I am working as a pathologist at the department of clinical pathology, Mandalay General Hospital, Mandalay Division, Myanmar. Dr San Yu Maung (M.B.B.S.) (M.Med.Sc.) (Pathology)

1. General
Criteria
of
Malignancy
in
Cytology
Presented by Dr San Yu Maung

2. CYTOPATHOLOGY
Cytopathology is the study of cells
that have exfoliated freely from the
tissue surfaces or that have been
collected by brushing, scraping,
washing or by needle aspiration.

3. • No morphological features that can be
used universally and consistently in
order to make a diagnosis of
malignancy in cytology.
• Criteria of malignancy constitute the
composite finding of abnormal features
in any individual case.

4. • A good knowledge of underlying
pathological processes & variations of
the normal morphology is a prerequisite
for a diagnosis of malignancy.

5. • The same morphological criteria cannot
be applied throughout all systems: each
system has its own specific features that,
when present, add up to the diagnosis.
• However, some of the features are more
important than others.

6. GENERAL FEATURES OF
MALIGNANCY
• Nuclear features
• Cytoplasmic features

7. 01
02
03
04
05
06
07
08
Nuclear size
Nuclear
shape
Position of
nucleus
Chromatin
pattern
Number of
nuclei
Nucleoli
Mitoses
Nuclear/
cytoplasmic
relationship
Nuclear features

8. 01. NUCLEAR SIZE

9. NUCLEAR SIZE
• Cytologists are interested in the
relative nuclear size in relation to cell
size and in comparison to other cells
on the slide.
• A raised N/C ratio is an important
feature when considering the
diagnosis of malignancy.

10. NUCLEAR SIZE
• The appreciation of a benign cell
population at a given site is needed in
order to avoid in making a wrong
judgment (e.g. in benign duct epithelium
of the breast there may be relatively little
cytoplasm and cells may appear to have
a high N/C ratio).

11. NUCLEAR SIZE
• Most reactive inflammatory processes
may have a slightly raised N/C ratio and
yet be benign.

12. Normal breast ductal epithelium

13. Syncytial cluster of malignant ductal cells beneath a
group of smaller benign ductal cells maintaining a
honeycomb pattern

14. Individually scattered malignant ductal cells having nuclei two to
three times the size of the benign ductal cells, which are arranged
in a cohesive honeycomb cluster

15. CHOLANGIOCARCINOMA

16. Cholangiocarcinoma

17. Cholangiocarcinoma

18. 02. NUCLEAR SHAPE

19. • The nucleus is usually round or oval
with a regular nuclear membrane.
Nuclear shape

20. • While many cytopathologists consider
changes in nuclear shape like nuclear
pleomorphism to be one of the main
features of a malignancy, it is not the
only one.
Nuclear shape

21. Cholangiocarcinoma

22. •Reactive conditions may show a
degree of nuclear pleomorphism,
usually with a preserved N/C ratio.
Nuclear shape

23. •The nuclear shape, as reflected in
the nuclear contour or nuclear
membrane, is generally better
appreciated on the Pap than
Romanowsky stains.
Nuclear shape

24. • Minute details of nuclear membrane
infoldings or protrusions can be seen
as well as the membrane thickening
and its irregularities.
Nuclear shape

25. Poorly differentiated SCC of lung

28. 03. POSITION OF
THE NUCLEUS

29. POSITION OF THE NUCLEUS
•The position of the nucleus within
a cell of a particular type is
usually constant.

30. POSITION OF THE NUCLEUS
•An eccentric position is usually a
sign of glandular differentiation
(respiratory or endocervical
epithelium), but the nucleus
usually holds a central position in
squamous epithelium.

31. SCC LUNG

32. ADENOCARCINOMA OF LUNG

33. POSITION OF THE NUCLEUS
• Whilst the position of the nucleus does
not usually contribute to the decision
about the nature of the pathological
process, it may contribute to the
decision about the possible cell origin.

