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Head and neck cytopathology (view source)

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Thyroid cytopathology is dealt with in the ''[[thyroid cytopathology]]'' article.  An introduction to cytopathology is in the ''[[cytopathology]]'' article.
Thyroid cytopathology is dealt with in the ''[[thyroid cytopathology]]'' article.  An introduction to cytopathology is in the ''[[cytopathology]]'' article.


==Normal==
''Salivary gland cytopathology'' and ''salivary gland cytology'' redirect to here.
 
=Proposed Milan system for reporting salivary gland cytopathology=
:''Milan system'' and ''Milan classification'' redirect here.
{| class="wikitable"
|-
! Category
! Typical management
! Comments
|-
| Nondiagnostic
| repeat FNA
|
|-
| Nonneoplastic
| follow-up/discharge
|
|-
| Atypia of undetermined significance (AUS)
| repeat FNA
| use should be minimized <br>- like [[FLUS]] and [[ASCUS]]
|-
| Neoplasm
| excision
| subdivided into: (a) benign (b) salivary gland neoplasm of uncertain malignant potential (SUMP)
|-
| Suspicious for malignancy
| wide excision +/-lymph nodes (?)
|
|-
| Malignant
| wide excision & lymph nodes (?)
|
|}
Notes:
*This classification is still evolving.<ref>URL: [http://www.cytopathology.org/the-milan-system-for-reporting-salivary-gland-cytopathology/ http://www.cytopathology.org/the-milan-system-for-reporting-salivary-gland-cytopathology/]. Accessed on: 31 March 2016.</ref> The preliminary version (above) was presented by Dr. William Faquin at [[USCAP]] 2016 in Seattle.<ref>URL: [http://www.uscap.org/meetings/detail/2016-annual-meeting/sessions/2334 http://www.uscap.org/meetings/detail/2016-annual-meeting/sessions/2334]. Accessed on: 13 March 2016.</ref>
*The goal is to complete the reporting system by the summer of 2017.
 
=Normal=
Depends on the structure that is needled.
Depends on the structure that is needled.


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**Dispersed chromatin.
**Dispersed chromatin.
**Indistinct [[nucleolus]].
**Indistinct [[nucleolus]].
*Low NC ratio cells.
*Low [[NC ratio]] cells.


Sticky lymphoid tissue:
Sticky lymphoid tissue:
*Irregular globs of tissue with small cells.
*Irregular globs of tissue with small cells.


==Salivary gland tumours - summary==
[[Skeletal muscle]]:
*Round red staining globs +/-apparent striations.
*Nuclei more at edges (peripheral).
 
===Images===
<gallery>
Image: Skeletal muscle - FNA 1 - intermed mag.jpg | SM - intermed. mag.
Image: Skeletal muscle - FNA 1a- high mag.jpg | SM - high mag.
Image: Skeletal muscle - FNA 1a- very high mag.jpg | SM - very high mag.
Image: Skeletal muscle - FNA 1b- very high mag.jpg | SM - very high mag.
 
Image: Skeletal muscle - FNA 2a- high mag.jpg | SM - high mag.
Image: Skeletal muscle - FNA 2b- high mag.jpg | SM - high mag.
Image: Skeletal muscle - FNA 2a- very high mag.jpg | SM - very high mag.
Image: Skeletal muscle - FNA 2b- very high mag.jpg | SM - very high mag.
</gallery>
 
