel-Lindau syndrome]].
*Usu. body or tail.
*Classically have a central stellate scar - seen radiologically.
 
===Cytology===
Features:
*Cuboidal/flat cells in clusters or sheets.
*+/-Nuclear grooves.
 
===Stains===
*PAS +ve.
*PASD -ve.
 
==Mucinous neoplasm==
===General===
*Pancreatic head: classically IPMN.
**IPMN assoc. with colloid carcinoma.
*Pancreatic body & tail: mucinous tumour.
 
===Cytology===
Features:
*Clusters or sheets of mucinous cells.
*+/-Nuclear atypia.
*+/-Thick mucin.
**Suggestive of IPMN.
 
Notes:
*In the body & tail mucinous cells may be contamination from the [[stomach]].
**Lesions in the pancreatic head are approached from the duodenum - do not have this problem.
*Ovarian stroma is '''not''' seen on cytology.
*Thick mucin may be from stomach.


Image:
Image:
Line 93: Line 210:
==Solid pseudopapillary neoplasm==
==Solid pseudopapillary neoplasm==
{{Main|Solid pseudopapillary neoplasm}}
{{Main|Solid pseudopapillary neoplasm}}
*Abbreviated ''SPN''.
===General===
*Young women.
*Tail of pancreas.
===Cytology===
===Cytology===
Features:<ref name=ouhsc_26>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-029-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-029-M.htm]. Accessed on: 9 April 2012.</ref>
Features:<ref name=ouhsc_26>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-029-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-029-M.htm]. Accessed on: 9 April 2012.</ref>
*Small cells with:
*Papillary formations - composed of small cells with:
**Scant cytoplasm.
**Scant cytoplasm.
**+/-Nuclear grooves.
**+/-Nuclear grooves.
*Papillary formations.
*+/-Cholesterol clefts.
 
Note:
*There are no '''true''' papillae in [[SPN]].
 
DDx:
*[[Pancreatic pseudocyst]].
*[[Pancreatic neuroendocrine tumour]] - single cells, classically plasmacytoid.


===IHC===
===IHC===
Line 110: Line 239:
==Pancreatic neuroendocrine tumour==
==Pancreatic neuroendocrine tumour==
{{Main|Pancreatic neuroendocrine tumour}}
{{Main|Pancreatic neuroendocrine tumour}}
*Previously known as ''islet cell tumour of the pancreas''.
===General===
*Classically solid.
**May be cystic.
===Cytology===
===Cytology===
Features:
Features:
*Round nuclei with granular chromatin.
*Round nuclei with salt and pepper chromatin.
**Moderate nuclear size variation.
**Moderate nuclear size variation.
*Classically single cells with [[plasma cell|plasmacytoid]] morphology.
DDx:
*[[Solid pseudopapillary neoplasm]].


===IHC===
===IHC===
*Chromogranin A +ve.
*Chromogranin A +ve.
*Synaptophysin +ve.
*Synaptophysin +ve.
==Pancreatic adenocarcinoma==
{{Main|Invasive ductal carcinoma of the pancreas}}
*[[AKA]] ''ductal carcinoma''.
===Cytology===
Features:
*Single cells.
**Should be present.
*Monolayer of irregularly spaced cells - described as "drunken honeycomb".
*Nuclear atypia +/-grooves, +/-chromatin clearing.
**Significant atypia: >=4:1 ratio between the nuclear diameter of cells.
Image:
*[http://www.flickr.com/photos/euthman/322383640/ Pancreatic adenocarcinoma - marked nuclear atypia - low mag. (flickr.com/euthman)].
*[http://www.flickr.com/photos/euthman/322383635/ Pancreatic adenocarcinoma - marked nuclear atypia - high mag. (flickr.com/euthman)].
*[http://www.flickr.com/photos/euthman/5558060009/ Pancreatic adenocarcinoma - drunken honeycomb - low mag. (flickr.com/euthman)].
*[http://www.flickr.com/photos/euthman/5558642608/ Pancreatic adenocarcinoma - drunken honeycomb - high mag. (flickr.com/euthman)].
==Acinar cell carcinoma==
{{Main|Acinar cell carcinoma of the pancreas}}
===General===
*Very rare.
===Cytology===
Features:
*High cellularity - '''important feature'''.
*Lack of ducts.
*Single cells and small cell clusters with abundant granular (metachromatic) cytoplasm - similar to normal pancreatic acini.
*Naked nuclei.
Note:
*Considered to be a difficult diagnosis.


