Inhaltsverzeichnis

Vorwort

Preface

The urge to write this book arose after years of storing glass slides from difficult cases into plastic folders where they have been breaking and fading. When discussing these cases at the weekly teaching for trainee pathologists, some of the observations that arose, made it obvious that experience cannot compensate for methodical approach, careful observation, clinical information and honest conclusion. Hence in writing this book, I had two major aims: firstly, to reiterate the importance of the approach to cytodiagnosis and, secondly, to expose diagnostic dilemmas in some of the most difficult areas of Fine Needle Aspiration Cytology (FNAC).

FNAC had become a well established diagnostic component in pathology. Within any pathology laboratory, FNAC has its dedicated proponents but also those who are practicing it occasionally, perhaps only to cover the absence of a colleague, or, alongside histopathology, as part of the subspecialty reporting. The differences in expertise often mean that the standard of reporting varies, the latter group being reluctant to ask some of the basic as well as more difficult questions for fear of appearing ignorant. Cytology training is variable in different institutions, depending on the local circumstances. Trainees without any prior experience in cytology may be exposed to difficult FNAC cases early in their career.

In order to help the approach to FNAC samples for those with and without any prior experience, the first part of this book lists principles of cytological diagnosis. The importance of a methodical approach to interpreting cytological material cannot be overstated. However, cytological interpretation is not merely a mathematical algorithm where numerical values are added up. In majority of cytology cases, the whole is more than the sum of parts: the interpretation of morphological features is complex. It needs careful observation of morphology but also, crucially, it needs to be taken in the clinical context. Without the clinical information, morphology alone may be misleading.

Chapters on diagnostic dilemmas in FNAC practice discuss potentially difficult morphological features. As well as to educate, the aim of these chapters is to expose difficult areas of diagnosis where FNAC has its limitations. To that end and in line with the developing area of medical litigation affecting all areas of practice, there is a chapter on medico-legal issues associated with FNAC. This is a growing field that has been addressed in a number of legal references but has thus far not been addressed extensively from a cytologicl standpoint.

In preparing this manuscript, I would like to thank, first of all, my patients for allowing me to use their clinical histories and photomicrographs. I would also like to thank my colleagues in the Department of Histopathology, University College London, in particular Dr. Mary Falzon for their help in sharing some of the diagnostic dilemmas presented in this manuscript. The ability to share problems with clinicians and fellow pathologists is the essential requirement for ensuring a good night´s sleep and one's professional reputation. I would also like to thank my clinical colleagues by their supportive approach to cytology in sending their patients for FNAC. The experience I have accumulated on these sound clinical grounds had been shared with generations of postgraduate trainee pathologists. I thank them for being a source of inspiration through curiosity and enthusiasm. Many went on to become dedicated cytopathologists and made me immensely proud of them. I would also like to give special thanks to Eva Kauerova for her help in the past five years.

I hope that you, the reader, will use this book in your daily practice, if only to find that there are no straight answers to difficult questions.

G. Kocjan
September 2005
London

Klappentext

Histopathologists all over the world have to report cytopathology during the course of their work and it is then that they find themselves facing diagnostic dilemmas. This practical, well illustrated book, explicitly dedicated to this readership will serve their needs and meets their requirements in daily practice.

ISBN 3-540-25639-3

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Subject Index

Italic entries refer to images.

A

abdomen 73, 160
accuracy 13, 152, 207, 218, 226, 227, 228
adequacy 233
adrenal cystic lesions 78
adrenal gland 78
air drying 19, 50, 119, 133, 144, 158, 183, 201
alcohol-fixed preparations 20, 133, 155
ancillary techniques 23, 26, 27, 105, 125, 134, 136, 142, 145, 146, 152
arm 164
aspiration techniques 15
aspirator 11, 13, 14, 15, 17, 28, 182, 219, 226, 229
axilla 118, 192

B

background 21, 22, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 84, 109, 119, 136, 137, 139, 146, 154, 155, 159, 160, 162, 167, 172, 186, 188, 191, 194, 195, 199, 203, 205
bile ducts 12
bone 134, 155
breast 11, 21, 26, 27, 36, 37, 38, 40, 44, 46, 47, 48, 56, 81, 82, 91, 96, 99, 106, 107, 122, 123, 128, 156, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204
breast 11, 107, 122, 181, 193, 204, 205, 206, 220, 225, 231, 232, 234
- apocrine changes 186, 193, 194
- fibroadenoma 182, 183, 184, 185, 186, 187, 188, 190, 191, 195, 198, 203, 204, 205, 206, 226, 233
- in situ carcinoma 198, 199
- invasive 199, 200, 201
- invasive carcinoma 186, 193, 198, 201
- lobular carcinoma 196, 233
- mucinous lesions 195
- papillary lesions 188, 189, 190, 191, 192, 193, 207, 226
- radiation changes 207
- rare lesions 202

