Part 1 of ebook Atlas of non-gynecologic cytology provide readers with content about: salivary gland fine needle aspiration; thyroid fine needle aspiration cytology; breast cytology; pulmonary cytology; gastrointestinal cytology;... Please refer to the ebook for details!
Xin Jing Momin T Siddiqui Qing Kay Li Editors Atlas of Non-Gynecologic Cytology 123 Atlas of Anatomic Pathology Series Editor Liang Cheng Indianapolis, Indiana USA This Atlas series is intended as a “first knowledge base” in the quest for diagnosis of usual and unusual diseases Each atlas will offer the reader a quick reference guide for diagnosis and classification of a wide spectrum of benign, congenital, inflammatory, nonneoplastic, and neoplastic lesions in various organ systems Normal and variations of “normal” histology will also be illustrated Each atlas will focus on visual diagnostic criteria and differential diagnosis It will be organized to provide quick access to images of lesions in specific organs or sites Each atlas will adapt the well-known and widely accepted terminology, nomenclature, classification schemes, and staging algorithms Each volume in this series will be authored by nationally and internationally recognized pathologists Each volume will follow the same organizational structure The first Section will include normal histology and normal variations The second Section will cover congenital defects and malformations The third Section will cover benign and inflammatory lesions The fourth Section will cover benign tumors and benign mimickers of cancer The last Section will cover malignant neoplasms Special emphasis will be placed on normal histology, gross anatomy, and gross lesion appearances since these are generally lacking or inadequately illustrated in current textbooks The detailed figure legends will concisely summarize the critical information and visual diagnostic criteria that the pathologist must recognize, understand, and accurately interpret to arrive at a correct diagnosis This book series is intended chiefly for use by pathologists in training and practicing surgical pathologists in their daily practice The atlas series will also be a useful resource for medical students, cytotechnologists, pathologist assistants, and other medical professionals with special interest in anatomic pathology Trainees, students, and readers at all levels of expertise will learn, understand, and gain insights into the complexities of disease processes through this comprehensive resource Macroscopic and histological images are aesthetically pleasing in many ways This new series will serve as a virtual pathology museum for the edification of our readers More information about this series at http://www.springer.com/series/10144 Xin Jing • Momin T Siddiqui • Qing Kay Li Editors Atlas of Non-Gynecologic Cytology Editors Xin Jing The University of Michigan-Michigan Medicine Ann Arbor, MI USA Momin T Siddiqui Weill-Cornell Medicine New York, NY USA Qing Kay Li The Johns Hopkins Medical Institutions Baltimore, MD USA Atlas of Anatomic Pathology ISBN 978-3-319-89673-1 ISBN 978-3-319-89674-8 (eBook) https://doi.org/10.1007/978-3-319-89674-8 Library of Congress Control Number: 2018945110 © Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Printed on acid-free paper This Springer imprint is published by the registered company Springer International Publishing AG part of Springer Nature The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland To my husband, Leilei Lin, for his continuous support and my mentor, Claire Michael, for instilling in me a passion for cytopathology Xin Jing To my parents, Masud and Meher Siddiqui, for their love and guidance Momin T. Siddiqui To my husband, my son, my family, Liz, Nathaniel and Emma, for their love and support Qing Kay Li Series Preface One Picture Is Worth Ten Thousand Words — Frederick Barnard, 1927 Remarkable progress has been made in anatomic and surgical pathology during the last 10 years The ability of surgical pathologists to reach a definite diagnosis is now enhanced by immunohistochemical and molecular techniques Many new clinically important histopathologic entities and variants have been described using these techniques Established diagnostic entities are more fully defined for virtually every organ system The emergence of personalized medicine has also created a paradigm shift in surgical pathology Both promptness and precision are required of modern pathologists Newer diagnostic tests in anatomic pathology, however, cannot benefit the patient unless the pathologist recognizes the lesion and requests the necessary special studies An up-to-date atlas encompassing the full spectrum of benign and malignant lesions, their variants, and evidence-based diagnostic criteria for each organ system is needed This atlas is not intended as a comprehensive source of detailed clinical information concerning the entities shown Clinical and therapeutic guidelines are served admirably by a large number of excellent textbooks This atlas, however, is intended as a “first knowledge base” in the quest for definitive and efficient diagnosis of both usual and unusual diseases The Atlas of Anatomic Pathology is presented to the reader as a quick reference guide for diagnosis and classification of benign, congenital, inflammatory, nonneoplastic, and neoplastic lesions organized by organ systems Normal histology and variations are illustrated for each organ and anatomic system The atlas focuses on visual diagnostic criteria and differential diagnosis The organization is intended to provide quick access to images and confirmatory tests for each specific organ or site The atlas adopts the well-known and widely accepted terminology, nomenclature, classification schemes, and staging algorithms This book series is intended chiefly for use by pathologists in training and practicing surgical pathologists in their daily practice It