ANSWER TO KCIAPM CYTOLOGY SLIDE SEMINAR JULY 2014

1. WELCOME TO KMIO
CYTOLOGY DIVISION
DEPARTMENT OF PATHOLOGY

2. All learning begins with the simple
phrase “I don’t know”

3. Case 1
53y/F who attended health
checkup camp. Pap smear

14. IMPRESSION
H S I L

15. Case 2
Smear for interpretation

25. Case 1
1. HSIL
2. ASCUS
3. Reactive Changes
4. Atropic Smear with inflammation/ASCUS
5. Inflammatory smear –TV with dysplasia
6. Inflammatory smear-S/O of Herpes
Simplex Inflammation

26. Case 2
1. Mixed Vaginosis – TV + shift in veginal flora
( cocco bacilli)
2. Mixed inflammation – Bact. Vaginosis + TV
3. Negative for SIL – TV
4. TV, Reactive Cellular Changes Assoc. with
Inflammation
5. TV Infection
6. SCC Cx

27. IMPRESSION
L S I L + Trichomonos Vaginitis

28. PAP Test
THE BETHESDA SYSTEM

29. Adequacy of smear
Cell spread more than 10% of the
slide surface
8000 to 12000 cells in conventional pap
smear/5000 cells in liquid based preparation
Presence or absence of endocervical TZ
component - 10 well preserved, endocervical
or metaplastic cells in singly or in cluster
If abnormal cells seen, never categorize as
unsatisfactory

30. LSIL
- cells in single/sheets,
- similar to superficial/intermediate cell,
- cytoplasm abundant, eosinophilic/
cyanophilic
- clear cell border
- Nucleus - increase in size 3 times the
nucleus of intermediate cell,
slight irregularity of nuclear outline,
hyperchromasia. Uniform and granular
chromatin, well defined nuclear margin.
No nucleoli
Management: followup, colposcopy HPV test

31. HSIL
Cell size smaller than the LSIL
Cells in singly/sheets/syncitial
Nuclear abnormalities resemble
parabasal/metaplastic cell,
coarse granular chromatin, no nucleoli,
nuclear margin irregular, decreased
cytoloplasm,
increased N/C ratio

32. C
ellular ASC
Cellular changes that are more
marked than those attributable to
reactive changes but that
qualitatively and quantitatively fall
short of definitive diagnosis of

34. ASC
Human Papilloma Virus (HPV)
Vaccine

35. 1. Screening test
2. “ PAP Test “ “VIA” – Good Screening Test
3.“ ASC “ - ? ? ?
4.Ancillary Tests – Colposcopy, HPV test
These are required for management of
women with Cervical Cytological
abnormality
This depends on a good communication
between the Clinician and the
Cytopathologist

37. Case 3
15y/boy presented with on and off
abdominal pain of 6months and a mass
felt to the left of umbilicus. USG FNA of
the mass done.

47. 1. GCT
2. GCT with Embryonal Carcinoma
3. GCT/ALCL
4. Testicular GCT
5. Pleomorphic Adenocarcinoma-Pancreas
6. HCC
7. High Grade Malignant Tumour
8. ALCL, GCT

50. Review smears - Poorly differentiated
tumour
Adv. Repeat test at KMIO
Poorly differentiated tumour - ?GCT,
?ALCL
Case will be reviewed after workup

51. H’gram – Nml
Biochemistry – Nml LDH – 1674 ( 450-N)
Tumour markers – AFP, β-HCG – within Nml
HBsAg & HIV – Non-reactive
USG Abdomen – Enlarged multiple abdominal
mesenteric lymphnodes, largest 3x4x2.5cm
(FNA node) with mild splenomegaly.
Scrotal scan – NAD
No peripheral Lymphadenopathy
Advised IHC on cell block
Lymphnode Biopsy done

54. LCA

55. CD3 CD20
CD30

56. ALK+

57. PAX5 CD34
CD138

58. MUM1

59. Kappa Lamda
Ki67

60. EMA

61. CD4

62. A young boy,
Abdnominal lymphnodes++,
Non- immunocompramised,
H&E- high grade lesion.

63. IHC
LCA+ CD20-
CD3- CD30-
EMA+ CD34-
CK- CD4 +
ALK+(Granular) LMP1-
CD68- LMP1 ?
CD138- MUM1+
Kappa+ Lamda-
Ki67-65% Pax5 focal+

64. DIAGNOSIS

65. FINAL DIAGNOSIS
ALK Positive Diffuse Large B- Cell Lymphoma

66. ALK Positive Diffuse Large
• B- Cell Lymphoma
•1997 – Delsol workers – Delsol’s Tumour
•Median Age – 36yrs. Paed. – 30%
•High Stage Nodal Disease.
•No Assoc. with immunosuppression
•Poor prognosis – 11months

67. MORPH: Immunoblastic/plasmablastic,
Sinusoidal infiltration,
Appear deceptively cohesive – D/D Ca
IHC: LCA + 75%, CD+ 3% (weak & focal)
CD79a+ 16%, EMA+ 100%,
CD30+ 6% (weak & focal)

68. IHC contd
ƛ/ƙ+ 90% (IgA), CD138+/-, CD4+ 64%,
CD57+ 40%, CK+ rare,
ALK+ usually granular cytoplasm
Cytg: t(2:17)(q23;q23) – Fusion of CLTC
(clathrin) gene with ALK gene
t(2:5)(q23;q35)(NPM:ALK) – Rare
EBV – Neg.