34. POSITION OF THE NUCLEUS
• This feature is commonly used when
trying to establish the primary site of a
metastatic tumour and, together with
cytoplasmic features, may narrow the
search.

35. 04. CHROMATIN PATTERN

36. CHROMATIN PATTERN
• In addition to N/C ratio, the chromatin
pattern is probably the single most
important feature when determining
the nature of the pathological process.

37. CHROMATIN PATTERN
• In order to accurately assess the
chromatin pattern, it is essential to
have good staining and fixation of the
material.
• Chromatin may be appreciated best on
the microscope high-power view.

38. CHROMATIN PATTERN
• The chromatin pattern of the
normal cell presents a dormant
nucleus with smooth, even
staining throughout.

39. Cholangiocarcinoma

40. CHROMATIN PATTERN
•In the case of increased cell
activity, either reactive or
neoplastic, the chromatin pattern
undergoes changes, becoming
more apparent.

41. CHROMATIN PATTERN
• It is variably described as reticular,
granular, coarse, clumped and, most
importantly, regular or irregular.
• An irregular chromatin pattern is one of
the stronger indications that the cell is
malignant.

42. NORMAL
CHROMATIN
PATTERN

43. BREAST DUCTAL EPITHELIUM

44. CERVICAL SMEAR

45. THYROID FOLLICULAR
EPITHELIUM

46. ENDOCERVICAL CELLS

47. ABNORMAL
CHROMATIN
PATTERN

49. METASTATIC SCC, BONE

50. OSTEOSARCOMA OF BONE

55. 05. NUMBER OF NUCLEI

56. NUMBER OF NUCLEI
• Multinucleation is a common occurrence
amongst cells and can be seen in all types
of cells, both in benign and malignant
conditions.

57. NUMBER OF NUCLEI
• The nuclei in benign multinucleated cells
are similar in size, shape , and chromatin
pattern in contrast to those of malignant
giant cells which show marked variation in
these features.

58. LANGHANS-TYPE
GIANT CELLS

59. n

60. Langhans type giant cell (sarcoidosis). Note the uniform
nuclei (Sputum, Pap, 630x)

61. FOREIGN BODY-TYPE
GIANT CELLS

64. TUMOR GIANT
CELLS

65. Multinucleated tumor cell. Note the variation among the
size, shape, and chromatin pattern of the nuclei
(Transthoracic fine needle aspiration, Pap, 1000x)

70. REED-STERNBERG GIANT CELLS
IN HODGKIN LYMPHOMA

74. 06. NUCLEOLI

75. NUCLEOLI
• Nucleoli may be visible to a
variable extent in the normal cells
stained with routine cytological
stains (e.g. bronchial epithelial
cells and squamous cells).

76. NORMAL
BRONCHIAL
EPITHELIAL
CELLS

78. NUCLEOLI
• The intensity of the staining under
physiological conditions reflects the
activity of RNA synthesis within the cell.
• It is therefore not surprising that the
nucleoli become more prominent when
cells undergo regenerative/repair
processes, as seen in inflammatory
conditions.

79. Reparative epithelium. These cells form a cohesive sheet and exhibit abundant
cytoplasm, prominent nucleoli, and nuclear enlargement. Bronchial brushing
(Papanicolaou, ×MP)

81. REPAIR AND REGENERATION
IN THE CERVIX
• Repair changes in a flat sheet of
metaplastic squamous cells.
• Note nuclear enlargement and
prominent nucleolation but with even
chromatin and maintenance of
polarity.

84. NUCLEOLI
•However, nucleoli are also
characteristically prominent in
many malignant tumours.

85. NUCLEOLI
•Nucleoli are characterised not
only by their prominence
(i.e. size and staining pattern)
but also by their shape and
number.

89. 07. MITOSES

90. MITOSES
• Mitotic figures may be seen in normal cells
undergoing division
• However, in FNAC practice, this is relatively
rare.
• Mitoses seen in normal cells are few and they
appear regular.

91. MITOSES
• Mitoses seen in malignant tumours are also
relatively rare in FNAC material compared to
histology samples, and may appear either
regular or irregular.