is also a useful resource for medical students, cytotechnologists, pathologist assistants, and other medical professionals with special interest in anatomic pathology We hope that our trainees, students, and readers at all levels of expertise will learn, understand, and gain insight into the pathophysiology of disease processes through this comprehensive resource Macroscopic and histological images are aesthetically pleasing in many ways We hope that the new series will serve as a virtual pathology museum for the edification of our readers Indianapolis, IN, USA Liang Cheng, M.D vii Preface As we all know, cytology not only provides an accurate diagnosis at the cellular level by using minimally invasive procedures but also provides material for molecular characterization of a lesion/tumor for targeted therapy In the era of personalized medicine, cytology has continued to grow and evolve as a critical diagnostic tool Recently, the diagnostic criteria of tumors have become more refined, and certain terminology has been changed based on current TCGA (the Cancer Genome Atlas) data and WHO classifications Therefore, it is necessary to update our knowledge and terminology in cytology In this book, we focus on all aspects of non-gynecologic cytopathology, from key features of benign and malignant lesions to diagnostic pearls and ancillary testing Although this book is written by multiple authors, all chapters follow a similar format: brief introduction of the specific organ/system (including types of specimens and techniques to obtain samples), description of normal findings, and a practical approach to diagnose benign and malignant lesions The key cytomorphological features and main differential diagnoses of lesions are also summarized in concise tables Images in each chapter are instructive and represent findings It also retains the quality and clarity of the Atlas of Anatomic Pathology series, and, like other volumes, this volume aims to be concise and comprehensive yet clinically relevant to daily practice We also discuss important ancillary tests in each chapter, such as flow cytometry, immunohistochemistry, and molecular testing, which are crucial for an accurate diagnosis and differential diagnosis as well as for targeted therapy The updated knowledge, key cytomorphological features, current terminology, and molecular diagnostic tests are the highlights of this book Finally, we wish for our book to be a practical resource for cytotechnologists, cytopathologists, and pathologists who are practicing general surgical pathology and cytopathology The book will also be a valued text for medical students, residents, fellows, and other allied health personnel who take care and/or treat patients based on the histological diagnosis of diseases Ann Arbor, MI, USA New York, NY, USA Baltimore, MD, USA Xin Jing, M.D Momin T. Siddiqui, M.D., F.I.A.C Qing Kay Li, M.D., Ph.D., F.C.A.P ix Acknowledgements First of all, we want to acknowledge our fellow cytopathologists, residents, and fellows for their help in collecting cases from their daily sign-out, and contributing to this book, which is a time-consuming process that often takes time away from other life duties We also want to thank Dr Liang Cheng for his role as the development editor of the atlas; Richard Hruska, executive editor; Lee Klein, senior editor for overseeing production; and others for their help during the production process xi Contents 1 Salivary Gland Fine Needle Aspiration������������������������������������������������������������������� 1 He Wang, Aatika Malik, and Yun Gong 2 Thyroid Fine Needle Aspiration Cytology ������������������������������������������������������������� 19 Xin Jing 3 Breast Cytology��������������������������������������������������������������������������������������������������������� 43 Gabriela Oprea-Ilies and Momin T Siddiqui 4 Pulmonary Cytology������������������������������������������������������������������������������������������������� 103 Derek B Allison and Qing Kay Li 5 Gastrointestinal Cytology����������������������������������������������������������������������������������������� 133 Gabriela Oprea-Ilies and Momin T Siddiqui 6 Pancreaticobiliary Tract Cytology��������������������������������������������������������������������������� 157 Judy Pang and Andrew Sciallis 7 Liver Cytology����������������������������������������������������������������������������������������������������������� 173 Derek B Allison, David Borzik, and Qing Kay Li 8 Kidney and Adrenal Gland Cytology��������������������������������������������������������������������� 199 Qing Kay Li 9 Urine Cytology ��������������������������������������������������������������������������������������������������������� 221 Madelyn Lew 10 Serous Effusion Cytology����������������������������������������������������������������������������������������� 235 Qing Kay Li 11 Lymph Node Cytology ��������������������������������������������������������������������������������������������� 259 Von G Samedi and Qian-Yun Zhang Index����������������������������������������������������������������������������������������������������������������������������������� 289 xiii 142 Neuroendocrine Tumors of the Stomach As in the entire GI tract, these tumors arise in the ubiquitous neuroendocrine system of the GI tract Gastric neuroendocrine tumors (NETs) are classified into four types, considering the cells of origin, usual location in the stomach, clinical presentation, pathology, and outcome [54]: • Type I, which is the most common, arises in a background of gastric atrophy and is associated with hypergastrinemia The enterochromaffin-like cells are the cells of origin in type I which usually forms multiple small tumors Type I NET may regress and usually has a good prognosis Lymph node metastases were described only if the tumor was larger than 2 cm • Type II is associated with multiple endocrine