C

carcinomas 187, 188, 190
cell arrangement 44, 45, 46, 47, 48, 49, 133, 134, 137, 195, 196, 202, 206
cell block 18, 78, 191, 227
cerebrospinal fluid 23
cervical 20
chest wall 177
clinical management (see management) 107
CNS 37, 83
complications 13, 14, 17, 80, 233
core biopsy (CB) 202, 207, 225, 226, 227
- abdominal 227
- breast 225, 226
CB vs. FNAC 207
- gynaecology 228
- hepatic 227
- lung 227
- prostate 228
- skeletal 228
- soft-tissue 228
- thyroid 228
cost 11, 220, 226
cystic 129
- background 39
change 62, 185, 198
- lesions 17, 59, 62, 69, 80, 122, 195, 205
- lesions of the liver 77
- lesions of the peritoneum 79
cystic 17
cystic lesions 217
- abdomen 73
- breast cysts 80
- head and neck 59, 60, 62
- lesions of the pancreas 73
- other cysts 82
- thoracic cysts 79
cysts 193, 215
cytoplasm 20, 21, 22, 69, 109, 110, 124, 133, 134, 137, 139, 140, 142, 144, 171, 172, 198, 203

D

desmoplastic small round cell
- tumour 143
diagnostic
- challenge 133
- principles 35
diagnostic interpretation 35
- criteria of malignancy 57
- cytology report 57, 58
- cytoplasm 53, 55, 56, 57
- nucleus 47, 49, 50, 52, 53, 54, 55
- slide background 35, 36
Diff-Quik 21, 22
dilemmas 81, 91, 99, 117, 156, 182, 188, 203
DNA amplification 27
DNA cytometry 26
duodenum 12

E

ES/PNET 134
EUS-FNAC 13, 40, 217
experience 13, 14

F

false negative diagnosis 19, 21, 66, 84, 232, 233, 234

false positive diagnosis 19, 21, 65, 77, 232, 233

fibroadenoma 191

fibrocystic change 182

fluorescence in situ hybridisation (FISH) 26, 27
FNAC 12, 126, 219
FNAC and core biopsy 108
FNAC clinic 9, 11, 28, 220
FNAC lymph node 139, 140
FNAC ovary 84, 85
FNAC skin 83
FNAC technique 7
- conventional preparations 17, 19
- cytochemistry 23
fixation techniques 19
- inpatient FNAC 12
- location of the FNAC 8
- other stains 23
- Romanowsky staining 22
- slide preparation 7, 13, 17
- staining methods 20
- suction FNAC 15
- the capillary method 16
- transport medium 20 forearm 163

G

gene microarray analysis 26
general principles 117
gomori 24
granuloma 99, 156
granulomatous lymphadenitis 92

H

haematoxylin and eosin 23
hand 159
head and neck 24, 41, 42, 60, 61, 62, 63, 69, 73, 109, 120, 123, 124, 125, 126, 128, 129, 137, 146, 147, 166, 174
health and safety guidelines 28
histochemistry 233
HIV 24, 28, 42, 63, 71, 219
hypopharynx 12

I

image guided FNAC 12
imaging 99
immunocytochemistry 24, 104, 120, 124, 125, 136, 137, 141, 143, 144, 146, 147, 165, 172, 174, 175, 183, 194, 233
immunohistochemistry 227
informed consent 7, 8
inguinum 138

J

jugulodigastric node 154

K

kidney 23, 78, 79
kidney 217
knee 164

L

liquid-based cytology (LBC) 13, 18
liquid-based preparations 18
liver 77, 78
lung 12, 13, 19, 25, 50, 52, 53, 55, 57, 99, 124, 125, 144
lymph node 24, 25, 27, 36, 39, 41, 43, 45, 46, 53, 54, 70, 92, 93, 94, 95, 96, 98, 108, 110, 123, 143, 145
lymphoid infiltrates 80, 91, 102, 105, 109
- extranodal sites 99
- granulomatous infiltrates 91
lymphoma 108
- solid neoplasms 109
lymphoma 27, 64
lymphoproliferative diseases 27, 103, 206

