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Pathology > Cytology > Flashcards

Cytology Flashcards

1
Q

List indications for urine cytology.

A
  1. Symptomatic patients: hematuria or LUTS
  2. F/U treated bladder neoplasms
  3. Abnormal radiographic or cystoscopy findings
  4. asymptomatic patients exposed to high-risk environments (eg. aniline dye, petrochemical industry)
  5. Polyomavirus in renal transplant patients.
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2
Q

When is it best to used bladder washings?

A

Recommended whenver clinical suspicion is high or cystoscopy is performed; best for FLOW CYTOMETRY and FISH..

Have high cellularity, low contamination, but has instrument changes.

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3
Q

If a urine specimen cannot be processed right away, how should anticipated delays be handled?

A

Process immediately or refrigerate then ASAP;

If delays anticipated –> FIX IN EQUAL VOLUME 50% ALCOHOL OR ETHANOL-BASED FIXATIVE.

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4
Q

What are the reporting categories for urinary cytology according to the Paris system?

A
  1. Negative for HGUC
    (includes reactive)
  2. Atypical urothelial cells
  3. Suspicious for HGUC
  4. Positive for HGUC
    (5. Low-grade urothelial neoplasia )
  5. Other malignancies.
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5
Q

What are possible origins of squamous cells in urine cytology?

A

Contaminants from gyne tract or urethra;

Metaplastic squamous cells: - trigone in women;

  • chronic inflammation or irritation
  • risk factor for squamous SCC
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6
Q

What are possible origins of columnar cells in urinary cytology?

A
  1. Urothelial cells: prostatic urethra or Low-grade papillary neoplasm.
  2. Cystitis Glandularis
  3. Renal tubular cells
  4. Prostate or seminal vesicle cells.
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7
Q

What % of patients presenting with hematuria will have a malignant dx on cytology?

A

5-10%

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8
Q

list causes of false-positive diagnosis in urinary cytology:

A
  1. Radiation changes (can persist for years! multinucleation, high N:C);
  2. BCG effect: degenerated cells, acute inflammation & histiocytes, granulomas. & chemotherapy?
  3. Reactive umbrella cells
  4. Lithiasis
  5. Instrumentation
  6. Polyoma virus
  7. Ileal bladder specimens
  8. Cells from seminal vesicles.
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9
Q

list causes of false-negative diagnoses in urinary cytology:

A
  1. Low-grade urothelial papillary Ca
  2. Obscuring by marked inflammation or blood
  3. Renal cell carcinoma
  4. Prostatic carcinoma.
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10
Q

List the criteria for Suspicious for HGUC.

A
  1. Non-superficial, NON-degenerated urothelial cell
  2. increased N:C ratio (>0.7)
  3. Hyperchromasia (required)
  4. At least one of: irregular clumpy chromatin, irregular nuclear membrane.

number of cells: 5 - 10.

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11
Q

List the criteria for Atypical Urothelial cells.

A
  1. Non-superficial urothelial cells
  2. Can be degenerated (or not)
  3. Increased N:C (>0.5)
  4. PLUS: (1 if non-degenerated, >1 if degenerated):
    - hyperchromasia
    - clumpy chromatin
    - irregular nuclear membranes
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12
Q

List 4 malignancies that metastasize to the bladder.

A 
Melanoma
Gastric carcinoma
Breast carcinoma
Lung carcinoma
(most common met to kidney  = lung)
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13
Q

List 2 soluble urine biomarkers of malignancy and 2 cell-based biomarkers.

A

Soluble urine markers:

  • bladder tumor antigen test (BTA stat)
  • Nuclear matrix protein 22 (NMP-22)

Cell-based markers:

  • ImmunoCyt (monoclonal Abs to CEA and mucin)
  • UroVysion (multi-target FISH assay; aneuploidy of ch. 3, 7, & 17, loss of 9p21))
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14
Q

List the categories for reporting in the Bethesda System for Reporting Cervical Cytology.

