Cytopath Flashcards

1
Q
A

SCC on Pap

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2
Q

Approximately __% of women with an LSIL Pap result prove to have HSIL (CIN2/CIN3) on biopsy.

__% of untreated LSILs progress to invasive squamous cancer.

A

Most LSILs regress. Approximately 18% of women with an LSIL Pap result prove to have HSIL (CIN2/CIN3) on biopsy. Less than 1% of untreated LSILs progress to invasive squamous cancer.

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3
Q

CELL SIZE

The size is compared to a normal cell or its nucleus (RBC, PMN, lymphocyte, intermediate squamous cell)

Small:

Medium:

Large:

Giant cell:

A

CELL SIZE

The size is compared to a normal cell or its nucleus (RBC, PMN, lymphocyte, intermediate squamous cell)

Small: 2 – 2.5x

Medium: 3 – 6x

Large: 6 – 10x

Giant cell: > 10x size of a lymphocyte

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4
Q

NUCLEOLI

  • Nucleoli are mostly protein and __
  • Chromocenters stain __
  • Conspicuous:
  • Prominent nucleoli:
  • Macronucleoli:
A

NUCLEOLI

  • Nucleoli are mostly protein and stain red
  • Chromocenters stain blue
  • Conspicuous: seen at 40x / high power
  • Prominent nucleoli: seen at 10x / scanning power
  • Macronucleoli: about the size of RBCs
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5
Q

STAINS / FIXATIVES

Stains / Fixatives used for FNAs

A

STAINS / FIXATIVES - I

Stains / Fixatives used for FNAs

  • Papanicolaou stain
    • Alcohol fixation
    • Nuclear stain – hematoxylin
    • Cytoplasmic counterstains – OG, EA
    • Alcohol and xylene rinses
  • Rapid Romanowsky stain
    • Air dried smears
    • Solutions I, II and III
  • H & E stain (alcohol fixed smears)
  • Histochemical and Immunohistochemical stains: fixation depends upon stain required
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6
Q

DQ / ROMANOWSKY GIEMSA STAIN

A

DQ / ROMANOWSKY GIEMSA STAIN

  • Azure B
  • Eosin Y
  • Romanowsky-Giemsa effect
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7
Q

STAINS / FIXATIVES

Effects of Alcohol Fixation

A

STAINS / FIXATIVES

Effects of Alcohol Fixation

  • Alcohol can act as a solvent
    • Example: RCC
    • DQ retains fat and subsequently can be stained with Sudan III
    • Alcohol fixation dissolves fat
  • Alcohol immersion may cause cell loss
    • Solution: spray fixatives, coated slides
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8
Q

PAPANICOLAOU STAIN

Advantages?

A

PAPANICOLAOU STAIN

Staining method which depends on degree of cell maturity and cellular metabolic activity

  • Advantages:
    • Nuclear detail
    • Cytoplasmic transparency
    • Cell differentiation (differential cytoplasmic staining)
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9
Q

PAPANICOLAOU STAIN

The main steps?

A

PAPANICOLAOU STAIN

The main steps are:

  1. Fixation
  2. Hydration
  3. Nuclear staining with hematoxylin
  4. Dehydration
  5. Cytoplasmic staining with Orange G and EA
  6. Rinsing, clearing and mounting
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10
Q

PAPANICOLAOU STAIN

FIXATION

A

PAPANICOLAOU STAIN

FIXATION

  • 95% ETOH or equivalent
  • Wet fixation (slide immersion)
  • Coating or spray fixatives
    • Alcohol and carbowax mixture
    • Carbowax must be dissolved before staining
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11
Q

PAPANICOLAOU STAIN

STAINS

A

PAPANICOLAOU STAIN

STAINS

  • Nuclear stain
    • Hematoxylin
    • Chromatin patterns of normal and abnormal cells
  • Cytoplasmic counterstains
    • Orange G and EA
    • Provide cytoplasmic transparency
    • Clear visualization through areas of overlapping cells, mucus and debris
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12
Q

PROGRESSIVE VS REGRESSIVE METHODS

A

PROGRESSIVE VS REGRESSIVE METHODS

  • Applies primarily to hematoxylin component
  • Progressive: stained until required nuclear optical density is achieved
  • Regressive: Overstains entire cell Acid bath to extract excess Greater variability of staining Less “forgiving” % of dilute HCl difficult to control Timing is critical to remove only excess hematoxylin Some cell loss (less suitable for non-GYN samples which do not adhere as well to the slides)
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13
Q

ADEQUACY

Minimum number of squamous cells?