=Salivary gland tumours - summary=
===Benign===
===Benign===
{| class="wikitable"
{| class="wikitable"
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| DDx (?)
| DDx (?)
| ?
| ?
| [http://commons.wikimedia.org/wiki/File:Pleomorphic_adenoma_-_cytology.jpg Pleomorphic adenoma (WC)]
| [[Image:Pleomorphic_adenoma_-_cytology.jpg | thumb| center| 150px| Pleomorphic adenoma. (WC)]]
|-
|-
| [[Warthin tumour]] (papillary cystadenoma lymphomatosum)
| [[Warthin tumour]] (papillary cystadenoma lymphomatosum)
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| Acinic cell carcinoma (AcCC), oncocytoma
| Acinic cell carcinoma (AcCC), oncocytoma
| AcCC: irregular spaced cells, lack well-defined cell borders
| AcCC: irregular spaced cells, lack well-defined cell borders
| [http://commons.wikimedia.org/wiki/File:Papillary_cystadenoma_lymphomatosum_cytology_high.jpg Warthin tumour high mag (WC)], [http://commons.wikimedia.org/wiki/File:Papillary_cystadenoma_lymphomatosum_cytology_intermed.jpg Warthin tumour intermed mag (WC)]
| [[Image:Papillary_cystadenoma_lymphomatosum_cytology_high.jpg | thumb| center| 150px| Warthin tumour - high mag. (WC)]]
|-
|-
|}
|}
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| Mucocele ?
| Mucocele ?
| Nuclear atypia
| Nuclear atypia
| [http://commons.wikimedia.org/wiki/File:Mucoepidermoid_carcinoma_2_-_high_mag.jpg Mucoepidermoid carcinoma (WC)]
| [[Image:Mucoepidermoid_carcinoma_2_-_high_mag.jpg | thumb| center| 150px| Mucoepidermoid carcinoma. (WC)]]
|-
|-
| [[Adenoid cystic carcinoma]] (AdCC)
| [[Adenoid cystic carcinoma]] (AdCC)
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| AcCC
| AcCC
| Basement membrane material - PAS-D+ve<ref name=pmid62333>{{cite journal |author=Chen SY |title=Adenoid cystic carcinoma of minor salivary gland. Histochemical and electron microscopic studies of cystlike space |journal=Oral Surg. Oral Med. Oral Pathol. |volume=42 |issue=5 |pages=606–19 |year=1976 |month=November |pmid=62333 |doi= |url=}}</ref>
| Basement membrane material - PAS-D+ve<ref name=pmid62333>{{cite journal |author=Chen SY |title=Adenoid cystic carcinoma of minor salivary gland. Histochemical and electron microscopic studies of cystlike space |journal=Oral Surg. Oral Med. Oral Pathol. |volume=42 |issue=5 |pages=606–19 |year=1976 |month=November |pmid=62333 |doi= |url=}}</ref>
| [http://commons.wikimedia.org/wiki/File:Adenoid_cystic_carcinoma_cytology.jpg Adenoid cystic carcinoma (WC)]
| [[Image:Adenoid_cystic_carcinoma_cytology.jpg | thumb| center| 150px| Adenoid cystic carcinoma. (WC)]]
|-
|-
| [[Acinic cell carcinoma]] (AcCC)
| [[Acinic cell carcinoma]] (AcCC)
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| Warthin tumour
| Warthin tumour
| AcCC missing lymphocytic background; irreg. spacing of cells
| AcCC missing lymphocytic background; irreg. spacing of cells
| [http://commons.wikimedia.org/wiki/File:Acinic_cell_carcinoma.jpg Acinic cell carcinoma (WC)]
| [[Image:Acinic_cell_carcinoma.jpg | thumb| center| 150px| Acinic cell carcinoma. (WC)]]
|}
|}
=Salivary gland=
{{Main|Salivary gland}}
==Sialoadenitis==
{{main|Chronic sialadenitis}}
===Cytology===
Features:
*Inflammatory cells - lymphocytes, plasma cells - '''key features'''.
*+/-Squamous metaplasia.
*+/-Necrotic debris.
*Benign ductal epithelium.
DDx:
*Squamous carcinoma.
*Mucoepidermoid carcinoma.


==Pleomorphic adenoma==
==Pleomorphic adenoma==
General:
{{Main|Pleomorphic adenoma}}
*Abbreviated ''PA''.
 
===General===
*Common benign tumour.
*Common benign tumour.
*Abbreviated ''PA''.


