Cytopathology. 7 Dr. Maha Al-Sedik 2015 CLS 422

1- Neoplasm. 2- Stages of carcinoma. 3- Differences between benign and malignant neoplasm. 4- Dysplasia. 5- Carcinoma in situ. 6- Nuclear changes in malignancy. 7- Cytoplasmic changes in malignancy. 8- Determination of cell type. Objectives:

Neoplasm Cell growth has escaped from normal regulatory mechanisms Benign Malignant

Benign

Dysplasia Insitu

Malignancy

Metastasis

Stages of malignancy: Stage 1: One cell acquire mutation of repeated cell division. One of the cells acquire mutation to start tumor. Stage 2: One cell acquire mutation to produce proteinase enzyme. Stage 3: Tumor is formed but at its place without invasion of the basement membrane ( carcinoma in situ ).

Stage 4: Cancer cell invade the blood and lymphatic vessels. Stage 5: Tumor cells ( metastatic ) appear in another place.

Benign neoplasm: Cells grow as a compact mass and remain at their site of origin ( cells are normal ). Malignant neoplasm: Growth of malignant cells is uncontrolled. Cells can spread into surrounding tissue and spread to distant sites. Cancer = a malignant growth.

 Premalignant condition.  Increased cell growth.  Cellular atypia.  Can range from mild to severe.  Sites : cervix - bladder - stomach. Dysplasia:

 Epithelial neoplasm with features of malignancy.  Altered cell growth.  Cytological malignant changes.  BUT no invasion through basement membrane. In-situ malignancy:

Benign Benign Benign Dysplasia Benign Dysplasia In-situ Benign Dysplasia In-situ Invasive Dysplasia In-situ Invasive In-situ Invasive Invasive Invasive POSSIBLE EVENTS

Key to the diagnosis of neoplasia is to determine that the "lesion" is not inflammatory and is not a normal structure.

 Neoplasia usually is recognized cytologically by the presence of cells that are neither inflammatory nor normally expected from the site of collection.  For example, the presence of squamous epithelial cells in a lymph node aspirate is highly suggestive of metastatic neoplasia.

CYTOLOGICAL CRITERIA OF MALIGNANCY A)Nuclear Changes: 1-Nuclear hypertrophy: nuclear enlargement that leads to increased N/C ratio. 2-Nuclear size variation 3-Nuclear shape variation

4- Hyperchromatism and chromatin irregularity: refers to increased chromatin materials. It is distributed as coarse, clumps. This is different from normal cells, which have evenly distributed chromatin.

5- Multinucleation: Malignant cells may contain more than one nucleus. However, some normal cells such as hepatocytes and histiocytes may contain more than one nucleus. Multinucleated malignant cells differ from nonmalignant multinucleated cells by the fact that the nuclei of malignant cells are unequal in size (in contrast to that of normal cells).

6-Irregularity of the nuclear membrane. 7-Irregular and prominent nucleoli: giant nucleoli or multiple nucleoli may be present that differ in their sizes and shapes. It should be remembered, however, that normal columnar and goblet cells may contain 2 nucleoli.

N/C ratio is markedly increased

Nuclear size variation

Hyperchromatism

Multi-nucleation with two, three, four, or more nuclei is a common finding in many cells

M ultinucleation

Prominent nucleoli

B) Cytoplasmic Changes: 1- Decrease of size of cytoplasm: in consequence to the high N/C ratio. 2- Cytoplasmic boundaries: sharp and distinct in Squamous cell carcinomas and indistinct in undifferentiated carcinomas. 3- Variation in size. 4- Variation in Shape.

5- Cytoplasmic inclusions: e.g. melanin pigments in melanoma. 6- Cytoplasmic and nuclear membrane relationship: cytoplasmic borders of malignant cells could be tightly molded against the nucleus, touching it in more than one place.

1. Increase in the number of cells with few or no inflammatory cells. 2. Large cells (find an inflammatory cell or a red blood cell for a size reference). 3. Variation in size and shape of nuclei, nucleoli and cytoplasm. 4. High nuclear to cytoplasmic ratio - large nuclei. Summary: Cytological criteria for malignancy:

5. Nuclear abnormalities:  Multiple nuclei, varying numbers.  Macronuclei.  Variation in shape and size.  Lobation, cleaving, molding, angulation.  Irregular clumping and dark chromatin. 6. Nucleolar abnormalities: different numbers, sizes, and shapes per nucleus; macronucleoli.

 The more neutrophils you see, the more likely the lesion is inflammatory and not a tumor.  True, neutrophils can infiltrate tumors and be present, but your rule is still the same – the greater the inflammation, the less likely there is a neoplasm.  If the preparation is cellular and no neutrophils are present one of your first differentials is neoplasia. Keep it simple, e.g. a mass in the skin or subcutaneous tissues and there are no neutrophils and there are lots of nucleated cells….. diagnosis: neoplasia. IMPORTANT NOTES:

 The shape of the cells and their nuclei is the main criteria used in attempting to classify the cell type of a neoplasm.  If the shape of the cell cannot be determined from visualization of cytoplasm then a good estimation can be made from the shape of the nuclei. Determination of cell type:

usually exfoliate easily (numerous cells seen) and tend to be shed in clusters. Cell shape may reflect that of the specific epithelial type (squamous, cuboidal, columnar), but these characteristics are often lost in poorly differentiated tumors. The key to recognition of an epithelial tumor is to see clusters, acini or aggregates of cells that represent their pattern of growth due to cell to cell adhesion (desmosomes, hemidesmosomes). Epithelial cells

 Tend to exfoliate poorly (low cell numbers) and are more prone to exfoliate individually (although groups of cells may be closely apposed in highly cellular specimens).  Cell shape is elongated (spindle-shaped) and nuclei are oval or elongated.  Cytoplasm is seen it tends to “stream” at the end of the cell making a tail or point. More specific characterization as to cell type may not be possible unless evidence of a cell product can be found. Mesenchymal (connective tissue) cells

 also exfoliate discrete cells, usually lots of them, but they lack the elongated shape common among connective tissue cells and they don’t form balls or morulae like epithelial tumors.  The amount of cytoplasm varies with the tumor type.  Nuclei are characteristically round and often quite uniform. Lymphoma, mast cell tumor. Round cell tumors

Reference: The Pathology of the Female Reproductive Tract John M. Craig, MD Boston Hospital for Women Harvard Medical School Boston, Massachusetts