69. NEOPLASIA
ALK-positive diffuse large B-cell lymphoma is
associated with Clathrin-ALK rearrangements:
report of 6 cases
Randy D. Gascoyne, Laurence Lamant, Jose I. Martin-Subero,
Valia S. Lestou, Nancy Lee Harris, Hans-Konrad Mu¨ ller-Hermelink,
John F. Seymour, Lynda J. Campbell, Douglas E. Horsman,
Isabelle Auvigne, Estelle Espinos, Reiner Siebert, and Georges Delsol
Blood. 2003;102:2568-2573

70. American Journal Clinical Pathology
(2011) Clinical Pathology, 136, 183-194.
Plasmablastic Lymphoma and
Related Disorders
Eric D. Hsi, MD1, Robert B. Lorsbach, MD, PhD2,
Falko Fend, MD3 and Ahmet Dogan, MD, PhD4
+Author Affiliations
1From the Department of Clinical Pathology, Cleveland Clinic, Cleveland, OH;
Department of Pathology, University of Arkansas for Medical Sciences, Little
Rock; 3Institute of Pathology, University Hospital Tuebingen, Eberhard-Karls
University, Tuebingen, Germany and 4Department of Laboratory Medicine a
and Pathology, Mayo Clinic, Rochester, MN

72. Case 4
28y/F , presented B/L cervical lymphnodes
of 1 – 4cm. in size of 6months duration.
FNA of lymphnodes done

84. Cytology: Cellular smear,
Lymphoid cells, histiocytes/macrophages,
A few large cells with mono/binucleate,
with prominent nucleoli, ?RS cells
Numerous eosinophils, occ. Plasma cells

85. DIAGNOSIS

86. Case 4
1. Histoplasmosis, Kimura’s Disease
2. Lymphoproliferative Diease
3. HD – Mixed Cellularaity
4. LCH
5. HD – Lypmphocytic Predominance
6. SHML with Eo
7. SHML with LCH
8. Kimura’s disease

87. IMP: Positive Malignancy –
1. Malignant lymphoma, HD/ALCL
2. Metastatic Undifferentiated
Carcinoma
Case will be reviewed after H & N workup
H & N workup was normal
FINAL IMP:
1. Malignant lymphoma, HD/ALCL
2. Histiocytic Lesion
Advised LN Bx and IHC study

91. CD1a

92. S100

93. CD30
CD15
CD30

94. CD15

95. Final diagnosis
Hodgkin Lymphoma-syncial type with LCH

96. Diagnosis of Hodgkin Lymphoma
Diagnosis of LCH

97. LCH – Systemic or single organ disease
lung, bone, lymphnode, skin, etc.
Cytology findings
Histomorphology –sinusoidal pattern + IHC
LCH+Lymphoma – Focal Langerhan Cell
Histiocytic Hyperplasia rather than LCH

98. J Res Med Sci. 2010 Jan-Feb; 15(1): 58–61.
Langerhans cell histiocytosis following Hodgkin
lymphoma: a case report from Iran
Nahid Reisi Dehkordi,a Parvin Rajabi,b Azar
Naimi,*,c and Mitra Heidarpourd
Occurrence of LCH after Hodgkin lymphoma
is seen in less than 0.3% of cases.
It can occur before, after or simultaneously
with Hodgkin Lymphoma.

99. Korean J Intern Med. Dec 2012; 27(4): 459–462.
Langerhans Cell Histiocytosis Followed by
Hodgkin's Lymphoma
IK Soo Park,1 In Keun Park,1 Eun Kyoung
Kim,1 Shin Kim,1 Sang Ryong Jeon,2 Joo Ryung
Huh,3 and Cheol Won Suh 1
This condition should be considered in the differential
diagnosis of recurrent lymphoma

101. Case 5

102. • 15yrs boy treated for ALL 6yrs back.
• Regular follow-up
• B/L submandibular cervical lymphadenopathy
2x3cm.
• FNA of the lymphnode done.

111. List of Differentials
• Reactive lymphoid hyperplasia
• Hemophagocytic lymphohisticytosis
• Recurrent ALL
• Secondary neoplasm : DLBCL
• NHL

112. Reactive lymphoid hyperplasia
? Significant lymphadenopathy
? Clinical history
Clinically : 2-3cm LN, soft to firm
patient in remission
PS : normal
LDH : normal
Toxoplasma : negative
Clinicians decided to do whole node biopsy to rule out
relapse

119. IHC : to exclude focal involvement
Tdt : Negative
Correlating clinical, serological and
pathological findings

121. FINAL DIAGNOSIS
Progressive Transformation of Germinal Centre

122. Progressive Transformation of Germinal Centre
• Benign reaction pattern in lymph nodes
• Florid or focal
• 3.5% of non specific lymphadenitis
• Pathogenesis premature arrest at an early
transition between primary and secondary
follicles because of incomplete blastic
transformation of B cells.

123. Progressive Transformation of Germinal Centre
Non hodgkins
• Malignant lymphoma
Hodgkins : NLPHL
• Reactive lymphadenitis
• Immunocompromised
• IgG4 related lymphadenopathy

124. Thank you….