neoplasia (MEN) type I with Zollinger-Ellison syndrome These tumors develop in the stomach body and are usually smaller than 1.5 cm They are more likely to metastasize (30%), mostly if the tumor is larger than 2 cm, and they may show muscularis propria and lymphovascular invasion • Type III, the second most common type, is sporadic and may localize anywhere in the stomach It metastasizes when larger and presenting with muscularis propria and lymphovascular invasion • Type IV NET is a high-grade, large tumor that usually has already metastasized at the time of presentation See Table 5.4 for the World Health Organization (WHO) classification of gastric NET Histologic grading of gastric NET, as for the entire GI system, is based on the mitotic rate and mitotic index The mitotic index is determined by immunostaining for Ki-67 Table 5.5 summarizes the grading of gastric NET. As the mitotic rate and mitotic index may differ, the highest grade of these is assigned to the tumor Usually the mitotic index is higher than the mitotic rate [55] Gastric Lymphoma Gastric lymphomas are the second most frequent malignancies involving the stomach Gastric lymphoma may be primary or metastatic An increase in extranodal lymphoTable 5.4 WHO classification of gastric neuroendocrine tumors Neuroendocrine tumor (NET) NET grade (carcinoid) NET grade Neuroendocrine carcinoma (NEC) Large cell NEC Small cell NEC Mixed adenoneuroendocrine carcinoma (MANEC) Enterochromaffin cell (EC-cell), serotonin-producing NET Gastrin-producing NET (gastrinoma) Reprinted from Bosman et al [55]; with permission G Oprea-Ilies and M T Siddiqui mas rather than in nodal forms has been reported [55] The GI tract represents 30–40% of extranodal lymphomas, of which the stomach is involved in 50% of cases [56, 57] Cytology specimens offer the advantage (when immediate evaluation is performed) of directing part of the specimen for flow-cytometry study One must be mindful about collecting enough specimen for cell block, as immunohistochemical staining plays a major role in rendering this diagnosis The ultimate diagnosis may require histoarchitecture evaluation and may require biopsy and/or an excision specimen Clinical Aspects The symptoms of gastric lymphoma, regardless of type, are most frequently nonspecific, suggesting gastritis or peptic ulcer disease Common symptoms are epigastric pain and dyspepsia, with nausea and vomiting, anorexia, and weight loss B symptoms are extremely rare Gastrointestinal hemorrhage (hematemesis or melena) occurs usually late during the disease progression (70–80% of patients), and gastric occlusion and perforation are quite uncommon [58] The physical examination is normal in more than half of patients; palpable abdominal masses and/or peripheral lymphadenopathy are found in advanced stages and/or aggressive histology Primary Gastric Lymphoma Primary gastric lymphoma, like all the other nodal and extranodal types, is classified into non-Hodgkin and Hodgkin lymphomas The most common primary gastric non-Hodgkin lymphomas are mucosa-associated lymphoid tissue (MALT), gastric lymphoma, and diffuse large B-cell lymphoma (DLBCL) of the stomach (see Figs. 5.9 and 5.10) MALT Gastric Lymphoma The B cells in MALT lymphomas present surface positivity for immunoglobulins, for pan-B antigens (CD19, CD20, CD79a), and for antigens typical of the marginal zone (CD35, CD21) They are negative for CD5, CD10, CD23, and cyclin D1 Lymphoepithelial lesions identified on cell block/histology may be stained with anti-CD20 antibodies and anti-pan-cytokeratin In addition, CD23 and CD35 antibodies mark follicular dendritic cells, allowing for differentiation from reactive follicles [59] At least three recurrent chromosomal translocations have been described in up to 65% of MALT lymphomas: the t(11;18)(q21;q21) translocation, which forms the chimeric fusion gene AP12-MALT1; the t(1;14)(p22;q32) translocation that leads to BCL10 deregulation; and the t(14;18) (q32;q21) translocation deregulating MALT1 All these translocations result in nuclear transcription factor Nf-kB activation, with a central role in the regulation of the various genes involved in immunity, inflammation, and apoptosis [60, 61] 5 Gastrointestinal Cytology 143 Table 5.5 Grading of gastric neuroendocrine tumors Grade G1 G2 Mitotic index (10 hpf)a 20 >20 Histology Well-differentiated Well-differentiated; may show punctate necrosis High-grade IHC Strong chromogranin/synaptophysin positivity Strong chromogranin/synaptophysin positivity Chromogranin may be negative; CD56 is usually positive IHC immunohistochemistry a Mitotic index: 50 high-power fields (40×) (hpf) in areas with highest mitotic activity (hot areas!) and reported as number of mitoses/10 hpf b Ki-67index: 500–2000 tumor cells are counted in areas with highest nuclear labeling (hot areas!) and reported as percentage of positive tumor cells Fig 5.9 Primary gastric follicular lymphoma This smear shows numerous isolated or clustering lymphocytes and few tangible body macrophages The well-known feature of the cleaved nuclei may be found in some of these follicular lymphoma cells (Diff-Quik, 10×) Both host genetic makeup and inflammatory factors play a role in gastric lymphoma Gene polymorphisms involved in anti-inflammatory and anti-oxidative processes, such as IL1RN and GSTT1, are described as part of the lymphoma- generating genetic background [62] Moreover, CagA-positive strains of Helicobacter organisms associated with severe gastritis and peptic ulcer play a role in producing free radicals responsible for B-cell damage [63] DLBCL of the Stomach As in other sites, DLBCL of the stomach can be immunohistochemically subclassified into germinal center B-cell-like (GCB) DLBCL and non-GCB DLBCL [64] In a large percentage of DLBCL, the oncogene BCL6 (located on chromosome 3q27) is altered through translocations, somatic hypermutations, or deregulating