cytology of the gi tract
DESCRIPTION
This presentation is intended for pathology residents and fellows to aid in the instruction of gastrointestinal cytopathology.TRANSCRIPT
Cytology of the GI Cytology of the GI TractTract
Teresa Alasio, MDTeresa Alasio, MD
Clinical IndicationsClinical Indications
►Suspected malignancySuspected malignancy►Screening for dysplasiaScreening for dysplasia
Surveillance of dysplasia for patients at Surveillance of dysplasia for patients at increased risk of squamous or increased risk of squamous or adenocarcinoma of the esophagusadenocarcinoma of the esophagus
►Suspected infectionSuspected infection
Advantages to Cytology vs. Advantages to Cytology vs. BiopsyBiopsy
►Samples wider areaSamples wider area►Reaches deep organsReaches deep organs►Stenotic lesions more amenable to Stenotic lesions more amenable to
cytologycytology►Better recognition of lymphoid cellsBetter recognition of lymphoid cells►Less invasiveLess invasive
Better for patients with clotting abnormalities Better for patients with clotting abnormalities or very vascular tumorsor very vascular tumors
►Shorter turnaround timeShorter turnaround time
Advantages to CytologyAdvantages to Cytology
►Exfoliative cytologyExfoliative cytology Dysplastic and malignant cells have a lower Dysplastic and malignant cells have a lower
level of intercellular cohesion than normal level of intercellular cohesion than normal cells, allowing the endoscopic brush cells, allowing the endoscopic brush procedure to selectively sample these procedure to selectively sample these discohesive elementsdiscohesive elements
less traumatic and less expensiveless traumatic and less expensive
►FNAFNA Preferable to core biopsy because tumor Preferable to core biopsy because tumor
stroma is left intactstroma is left intact
Types of GI Cytology Types of GI Cytology SpecimensSpecimens
► BrushingsBrushings► Salvage cytologySalvage cytology
Processing material present on external biopsy Processing material present on external biopsy forceps after biopsy is takenforceps after biopsy is taken
► Transmucosal FNATransmucosal FNA Endoscopic Ultrasound (EUS) guidedEndoscopic Ultrasound (EUS) guided Better visualization of lesionsBetter visualization of lesions Allows lymph node samplingAllows lymph node sampling GI tract, liver, pancreas all amenable GI tract, liver, pancreas all amenable
► Balloon cytologyBalloon cytology Experimental procedure but results highly Experimental procedure but results highly
predictive of gastric-cardia cancer and esophageal predictive of gastric-cardia cancer and esophageal cancerscancers
Review of SmearsReview of Smears
► Low power featuresLow power features CellularityCellularity Cellular arrangementsCellular arrangements BackgroundBackground
► High power featuresHigh power features Cytoplasmic characteristicsCytoplasmic characteristics Nuclear detailsNuclear details
► LBPLBP Smaller cellsSmaller cells More single cellsMore single cells Less obvious gland formationLess obvious gland formation Tumor diathesis in small clumps of debrisTumor diathesis in small clumps of debris
EsophagusEsophagus
EsophagusEsophagus
► InfectionsInfections CandidaCandida HerpesHerpes CMVCMV
► RepairRepair► Barrett’sBarrett’s
Dysplasia (low grade, high grade)Dysplasia (low grade, high grade)
► AdenocarcinomaAdenocarcinoma► Squamous cell carcinomaSquamous cell carcinoma
Candida EsophagitisCandida Esophagitis
Herpes EsophagitisHerpes Esophagitis
Other InfectionsOther Infections
► CMVCMV►MucormycosesMucormycoses► IC PatientsIC Patients
Epithelial RepairEpithelial Repair
► Cohesive sheets with flowing or streaming Cohesive sheets with flowing or streaming pattern on direct smear (not seen on LBP)pattern on direct smear (not seen on LBP)
► Uniform nuclei withUniform nuclei with EnlargementEnlargement Smooth and thin nuclear bordersSmooth and thin nuclear borders Fine chromatinFine chromatin Prominent nucleoliProminent nucleoli
► Evident mitosesEvident mitoses► Background inflammationBackground inflammation► Atypical stromal cellsAtypical stromal cells
RepairRepair
Barrett’s EsophagusBarrett’s Esophagus
► Epithelial repairEpithelial repair►Goblet cellsGoblet cells
►DysplasiaDysplasia Background of Barrett’s epitheliumBackground of Barrett’s epithelium Scattered atypical cells with some but not all Scattered atypical cells with some but not all
features of adenocarcinomafeatures of adenocarcinoma Crowded groupsCrowded groups
►LG – stratified with mild atypia and pleomorphismLG – stratified with mild atypia and pleomorphism►HG – can be isolated, more atypia and pleomorphismHG – can be isolated, more atypia and pleomorphism