===Cytology===
===Cytology===
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#Chondromyxoid stroma.
#Chondromyxoid stroma.
#*Whispy/fluffy groups of spindle cells that overlap (fibromyxoid tissue) - blue-ish.
#*Whispy/fluffy groups of spindle cells that overlap (fibromyxoid tissue) - blue-ish.
Image:
*[http://commons.wikimedia.org/wiki/File:Pleomorphic_adenoma_-_cytology.jpg Pleomorphic adenoma (WC)].


DDx:  
DDx:  
*[[Adenoid cystic carcinoma]].
*[[Adenoid cystic carcinoma]].
**Big circular globs (cysts) - common in AdCC.
**Big circular globs (cysts) - common in AdCC.
====Images====
<gallery>
Image: Pleomorphic adenoma - cytology -- high mag.jpg | PA - high mag. (WC)
Image: Pleomorphic adenoma - cytology - alt -- high mag.jpg | PA - high mag. (WC)
Image: Pleomorphic adenoma - cytology -- very high mag.jpg | PA - very high mag. (WC)
Image: Pleomorphic adenoma - cytology - alt -- very high mag.jpg | PA - very high mag. (WC)
</gallery>
<gallery>
Image:Pleomorphic_adenoma_-_cytology.jpg | Pleomorphic adenoma. (WC)
</gallery>


==Warthin tumour==
==Warthin tumour==
*AKA ''papillary cystadenoma lymphomatosum''.
*AKA ''papillary cystadenoma lymphomatosum''.
===General===
*Usual smokers.
*May be bilateral.


===Histology===
===Cytology===
Features:<ref>[http://sciencelinks.jp/j-east/article/200123/000020012301A0753392.php http://sciencelinks.jp/j-east/article/200123/000020012301A0753392.php]</ref>
Features:<ref>[http://sciencelinks.jp/j-east/article/200123/000020012301A0753392.php http://sciencelinks.jp/j-east/article/200123/000020012301A0753392.php]</ref>
*Oncocytes.
*Oncocytes.
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***Granular cytoplasm.
***Granular cytoplasm.
***Nucleoli.
***Nucleoli.
**Oncocytes are often associated with ''mast cells'', i.e. on "top of" oncocytes.
**Oncocytes are often associated with ''[[mast cell]]s'', i.e. on "top of" oncocytes.
***Mast cells: very granular dark staining cytoplasm (on smears).
***Mast cells: very granular dark staining cytoplasm (on smears).
*Lymphocytes.
*Lymphocytes.
*Necrotic material (cyst contents).
*Necrotic material (cyst contents).
Images:
*[http://commons.wikimedia.org/wiki/File:Papillary_cystadenoma_lymphomatosum_cytology_high.jpg Warthin tumour high mag (WC)].
*[http://commons.wikimedia.org/wiki/File:Papillary_cystadenoma_lymphomatosum_cytology_intermed.jpg Warthin tumour intermed mag (WC)].
*[http://commons.wikimedia.org/wiki/File:Papillary_cystadenoma_lymphomatosum2.jpg Warthin tumour - surgical excision specimen (WC)].


DDx:  
DDx:  
*Acinic cell carcinoma.
*[[Acinic cell carcinoma]].
**Spacing of tumour in AcCC is more irregular and appear more crowded.
**Spacing of tumour in AcCC is more irregular and appear more crowded.
**The cell borders in AcCC is less obvious.
**The cell borders in AcCC is less obvious.
*Oncocytoma  
*Oncocytoma.
**Oncocytoma (vis-a-vis Warthin tumour) has more '''c'''ells, more '''c'''ytoplasm, more granularity of '''c'''ytoplasm, more '''c'''omplex architecture.<ref name=boerner2003/>
**Oncocytoma (vis-a-vis [[Warthin tumour]]) has more '''c'''ells, more '''c'''ytoplasm, more granularity of '''c'''ytoplasm, more '''c'''omplex architecture.<ref name=boerner2003/>
 