A 
1. NILM
Includes:
- non-neoplastic findings - cellular variations, reactive cellular changes, and glandular cells s/p hysterectomy).
- Organisms 
- Endometrial cells in a woman >45

SQUAMOUS

  1. ASC-US
  2. ASC-H
  3. LSIL
  4. HSIL
  5. Squamous cell carcinoma

GLANDULAR

  1. Atypical glandular cells (either NOS or specify; favour neoplastic can only be used for endocervical.)
    - endocervical
    - endometrial
    - glandular
  2. Endocervical adenocarcinoma in situ (AIS)
  3. Adenocarcinoma
    - endocervical
    - endometrial
    - extrauterine
    - NOS
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15
Q

List some reportable infectious organisms that may be seen in cervical cytology.

A
  1. Trichomonas vaginalis
  2. Fungal organisms morphologically consistent with Candida spp.
  3. Shift in flora suggestive of bacterial vaginosis
  4. Bacteria morphologically consistent with Actinomyces
  5. Cellular changes consistent with herpes simplex virus (HSV)
  6. Cellular changes consistent with cytomegalovirus (CMV)
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16
Q

List non-neoplastic cellular variations that are (optionally) reported in cervical cytology.

A

NON-neoplastic cellular variations:

  1. squamous metaplasia
  2. keratotic changes
  3. tubal metaplasia
  4. atrophy
  5. pregnancy-associated changes.
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17
Q

List Reactive cellular changes that are (optionally) reported in cervical cytology.

A
  1. Inflammation (includes typical repair)
    - lymphocytic (follicular) cervicitis
  2. Radiation
  3. Intrauterine contraceptive device (IUD)
  4. Glandular cells s/p hysterectomy.
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18
Q

List the criteria for ASC-US according to the Bethesda system for cervical cytology.

A
  1. Nuclei: 2.5 - 3x the area of a normal intermediate squamous cell.
  2. Slightly increased N:C
  3. minimal nuclear hyperchromasia and irregularity in chromatin or nuclear shape
  4. Nuclear abnormalities associated with dense orangeophilic cytoplasm (atypical parakeratosis), or HPV cytopathic effect including poorly-defined cytoplasmic halos or cytoplasmic vacuoles resembling koilocytes but with absent or minimal concurrent nuclear changes.
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19
Q

What are the adequacy criteria in cervical cytology?

A

Conventional preparation: 8,000 - 12,000 well-visualized squamous cells
- can accept less if atrophic or post-radiation.

Liquid-based: 5,000 well-visualized squamous cells
- can accept 2,000 - 5,000 if atrophic or post-radiation.

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20
Q

How is presence of the transformation zone defined?

A
  • 10 well-preserved endocervical or squamous metaplastic cells.
  • can be clusters or single cells.
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21
Q

What are histologic clues to the presence of trichomonas ?

A

Leptothrix

neutrophil clumps

= “spaghetti and meatballs”

22
Q

List conditions that raise the threshold for declaring atypia (ASC-US) in cervical cytology

A

Candida

Trichomonas

Atrophy

Radiation

(TRAC mnemonic)

23
Q

What context is required to dx bacterial vaginosis?

A

Clinical context - need clinical concern (“fishy odor”)

Clinically significant in PREGNANT patients

  1. association with pelvic Inflammatory disease
  2. preterm birth
  3. post-op gynecologic infections.
24
Q

What are the 3 M’s of HSV infection?

A

Multinucleation
Molding
Margination

25
Q

What are the cytologic features of typical parakeratosis in the cervix?

how does it differ from Atypical Parakeratosis?

A

TYPICAL:
- Miniature superficial squamous cells with dense eosinophilic cytoplasm
- cell shape may be round, oval, or spindled.
- nuclei are small and dense (pyknotic)
(“nuclei appear normal” - Bethesda)
= NILM

ATYPICAL:
- nuclei enlarged, hyperchromatic, or irregular in contour
- cells in 3D clusters (“atypical parakeratosis”)
= ASC-US

26
Q

What are the criteria for LSIL in cervical cytology?