M

management 50, 117, 124, 129, 140, 172, 190, 198, 214, 217, 218, 219, 220, 232
- adrenal and kidney 217
- bone 218
- breast 214
- cost-effectiveness 219, 220
- diagnostic accuracy 217, 219
- gastrointestinal tract 217
- gynaecology 219
- head and neck conditions 216
- HIV-related lesions 219
- lymph nodes 216
- soft-tissue 218
- thyroid 215, 220
- transrectal 219
May Grünwald Giemsa (MGG) 22, 23, 206
mediastinum 12, 79, 80, 98, 110, 125, 127
medicolegal issues 231
meningioma 123
metastasis 38
metastatic 65, 136, 137, 138, 147, 152, 161, 170, 172, 192, 214, 216, 217, 218, 227
metastatic tumours 22, 23, 27, 47, 117, 134, 141, 142, 143, 204, 215, 218
- carcinoma 118, 228, 229
metastases of non-epithelial tumours 129
methenamine silver (Grocott) 23
- staining 24
misleading 202
missed cases 232
mitoses 165
molecular markers in cytology 26
molecular studies 136, 233
mucinous 185
- carcinoma 187
multi-disciplinary team 229
myofibrosarcoma 157

N

nucleus 20, 21, 22, 23, 69, 109, 110, 134, 137, 144, 146, 155, 162, 165, 170, 172, 194, 195, 196, 198, 203

O

operation scar 119
operation site 97, 167
oral cavity 39, 41, 72
orbit 91
ovarian cysts 83
ovary 36, 43, 46, 56, 79, 83, 84, 85

P

pancreas 12, 41, 43, 45, 51, 52, 54, 55, 56, 73, 74, 75, 76, 77
Papanicolaou (Pap) stain 20, 21, 22, 23, 28, 156, 185
papillary carcinoma 185
paraspinal mass 136
parathyroid 71
parotid gland 21, 92, 106
PAS 23
PAS-d 23, 37
PAS distase 23
PCR 26
pelvic mass 159
periodic acid-Schiff 23
perls 23
pitfall 22, 183, 185, 188, 190, 204, 206
preparations 19, 35

R

real-time PCR 27
rectum 12
renal 217
renal cystic lesions 78
report 28, 58
retroperitoneum 140, 158
Romanowsky staining 20, 21, 22

S

safety 27, 28, 219, 227, 228, 234
salivary gland 14, 21, 36, 39, 44, 45, 62, 64, 65, 66, 67, 68, 71, 83, 91, 103, 104, 106, 119
scalp 173
scar 96, 166
shin 175
skin 16, 38, 40, 44, 47, 83
slide preparation 7
- air drying 19
- alcohol fixation 20
- ancillary techniques 23, 27
- aspiration techniques 15
- aspirator 11, 13, 14, 15, 17, 28
- capillary method 16
- cell block 18
- conventional preparations 17, 19
- cytochemistry 23
- fixation techniques 19
- FNAC clinic 9, 11, 28
- image guided FNAC 12
- immunocytochemistry 24
- informed consent 7, 8
- inpatient FNAC 12
- liquid-based preparations 18
- location of the FNAC 8
- molecular markers in cytology 26
- other stains 23
- Romanowsky staining 20, 21, 22
safety 27, 28
staining methods 20
suction FNAC 15
- transport medium 20
small-cell variant of synovial
sarcoma 142
small round cell tumours 133
- acute lymphoblastic leukaemia and LBL 139
- Burkitts lymphoma 144
- desmoplastic SRCT (DSRCT) 143
- Ewing's Sarcoma/Primitive Neuroectodermal Tumour 134
- ganglioneuroblastomas 136
- hepatoblastoma 141
- in adults 142
- lymphoglandular bodies 145
- Merkel cell carcinoma 146
- neuroblastoma 136
- of childhood 133
- of kidney 141
- olfactory neuroblastoma 147
- pleuropulmonary blastoma 142
- rhabdomyosarcoma 137
small-cell carcinoma of the lung 144
small-cell synovial sarcoma 142
smear background 133
soft-tissue lesions 151
- breast 157
- lung 156, 172
- myxoid and chondroid lesions 157
- pseudosarcomatous lesions 162, 165
- rare and difficult sarcomas 172
salivary gland 156
sarcomas mimicking other lesions 171
soft-tissue deposits of non-sarcomatous lesions 171
- tumours of low or borderline malignancy 169
solid-organ transplant 219
spindle-cell lesions 153, 156, 157
- of the breast 82
subcutaneous mass 147
submandibular swelling 122
supraclavicular fossa 167
supraclavicular mass 98

T

techniques 35
testicular 37
testis 36, 82
thigh 136, 154, 160, 163
thyroid 9, 14, 27, 36, 38, 39, 43, 46, 47, 48, 51, 52, 53, 54, 56, 60, 68, 69, 91, 97, 98, 100, 101, 102, 123
training 36
trunk 168, 170
tuberculous lymphadenitis 92
tumour in the stomach wall 161

U

upper arm 157

Z

Ziehl Nielsen stain 23

Autor

Dr. Gabrijela Kocjan
University College London
Medical School
Dept. of Histopathology
Rockefeller Building
WC1E 6JJ London

United Kongdom