====Images====
<gallery>
Image:Papillary_cystadenoma_lymphomatosum_cytology_high.jpg | Warthin tumour - high mag. (WC)
Image:Papillary_cystadenoma_lymphomatosum_cytology_intermed.jpg | Warthin tumour - intermed. mag. (WC)
Image:Papillary_cystadenoma_lymphomatosum2.jpg | Warthin tumour - surgical specimen. (WC)
</gallery>


==Oncocytoma==
==Oncocytoma==
*May be confused with Warthin tumour.
{{Main|Oncocytoma of the salivary gland}}
===General===
*May be confused with [[Warthin tumour]].


===Cytology===
Features:
Features:
*Oncocytes.
*Oncocytes.
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==Mucoepidermoid carcinoma==
==Mucoepidermoid carcinoma==
{{Main|Mucoepidermoid carcinoma}}
{{Main|Mucoepidermoid carcinoma}}
===General===
*A challenging FNA diagnosis.<ref name=pmid2296840>{{Cite journal  | last1 = Cohen | first1 = MB. | last2 = Fisher | first2 = PE. | last3 = Holly | first3 = EA. | last4 = Ljung | first4 = BM. | last5 = Löwhagen | first5 = T. | last6 = Bottles | first6 = K. | title = Fine needle aspiration biopsy diagnosis of mucoepidermoid carcinoma. Statistical analysis. | journal = Acta Cytol | volume = 34 | issue = 1 | pages = 43-9 | month =  | year =  | doi =  | PMID = 2296840 }}</ref>
===Cytology===
Features:
Features:
*Sheets of cells.
*Sheets of cells.
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**Cell borders are often distinct.  
**Cell borders are often distinct.  


Images:
DDx:
*[http://commons.wikimedia.org/wiki/File:Mucoepidermoid_carcinoma_2_-_high_mag.jpg Mucoepidermoid carcinoma (WC)].
*[[Squamous cell carcinoma]] - extensive keratinization and squamous pearls.<ref name=Ref_FNAC25>{{Ref FNAC|25}}</ref>
*[http://commons.wikimedia.org/wiki/File:Mucoepidermoid_carcinoma_2_-_very_high_mag.jpg Mucoepidermoid carcinoma - very high mag. (WC)].
 
*[http://commons.wikimedia.org/wiki/File:Mucoepidermoid_carcinoma_-_cytology.jpg Mucoepidermoid carcinoma - not a very good image (WC)].
===Images===
<gallery>
Image:Mucoepidermoid_carcinoma_2_-_high_mag.jpg | Mucoepidermoid carcinoma. (WC)
Image:Mucoepidermoid_carcinoma_2_-_very_high_mag.jpg | Mucoepidermoid carcinoma - very high mag. (WC)
</gallery>


==Acinic cell carcinoma==
==Acinic cell carcinoma==
{{Main|Acinic cell carcinoma}}
===General===
*Uncommon.
===Cytology===
Features:<ref>SB. 12 January 2010.</ref>
Features:<ref>SB. 12 January 2010.</ref>
*Abundant granular cytoplasm.
*Abundant granular cytoplasm.
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**Ductal structures (differentiates from normal).
**Ductal structures (differentiates from normal).


Image:
Memory device:
*[http://commons.wikimedia.org/wiki/File:Acinic_cell_carcinoma.jpg Acinic cell carcinoma - cytology (WC)].
*AcCC - lots of "C"s: lots of cytoplasm, [[carcinoid]]-like (stippled chromatin, granular cytoplasm).