Barrett’sBarrett’s
DysplasiaDysplasia
Esophageal Adenocarcinoma - Esophageal Adenocarcinoma - FeaturesFeatures
► Increased cellularityIncreased cellularity► Abnormal cellular Abnormal cellular
arrangementarrangement Numerous isolated cellsNumerous isolated cells Feathering at edges of Feathering at edges of
cellular groupscellular groups Haphazard crowded Haphazard crowded
arrangementarrangement Gland formationGland formation
► Barrett’s epithelium Barrett’s epithelium may or may not be may or may not be presentpresent
► Atypical nuclear Atypical nuclear featuresfeatures EnlargementEnlargement HyperchromasiaHyperchromasia Uneven and irregular Uneven and irregular
nuclear membranenuclear membrane PleomorphismPleomorphism
► Various amounts of Various amounts of vacuolated cytoplasmvacuolated cytoplasm
► Tumor diathesesTumor diatheses
AdenocarcinomaAdenocarcinoma
Esophageal SCCEsophageal SCC
► Well differentiatedWell differentiated Hyperchromatic pyknotic Hyperchromatic pyknotic
nucleinuclei Completely obscured Completely obscured
chromatinchromatin Variable cell shapesVariable cell shapes Irregular angulated Irregular angulated
nucleinuclei Keratinized cytoplasmKeratinized cytoplasm Sharp cytoplasmic Sharp cytoplasmic
borderborder Prominent tumor Prominent tumor
diatheses and necrosisdiatheses and necrosis
► Poorly differentiatedPoorly differentiated Less keratinization, Less keratinization,
nuclear angularity and nuclear angularity and pyknosispyknosis
Indistinct cell bordersIndistinct cell borders Coarsely textured Coarsely textured
chromatinchromatin Prominent nucleoliProminent nucleoli
SCCSCC
Uncommon Tumors of the Uncommon Tumors of the EsophagusEsophagus
► Verrucous carcinomaVerrucous carcinoma Pushing rather than infiltrative margins, need to Pushing rather than infiltrative margins, need to
examine the base of the tumorexamine the base of the tumor
► Adenosquamous carcinomaAdenosquamous carcinoma►MECMEC► Basaloid carcinomaBasaloid carcinoma► Adenoid cystic carcinomaAdenoid cystic carcinoma► Small cell carcinomaSmall cell carcinoma
Mimic lymphocytesMimic lymphocytes
StomachStomach
Normal StomachNormal StomachHoneycomb configuration - normal Intestinal metaplasia
StomachStomach
► InfectionsInfections Same as for esophagusSame as for esophagus H. pyloriH. pylori GiardiaGiardia
► RepairRepair►DysplasiaDysplasia► AdenocarcinomaAdenocarcinoma► Endocrine tumorEndocrine tumor►NHLNHL►GISTGIST
H. pyloriH. pylori
► Faintly basophilic s-Faintly basophilic s-shaped rods entrapped shaped rods entrapped in mucus (pap)in mucus (pap)
► Imprint and brushing Imprint and brushing cytology specimens are cytology specimens are equivalent to H&E equivalent to H&E sections in sensitivity sections in sensitivity (88%) and specificity (88%) and specificity (61%)(61%) Rapid resultsRapid results Inexpensive compared Inexpensive compared
with biopsywith biopsy
Dysplasia and Gastric Dysplasia and Gastric AdenomasAdenomas
► Similar appearanceSimilar appearance► Precursor lesions to carcinomaPrecursor lesions to carcinoma► ““dysplasia” = flat, “adenoma” = polypoiddysplasia” = flat, “adenoma” = polypoid► Both are rare in USBoth are rare in US► Features:Features:
Cohesive 3D clustersCohesive 3D clusters Uniformly enlarged nucleiUniformly enlarged nuclei Increased NC ratioIncreased NC ratio Crowded but regular nuclear spacingCrowded but regular nuclear spacing Absent or inconspicuous nucleoliAbsent or inconspicuous nucleoli
AdenocarcinomaAdenocarcinoma
► Cellularity and dyshesion more than dysplasiaCellularity and dyshesion more than dysplasia► Intestinal typeIntestinal type
Resembles typical colorectal and esophageal Resembles typical colorectal and esophageal adenocarcinomasadenocarcinomas
► Diffuse (signet ring cell type)Diffuse (signet ring cell type) Difficult to sample with brush unless ulceration is Difficult to sample with brush unless ulceration is
present because of infiltrative behaviorpresent because of infiltrative behavior►Reactive atypia will be present and may complicate Reactive atypia will be present and may complicate
diagnosisdiagnosis
Signet ring cells can look bland and be confused Signet ring cells can look bland and be confused with histiocyteswith histiocytes
Gastric AdenocarcinomaGastric AdenocarcinomaIntestinal TypeIntestinal Type
► Large cancer cellsLarge cancer cells► Cuboidal or columnar Cuboidal or columnar
configurationconfiguration► Loosely structuredLoosely structured► 3D clusters3D clusters► Enlarged pale nucleiEnlarged pale nuclei► Irregular nuclear Irregular nuclear