=See also=
=See also=
Line 125: Line 295:
=References=
=References=
{{Reflist|2}}
{{Reflist|2}}
=External links=
*[http://www.thejgo.org/article/view/438/html Cytopathology of the GI tract (thejgo.org)].


[[Category:Cytopathology]]
[[Category:Cytopathology]]

Latest revision as of 21:57, 19 August 2015

Gastrointestinal cytopathology, also known as GI cytology, is a relatively small part of cytopathology.

This article deals only with gastrointestinal cytopathology. An introduction to cytopathology is in the cytopathology article. Histopathology of the gastrointestinal tract is dealt with in gastrointestinal pathology.

Liver

Brief DDx:

  • Metastatic adenocarcinoma, usu. colorectal adenocarcinoma.
  • Hepatocellular carcinoma.

Others:

Normal liver

Cytology

Features:

  • Hepatocytes:
    • Abundant cytoplasm
    • central nucleus +/- binucleation.
    • +/-Yellow granular pigment (bile).
  • Bile ductules between adjacent cells.

Hepatocellular carcinoma

Main article: Hepatocellular carcinoma

Cytology

Features:

  • Architecture - single cells and large clusters:
    • Cohesive clusters of cells (hepatocytes) surrounded by endothelial cells - diagnostic.[1]
    • Capillaries traversing the fragments.
  • Cells:
    • Central nucleus +/-prominent nucleoli,[2] +/-nuclear inclusions.
    • +/-Multinucleation.
    • +/-Yellow cytoplasmic pigment (bile).
    • +/-Nuclear atypia.
    • +/-High NC ratio.

Notes:

  • Low grade HCC is composed of cytologically normal appearing cells; the arrangement is what is diagnostic of malignancy.[1]
  • Fibrolamellar HCC has very large cells.

Images:

Cholangiocarcinoma

Main article: Cholangiocarcinoma

Cytology

Features:

  • Looks like an adenocarcinoma:
    • Eccentric nuclei, one nucleolus per cell, abundant cytoplasm, nuclear size var. cell-to-cell, irregular nuclear membrane, irregular/uneven chromatin pattern.

Epithelioid hemangioendothelioma

Main article: Epithelioid hemangioendothelioma

General

  • Rare.

Cytology

Features:

  • Large atypical cells with:
    • Nuclear inclusions
    • Moderate cytoplasm.
    • +/-Multinucleation.

IHC

  • Factor VIII +ve.

Common bile duct

Normal:

  • Monolayer of small blue cells.

Notes:

  • Caution is advised when calling malignancy in the setting of a stent or stones.

Adenocarcinoma

Features:

  • Hyperchromasia.
  • Pencil-shaped nuclei.
  • Nuclear membrane irregularities.

Images

  • Colorectal adenocarcinoma - low mag. (WC)

  • Colorectal adenocarcinoma - intermediate mag. (WC)

www

Stomach

Normal stomach

General

  • Important as it may be a contaminant in a pancreatic FNA.

Cytology

Features:

  • Bland cells with round nuclei.
  • Granular cells with red cytoplasm (on Pap stain) - parietal cells - distinctive.

Note:

  • May be difficult to distinguish from pancreas ductal epithelium.[4]

Small bowel

Epithelium:[4]

  • Orderly flat sheets of smaller (blue) cells without atypia.[3]
    • "Orderly" = nuclei do not overlapped.
  • Goblet cells - key feature.

Notes:

  • May appear to be similar to stomach and pancreatic duct.[4]

Images

www

Esophagus

  • Cytology may be done to look for candida.
    • Report should comment on the presence of candida - if it is seen.

A short DDx:

  • Barrett's esophagus.
  • Candida.
  • HSV.
  • GIST.

Pancreas

A short DDx:

Normal pancreas

Cytology

Features - duct:

  • 2-D sheet of cells - equally spaced.
  • Moderate-to-abundant cytoplasm.

Features - acini:

  • Clustered cells +/- nuclear overlap.
  • Round bland nuclei.
    • Small nucleoli.
  • Moderate cytoplasm.

Pancreatic pseudocyst

General

  • Symptomatic, e.g. abdominal pain.
    • Asymptomatic pseudocysts are typically observed, as a large number resolve spontaneously.[5]
  • Classically associated with pancreatitis secondary to alcohol.[6]
  • Pathologic diagnosis of exclusion.

Cytology

Features:

  • Histiocytes.
    • Should be paucicellular otherwise.
  • Necrotic debris - granular.

Note:

  • Pseudocysts, by definition, do not have an epithelial lining.
  • Luminal GI tract contamination - may lead to confusion with mucinous neoplasm.