mutations involving the promoter region; this finding may predict a better prognosis [65] Recently, Chung et al [66] reported in a Taiwanese population series that bcl-6 expression was a favorable Fig 5.10 Primary gastric follicular lymphoma This smear better features the cleaved nuclei in follicular lymphoma cells (Papanicolaou, 10×) prognostic marker, and elevated lactate dehydrogenase (LDH) level was a poor prognosticator Starostik et al [67] reported that de novo gastric DLBCL large-cell lymphomas and those derived from a low-grade MALT lymphoma may develop along distinct pathogenetic pathways Primary Hodgkin Lymphoma of the Stomach Primary Hodgkin lymphoma of the stomach is rare; it appears in case reports The diagnosis of Hodgkin’s disease depends primarily on the detection of Reed-Sternberg cells on cytology and histology specimens, supported by immunohistochemical staining for CD30 [68] Gastrointestinal Stromal Tumor Gastrointestinal stromal tumor (GIST) may arise along the entire GI tract; it originates in the peristalsis pacemaker cells of Cajal, usually owing to an activating mutation of c-kit It is the most common mesenchymal tumor of the GI tract, occurring in older adults of both sexes Up to 60% of cases arise in the stomach It may be asymptomatic or may present with 144 G Oprea-Ilies and M T Siddiqui abdominal pain, gastric outlet obstruction, and bleeding (hematemesis and/or melena) Most cases are sporadic, but association with neurofibromatosis type 1, Carney’s triad (gastric GIST, paraganglioma, pulmonary chondroma), familial GIST syndrome, and Carney-Stratakis syndrome (Familial paraganglioma and GIST) has been reported [69] Grading of GIST depends entirely on mitotic count per 5 mm2 on glass slide section (equivalent to 50 hpf on older microscopes or 20 hpf on newer microscopes with a different 40× lens field; the pathologist must measure the surface covered by their 40× lens) Low-grade GIST (G1) has a low mitotic rate of ≤5/50 hpf, whereas high-grade GIST has a mitotic rate > 5/50 hpf The risk assessment for GIST depends on size, the GI segment involved, and the mitotic rate GIST Cytology FNA is a useful and rapid way to render the diagnosis of GIST GIST may show either a spindle or epithelioid cytomorphology, and collecting material for cell block and/or core biopsy for immunohistochemistry (IHC) and molecular markers will help in rendering the diagnosis Cellular aspirate may show fragments and loose clusters of spindle cells with a fair amount of cytoplasm that may display bipolar cytoplasmic processes The nuclei are elongated and wavy, with blunt to tapered ends and may display palisading in cells clusters (Figs. 5.11, 5.12, 5.13, 5.14, and 5.15) In the epithelioid variant, cellular specimens show fragments and loose clusters of plasmacytoid cells with fair amount of cytoplasm The nucleus is round, eccentrically positioned in the cells, and shows smooth membrane and fine chromatin In cases of malignant GIST, nuclear chromatin may be coarse or may show prominent nucleoli or intranuclear Fig 5.12 Gastric GIST. This cellular aspirate shows a large cluster of spindle cells with a fair amount of cytoplasm; the cytoplasm displays bipolar processes The nuclei are elongated and wavy, with blunt to tapered ends (Papanicolaou, 40×) Fig 5.13 Gastric GIST. Higher magnification of this GIST tumor features oval to elongated and wavy nuclei (Diff-Quik, 60×) Fig 5.11 Gastric GIST This cellular aspirate shows fragments and single spindle cells with a fair amount of cytoplasm The nuclei are oval to elongated and wavy, with blunt to tapered ends (Diff-Quik, 40×) inclusions; some GIST with malignant behavior may show insignificant cellular pleomorphism Necrosis may be rarely present However, FNA findings alone are unreliable in grading GIST or predicting outcome, as not enough material may be obtained to accurately evaluate mitoses [70] IHC performed on cell block will support the cytologic diagnosis if it is positive for c-Kit, DOG, or CD34 vimentin and negative for S100 and desmin (Fig. 5.16) Differential diagnosis for the spindle-cell variant includes leiomyoma and neural-derived tumors The epithelioid cell variant differential diagnosis may include carcinomas, lymphomas, and melanoma The vast majority of GISTs have c-Kit and, more rarely, platelet-derived growth factor alpha (PDGFA) mutations Up to 15% of pediatric cases that are sporadic or associated 5 Gastrointestinal Cytology 145 with neurofibromatosis type lack these mutations Miettinen et al reported on rare GISTs associated with Carney- Stratakis syndrome and familial paraganglioma syndromes that showed loss-of-function mutations of the succinate dehydrogenase complex [71] Duodenal Cytology Fig 5.14 Gastric GIST The cell block from this gastric GIST in medium magnification demonstrates palisading of cells in the upper fragment (H&E, 10×) Fig 5.15 Gastric GIST. A higher magnification from the same GIST specimen shows cells with a fair amount of cytoplasm and elongated, round to spindle, wavy nuclei (H&E, 40×) Fig 5.16 Gastric GIST The cell block from this gastric GIST in medium magnification displays strong positive staining for CD117/c- Kit, a hallmark marker for this tumor (CD117, 10×) Glandular cells of the normal benign duodenal mucosa are tall and columnar, with basally located small nuclei and apical cell borders interspersed with mucin-secreting goblet cells Cytology specimens show flat sheets with a predictive honeycomb pattern with interspaced goblet cells Cytological specimens include washing and brushing from the extrahepatic biliary system and pancreatic ducts and from periampullary tumors These techniques offer better access to these structures than a larger biopsy forceps [72] Reparative changes may be seen in inflammation, infections (e.g., Giardia, microsporidia), biliary calculi, or adenomas or following stent placement Duodenal adenomas show