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INTERESTING CASE
PRESENTATION - CYTOLOGY
DR TAMIL NILA
POST GRADUATE
CASE HISTORY
A 65 YEAR OLD MALE CAME WITH A COMPLAINT OF SWELLING IN THE
ANTERIOR ASPECT OF NECK FOR PAST 6 MONTHS
NOT ASSOCIATED WITH PAIN
INCREASING IN SIZE RAPIDLY
EXAMINATION
SINGLE SWELLING
3 X 3 CM
EXTERNAL SURFACE – ENGORGED VEINS
CONSISTENCY – SOFT
RESTRICTED MOBILITY
PAST HISTORY
TOTAL THYROIDECTOMY WITH MODIFIED RADICAL NECK DISSECTION
DONE 7 YEARS BACK
PATIENT WAS ON TAB ELTROXIN 100 MCG 1 – 0 – 0 OD
DISCONTINUED SUPPRESSIVE DOSE DUE TO COVID PANDEMIC
FNAC
• BLOODY ASPIRATE
• 2 SLIDES
• SEVERE BLEEDING WAS PRESENT
FNAC – SCANNER VIEW
CELLULAR SMEAR
ARRANGEMENT
CLUSTERS
MONOLAYERED SHEETS
PAPILLARY PATTERN
SCATTERED
FNAC – LOW POWER VIEW
ANATOMICAL EDGING PRESENT
NUCLEAR CROWDING
FNAC – HIGH POWER VIEW
NUCLEI FEATURES
ENLARGED
OVAL
CROWDING
OVERLAPPING
THICK NUCLEAR MEMBRANE
PALE CHROMATIN
NUCLEAR GROOVING
DIAGNOSIS
PAPILLARY CARCINOMA OF
THYROID
COLLOID • GROSS: SHINY, VISCOUS AND
LIGHT YELLOW OR GOLD
• CRACKS & BUBBLES
• BROKEN GLASS APPEARANCE –
AIR DRIED
• TISSUE PAPER LIKE FOLDING
• SURROUNDS FOLLICULAR
EPITHELIAL CELLS
• MORE COLLOID – MORE LIKELY
BENIGN
• ALTERS THE ADEQUACY
NORMAL FOLLICULAR EPITHELIUM
• LARGE FLAT SHEETS OF COHESIVE FOLLICULAR
CELLS – MACROFOLLICLES
• HONEY COMB APP
• NUCLEUS – ROUND, COARSE CHROMATIN
• CYTOPLASM
SCANT – MOD
DELICATE
INTACT MACRO & MICRO FOLLICLES
DEFINITION - PTC
CONVENTIONAL (CLASSIC) PTC IS A MALIGNANT EPITHELIAL TUMOR
DERIVED FROM THE THYROID FOLLICULAR EPITHELIUM
DISPLAYS PAPILLARY ARCHITECTURE
CHARACTERISTIC NUCLEAR ALTERATIONS.
CRITERIA
• PAPILLAE AND/OR MONOLAYERS
• CELLULAR SWIRLS
• ENLARGED NUCLEI
• CROWDED NUCLEI, OFTEN
MOLDED
• OVAL OR IRREGULARLY SHAPED
NUCLEI
• LONGITUDINAL NUCLEAR
GROOVES
• INCIS
• PALE NUCLEI WITH POWDERY
CHROMATIN
• THICK NUCLEAR MEMBRANES
• MARGINALLY PLACED
MICRONUCLEOLI (1 OR >1)
• PSAMMOMA BODIES
• MULTINUCLEATED GIANT CELLS
• BUBBLEGUM COLLOID
• “HOBNAIL” CELLS
• ONCOCYTIC (HÜRTHLE CELL)
METAPLASIA
• SQUAMOID METAPLASIA
• “HISTIOCYTOID” CELLS
PAPILLARY CARCINOMA THYROID - GROSS
• FIBROSIS, ENCAPSULATION &
CYSTIC CHANGE
• C/S – WHITISH TAN, FLESHY &
FIRM, PAPILLARY AREAS
• MULTIFOCAL
BASIC ARCHITECTURE
SWIRLING OF TUMOUR CELLS
• MINOR ARCHICTECTURAL
DIAGNOSTIC CRITERION
• FLATTENING OF CELLS AT EDGE
OF CELL CLUSTERS
MOLDED NUCLEI
INTRA NUCLEAR CYTOPLASMIC INCLUSIONS
• TRUE INCLUSION
• SAME COLOR & TEXTURE OF
CYTOPLASM
• SHARP DISCRETE BORDER
• BEST SEEN IN PAP STAIN
• F/O TALL CELL VARIANT