Liquid-based:

Conventional:

A

ADEQUACY

Minimum number of squamous cells

  • Liquid-based: 5000
  • Conventional: 8000-12000
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14
Q

UNSATISFACTORY?

A

UNSATISFACTORY

  • Lack of patient identification
  • Unacceptable specimen
  • Slide broken beyond repair
  • Insufficient squamous component > 75% epithelial cells obscured
    • Blood, inflammation, drying artifact, other
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15
Q

Gyn CATEGORIES

A

CATEGORIES

  • NILM (negative for intraepithelial lesion or malignancy)
  • Epithelial cell abnormality
    • Squamous
    • Glandular
    • AIS
    • Adenocarcinoma
    • Other
  • Other
    • Endometrial cells in woman > 40yr*
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16
Q
A

PARABASALS

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17
Q
A

STICKY HISTIOCYTES!

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18
Q
A

LUS, ENDOMETRIUM

  • Large and small tissue fragments
  • Glands
  • Stroma (oval, spindle-shaped)
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19
Q
A

IUD Changes

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20
Q

ASC (ASCUS)

  • Management?
  • ASC rates less than _% of all PAP cases
  • Labs with high-risk populations:
    • ASC/SIL ratio should not exceed __ (median ratio in US labs is __)
A

ASC (ASCUS)

  • Suspicion of SIL – LSIL
  • Reflex HPV testing (if +, colposcopy + directed biopsy)
  • ASC rates less than 5% of all PAP cases
  • Labs with high-risk populations:
    • ASC/SIL ratio Should not exceed 3:1 (median ratio in US labs is 1:5)
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21
Q

ASC-H

  • __% of all Pap tests
  • Management?
A

ASC-H

  • 0.3% of all Pap tests
  • Higher rate of histologic CIN 2/3 than ASC-US
  • Refer for coloposcopy regardless of HPV status
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22
Q
A

ENDOMETRIAL CARCINOMA

  • 3-D groups
  • Nuclear enlargement
  • Nucleoli
  • Hyperchromasia
  • Scant cytoplasm
  • Cytoplasmic vacuoles
  • Finely granular (watery) diathesis
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23
Q

ENDOCERVICAL vs. ENDOMETRIAL CA

A

ENDOCERVICAL vs. ENDOMETRIAL CA

Endocervical CA

  • More cells
  • Larger
  • Columnar
  • Preserved
  • Rosettes
  • Crowded sheets
  • Granular
  • PMNs rare

Endometrial CA

  • Less cells
  • Smaller
  • Rounded
  • Degenerated
  • Balls
  • Molded groups
  • PMNs common
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24
Q
A

PSAMMOMA BODIES

  • Infrequently found in cervical smears
  • Associated with both benign and malignant conditions
  • IUCD Endosalpingiosis
  • TB endometritis
  • Benign endometrial and ovarian lesions
  • Serous papillary carcinoma of the ovary or peritoneum and endometrial malignancies
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25
Q
A

Chlamydia

26
Q
A

COCKLEBURRS CRYSTALS

  • Radiate arrays of crystalline material often surrounded by macrophages
  • Thick club-like spokes
  • More likely to be seen in smears from pregnant women
  • No significance
  • D/D:
    • Haematoidin crystals (finer crystalline rays)
    • ‘Sulphur granules’ of Actinomyces
27
Q
A

Barr Body

28
Q

LOW ESTROGEN STATES

A

LOW ESTROGEN STATES

  • Premenarche
  • Postpartum
  • Post menopause
  • Turner syndrome
  • S/P bilateral oophorectomy
  • Basal
  • Parabasal cells
  • Transitional cell metaplasia (grooves)
29
Q

Vaginal

A

PINWORM (Enterobius vermicularis) EGGS

  • rectovaginal fistula
30
Q
A
31
Q
A
32
Q
A

Coccidioidomycosis in a liquid-based (ThinPrep) Pap test

  • Large round and tear-shaped fungal spherules
  • some endospores characteristic for coccioidomycosis
33
Q
A

Schistosoma haematobium in a conventional Pap test.