membranemembrane► HyperchromasiaHyperchromasia► Coarse chromatinCoarse chromatin
Gastric AdenocarcinomaGastric AdenocarcinomaDiffuse TypeDiffuse Type
► Small inconspicuous Small inconspicuous cellscells
► Large nucleiLarge nuclei►HyperchromaticHyperchromatic► Conspicuous Conspicuous
nucleolinucleoli► Scanty cytoplasmScanty cytoplasm
Gastric AdenocarcinomaGastric AdenocarcinomaSignet Ring Cell TypeSignet Ring Cell Type
► Large sizeLarge size► Large cytoplasmic Large cytoplasmic
vacuoles push nuclei vacuoles push nuclei to peripheryto periphery
► Large hyperchromatic Large hyperchromatic nucleinuclei
► Irregularly shaped Irregularly shaped nuclear membranenuclear membrane
► Large irregular Large irregular nucleolinucleoli
Endocrine Tumors Endocrine Tumors (including carcinoid)(including carcinoid)
►Derived from diffuse endocrine system Derived from diffuse endocrine system of GI tractof GI tract
►Used to be called “neuroendocrine” Used to be called “neuroendocrine” because of presumed derivation from because of presumed derivation from neural crest cellsneural crest cells Found not to be true, now called Found not to be true, now called
“endocrine” instead of “neuroendocrine”“endocrine” instead of “neuroendocrine”
GI Endocrine Tumors – GI Endocrine Tumors – WHO ClassificationWHO Classification
►Well-differentiated endocrine tumorsWell-differentiated endocrine tumors►Well-differentiated endocrine carcinomasWell-differentiated endocrine carcinomas
Size, site, local invasion, angioinvasion, Size, site, local invasion, angioinvasion, metastasesmetastases
► Poorly differentiated endocrine (small cell) Poorly differentiated endocrine (small cell) carcinomascarcinomas
► Found in the appendix, ileum, rectum and Found in the appendix, ileum, rectum and stomach stomach
► 1% of all gasstric malignancies1% of all gasstric malignancies► Cytologic specimens rarely obtained from Cytologic specimens rarely obtained from
ileum, rectum and appendixileum, rectum and appendix
Lymphomas of GI TractLymphomas of GI Tract
►NHL second most common malignancy NHL second most common malignancy of stomachof stomach 5% of all gastric malignancies5% of all gastric malignancies
►MALTMALT Low grade, high grade (transformed from Low grade, high grade (transformed from
LG)LG)
►Large cell lymphomasLarge cell lymphomas►Small cell lymphomasSmall cell lymphomas
Stomach - GISTStomach - GIST
►Submucosal locationSubmucosal location Accessible via EUS FNAAccessible via EUS FNA
►Ddx includes leiomyoma and Ddx includes leiomyoma and leiomyosarcomaleiomyosarcoma
►C-kit needed on cell blockC-kit needed on cell block
GISTGIST
► Cellular specimensCellular specimens► Irregularly outlined clusters of cellsIrregularly outlined clusters of cells► Spindle shaped or epithelioidSpindle shaped or epithelioid► Wispy cytoplasm with long extensionsWispy cytoplasm with long extensions► Mitoses, necrosis (occasionally)Mitoses, necrosis (occasionally)
DuodenumDuodenum
DuodenumDuodenum
► InfectionsInfections GiardiaGiardia MicrosporidiaMicrosporidia CryptosporidiaCryptosporidia
►AdenomaAdenoma►adenocarcinomaadenocarcinoma
InfectionsInfectionsGiardia Cryptosporidia
Microsporidia
Extrahepatic Biliary TractExtrahepatic Biliary Tract
Extrahepatic Biliary TractExtrahepatic Biliary TractTypes of SpecimensTypes of Specimens
►Washings and brushingsWashings and brushings►Exfoliated bileExfoliated bile►Rinses from biliary stentsRinses from biliary stents
►ERCPERCP►PTCPTC
More sensitiveMore sensitive
Extrahepatic Biliary TractExtrahepatic Biliary TractIndicationsIndications
►Biliary strictureBiliary stricture► Identification of infectious agentsIdentification of infectious agents
AFBAFB MicrosporidiaMicrosporidia GiardiaGiardia
►PSC vs. neoplasmPSC vs. neoplasm
Normal Normal Honeycomb arrangement Reactive/Inflammatory atypia
Features of MalignancyFeatures of Malignancy
► Increased N/C ratioIncreased N/C ratio► Chromatin clumpingChromatin clumping►Nuclear molding, Nuclear molding,
loss of loss of honeycombinghoneycombing
ColonColon
Colon CytologyColon Cytology
►Not commonNot common►Colonoscopy with biopsy has replaced Colonoscopy with biopsy has replaced
brushings for diagnosis of IBD and brushings for diagnosis of IBD and colitiscolitis
►Diagnosis of dysplasia is controversial Diagnosis of dysplasia is controversial on cytologyon cytology
►Cannot tell behavior of lesion on Cannot tell behavior of lesion on cytology (invasive vs. superficial)cytology (invasive vs. superficial)
Which is benign?Which is benign?A B
C D