• SOAP BUBBLE NUCLEUS
• FALSE INCLUSIONS
DEGENERATIVE VACUOLES
ARTIFACT
SUPERIMPOSED RBC *
PIN POINT SMALL NUCLEOLUS
• SUBMEMBRANAL NUCLEOLUS
• CYTOPLASM
• DENSE
• SQUAMOID
PICKET FENCE ARCHITECTURE & TRUE
ANATOMIC EDGE
PSAMMOMA BODIES
• AT TIP OF PAPILLAE
• AVASCULAR NECROSIS
• CONCENTRIC LAMELLATIONS
• CALCIUM PHOSPHATE
• 1 OR >1
• EXTRA / INTRA FOLLICULAR
• 5 – 20% CASES OF FNA
• PPV – 50%
MULTINUCLEATED GIANT CELLS
CHEWING GUM COLLOID
HISTIOCYTOID CELLS • SPECIFIC FOR PAP CA
• FOLLICULAR ORIGIN
• NUCLEUS – ENLARGED
• COARSE CHROMATIN
• PROMINENT NUCLEOLI
• INTRANUCLEAR CYTOPLASMIC
PSEUDOINCLUSIONS
• ABUNDANT VACUOLATED
CYTOPLASM
VARIANTS
FOLLICULAR VARIANT
COMPLETELY OR ALMOST COMPLETELY
COMPOSED OF SMALL- TO MEDIUM-
SIZED FOLLICLES LINED BY CELLS WITH
VARIABLE NUCLEAR FEATURES OF PTC.
TRABECULAR PATTERN THICK & STICKY COLLOID
MACROFOLLICULAR VARIANT
>50% OF THE FOLLICLES ARE
ARRANGED AS MACROFOLLICLES
MORE THAN 200 ΜM IN DIAMETER
SUBTLE PTC FEATURES
NO PAPILLAE
NO PSAMOMMA BODIES
ABUNDANT COLLOID
CYSTIC VARIANT
• PREDOMINANTLY CYSTIC
• COMPRISED OF THIN,
WATERY FLUID
• ABUNDANT HISTIOCYTES
• HYPERVACUOLATED
TUMOR CELLS
ONCOCYTIC VARIANT
• NUCLEAR CHANGES
CHARACTERISTIC OF PTC
• COMPOSED
PREDOMINANTLY OF
ONCOCYTIC CELLS WITH
VARIABLE ARCHITECTURE
• WARTHIN – LIKE VARIANT
• ONCOCYTES
• LYMPHOCYTES
TALL CELL VARIANT
• AGGRESSIVE FORM OF PTC
• ELONGATED (“TALL”) TUMOR CELLS
• HEIGHT IS AT LEAST THREE TIMES
THEIR WIDTH
• ABUNDANT DENSE GRANULAR
CYTOPLASM
• TYPICAL NUCLEAR CHANGES OF PTC
COLUMNAR CELL VARIANT
• COLUMNAR CELLS
• HYPERCHROMATIC, OVAL, AND
PSEUDOSTRATIFIED NUCLEI
• SUPRANUCLEAR OR SUBNUCLEAR
CYTOPLASMIC VACUOLES
• REMINISCENT OF A COLONIC
ADENOMA OR SECRETORY-TYPE
ENDOMETRIUM
SOLID VARIANT
• PRESENCE OF SOLID AREAS THAT LACK PAPILLAE, FOLLICLES, AND COLLOID
STORAGE
• OCCUPY AT LEAST 50% OF THE LESION
• THE NEOPLASTIC CELLS HAVE TYPICAL NUCLEAR FEATURES OF PTC.
DIFFUSE SCLEROSING VARIANT
• DIFFUSE INVOLVEMENT OF ONE OR BOTH THYROID
LOBES
• EXTENSIVE LYMPHOVASCULAR INVASION
• NUMEROUS PSAMMOMA BODIES
• SQUAMOUS METAPLASIA
• MARKED LYMPHOCYTIC INFILTRATION
• PROMINENT FIBROSIS
CRIBRIFORM MORULAR VARIANT
• CRIBRIFORM AND SOLID ARCHITECTURE
LACKING COLLOID
• TALL AND COLUMNAR OR SPINDLE SHAPED
CELLS & SQUAMOID MORULES
• NUCLEI - HYPERCHROMATIC &
PSEUDOSTRATIFIED
• TYPICAL NUCLEAR FEATURES OF PTC
• NUCLEAR CLEARING CAUSED BY BIOTIN
ACCUMULATION (MORULES)
HOBNAIL VARIANT
• LOSS OF CELLULAR POLARITY/COHESIVENESS
• APICALLY PLACED NUCLEI AND BULGING OF THE APICAL CELL
SURFACE
• >30% OF NEOPLASTIC CELLS.