cohesive, tridimensional cell clusters with crowding, increased nuclear-to-cytoplasm ratio, and lack or rarity of goblet cells Malignant tumors show cellular specimens composed of tissue fragments, loose clusters, and single cells with malignant features such as loss of polarity, a high nuclear-to- cytoplasm ratio, and malignant nuclear features that not pose a diagnostic dilemma As in all cases, in cytology (and histology), the challenge resides in differentiating well- differentiated tumors from reactive changes In brush cytology of biliary and pancreatic duct strictures, Logrono et al [73] reported a good specificity of 98%, with a sensitivity of only 48% Sampling error was a major cause of their falsenegative diagnoses (67%) Though sampling errors are generally regarded as outside the control of the pathologist, optimal patient care can be provided by ensuring good communication with the endoscopist Also, when clinical or radiologic findings are s uspicious for malignancy, an inconclusive cytologic result should be followed by repeated cytology, biopsy, or both In addition, optimal slide preparations necessary for an accurate diagnosis should be done, ideally by cytology personnel or by clinical staff previously trained in preparing satisfactory smears In many places, the brushes are rinsed in liquid-based fixative for cell concentration procedures and liquid prep cytology, to prevent suboptimal smear preparation and drying artifact Duodenal adenocarcinoma, neuroendocrine tumors, lymphoma, and GIST all may be encountered The cytology features resemble those of similar lesions in the stomach 146 Colon Cytology G Oprea-Ilies and M T Siddiqui Colorectal cancer is the second leading cause of cancer death (after lung cancer) in the United States No cytology screening is possible for colon adenocarcinoma, but screening programs for squamous anal cell carcinoma are in place, and the cytology is similar to that of cervical squamous lesions Benign colon mucosa is composed of orderly, straight, and test tube-like glands lined by tall, columnar cells with basally located small nuclei and apical cell borders interspersed with mucin-secreting goblet cells Cytology specimens from the benign glands show flat, large sheets with predictive, honeycomb pattern with interspaced goblet cells The cells are tall and columnar, with abundant cytoplasm and a terminal bar apical border The nuclei are basally located, small, round with smooth nuclear membrane, fine chromatin, and inconspicuous nucleoli Interspaced are the goblet cells, with large, mucin-containing, pale cytoplasm Reparative changes may be seen in inflammation or infections such as bacillary dysentery, amebiasis, or CMV infection Reactive and reparative changes may occur in nonspecific colitis and in inflammatory bowel disease (IBD) Intraepithelial polymorphonuclear cells, crypt abscesses, and reactive changes, characteristic for IBDs, may be seen on cytology samples IBD surveillance for disease status, dysplasia, and carcinoma in these patients is usually done by targeted biopsy of both lesional and nonlesional colon mucosa, separately obtained and precisely labeled from the different segments of the colon Duodenal adenomas, adenocarcinomas, neuroendocrine tumors, and lymphomas all may be encountered, and the cytology features resemble those of similar lesions in the stomach or any other glandular epithelium HIV infection, transplantation, or chronic conditions More than 90% of anal squamous cell carcinoma (SqCC) is attributable to persistent HPV infections, particularly to HPV 16 [75] Anal SqCC is estimated at 131/100,000 among HIV-infected men who have sex with men (MSM), which exceeds the rate of cervical cancer in women prior to initiating screening [76] High-grade dysplasia confirmed in a histology specimen is a cancer precursor lesion Anal cytology reporting was first included in the 2001 Bethesda System Atlas, and it has been updated in the 2014 edition It represents a recognized tool for cancer screening, in conjunction with the clinical exam, digital anorectal exam (DARE), anoscopy, and biopsy, similar to the Pap test It has been reported that there is relatively poor correlation in grading anal squamous intraepithelial lesions, where cytology underestimating the high-grade squamous intraepithelial lesion (HSIL) However, the positive predictive value of HSIL in anal cytology is high [77], and generally, any level of abnormal anal cytology showed histologic HSIL In regard to concordance and interobserver variability, the College of American Pathologists interlaboratory comparison program in nongynecologic cytology reported significant improvement during a period of 6 years in the concordance rates of participants’ responses for low-grade squamous intraepithelial lesion (LSIL) challenges, but not for HSIL. There was no significant difference in performance by slide preparation type Performance on challenges with target diagnoses of HSIL and squamous cell carcinoma was poor, with concordance rates of 57.1% and 56.2%, respectively, pointing to a need for continued education in interpreting anal cytology [78, 79] Anal Cytology Anal Cytology Sampling It was estimated that 8200 new cases of anal carcinoma would be diagnosed in the United States in 2017, with an estimated 1100 deaths [74] It is slightly more common in women than in men and it is considered to be an human papillomavirus (HPV) associated carcinoma The number of new cases was 1.8 per 100,000 men and women per year based on 2010–2014 cases Rates for new anal carcinoma cases have been rising on average 2.2% each year over the past 10 years, and death rates rose by an average 2.9% each year between 2005 and 2014 Known risk factors are infections with HPV, multiple sexual partners, receptive anal intercourse, age older than 50 years, and a compromised immune system secondary to The target of sampling for anal cancer screening