DDx:

  • Mucinous neoplasm.
  • Serous neoplasm.

Serous neoplasm

General

  • May be associated with von Hippel-Lindau syndrome.
  • Usu. body or tail.
  • Classically have a central stellate scar - seen radiologically.

Cytology

Features:

  • Cuboidal/flat cells in clusters or sheets.
  • +/-Nuclear grooves.

Stains

  • PAS +ve.
  • PASD -ve.

Mucinous neoplasm

General

  • Pancreatic head: classically IPMN.
    • IPMN assoc. with colloid carcinoma.
  • Pancreatic body & tail: mucinous tumour.

Cytology

Features:

  • Clusters or sheets of mucinous cells.
  • +/-Nuclear atypia.
  • +/-Thick mucin.
    • Suggestive of IPMN.

Notes:

  • In the body & tail mucinous cells may be contamination from the stomach.
    • Lesions in the pancreatic head are approached from the duodenum - do not have this problem.
  • Ovarian stroma is not seen on cytology.
  • Thick mucin may be from stomach.

Image:

Solid pseudopapillary neoplasm

Main article: Solid pseudopapillary neoplasm
  • Abbreviated SPN.

General

  • Young women.
  • Tail of pancreas.

Cytology

Features:[8]

  • Papillary formations - composed of small cells with:
    • Scant cytoplasm.
    • +/-Nuclear grooves.
  • +/-Cholesterol clefts.

Note:

  • There are no true papillae in SPN.

DDx:

IHC

  • PR +ve.
  • Beta-catenin +ve.
  • CD10 +ve.

Others:

  • Chromogranin A -ve.

Pancreatic neuroendocrine tumour

Main article: Pancreatic neuroendocrine tumour
  • Previously known as islet cell tumour of the pancreas.

General

  • Classically solid.
    • May be cystic.

Cytology

Features:

  • Round nuclei with salt and pepper chromatin.
    • Moderate nuclear size variation.
  • Classically single cells with plasmacytoid morphology.

DDx:

IHC

  • Chromogranin A +ve.
  • Synaptophysin +ve.

Pancreatic adenocarcinoma

Main article: Invasive ductal carcinoma of the pancreas
  • AKA ductal carcinoma.

Cytology

Features:

  • Single cells.
    • Should be present.
  • Monolayer of irregularly spaced cells - described as "drunken honeycomb".
  • Nuclear atypia +/-grooves, +/-chromatin clearing.
    • Significant atypia: >=4:1 ratio between the nuclear diameter of cells.

Image:

Acinar cell carcinoma

Main article: Acinar cell carcinoma of the pancreas

General

  • Very rare.

Cytology

Features:

  • High cellularity - important feature.
  • Lack of ducts.
  • Single cells and small cell clusters with abundant granular (metachromatic) cytoplasm - similar to normal pancreatic acini.
  • Naked nuclei.

Note:

  • Considered to be a difficult diagnosis.

See also

References

  1. ↑ 1.0 1.1 Lefkowitch, Jay H. (2006). Anatomic Pathology Board Review (1st ed.). Saunders. pp. 679. ISBN 978-1416025887.
  2. ↑ 2.0 2.1 URL: http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-034-M.htm. Accessed on: 9 April 2012.
  3. ↑ 3.0 3.1 3.2 Conrad, R.; Cobb, C.; Raza, A. (Sep 2012). "Role of cytopathology in the diagnosis and management of gastrointestinal tract cancers.". J Gastrointest Oncol 3 (3): 285-98. doi:10.3978/j.issn.2078-6891.2012.023. PMID 22943018.
  4. ↑ 4.0 4.1 4.2 Lefkowitch, Jay H. (2006). Anatomic Pathology Board Review (1st ed.). Saunders. pp. 680 (Q23). ISBN 978-1416025887.
  5. ↑ Gumaste, VV.; Aron, J.. "Pseudocyst management: endoscopic drainage and other emerging techniques.". J Clin Gastroenterol 44 (5): 326-31. doi:10.1097/MCG.0b013e3181cd9d2f. PMID 20142757.
  6. ↑ Andrén-Sandberg, A.; Dervenis, C. (Jan 2004). "Pancreatic pseudocysts in the 21st century. Part I: classification, pathophysiology, anatomic considerations and treatment.". JOP 5 (1): 8-24. PMID 14730118.
  7. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/OPAQ/PNPT/PN-NS01-Ans.htm. Accessed on: 22 February 2012.
  8. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-029-M.htm. Accessed on: 9 April 2012.

External links

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