Digital still cytology

1. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
ROSE FNA OF
LUNG:
ADEQUACY AND
MORPHOLOGY
Tricia Schumaker, BS, CT(ASCP)
DCYT5320E00W Digital Pathology
Digital Photography Portfolio

2. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
OUTLINE
Adequacy criteria
Non-diagnostic
Negative for Malignancy
Non-Small Cell Carcinoma
Small Cell Carcinoma
Neuroendocrine Tumors
Metastatic Carcinoma
ROSE
FNA
OF
LUNG:
ADEQUACY
AND
MORPHOLOGY
2

3. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Introduction
Rapid on-site evaluation (ROSE)
adequacy assessment of Pulmonary
Endobronchial Ultrasound-guided
Specimen (EBUS) Fine Needle
Aspirations (FNA) are common practice
due to the time-consuming and
expensive nature of the procedure.1
Adequate tissue collection for ancillary
studies is crucial for both differentiating
malignancies and for determining
mutations for future targeted therapies.1,2
ROSE FNA OF LUNG: ADEQUACY AND MORPHOLOGY 3

4. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
ADEQUACY
Adequacy of EBUS specimens is determined by whether the specimen is
cellular and if it is representative of the target tissue.2
Inadequate: pauci-cellular smear, no ciliated or atypical bronchial cells when
mass or lesion is present, no lymphocytes in lymph node tissue, excessive
obscuring blood2
Adequate: cellular smear with ciliated bronchial cells and ill-defined mass, or
malignant cells in lung tissue with mass, lymphocytes or malignant cells in
lymph node tissue, granulomas when sarcoidosis is suspected2

5. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image-Inadequate
5
75 yo. Female. ThinPrep Pap stained slide. Photo taken
with 4x objective and AmScope MD1200A digital Camera.
11.7MP 3840x3040 Bx. Positive for SCCA
Same photo taken with 40x objective and AmScope
MD1200A digital camera. 11.7MP 3840x3040 Rare atypical
cell cluster. Bx. Positive for SCCA

6. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Adequate
6
78 yo. female with hx. of ovarian carcinoma. ThinPrep with Pap stain. Photo
taken with 4x objective and AmScope MD1200A ocular camera. 11.7MP
3840x3040
75 yo. Female. ThinPrep Pap stained slide. Photo taken with 4x objective and
AmScope MD1200A digital Camera. 11.7MP 3840x3040 Bx. Positive for SCCA

7. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
ADEQUACY
Ideally, 3 to 5 FNA needle passes/3 core biopsies should be performed with
additional passes to collect tissue for ancillary testing.3,4 The collected tissue
should contain approximately 3000 nucleated well-preserved cells. Although as
few as 50 tumor cells can be used to detect K-RAS and EGFR, and at least 100
cells are needed for FISH and CISH, the total number of test panels being run
should be taken into consideration.4 Thus the number of levels needed when
running several IHC stains to determine cancer type along with tumor marker
panels to determine sensitivity, (H&E, ER/PR, ALK, PD-L1, Ki-67) should be
taken into consideration.

8. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Adequate
8
75 yo. female with hx of stage IV adenocarcinoma of the lung. Cell block of
lymph node with H&E. Benign lymphocytes. Photo taken with 4x objective
and AmScope MD1200A ocular camera. 11.7MP 3840x3040
75 yo. female with hx of stage IV adenocarcinoma of the lung. Cell block
H&E stain of lymph node. Rare cluster of adenocarcinoma. Photo taken with
10x objective and AmScope MD1200A ocular camera. 11.7MP 3840x3040

9. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
ADEQUACY
Molecular Testing, such as DNA microarray, require approximately 84,000 cells,
and RNA microarray requires 20,000 to 50,000 cells.5 Mayo Laboratories
requires approximately 5000 cells with at least 20% tumor nuclei for their Lung
Cancer-Targeted Gene Panel with Rearrangements.5

10. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Adequate
10
75 yo. female with hx of stage IV adenocarcinoma of the lung. Cell block of lymph
node with H&E. Adenocarcinoma. Sufficient cells for ancillary testing. Photo taken
with 4x objective and AmScope MD1200A ocular camera. 11.7MP 3840x3040

11. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
UNSATISFACTORY/
NON-DIAGNOSTIC
Non-diagnostic Lung EBUS specimens provide no useful diagnostic information
about the lesion.2 This includes FNA specimens that are pauci-cellular,
obscured by blood or mucus, or only contain ciliated bronchial cells, cartilage or
pneumocytes.2

12. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Non-Diagnostic
12
29 yo. Male. Direct smear Pap stained slide. Anthracotic
hisitocytes from an EBUS specimen taken with iPhone 13 and
Nikon microscope with 10x/22 oculars and 10x lens. 3024x4032

13. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
NEGATIVE FOR
MALIGNANCY
Negative Lung EBUS slides do not have cells indicative of malignancy. The
Negative category includes those slides which contain reactive bronchial cells.2
Qualification of benign changes, such as the presence of granulomatous
inflammation, fungus or bacteria, should be included in the report.2

14. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Negative for Malignancy
14
75 yo. Female with pneumonia. ThinPrep Pap stained slide.
Negative for malignancy due to granulomas present. Presence of
fungal hyphae. Photo taken with 4x objective and AmScope
MD1200A digital Camera. 11.7MP 3840x3040
Same case with closeup of hyphae. Photo taken with 40x
objective and AmScope MD1200A digital Camera. 11.7MP
3840x3040

15. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Negative for Malignancy
15
63 yo. male. Cell block H&E stained slide. Negative for
malignancy. Presence of fungal hyphae. Photo taken with 40x
objective and AmScope MD1200A digital Camera. 11.7MP
3840x3040
Same case with closeup of hyphae. Cytospin stained with Dif
Quik stain. Photo taken with 40x objective and AmScope
MD1200A digital Camera. 11.7MP 3840x3040

16. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
EBUS slides containing cells Positive for Malignancy, or Positive for Metastatic
Malignancy will display cytologic features corresponding to their tumor type.
They are categorized into four subtypes: Non-Small Cell Carcinoma, Small
Cell/Neuroendocrine Carcinoma, Rare Pulmonary Carcinomas and Metastatic
Carcinoma.2
Non-Small Cell Carcinoma includes Squamous Cell Carcinoma and
Adenocarcinoma.

17. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
Non-Small Cell Carcinoma includes Squamous Cell Carcinoma and
Adenocarcinoma.
Squamous Cell Carcinoma may be keratinized or non-keratinized. Slide
background usually contains necrotic debris. Cells show great variability and
often have angular nuclear borders and anisonucleosis. Nucleoli are usually
inconspicuous and eccentrically. Cells are often single, in strips or clusters.2

18. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
NSCLC SCCA
18
75 yo. Female. ThinPrep Pap stained slide. Photo taken with 40x
objective and AmScope MD1200A digital camera. 11.7MP
3840x3040 Bx. Positive for SCCA
Same case, different nodule. ThinPrep Pap stained slide.
Photo taken with 40x objective and AmScope MD1200A digital
camera. 11.7MP 3840x3040. Positive for SCCA

19. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
NSCLC SCCA
19
70 yo. Female. Pap stained smear made during ROSE. Squamous
cell carcinoma. Photo taken with 4x objective and AmScope
MD1200A digital camera. 11.7MP 3840x3040 Bx. Positive for SCCA
Same case. Pap stained slide. Squamous cell carcinoma.
Photo taken with 40x objective and AmScope MD1200A digital
camera. 11.7MP 3840x3040. Positive for SCCA

20. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
NSCLC SCCA
20
Same case. Cell block H&E stained slide. Squamous cell
carcinoma. Photo taken with 10x objective and AmScope MD1200A
digital camera. 11.7MP 3840x3040 Bx. Positive for SCCA

21. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
Adenocarcinoma may have a clean background or contain tumor diathesis.
Cells are in three-dimensional groups, spheres and papillary-like groups.
Cytoplasm is delicate and may be granular or vacuolated. Nuclei are eccentric,
sometimes with nuclear inclusions or grooves, and often with prominent red
nucleoli on Pap stain.2 Some Pulmonary Adenocarcinomas may present with a
lepidic pattern. Mucinous Adenocarcinoma has a mucinous background and
are often arranged in sheets of drunken honeycombs. Signet rings may be
seen. Clear cell features may be present.2

22. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
NSCLC Adenocarcinoma
22
63 yo. Male. Smear Pap stained slide. Adenocarcinoma of the
lung taken with iPhone 13 and a Nikon microscope fitted with
10x/22 oculars and 4x lens 3024x4032
75 yo. female with hx of stage IV adenocarcinoma of the lung. ThinPrep Pap
stain of lymph node. Rare cluster of adenocarcinoma. Photo taken with 10x
objective and AmScope MD1200A ocular camera. 11.7MP 3840x3040

23. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
NSCLC Adenocarcinoma
23
75 yo. female with hx of stage IV adenocarcinoma of the lung. ThinPrep Pap
stain of lymph node. Rare cluster of adenocarcinoma. Photo taken with 40x
objective and AmScope MD1200A ocular camera. 11.7MP 3840x3040
Same patient. Dif Quik stained smear of same lymph node made during
ROSE. Rare cluster of adenocarcinoma. Photo taken with 40x objective and
AmScope MD1200A ocular camera. 11.7MP 3840x3040

24. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
NSCLC Adenocarcinoma
24
Same patient. Smear taken during ROSE with Pap stain of lymph node.
Adenocarcinoma. Photo taken with 40x objective and AmScope MD1200A
ocular camera. 11.7MP 3840x3040
Same patient. Smear taken during ROSE with Pap stain of lymph node.
Adenocarcinoma. Photo taken with 10x objective and AmScope MD1200A
ocular camera. 11.7MP 3840x3040

25. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
Adenosquamous carcinoma usually contains a background of necrotic debris.
Cells are seen singular and in three-dimensional groups. Cells may have
keratinized cytoplasm or be vacuolated. Nuclei are often large and atypical
with prominent nucleoli.2

26. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
NSCLC Adenosquamous carcinoma
26
75 yo. female. Two lesions. First lesion Touch Prep Dif Quik stain.
Squamous cell carcinoma. Photo taken with 40x objective and AmScope
MD1200A ocular camera. 11.7MP 3840x3040. P40 and CK5/6 stains
positive consistent with squamous cell carcinoma
Same patient, second lesion Touch Prep Dif Quik stain.
Adenocarcinoma. Photo taken with 40x objective and AmScope
MD1200A ocular camera. 11.7MP 3840x3040.

27. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy NSCLC
Adenocarcinoma and Thymoma
27
73 yo female. Smear taken during ROSE with Pap stain of first
mass. Adenocarcinoma. Photo taken with 40x objective and
AmScope MD1200A ocular camera. 11.7MP 3840x3040. TTF and
Napsin stains positive consistent with adenocarcinoma
Same patient. Cell block of second mass. Photo taken with 10x
objective and AmScope MD1200A ocular camera. 11.7MP
3840x3040. P63 and CK-AE1/AE3 stains positive consistent with
Thymoma

28. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
Neuroendocrine tumors come in neoplasms such as carcinoid tumors or
malignant such as seen in Small Cell Carcinoma.2
Small Cell Carcinoma usually presents with a background of necrotic debris.
Smears may create tangles of bare, small and dark nuclei. Groups are loosely
arranged. Size may vary but are usually small with oval to spindle-shaped
nuclei. Nucleoli are not visible and cytoplasm is scant.2

29. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy Small
Cell Carcinoma
29
75 yo. Female. ThinPrep Pap stained slide from ROSE. Small
cell carcinoma. Photo taken with 40x objective and AmScope
MD1200A ocular camera. 11.7MP 3840x3040
Same case. Pap stained smear from ROSE. Small cell
carcinoma. Photo taken with 40x objective and AmScope
MD1200A ocular camera. 11.7MP 3840x3040

30. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy Small
Cell Carcinoma
30
Same case. TTF stained cell block. Consistent with small cell
carcinoma. Photo taken with 10x objective and AmScope
MD1200A ocular camera. 11.7MP 3840x3040
Same case. Synaptophysin stained cell block. Consistent with
neuroendocrine origin. Photo taken with 40x objective and
AmScope MD1200A ocular camera. 11.7MP 3840x3040

31. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy Small
Cell Carcinoma
31
73 yo. male. Smear made during ROSE stained with Pap stain.
Small cell carcinoma. Photo taken with 40x objective and
AmScope MD1200A ocular camera. 11.7MP 3840x3040
Same case. Cell block H&E stain. Small cell carcinoma. Photo
taken with 10x objective and AmScope MD1200A ocular camera.
11.7MP 3840x3040

32. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
Neuroendocrine and Carcinoid Tumors.2
Carcinoid Tumors present as non-cohesive pleomorphic palisaded sheets,
trabeculae and branching grape-like clusters with monotonous oval or spindle-
shaped cells, granular chromatin and scant cytoplasm. Stroma is
metachromatic and nuclear atypia may be variable. The background is usually
clean. A large cell neuroendocrine variant is also possible presenting in
rosettes with abundant cytoplasm.2

33. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
Carcinoid Tumors
33
22 yo. Female with granulomatous lung mass. ThinPrep Pap stained slide
from ROSE. Carcinoid. Photo taken with 4x objective and AmScope
MD1200A ocular camera. 11.7MP 3840x3040
Same patient. Cell Block CD68 highlighting granulomas. Carcinoid. Photo
taken with 10x objective and AmScope MD1200A ocular camera. 11.7MP
3840x3040

34. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
34
Same patient. Touch prep Pap stained slide from ROSE. Carcinoid. Photo
taken with 10x objective and AmScope MD1200A ocular camera. 11.7MP
3840x3040
Image- Positive for Malignancy
Carcinoid Tumors

35. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
Carcinoid Tumors
35
80 yo. Female with lung mass. H&E smear from ROSE. Monomorphic
pattern. Atypical carcinoid. Photo taken with 10x objective and AmScope
MD1200A ocular camera. 11.7MP 3840x3040
Same patient. Cell Block Synaptophysin highlighting cells. Atypical Carcinoid.
Photo taken with 10x objective and AmScope MD1200A ocular camera. 11.7MP
3840x3040

36. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
Lymphomas.
Lymphomas present with a granular background and lymphoglandular bodies.
They are highly cellular, monomorphic and mainly contain large or small
lymphocytes with atypical features.2

37. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
Lymphomas
37
71 yo. Male. Pap stained smear during ROSE. Patient with hx. Of
B-cell lymphoma. Photo taken with 40x objective and AmScope
MD1200A ocular digital camera. 11.7MP 3840x3040
Same patient. CD20 highlighting B cells. Photo taken with 40x
objective and AmScope MD1200A ocular digital camera. 11.7MP
3840x3040

38. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
POSITIVE FOR
MALIGNANCY
Metastatic Carcinoma will take on the features of the originating tissue. Breast
is a common metastatic carcinoma seen in women. It presents either in a
ductal or lobular pattern often in three dimensional cell balls.2

39. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
Image- Positive for Malignancy
Metastatic
39
78 yo. Female with hx. Of ovarian carcinoma. ThinPrep photo taken with 40x
objective and AmScope MD1200A ocular digital camera. 11.7MP 3840x3040
67 yo. male with hx. Of mesothelioma. Pap stained smear made during
ROSE. Positive for metastatic mesothelioma photo taken with 40x objective
and AmScope MD1200A ocular digital camera. 11.7MP 3840x3040

40. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
The way to get
started is to quit
talking and begin
doing.
Walt Disney
ROSE
FNA
OF
LUNG:
ADEQUACY
AND
MORPHOLOGY
40

41. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
References
1. Hoda RS, VandenBussche C, Hoda SA. Fine needle aspiration of the lung. In:Diagnostic liquid-based
cytology. Springer. 2017: 159-181. doi:10.1007/978-3-662-53905-7_9.
2. Layfield LJ, Baloch Z. The Papanicolaou society of cytopathology system for reporting respiratory cytology.
Springer. 2019. doi:10.1007/978-3-319-97235-0.
3. Roy-Chowdhuri S, Dacic S, Ghofrani M, Illei PB, Layfield LJ, Lee C, et. al. Collection and handling of
thoracic small biopsy and cytology specimens for ancillary studies: guideline from the college of american
pathologists in collaboration with the american college of chest physicians, association for molecular
pathology, american society of cytopathology, american thoracic society, pulmonary pathology society,
papanicolaou society of cytopathology, society of interventional radiology, and society of thoracic radiology.
Arch Pathol Lab Med. 2020; 144(8):933-958. doi:10.5858/arpa.2020-0119-CP.
4. Yang B, Rao J. Molecular biomarkers in pulmonary cytology. In:Molecular cytopathology: essentials in
cytopathology. Springer. 2016. doi:10.1007/978-3-319-30741-1.
5. Shidham VB. Cell-blocks and other ancillary studies (including molecular genetic tests and proteomics).
Cytojournal. 2021; 18(4). Doi:10.25259/Cytojournal_3_2021.

42. Sensitivity: General Business Use. This document contains proprietary information and is intended for business use only.
THANK YOU
ROSE
FNA
OF
LUNG:
ADEQUACY
AND
MORPHOLOGY
Tricia Schumaker, BS, CT(ASCP)
42