is the entire anal canal, to include the transition zone and the keratinized and nonkeratinized squamous epithelium Samples may be obtained with direct visualization, using a small anoscope, or without direct visualization Of the many collection devices, it appears that a Dacron or polyester synthetic fiber swab has better tolerance and obtains superior cellularity Self- collected anal cytology was reported to obtain adequate specimens when investigated in a community-based study of MSM. Both conventional smears and liquid-based cytology may be used, and these methods are reported to be equally effective in screening for anal cancer [78] 5 Gastrointestinal Cytology Anal Cytology Adequacy Cells collected from the anal canal consist of superficial and intermediate-type squamous cells, squamous metaplastic cells, rectal columnar cells from the transition zone, and anucleated squamous cells from the distal anal canal The presence of rectal columnar cells from the transition zone represents a quality indicator, as a sign that the transition zone was sampled, but (as in the case of the Pap test) it is not a measure of the specimen’s overall adequacy Adequacy of the anal cytology specimen in regard to the lower cell-number limit is not yet well defined Based on expert opinion, minimal cellularity for a conventional anal Pap is considered to be 2000–3000 nucleated squamous cells (nsc) In liquid-based preparates, it translates to an average of 1–2 nsc/hpf for ThinPrep (with a diameter of 20 mm) and 3–6 nsc/hpf for SurePath (with a diameter of 13 mm) [80] Samples with no abnormal findings containing fewer nucleated squamous cells than in the mentioned guidelines should be considered unsatisfactory because of scant cellularity A sample containing mostly anucleated squamous cells and/or obscuring bacteria and fecal matter is also deemed unsatisfactory for evaluation [80] As in the Pap test, any abnormal finding makes the anal sample adequate Morphologic criteria, terminology, and guidelines for anal cytology evaluation parallel those of cervical cytology but modified to reflect the anatomy For example, rectal columnar cells substitute for endocervical cells as a measure of transition zone sampling The cytology report should include a statement about adequacy and the cytology interpretation Table 5.6 offers suggestions for anal cytology reporting [81] Table 5.7 is an example of an education statement that is included by computer software with each cytology report issued by our department, as Table 5.6 Example of anal cytology reporting Adequacy statements Specimen adequate for evaluation; transition zone component present Or Unsatisfactory for evaluation due to scant nucleated squamous cells; predominantly anucleated squamous cells are present; no transition zone component present Interpretations Negative for intraepithelial lesion or malignancy (NILM) Reactive cellular changes Organisms present; see comment Low-grade squamous intraepithelial lesion (LSIL) High-grade squamous intraepithelial lesion (HSIL) Atypical squamous cells 147 Table 5.7 Educational statement to accompany the anal cytology report (for anal Pap test) Report 1. Unsatisfactory 2. NILM (HIV+) NILM (HIV–) 4. ASC-US (unknown HPV or HPV–) 5. ASC-US, HPV+ 6. ASC-H, LSIL, HSIL Recommendation Repeat cytology in 6 months Repeat cytology in 1 year Repeat cytology in 2–3 years Co-testing: anal Pap and HPV in 1 year Colorectal consultation Colorectal consultation This is an example of an education statement included by computer software with each cytology report issued by our department, as developed by Dr Talaat Tadros, Director of Cytology, and Dr George Birdsong, Director of Anatomic Pathology at Grady Memorial Hospital, following the 2014 Bethesda Guidelines ASC-H high-grade atypical squamous cells, ASC-US atypical squamous cells of unknown significance, HPV human papillomavirus, HSIL high- grade squamous intraepithelial lesion, LSIL low-grade squamous intraepithelial lesion, NILM negative for intraepithelial lesion or malignancy developed by Dr Talaat Tadros, Director of Cytology, and Dr George Birdsong, Director of Anatomic Pathology at Grady Memorial Hospital, following the 2014 Bethesda Guidelines egative for Intraepithelial Lesion or N Malignancy (NILM) The result of an anal Pap test may be designated as “Negative for intraepithelial lesion or malignancy” (NILM) Benign cellular changes in anal cytology are partially similar to those in cervical cytology, such as narrow perinuclear halo, small nucleoli, keratotic changes, and parakeratosis that may or may not be associated with HPV infection Reparative changes like those seen in the cervix are not seen in anal Pap tests, however Anucleated squamous cells originating in the keratinized portion of the anal canal cannot be distinguished from hyperkeratotic lesions, including condylomas (Figs. 5.17, 5.18, 5.19, 5.20, and 5.21) [80] In comparison, Figs. 5.22, 5.23, and 5.24 depict examples of unsatisfactory anal Pap specimens Infections Some organisms encountered in anal cytology are identical to those found in the cervical Pap test, including fungal organisms such as Candida and herpesvirus (Figs. 5.25, 5.26, and 5.27) Unique to the intestinal tract and rarely found on cervical Pap tests are amoebas, 148 Fig 5.17 Anal Pap test: NILM. No intraepithelial lesion or malignancy (NILM) is present in this cellular specimen with evenly spread superficial and intermediate squamous cells (Papanicolaou, 10×) Fig 5.18 Anal Pap test: NILM. No intraepithelial lesion or malignancy is present in this cellular specimen with a predominance of superficial squamous cells (Papanicolaou, 10×) Fig 5.19 Anal Pap test: NILM. No intraepithelial lesion or malignancy is present in this specimen with evenly spread superficial and intermediate squamous cells (Papanicolaou, 40×) G Oprea-Ilies and M T Siddiqui Fig 5.20 Anal Pap test: NILM. A fragment of benign