A

Mature cells with nuclei >3x the size of normal intermediate cells.

Koilocytosis is characteristic but not required.

27
Q

What are the criteria for ASCUS in cervical cytology?

A
  • Nuclei 2.5 - 3x the area of the nucleus of a normal intermediate cell.
  • slightly increased N:C
  • atypical parakeratosis
28
Q

What % of women with ASCUS will have HSIL on follow-up?

What % of women with ASC-H will have HSIL on follow-up?

A

10 - 15% of ASCUS

30 - 40% of ASC-H

will have HSIL on follow-up.

29
Q

What % of ASC cases is made up of ASCUS and what percentage by ASC-H?

A

ASC-US: 90% of atypical squamous cell interpretations.

ASC-H: 5 - 10%

30
Q

What are the criteria for ASC-H?

A

Small cells

N:C > 0.5

Nuclei 1.5 - 2x larger than normal squamous intermediate cell

Other features: cells smaller than LSIL; single cells, sheets or syncytia; irregular nuclear contour, cookie cutter; nucleoli usually absent.

YOU NEED 10 CELLS TO CALL HSIL

31
Q

What is the ddx for hyperchromatic crowded groups?

A
  1. Reactive endocervical cells
  2. Endometrial cells
  3. Atrophy / parabasal squamous cells.
  4. HSIL
  5. AIS (adenocarcinoma in situ)
HCGs description:
crowded cells 
nuclei with loss of polarity
dense cytoplasm
polygonal cell shape
sharp edges
32
Q

What is the classic DDX of poorly differentiated squamous cell carcinoma of the cervix?

A
  1. Repair : both usually present in flat sheet arrangement and both show prominent nucleoli.

Repair shows less pleomorphism and no single abnormal cells (in contrast to SCC).

33
Q

List the Bethesda cervical classification for epithelial cell abnormalities: Glandular

A
  1. AGC: atypical glandular cells
    - specify endocervical, endometrial, NOS
    (uncommon dx, less than 1%)
  2. Atypical glandular cells
    - favor neoplastic
    - specify endocervical or NOS (HSIL identified in 40% on f/u)
  3. AIS: Endocervical adenocarcinoma in situ
  4. Adenocarcinoma
    - endocervical
    - endometrial
    - extrauterine
34
Q

List suspicious features of thyroid nodules on ultrasound.

A

Taller than wide

Irregular margins

HYPOechoic, solid nodules

Intranodular vascularity

Spread beyond capsule

Nodal metastases

35
Q

List the American Thyroid Association guidelines for FNA according to risk stratification based on ultrasound findings.

A

High-risk US features : nodules >1cm

Intermediate-risk US features: nodules >1cm

Low-risk US features: nodules >1.5cm

Very low risk US features: nodules >2cm

Purely cystic: not recommended to do FNA

36
Q

List the diagnostic categories for reporting Thyroid cytology according to the Bethesda criteria.

A
  1. Unsat / non-diagnostic
  2. Benign
  3. Atypia of Undetermined Significance (AUS);
  4. Follicular neoplasm / suspicious for follicular neoplasm
    - specify if Hurthle cell type
  5. Suspicious for malignancy
  6. Malignant
37
Q

What is the risk of malignancy in an unsat/non-diagnostic specimen in thyroid cytology?

A

5-10%

38
Q

What is the risk of malignancy in a Benign case in thyroid cytology?

A

0 - 3%

39
Q

What is the risk of malignancy in an AUS / or Follicular lesion of undetermined significance in thyroid cytology?

A

10 - 30%

40
Q

What is the risk of malignancy in a Suspicious for follicular neoplasm in Thyroid cytology?

A

25 - 40%

41
Q

What is the risk of malignancy in a Thyroid case that is diagnosed as Suspicious for malignancy?

A

50 - 75%

42
Q

What is the risk of malignancy in a Thyroid case diagnosed as Malignancy on cytology?