Memory device:
====Image====
*AcCC - lots of "C"s: lots of cytoplasm, carcinoid-like (stippled chromatin, granular cytoplasm).
<gallery>
Image:Acinic_cell_carcinoma.jpg | Acinic cell carcinoma - cytology. (WC)
</gallery>


==Adenoid cystic carcinoma==
==Adenoid cystic carcinoma==
===General===
*Usu. distinctive.
*May be painful due the presence of [[perineural invasion]].
===Cytology===
Features:
Features:
*Solid circular islands that are well-circumscribed.
*Solid circular islands that are well-circumscribed.
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*Memory device: A'''d'''CC = lotsa '''D'''NA in relation to cell.
*Memory device: A'''d'''CC = lotsa '''D'''NA in relation to cell.


Image:
====Image====
*[http://commons.wikimedia.org/wiki/File:Adenoid_cystic_carcinoma_cytology.jpg Adenoid cystic carcinoma -cytology (WC)].
<gallery>
Image:Adenoid_cystic_carcinoma_cytology.jpg | Adenoid cystic carcinoma - cytology. (WC)
</gallery>
 
==Epithelial-myoepithelial carcinoma==
{{Main|Epithelial-myoepithelial carcinoma}}
===Cytology===
Features:
*Single cells/stripped nuclei.
*3-dimensional clusters.
*Two cell population:
**Dark small cells.
**Light large cells.
 
=Common=
==Squamous carcinoma==
{{Main|Squamous cell carcinoma}}
*AKA ''squamous cell carcinoma''.
 
===Cytopathology===
Features:
*Mix of spindle cells/epithelioid cells, present in clusters, +/-small number of single cells.
*Keratinization:
**Orange/red staining on Pap stain.
***Poorly differentiated SCC = not orange/red.
**"Intense" (blue) staining of cells on rapid Romanowsky + pyknotic (small shriveled) nucleus.<ref>GS. 24 February 2010.</ref>
*"Dense" appearing cytoplasm.
**+/-Laminae (layers)/lines in the cytoplasm.
*Nuclear features of malignancy (required for diagnosis):
*#Irregular nuclear membrane, e.g. notches, sharp discontinuities.
*#Nuclear hyperchromasia - "jet-black" nuclei on Pap stain '''key feature'''.
*#Increased NC ratio.
*#Variation of nuclear size from cell-to-cell.
*#Granular chromatin.
 
Notes:
#One should see abnormal squamous cells to call it SCC.
#Poorly differentiated SCC may look like [[adenocarcinoma]].


==Melanoma==
==Melanoma==
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Notes:
Notes:
#IHC stains are needed in many cases (S-100, HMB-45, Melan A).
#[[IHC]] stains are needed in many cases (S-100, HMB-45, Melan A).
#The classic appearance of melanoma without pigment is closest to adenocarcinoma (which may have red nucleoli, large cells, abundant cytoplasm, occasional binucleation).
#The classic appearance of melanoma without pigment is closest to [[adenocarcinoma]] (which may have red nucleoli, large cells, abundant cytoplasm, occasional binucleation).
#*Differentiating morphologic features: adenocarcinoma - 3-D clusters of cells, no spindle-shaped cells.
#*Differentiating morphologic features: adenocarcinoma - 3-D clusters of cells, no spindle-shaped cells.


==Lymph nodes==
=Lymph nodes=
Normal:
==Normal lymph node==
===Cytology===
*Mixed population of lymphoid cells.
*Mixed population of lymphoid cells.
*+/-Lymphoglandular bodies.
====Image====
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CI-Image-0803/FQ-044b.gif Lymphoglandular bodies in a DLBCL (ouhsc.edu)].<ref name=ouhsc_nine>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-024-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-024-M.htm]. Accessed on: 9 April 2012.</ref>


==Lymphoma==
==Non-Hodgkin's lymphoma==
===Non-Hodgkin's lymphoma===
*[[AKA]] ''[[lymphoma]]''.
 
===Cytology===
Features:
Features:
*Population of monomorphous lymphoid cells.
*Population of monomorphous lymphoid cells - usu. ~2x the size of a RBC.
*Lymphoglandular bodies - blue-grey bodies.
*Lymphoglandular bodies - blue-grey bodies.
**Often about 1/2 the size of a RBC.
**Often about 1/2 the size of a RBC.
***These may be seen in benign tissue.
***These may be seen in benign tissue.