columnar cells in high magnification is seen in this photomicrograph, displaying the classic “honeycomb” pattern of benign glandular cells when seen en face (Papanicolaou, 40×) Fig 5.21 Anal Pap test: NILM. A fragment of benign columnar cells in high magnification, displays the classic well-organized “honeycomb” pattern of benign glandular cells when seen en face Actually, two colonic crypts are conspicuous in this generous glandular fragment (Papanicolaou, 40×) Fig 5.22 Anal Pap test: Unsatisfactory This is basically an acellular specimen with only a few anucleated squamous cells and a fibrillary artifact (Papanicolaou, 10×) 5 Gastrointestinal Cytology Fig 5.23 Anal Pap test: Unsatisfactory This is a paucicellular specimen with a single nucleated squamous cell visible in this SurePath specimen (Papanicolaou, 10×) 149 Fig 5.26 Anal Pap test: Herpesvirus This anal cytology specimen shows in the center cells with herpesvirus cytopathic effect A Cowdry type A inclusion is a large, pink to purple eosinophilic intranuclear inclusion containing disrupted virions localized in the center of the cell and leading to nuclear margination in the host cell The background is predominantly formed by inflammatory cells (Papanicolaou, 40×) Fig 5.24 Anal Pap test: Unsatisfactory No nucleated squamous cells are visible in this paucicellular SurePath specimen (Papanicolaou, 10×) Fig 5.27 Anal Pap test: Herpesvirus This anal cytology specimen shows in the center a cluster of cells with herpesvirus cytopathic effect The background is formed by inflammatory cells and squamous cells with reactive changes (Papanicolaou, 40×) Fig 5.25 Anal Pap test: Herpesvirus This anal cytology specimen shows in the center a cell with “3M” herpesvirus cytopathic effect: multinucleation, molding, and margination of chromatin The background characteristically shows heavy acute inflammatory exudate (Papanicolaou, 40×) as cysts and/or trophozoites, most of which are considered nonpathogenic commensals, with the exception of Entamoeba histolytica, which is a pathogenic organism Caveat: macrophages that may be present in anal cytology after ablative treatment may represent a pitfall in diagnosing amoebas Intestinal parasites and their eggs may be present on anal cytology [80] Helpful information on comparative morphology of intestinal parasites may be found on the website of the Centers for Disease Control (CDC) [81] 150 G Oprea-Ilies and M T Siddiqui Squamous Cell Abnormalities Atypical Squamous Cells Atypical Squamous Cells of Unknown Significance (ASC-US) The criteria used for atypical squamous cells of unknown significance (ASC-US) are analogous to those on cervical cytology: enlarged nucleus but smooth nuclear membrane, bland chromatin, and narrow perinuclear halo Binucleation may be observed (Fig. 5.28) [80] Atypical Squamous Cells Cannot Exclude High-Grade Squamous Intraepithelial Lesion (ASC-H) It is difficult to rule out high-grade atypical squamous cells (ASC-H), which frequently present as immature metaplastic cells with dark but smudgy chromatin (see Figs. 5.29 and 5.30) [80] Fig 5.29 Anal Pap test: ASC-H This microphotograph shows atypical squamous cells and cannot rule out high grade (ASC-H) These are immature metaplastic cells with hyperchromatic but rather smudgy nuclei (Papanicolaou, 60×) ow-Grade Squamous Intraepithelial Lesion L (LSIL) LSIL is a sign of active HPV replication in superficial and intermediate squamous cells Similar to the Pap test, the cells are larger and show abundant cytoplasm with frequent keratinization and broad perinuclear halo The nucleus is obviously enlarged and hyperchromatic, with accentuated and irregular nuclear contour (Figs. 5.31, 5.32, 5.33, 5.34, and 5.35) [80] igh-Grade Squamous Intraepithelial Lesion H (HSIL) HSIL cells have scant cytoplasm, with high nuclear-to- cytoplasm ratio and a large hyperchromatic nucleus with accentuated and irregular nuclear contour When nucleoli are Fig 5.30 Anal Pap test: ASC-H. The ASC-H cell in this microphotograph shows an immature metaplastic cell with hyperchromatic nucleus with irregular nuclear membrane (Papanicolaou, 60×) prominent, the possibility of invasive carcinoma should be considered (Figs. 5.36, 5.37, 5.38, and 5.39) [80] Fig 5.28 Anal Pap test: Atypical squamous cells of unknown significance (ASC-US) Paracentrally, there is a cluster of squamous cells with enlarged nuclei but smooth nuclear membrane and bland chromatin; a binucleated cell is also noticeable These changes not meet the criteria for low-grade squamous intraepithelial lesion (LSIL) interpretation (Papanicolaou, 40×) quamous Cell Carcinoma S Anal squamous cell carcinoma may present as either keratinizing or nonkeratinizing Keratinizing squamous cell carcinoma shows markedly pleomorphic cells with size and shape reminiscent of tadpoles and reptiles The nuclei are intensely hyperchromatic, and diatheses may not be present Nonkeratinizing squamous cell carcinoma shows the usual clusters of malignant cells with enlarged nuclei The chromatin may be hyperchro- 5 Gastrointestinal Cytology 151 Fig 5.31 Anal Pap test: LSIL Centrally there is a binucleated cell with enlarged, hyperchromatic nuclei and irregular and accentuated nuclear membrane A weel visualized perinuclear halo may be seen (Papanicolaou, 40×) Fig 5.34 Anal Pap test: LSIL. This squamous cell with HPV- cytopathic effect demonstrates multinucleation The nuclei are enlarged and hyperchromatic (Papanicolaou, 40×) Fig 5.32 Anal Pap test: LSIL. Centrally there is a binucleated cell with enlarged, hyperchromatic nuclei The perinuclear koilocytic halo is better visualized in this image (Papanicolaou, 40×) Fig 5.35 Anal Pap test: LSIL. This squamous cell with HPV- cytopathic effect demonstrates multinucleation The multiple nuclei are hyperchromatic and resinoid with irregular nuclear membrane (Papanicolaou, 60×) Fig 5.33 Anal Pap test: LSIL. The cell cluster in this