A

97 - 99%

43
Q

What are the criteria for adequacy in Thyroid cytology?

A

> 6 groups of 10 well-visualized follicular cells

OR

Exception: colloid only (benign colloid nodule)

inflammation: thyroiditis

44
Q

What is a macrofollicle (in thyroid cytology)?

What is a microfollicle?

A

larger than normal follicles, eg. larger spheres composed of >15 follicular cells which are venly spaced.

Micro: 6 - 15 follicular cells arranged in circular formation, occasionalyl wtih a central blob of colloid

45
Q

What is the cytologic DDX for thyroid lesions with hurthle cells?

A
  1. Hurthle cell metaplasia in non-neoplastic lesion
    - nodular goiter
    - lymphocytic thyroiditis
  2. Hurthle cell metaplasia in a neoplastic lesion
    - papillary thyroid carcinoma
  3. Hurthle cell neoplasm
46
Q

List examples of critical values in cytology.

A
  1. unusual or unexpected cytology result
  2. A malignancy involving a critical anatomic site in a non-GYN or FNA specimen
  3. Identification of possible pathogenic organisms in a non-GYN or FNA specimen from an immunosuppressed patient OR in any CSF or orbital specimen (even in immunocompetent)
  4. Identification of HSV changes in a GYN sample of near-term pregnant patient.
  5. Any corrected report, where dx is significantly changed and will result in different patient management.
47
Q

Describe the retention practices mandated for cytology material.

A
  1. All slides, cell blocks and reports for the previous 2 years should be kept on site; all other materials should be easily retrievable.
  2. At a minimum, all NEGATIVE GYN and non-GYN cytology slides should be retained for 5 years
  3. All ABNORMAL slides on GYN and non-GYN cytology slides should be retained for 20 years.
  4. Cell blocks should be retained for 20 years.
  5. Reports should be kept indefinitely.
48
Q

What is retrospective screening?

A

When current GYN cytology shows HSIL or AIS –> all NEGATIVE (including reactive and repair) from the previous 3 years should be rescreened by a Cytotech and then referred to a pathologist.

49
Q

What is Prospective rescreening?

A

RE-SCREENING INTENDED TO PICK UP FALSE NEGATIVES.
Methods:

  1. Screening of 10% of negative cases, randomly selected
    - ineffective for picking up false-negatives
  2. Targeted: smear reviewed if pt in high-risk groups, ex symptomatic, hx of carcinoma, abnormal previous cytology, DES exposure
  3. Rapid (less than 1 minute): more efficient at picking up false negatives
    - rapid re-screening of all negative cases
    - rapid pre-screening (all cases) –> better because it rapidly triages the obviously abnormal cases and gets them reported faster.
50
Q

When does rapid pre-screening in cytology trigger a review of the case and sign-out different from usual?

A

When the rapid pre-screener (RPS) finds an abnormality that is then missed by the full screener, it signals a possible false negative by the full screen.

All R-N mismatch cases go to pathologist, even if prescreener changes their mind after reviewing the full case.

51
Q

List Quality Assurance measures in GYN cytology.

A
  1. Interpretive rates of all Bethesda diagnostic categories
    - # of cases in lab, individual CT stats, TAT, comparison to benchmark references (interlaboratory comparison)
  2. ASC rate
  3. ASC:SIL ratio
  4. Positivity rate of hrHPV in ASC-US cases
  5. Cytotechnologist-Pathologist discrepancy logs
  6. Cyto-histologic correlation
  7. Monitoring of screening performance / sensitivity
    - prospective screening (random, rapid)
    - retrospective (5-year screening)
52
Q

What are recommended rates of ASC in gyne cytology?

A

No “correct” percentage
In general:

Low-risk population: ASC rate should be <5%

High-risk population, may be higher.

90% of ASC should be ASCUS

10% ASC-H

ASC-SIL ratio: 3:1

If proportion differs, lab needs to investigate and possibly adjust diagnostic criteria.

Pathology (16 decks)

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