  • Several ova can be seen with a terminal spine (circles) that are scattered among numerous inflammatory cells.
34
Q

CORNFLAKING

A

CORNFLAKING

  • Trapped air bubbles on superficial squamous cells
  • Reverse
  • Return slide through xylene and alcohol to water rinses
  • Restain
  • Recoverslip
35
Q

LIQUID-BASED CYTOLOGY
ThinPrep

SurePath

Advantages:

A

LIQUID-BASED CYTOLOGY
ThinPrep

SurePath

Advantages:

  1. Duplicate slides
  2. Cell blocks
  3. Testing (HPV, chlamydia, gonorrhea)
  4. Automated screening
36
Q

Sputum collection and fixation

A

SPUTUM

  • Formerly most common respiratory tract specimen
  • Used in symptomatic patients
  • Collect multiple samples over several days
  • Early morning deep cough specimens
  • Sputum induction
  • Fresh, 70% ethanol fixation
  • Pick and smear, Saccomanno method (50% ethanol 2% carbowax)
37
Q

Lung PERCUTANEOUS FNA CONTRAINDICATIONS

A

PERCUTANEOUS FNA CONTRAINDICATIONS

  • COPD
  • Emphysema
  • Bleeding diathesis
  • Patient: uncooperative, coughing
  • Severe pulmonary hypertension
  • AV malformation
  • Suspected echinococcal cyst
38
Q

Lung

A

Lung SQUAMOUS METAPLASIA

39
Q
A

SIALADENOSIS

  • Diffuse, often bilateral swelling
  • Peripheral autonomic neuropathy
  • Acinar hypertrophy, fat
  • Malnutrition, DM, alcoholism, antihypertensive medications
40
Q

Urine Cytology specimens/fixation/stain

A

URINE

  • Fresh, or refrigerated, 50% ethanol fixative
  • Pap stain preferred, 100 – 300 ml, 3

samples over several days optimum

• Voided urine: take 2nd voided urine of

day, after hydrating for 2 – 3 hours +/-

jumping up and down, mid stream, clean

  • Bag urine unsuitable
  • Do not diagnose malignancy in cells

without intact nuclear membranes

41
Q
A

Urine FISH

42
Q
A

Leydig cell tumor

43
Q

Pancreas SIMPLIFIED WHO CLASSIFICATION

A

Pancreas SIMPLIFIED WHO CLASSIFICATION

  • Ductal adenocarcinoma
  • Acinar cell carcinoma
  • Pancreatic endocrine neoplasm
  • Solid-pseudopapillary neoplasm
  • Pancreatoblastoma
  • Mucus-producing cystic neoplasm

– Intraductal papillary mucinous neoplasm

– Mucinous cystic neoplasm

  • Serous cystadenoma
  • Nonepithelial tumors
  • Metastases
44
Q
A

Pancreatic DUCTAL ADENOCARCINOMA

  • • Necrotic background
  • • Cellular aspirates, predominantly ductal cells
  • • Disordered sheets of cells – “drunken honeycombs”
  • • Loss of polarity
  • • Pleomorphism
  • • Squamoid cytoplasm
  • • “Tombstone cells” – large, tall columnar cells
  • • Nucleomegaly (greater than RBCs)
  • • Anisonucleosis (4:1 or greater ratios)
  • • Irregular nuclear membranes: grooves, folds, clefts (“popcorn”,
  • “tulip nuclei”)
  • • Intranuclear cytoplasmic invaginations
  • • Abnormal chromatin, thick nuclear membranes
  • • Nucleoli
  • • Mitoses +++
45
Q

Pancreatic DUCTAL ADENOCARCINOMA

Special studies:

A

Pancreatic DUCTAL ADENOCARCINOMA

Special studies:

  • Mucicarmine+
  • PASD+ mucin in tumor cells
  • EMA, Keratin (AE1/AE3), CK 7, polyclonal CEA, CAM 5.2 +
  • Some CD10, CK 20 +
  • Focal chromogranin, pancreatic enzyme markers +
  • CA 19-9 +
  • K-ras mutation detection
46
Q

Pancreas

A

INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)

  • Rare, M > F
  • 60 – 70 years old
  • More commonly in head of pancreas
  • Radiological and clinical input is essential
    • Single or multiloculated cysts
    • Dilated pancreatic ducts
    • Abundant mucin flowing from patulous ampulla at endoscopy
  • Cytology
    • Rounded, papillary cell islands and fragments
    • Mucinous cells
  • Potential for malignant transformation – obvious malignant cytologic features
  • Positive Stains:
    • EMA, CK, Mucin, MUC 2, MUC 1, PCNA
    • Ki 67 increased inmalignant tumors
    • P53 + in borderline tumors and carcinomas
  • Better prognosis than usual pancreatic cancer
47
Q

Pancreas

A

MUCINOUS CYSTIC TUMOR

  • Rare, indolent, potentially malignant
  • Middle-aged women
  • Cytology:
    • Intracellular and extracellular mucin
    • Subepithelial stroma, resembles ovarian stroma
    • Mucinous background, moderate cellularity
    • Regularly honeycombed epithelial sheets
    • Papillary structures, psammoma bodies may be present
    • Mucinous epithelial cells – goblet, signetring cells
    • Well differentiated – resemble benign endocervical cells
    • Mucinous macrophages
    • Stroma may be present
  • Special studies:
    • • EMA +
    • • CK 7, 18, 18, 19 +
    • • CEA +
    • • CA 19-9+
    • • DUPAN-2 +
    • • Stromal component: vimentin, SMA, desmin, ER, PR, inhibin +
    • • MUC 2 +
    • • MUC 1 +
48
Q