image demonstrates the large, hyperchromatic nuclei in a keratinizing dysplasia (Papanicolaou, 40×) Fig 5.36 Anal Pap test: HSIL This cluster of high-grade squamous intraepithelial lesion (HSIL) cells demonstrates scant cytoplasm, with high nuclear-to-cytoplasm ratio and large, hyperchromatic nuclei with accentuated and irregular nuclear contour Nucleoli are not prominent in this cluster, making invasive carcinoma less likely (Papanicolaou, 40×) 152 G Oprea-Ilies and M T Siddiqui matic or clearing with irregular chromocenters and prominent nucleoli (Figs. 5.40, 5.41, 5.42, and 5.43) [80] Nonkeratinizing squamous cell carcinoma may form clusters composed of pleomorphic cells with reduced cytoplasm and high nuclear-to-cytoplasm ratio; prominent nucleoli may be present Tumor diathesis may be seen clinging to the malignant cell clusters, although not prominent [80] Glandular Cell Abnormalities HPV-associated glandular cell abnormalities have not yet been defined in anal cytology as a counterpart for adenocarcinoma in situ (AIS) in cervical cytology However, we encountered a Fig 5.37 Anal Pap test: HSIL. This cluster of HSIL cells demonstrates in higher magnification scant cytoplasm, with high nuclear-to- cytoplasm ratio and large, hyperchromatic nuclei with accentuated and irregular nuclear contour (Papanicolaou, 60×) Fig 5.38 Anal HSIL: Anal intraepithelial neoplasia III (AIN III) The biopsy from this patient shows the entire thickness of the squamous mucosa to be occupied by this high-grade intraepithelial lesion (AIN III), mirroring the cytology of HSIL Of note, the dysplasia is present in the transition from squamous to glandular epithelium, which appears vulnerable to HPV infection, exactly as in cervical lesions! (H&E stain, 10×) Fig 5.39 Anal HSIL (AIN III) The biopsy stained for p16 demonstrates en bloc nuclear and cytoplasmic staining, confirming the HPV nature of this lesion (IHC for p16 stain, 10×) Fig 5.40 Anal squamous cell carcinoma Low magnification of this SurePath specimen shows a few clusters of malignant cells A bloody diathesis occupies the right side of the photomicrograph (Papanicolaou, 10×) Fig 5.41 Anal squamous cell carcinoma Higher magnification of the same specimen shows these clusters of nonkeratinizing squamous cell carcinoma The enlarged nuclei show chromatin clearing, irregular chromocenters, and prominent, cherry-red nucleoli, consistent with invasion (Papanicolaou, 40×) 5 Gastrointestinal Cytology Fig 5.42 Anal squamous cell carcinoma The same specimen in even higher magnification better demonstrates the malignant nuclei characteristics: clearing of the nuclear chromatin, irregular chromocenters, and prominent, cherry-red nucleoli, consistent with invasion (Papanicolaou, 60×) Fig 5.43 Anal squamous cell carcinoma The same specimen in this high magnification contrasts the malignant squamous cells with a cluster of benign columnar cells The malignant cell is reminiscent of a tadpole shape, with monstrously enlarged nuclei with irregular chromatin and nuclear membrane (Papanicolaou, 60×) rare case of carcinoma of the anal glands that had shed a few cells in an anal cytology specimen (Figs. 5.44 and 5.45) Other Lesions Paget disease of the perianal area can extend onto the anal canal, and glandular lesions of the distal colon or rectal neuroendocrine tumors may rarely be present in anal smears [80] Biomarkers The optimal use of HPV testing in anal cytology has not yet been defined, and no commercially available HPV testing is 153 Fig 5.44 Ductal carcinoma of anal glands This anal cytology specimen showed rare clusters of a well-differentiated carcinoma composed of columnar-shaped cells with enlarged, hyperchromatic nuclei , consistent with invasion (Papanicolaou, 60×) Fig 5.45 Ductal carcinoma of the anal glands The excision specimen showed a rare type of carcinoma originating in the anal glands The microphotograph shows a well-differentiated carcinoma composed of malignant glands undermining the squamous epithelium (H&E stain, 10×) FDA-approved for anal cytology Given the high prevalence of HPV in the targeted population, reflex testing, though it may be helpful in triaging ASC-US specimens, is not cost- effective It is argued that genotyping may have a more significant role, as a majority of anal SqCC cases are associated with HPV 16 Comparing the performance of several biomarkers on anal samples, it has been reported that HPV DNA testing had the highest sensitivity for biopsy-proven HSIL, followed by p16/Ki67, HPV E6/E7 mRNA testing, and HPV 16/18 genotyping [82] Stier et al [83] reported in a recent study that administering the 9-valent HPV vaccine to girls and boys 154 prior to the onset of sexual activity could effectively prevent almost all anal cancers (primary prevention) In addition, the 9v HPV vaccine may be helpful in preventing recurrent AIN2+ and possibly the progression to squamous cell carcinoma, especially in individuals at increased risk for squamous cell carcinoma, including all HIV-positive men and women, HIV-negative MSM, and women with a history of CIN3 or cervical cancer [83] References Chhieng DC, Stelow EB. 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Prophylactic HPV vaccination and anal cancer Hum Vaccin Immunother 2016;12:1348–51 ... affected by benign salivary gland tumors (Figs.? ?1. 12, 1. 13, 1. 14, 1. 15, 1. 16, 1. 17, 1. 18, 1. 19, 1. 20, 1. 21, 1. 22, 1. 23, 1. 24, and 1. 25) Fig 1. 13 Pleomorphic adenoma In the air-dried preparation,... sacrifice of the facial nerve (Figs.? ?1. 26, 1. 27, 1. 28, 1. 29, 1. 30, 1. 31, 1. 32, 1. 33, 1. 34, 1. 35, 1. 36, 1. 37, 1. 38, 1. 39, 1. 40, 1. 41, 1. 42, and 1. 43) Fig 1. 26 Mucoepidermoid carcinoma The smear... differentiated from cystic metastatic squamous cell carcinoma (Figs.? ?1. 1, 1. 2, 1. 3, 1. 4, 1. 5, 1. 6, 1. 7, 1. 8, 1. 9, 1. 10, and 1. 11) Fig 1. 3 Non-tyrosine crystals in a parotid gland cystic lesion Many