DIFFERENTIAL DIAGNOSIS
HYALINIZING TRABECULAR ADENOMA
• RARE TUMOUR
• FOLLICULAR CELL ORIGIN
• TRABECULAR GROWTH
• MARKED INTRATRABECULAR
HYALINIZATION
• NUCLEAR CHANGES OF PAP CA
HURTHLE CELL ATYPIA IN LYMPHOCYTIC
THYROIDITIS
• REACTIVE ATYPIA
• MARKED NUCLEAR
PLEOMORPHISM
• CROWDING & OVERLAPPING
• PALE CHROMATIN
• SMALL NUCLEOLI
• ?ONCYTIC VARIANT OF PAP CA
BENIGN PAPILLARY HYPERPLASIA
PAPILLARY HYPERPLASIA IN ADENOMATOID
NODULE
CYSTIC DEGENERATION IN BENIGN NODULE
ATYPIA WITH TREATED GRAVE’S DISEASE
• RADIOIODINE – NUCLEAR
CHANGES
• PALE CHROMATIN
• RARE NUCLEAR GROOVES
ATYPIA OF UNDETERMINED SIGNIFICANCE
SUSPICIOUS OF MALIGNANCY
• POSITIVE PREDICTIVE VALUE – 60 – 75%
• CELLULAR
• NUCLEI – ENLARGED, ROUND
• POWDER CHROMATIN
• NUCLEAR GROOVES
• SMALL DISTINCT NUCLEOLI
• FOLLICULAR VARIANTS PAP CA PRESENT
AS SOM
REFERENCES
• ORELL & STERRETTS FINE NEEDLE ASPIRATION CYTOLOGY 5TH
EDITION
• DIAGNOSTIC CYTOLOGY, PRANAB DEY
• BIBBO M., WILBUR D. COMPREHENSIVE CYTOPATHOLOGY
• THE BETHESDA SYSTEM FOR REPORTING THYROID PATHOLOGY
• ATLAS OF THYROID CYTOPATHOLOGY, SYED Z ALI
• COMMON DIAGNOSTIC PITFALLS IN THYROID CYTOPATHOLOGY

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Papillary Carcinoma thyroid cytology.pptx

  • 1. INTERESTING CASE PRESENTATION - CYTOLOGY DR TAMIL NILA POST GRADUATE
  • 2. CASE HISTORY A 65 YEAR OLD MALE CAME WITH A COMPLAINT OF SWELLING IN THE ANTERIOR ASPECT OF NECK FOR PAST 6 MONTHS NOT ASSOCIATED WITH PAIN INCREASING IN SIZE RAPIDLY
  • 3. EXAMINATION SINGLE SWELLING 3 X 3 CM EXTERNAL SURFACE – ENGORGED VEINS CONSISTENCY – SOFT RESTRICTED MOBILITY
  • 4. PAST HISTORY TOTAL THYROIDECTOMY WITH MODIFIED RADICAL NECK DISSECTION DONE 7 YEARS BACK PATIENT WAS ON TAB ELTROXIN 100 MCG 1 – 0 – 0 OD DISCONTINUED SUPPRESSIVE DOSE DUE TO COVID PANDEMIC
  • 5. FNAC • BLOODY ASPIRATE • 2 SLIDES • SEVERE BLEEDING WAS PRESENT
  • 6. FNAC – SCANNER VIEW CELLULAR SMEAR ARRANGEMENT CLUSTERS MONOLAYERED SHEETS PAPILLARY PATTERN SCATTERED
  • 7. FNAC – LOW POWER VIEW ANATOMICAL EDGING PRESENT NUCLEAR CROWDING
  • 8. FNAC – HIGH POWER VIEW NUCLEI FEATURES ENLARGED OVAL CROWDING OVERLAPPING THICK NUCLEAR MEMBRANE PALE CHROMATIN NUCLEAR GROOVING
  • 10. COLLOID • GROSS: SHINY, VISCOUS AND LIGHT YELLOW OR GOLD • CRACKS & BUBBLES • BROKEN GLASS APPEARANCE – AIR DRIED • TISSUE PAPER LIKE FOLDING • SURROUNDS FOLLICULAR EPITHELIAL CELLS • MORE COLLOID – MORE LIKELY BENIGN • ALTERS THE ADEQUACY
  • 11. NORMAL FOLLICULAR EPITHELIUM • LARGE FLAT SHEETS OF COHESIVE FOLLICULAR CELLS – MACROFOLLICLES • HONEY COMB APP • NUCLEUS – ROUND, COARSE CHROMATIN • CYTOPLASM SCANT – MOD DELICATE
  • 12. INTACT MACRO & MICRO FOLLICLES
  • 13. DEFINITION - PTC CONVENTIONAL (CLASSIC) PTC IS A MALIGNANT EPITHELIAL TUMOR DERIVED FROM THE THYROID FOLLICULAR EPITHELIUM DISPLAYS PAPILLARY ARCHITECTURE CHARACTERISTIC NUCLEAR ALTERATIONS.