Pancreas

A

PANCREATIC PSEUDOCYST

49
Q

CALCIUM OXALATE CRYSTALS in lung

A

CALCIUM OXALATE CRYSTALS

  • Aspergillus niger fungal infection
  • Produces large amounts of oxalic acid
  • Toxic to the blood vessels
  • Fatal pulmonary hemorrhages
  • Consequently calcium oxalate crystals in sputum or lung specimens is also an indication of an Aspergillus infection of the lung
50
Q

CLIA Dates

1967

1988

1990-92

1994

A

CLIA Dates

1967 CLIA Act

1988 Ammended CLIA

1990-92 Rules published in Federal Register

1994 Enforced

51
Q

CLIA 88 Personnel Standards

  • Technical Supervisor
  • General Supervisor
  • Cytotech
A

CLIA 88 Personnel Standards

  • Technical Supervisor
    • MD/DO
    • ABP/ASC w state license
    • Must review all non-gyn
    • Must confirm react/repair and ECA
  • General Supervisor (Debbie)
    • TS or CT w 3 yr cyto experience
    • Day to day supervision of lab
    • Document daily workload
  • Cytotech
    • Graduate from school accredited by CAAHEP
52
Q

CLIA 88 Workload Limits

  • Conventional smear:
    • liquid based =
  • Location guided
    • field of view (FOV) =
    • FOV + full manual =
  • No less than __ hrs
  • __ slides/hr max
  • Reassessed q __
  • CA & NY __ slide limit
A

CLIA 88 Workload Limits

  • Conventional smear: 100 slides
    • liquid based = 0.5
  • Location guided
    • field of view (FOV) = 0.5 (if negative)
    • FOV + full manual = 1.5
  • No less than 8 hrs
  • 12.5 slides/hr max
  • Reassessed q 6 mo
  • CA & NY 80 slide limit
53
Q

CLIA 88 10% Rescreen

A

CLIA 88 10% Rescreen

  • Prospective rescreen of negatives
  • TS, GS or designee
  • Include % high risk cases
  • Document results and remedial measures
54
Q

CLIA 88 5 yr Retrospective

A

CLIA 88 5 yr Retrospective

  • Review previous negatives in current cases of HSIL or cancer
  • Types of error
    • None
    • Screening - tech
    • Interpretation - pathologist
  • Document stats
  • Only report if it affects current management
55
Q

CLIA 88 Cyto/Histo Correlation

  • What cases need it?
  • What’s the #1 cause for non-correlation?
A

CLIA 88 Cyto/Histo Correlation

  • Mandated for HSIL & cancers
  • Good QA
  • # 1 reason for non-correlation is sampling
56
Q

CLIA 88 Statistics (4)

A

CLIA 88 Statistics

  1. Anual gyn & non-gyn
  2. Breakdown of gyns, including unsats
  3. # cases with + 10% rescreen or 5 yr lookback
  4. Cyto/Histo correlation
57
Q

CLIA 88 Performance eval and workload limits

  • for who?
  • how often?
  • by who?
  • using what?
A

Performance eval and workload limits

  • q 6 mo for techs
  • by TS (MD)
  • use stats
58
Q

CLIA 88 Proficiency Testing

  • where?
  • what’s passing?
  • what if you fail (1,2,3)?
A

Proficiency Testing

  • on site
  • 10 slide test, 90% to pass
  • 1st fail: retest 10 slides in 45 days
  • 2nd fail: 20 slide test, all paps reexamined
  • 3rd fail: 35 hr CME, 20 slide test
59
Q

CLIA 88 Regulatory

  • Who enforces CLIA?
  • Must notify CAP if:
A

Regulatory

  • CMS enforces CLIA
    • Contract ASCT for complaints
    • CAP > CMS > COLA > JC
    • CMS does 10% reinspection after CAP
  • Must notify CAP if:
    • negative media
    • investigation
60
Q

CLIA 88 Retention

  • Glass exfoliative
  • FNA
  • Report
  • Accesion log/worksheet
A

CLIA 88 Retention

  • Glass exfoliative - 5 yr
  • FNA - 10 yr
  • Report - 10 yr
  • Accesion log/worksheet - 2 yr
61
Q
A