104. Cancer cell with an atypical mitotic figure.
(Ascites, Pap, 1000x)

105. 08. NUCLEAR/CYTOPLASMIC
RELATIONSHIP

106. NUCLEAR/CYTOPLASMIC
RELATIONSHIP
• Cytoplasmic border "hugging" the
nuclear border for a long distance.
• This nuclear / cytoplasmic relationship,
when it occurs without any apparent
reason (e.g. large intracytoplasmic
vacuole pushing the nucleus against the
cytoplasmic border), is a good malignant
feature.

107. (Ascitic fluid, Pap, 630x)

108. (Bladder wash, Pap, 1000x)

109. CYTOPLASM

110. 01
02
Relative
amount
Quality
and
Content
Cytoplasmic features

111. RELATIVE AMOUNT

112. RELATIVE AMOUNT
•Rather than the absolute amount,
the relative amount or N/C ratio is
important.

113. RELATIVE AMOUNT
•The reduction of cytoplasm due to
the expansion of the nucleus is
usually an important feature of
malignancy and, if observed, is
significant.

114. RELATIVE AMOUNT
• Cytoplasmic boundaries are sometimes
not sharp enough to allow judgment of
the N/C ratio.
• In this case, other features have to be
considered in order to make the
diagnosis.

115. QUALITY
AND
CONTENT

116. QUALITY AND CONTENT
•The quality of the cytoplasm
reflects cell differentiation.
➢ keratinised cells
➢ mucin-producing cells

117. QUALITY AND CONTENT
• Sometimes this is visible with routine
staining and sometimes it needs
special stains.
▪ amyloid-producing cells of medullary
carcinoma
▪ melanin-producing cells of a melanoma
▪ c-kit positive cells from a GIST

118. SCC

119. LOBULAR CARCINOMA OF BREAST

120. LOBULAR CARCINOMA OF BREAST

121. PLEURAL EFFUSION DUE TO
METASTATIC SIGNET RING CELL
CARCINOMA OF STOMACH

123. METASTATIC MELANOMA, LYMPH
NODE

124. DIAGNOSTIC PITFALLS
• Poor collection technique
• Poor fixation
• Inflammatory changes
• Cellular changes related to radiation and/or
chemotherapy
• Atypical cellular changes related to
hemorrhage, infarction, or necrosis

125. FALSE NEGATIVE DIAGNOSES
• Desmoplasia
• Well-differentiated tumor cells
• Sampling problems
• The presence of inflammation, radiation, and
chemotherapy changes sometime can be
over interpreted

126. FALSE POSITIVE DIAGNOSES
• Pregnancy
• Contamination
• Inflammation and inflammatory changes,
radiation and chemotherapy effects
• The presence of hemorrhage and infarction
sometimes induce atypical changes in the cells
• Inexperience by the pathologist may induce
false positive diagnosis

128. TAKE HOME MESSAGE
• No single feature diagnostic of malignancy
• Each organ has its own diagnostic limitation by cytology
• Simple clear communication between pathologists and
clinicians is very important
• All the information about the patient should be given to
the pathologist in order to decrease the frequency of
pitfalls
• Sources of error are avoidable, to a certain extent, by
experience and by knowledge of the clinical history

129. REFERENCES
1. Criteria of malignancy in cytology by Prof.Win Naing, MBBS
MMedSc PhD (Pathology) DipMedEd, Professor/Head, University
of Medicine, Magway
2. http://pathology.jhu.edu/cytopath/masterclass/general/main.htm
3. Koss' Diagnostic Cytology and Its Histopathologic Bases, 5th
Edition
4. Basics of cytology; Mousa A. Al-Abbadi; Department of Pathology
and Cytopathology, King Fahad Specialist Hospital, Dammam,
Saudi Arabia; Copyright : © Avicenna Journal of Medicine
5. Comprehensive cytopathology, 4th Edition
6. Diagnostic Cytology by Pranab dey Mbbs md miac frcpath, First
Edition: 2014