  • 14. CRITERIA • PAPILLAE AND/OR MONOLAYERS • CELLULAR SWIRLS • ENLARGED NUCLEI • CROWDED NUCLEI, OFTEN MOLDED • OVAL OR IRREGULARLY SHAPED NUCLEI • LONGITUDINAL NUCLEAR GROOVES • INCIS • PALE NUCLEI WITH POWDERY CHROMATIN • THICK NUCLEAR MEMBRANES • MARGINALLY PLACED MICRONUCLEOLI (1 OR >1) • PSAMMOMA BODIES • MULTINUCLEATED GIANT CELLS • BUBBLEGUM COLLOID • “HOBNAIL” CELLS • ONCOCYTIC (HÜRTHLE CELL) METAPLASIA • SQUAMOID METAPLASIA • “HISTIOCYTOID” CELLS
  • 15. PAPILLARY CARCINOMA THYROID - GROSS • FIBROSIS, ENCAPSULATION & CYSTIC CHANGE • C/S – WHITISH TAN, FLESHY & FIRM, PAPILLARY AREAS • MULTIFOCAL
  • 17. SWIRLING OF TUMOUR CELLS • MINOR ARCHICTECTURAL DIAGNOSTIC CRITERION • FLATTENING OF CELLS AT EDGE OF CELL CLUSTERS
  • 19. INTRA NUCLEAR CYTOPLASMIC INCLUSIONS • TRUE INCLUSION • SAME COLOR & TEXTURE OF CYTOPLASM • SHARP DISCRETE BORDER • BEST SEEN IN PAP STAIN • F/O TALL CELL VARIANT • SOAP BUBBLE NUCLEUS • FALSE INCLUSIONS DEGENERATIVE VACUOLES ARTIFACT SUPERIMPOSED RBC *
  • 20. PIN POINT SMALL NUCLEOLUS • SUBMEMBRANAL NUCLEOLUS • CYTOPLASM • DENSE • SQUAMOID
  • 21. PICKET FENCE ARCHITECTURE & TRUE ANATOMIC EDGE
  • 22. PSAMMOMA BODIES • AT TIP OF PAPILLAE • AVASCULAR NECROSIS • CONCENTRIC LAMELLATIONS • CALCIUM PHOSPHATE • 1 OR >1 • EXTRA / INTRA FOLLICULAR • 5 – 20% CASES OF FNA • PPV – 50%
  • 25. HISTIOCYTOID CELLS • SPECIFIC FOR PAP CA • FOLLICULAR ORIGIN • NUCLEUS – ENLARGED • COARSE CHROMATIN • PROMINENT NUCLEOLI • INTRANUCLEAR CYTOPLASMIC PSEUDOINCLUSIONS • ABUNDANT VACUOLATED CYTOPLASM
  • 27. FOLLICULAR VARIANT COMPLETELY OR ALMOST COMPLETELY COMPOSED OF SMALL- TO MEDIUM- SIZED FOLLICLES LINED BY CELLS WITH VARIABLE NUCLEAR FEATURES OF PTC.