===Hodgkin's lymphoma===
Note:
*[[Small cell lymphoma]]s cannot be diagnosed definitively from cytology.
 
====Image====
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CI-Image-0803/FQ-044b.gif DLBCL with lymphoglandular bodies (ouhsc.edu)].<ref name=ouhsc_nine>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-024-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-024-M.htm]. Accessed on: 9 April 2012.</ref>
 
==Hodgkin's lymphoma==
{{Main|Hodgkin lymphoma}}
===Cytology===
Features:
Features:
*Reed-Sternberg cell (diagnostic).
*Reed-Sternberg cell (diagnostic).
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**Huge cell with macronucleus.
**Huge cell with macronucleus.
**Each nucleus has a huge macro[[nucleolus]].
**Each nucleus has a huge macro[[nucleolus]].
***[[Macronucleolus]] approximately the size of a RBC.
***[[Macronucleolus]] approximately the size of a [[RBC]].
*Commonly seen with eosinophils.
*Commonly seen with eosinophils.


==Cystic lesions of the neck==
Note:
*RSCs are usually found at the edge of smears.<ref name=ouhsc_q26>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-026-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-026-M.htm]. Accessed on: 9 April 2012.</ref>
 
====Images====
<gallery>
Image:Hodgkin_lymphoma_cytology_small.jpg | HL - higher mag. (WC)
Image:Hodgkin_lymphoma_cytology_large.jpg | HL - lower mag. (WC)
</gallery>
www:
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040-Ans/CI-Image-0803/FQ-046b.gif HL (ouhsc.edu)].<ref name=ouhsc_q26/>
 
=Cystic lesions of the neck=
===General===
===General===
*One should never sign-out a cytology specimen as: "[[branchial cleft cyst]]" or "[[thyroglossal duct cyst]]".
*One should never sign-out a cytology specimen as: "[[branchial cleft cyst]]" or "[[thyroglossal duct cyst]]".
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===DDx===
===DDx===
Lateral:
Lateral:
*Brachial cleft cyst.
*[[Branchial cleft cyst]].
*Cystic hygroma.
*[[Cystic hygroma]].


Medial:
Medial:
*Thyroglossal duct cyst.
*[[Thyroglossal duct cyst]].


Both:
Both:
*Epidermoid cyst.
*[[Epidermoid cyst]].
*Cystic squmaous cell carcinoma.
*Cystic [[squamous cell carcinoma]].
 
==Squamous carcinoma==
{{Main|Squamous cell carcinoma}}
*AKA ''squamous cell carcinoma''.
 
===Cytopathology===
Features:
*Mix of spindle cells/epithelioid cells, present in clusters, +/-small number of single cells.
*Keratinization:
**Orange/red staining on Pap stain.
***Poorly differentiated SCC = not orange/red.
**"Intense" (blue) staining of cells on rapid Romanowsky + pyknotic (small shriveled) nucleus.<ref>GS. 24 February 2010.</ref>
*"Dense" appearing cytoplasm.
**+/-Laminae (layers)/lines in the cytoplasm.
*Nuclear features of malignancy (required for diagnosis):
*#Irregular nuclear membrane, e.g. notches, sharp discontinuities.
*#Nuclear hyperchromasia - "jet-black" nuclei on Pap stain '''key feature'''.
*#Increased NC ratio.
*#Variation of nuclear size from cell-to-cell.
*#Granular chromatin.
 
Notes:
#One should see abnormal squamous cells to call it SCC.
#Poorly differentiated SCC may look like adenocarcinoma.


==See also==
=See also=
*[[Cytopathology]].
*[[Cytopathology]].
*[[Thyroid]].
*[[Thyroid]].
*[[Head and neck pathology]].
*[[Head and neck pathology]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


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