  • 28. TRABECULAR PATTERN THICK & STICKY COLLOID
  • 29. MACROFOLLICULAR VARIANT >50% OF THE FOLLICLES ARE ARRANGED AS MACROFOLLICLES MORE THAN 200 ΜM IN DIAMETER SUBTLE PTC FEATURES NO PAPILLAE NO PSAMOMMA BODIES ABUNDANT COLLOID
  • 30. CYSTIC VARIANT • PREDOMINANTLY CYSTIC • COMPRISED OF THIN, WATERY FLUID • ABUNDANT HISTIOCYTES • HYPERVACUOLATED TUMOR CELLS
  • 31. ONCOCYTIC VARIANT • NUCLEAR CHANGES CHARACTERISTIC OF PTC • COMPOSED PREDOMINANTLY OF ONCOCYTIC CELLS WITH VARIABLE ARCHITECTURE • WARTHIN – LIKE VARIANT • ONCOCYTES • LYMPHOCYTES
  • 32. TALL CELL VARIANT • AGGRESSIVE FORM OF PTC • ELONGATED (“TALL”) TUMOR CELLS • HEIGHT IS AT LEAST THREE TIMES THEIR WIDTH • ABUNDANT DENSE GRANULAR CYTOPLASM • TYPICAL NUCLEAR CHANGES OF PTC
  • 33. COLUMNAR CELL VARIANT • COLUMNAR CELLS • HYPERCHROMATIC, OVAL, AND PSEUDOSTRATIFIED NUCLEI • SUPRANUCLEAR OR SUBNUCLEAR CYTOPLASMIC VACUOLES • REMINISCENT OF A COLONIC ADENOMA OR SECRETORY-TYPE ENDOMETRIUM
  • 34. SOLID VARIANT • PRESENCE OF SOLID AREAS THAT LACK PAPILLAE, FOLLICLES, AND COLLOID STORAGE • OCCUPY AT LEAST 50% OF THE LESION • THE NEOPLASTIC CELLS HAVE TYPICAL NUCLEAR FEATURES OF PTC.
  • 35. DIFFUSE SCLEROSING VARIANT • DIFFUSE INVOLVEMENT OF ONE OR BOTH THYROID LOBES • EXTENSIVE LYMPHOVASCULAR INVASION • NUMEROUS PSAMMOMA BODIES • SQUAMOUS METAPLASIA • MARKED LYMPHOCYTIC INFILTRATION • PROMINENT FIBROSIS
  • 36. CRIBRIFORM MORULAR VARIANT • CRIBRIFORM AND SOLID ARCHITECTURE LACKING COLLOID • TALL AND COLUMNAR OR SPINDLE SHAPED CELLS & SQUAMOID MORULES • NUCLEI - HYPERCHROMATIC & PSEUDOSTRATIFIED • TYPICAL NUCLEAR FEATURES OF PTC • NUCLEAR CLEARING CAUSED BY BIOTIN ACCUMULATION (MORULES)
  • 37. HOBNAIL VARIANT • LOSS OF CELLULAR POLARITY/COHESIVENESS • APICALLY PLACED NUCLEI AND BULGING OF THE APICAL CELL SURFACE • >30% OF NEOPLASTIC CELLS.
  • 39. HYALINIZING TRABECULAR ADENOMA • RARE TUMOUR • FOLLICULAR CELL ORIGIN • TRABECULAR GROWTH • MARKED INTRATRABECULAR HYALINIZATION • NUCLEAR CHANGES OF PAP CA
  • 40. HURTHLE CELL ATYPIA IN LYMPHOCYTIC THYROIDITIS • REACTIVE ATYPIA • MARKED NUCLEAR PLEOMORPHISM • CROWDING & OVERLAPPING • PALE CHROMATIN • SMALL NUCLEOLI • ?ONCYTIC VARIANT OF PAP CA
  • 42. PAPILLARY HYPERPLASIA IN ADENOMATOID NODULE
  • 43. CYSTIC DEGENERATION IN BENIGN NODULE
  • 44. ATYPIA WITH TREATED GRAVE’S DISEASE • RADIOIODINE – NUCLEAR CHANGES • PALE CHROMATIN • RARE NUCLEAR GROOVES
  • 45. ATYPIA OF UNDETERMINED SIGNIFICANCE
  • 46. SUSPICIOUS OF MALIGNANCY • POSITIVE PREDICTIVE VALUE – 60 – 75% • CELLULAR • NUCLEI – ENLARGED, ROUND • POWDER CHROMATIN • NUCLEAR GROOVES • SMALL DISTINCT NUCLEOLI • FOLLICULAR VARIANTS PAP CA PRESENT AS SOM
  • 47. REFERENCES • ORELL & STERRETTS FINE NEEDLE ASPIRATION CYTOLOGY 5TH EDITION • DIAGNOSTIC CYTOLOGY, PRANAB DEY • BIBBO M., WILBUR D. COMPREHENSIVE CYTOPATHOLOGY • THE BETHESDA SYSTEM FOR REPORTING THYROID PATHOLOGY • ATLAS OF THYROID CYTOPATHOLOGY, SYED Z ALI • COMMON DIAGNOSTIC PITFALLS IN THYROID CYTOPATHOLOGY