Gastrointestinal Tract Cytology 2 PDF

INSTITUTE OF MEDICAL SCIENCE TECHNOLOGY Topic 5 GASTROINTESTINAL TRACT CYTOLOGY 2 Universiti Kuala Lumpur (UniKL) | Where Knowledge Is Applied and Dreams Realised  PROGRAMME LEARNING OUTCOME (PLO)...

INSTITUTE OF MEDICAL SCIENCE TECHNOLOGY Topic 5 GASTROINTESTINAL TRACT CYTOLOGY 2 Universiti Kuala Lumpur (UniKL) | Where Knowledge Is Applied and Dreams Realised  PROGRAMME LEARNING OUTCOME (PLO) 2 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  COURSE LEARNING OUTCOME (CLO) CLO1 Discuss various techniques involved in cytopathology investigations. (C5,PLO6) Integrate the fundamental knowledge and technique in CLO2 cytopathology diagnostic laboratory such as sample collection, staining and screening techniques. (P6,PLO2) CLO3 Prepare cytopathology report according to the specified format. (A2,PLO5) 3 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  LESSON LEARNING OUTCOME At the end of the lesson, students are able to: Discuss about gastrointestinal tract sample collection, preparation of smear & staining Differentiate cytology features of normal, non-malignancy and malignancy of the gastrointestinal tract 4 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  LESSON OUTLINE Overview of gastrointestinal tract (GIT) cytology GIT sample collection, preparation of smear & staining Cytological examination & findings of esophagus, stomach & intestine 5 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Overview of gastrointestinal tract cytology Clinical indications for gastrointestinal tract (GIT) cytology examination: (1) Suspected malignancy (2) Screening of dysplasia (e.g. in Barrett’s esophagus) (3) Suspected infections GIT cytology is complementary to tissue biopsy 6 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Sample collection Sites for cytological sampling: Cytology of colon is less commonly used Upper GIT Lower GIT Small Esophagus Stomach intestine Rectum Anus (duodenum) 7 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Sample collection Common techniques for GIT sample collection: Endoscopic direct brushing Visible lesion Lesions beneath mucosa Endoscopic FNA + ultrasound guided Deeper lesions Metastatic (extrinsic/adjacent to GIT) malignancy Balloon sampler / Encapsulated sponge Esophagus sampler 8 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Sample collection Sponge sampler Esophageal cytology endoscope + brush 9 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Preparation of smears Material on the brush, needle or sampler is rolled or spread onto 1 or more slide(s) Slides are immersed immediately in 95% alcohol for fixation; AND; Slides are left to air-dry (if required) *Samples taken for LBC should be processed strictly in accordance with the manufacturer’s instructions 10 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Staining methods Papanicolaou Romanowsky Immunocytoche stain staining mistry staining May-Grunwald- Giemsa (MGG) Nucleus: Purple Cytoplasm: Greyish purple/blue 11 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination of GIT samples It is important to examine the slides under low magnification. Features to note: (1) Cellularity (2) Cellular arrangements → flat sheets, 3D clusters, isolated cells (3) Smear background → clean, inflammatory, necrotic 12 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination of GIT samples Cellular arrangement Cells in reactive processes Flat cohesive sheets Neoplastic cells (benign/malignant) Tend to aggregate in 3D clusters Malignant cells Tight or loose 3D clusters Cells may arranged as isolated cells (due to loss of cellular cohesion) 13 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination of GIT samples Indicates a benign Clean background process Smear background Indicate either Dirty, inflammatory benign or malignant background process Ghost cells Malignancy should be suspected when many Swollen eosinophilic necrotic ghost cells are present without numerous epithelial cells that have inflammatory cells lost the nuclei but retain the cellular & nuclear outline 14 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination of GIT samples Slides are examined under high magnification for evaluation of (1) Cytoplasmic characteristics (2) Nuclear details 15 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination of GIT samples Benign process is characterized by uniformity of (1) Cellular arrangement (2) Nuclear size & shape (3) Number of nucleoli Malignant neoplasm is characterized by (1) Haphazard cellular arrangement (2) Marked irregularities in cell size & shape, nuclear chromatin pattern, no. of nucleoli 16 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination of esophagus Barrett’s Infections Epithelial repair esophagus & dysplasia Squamous cell Adenocarcinoma of carcinoma of esophagus esophagus 17 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Normal morphology of esophagus Specimen: Brushing, Pap stain Composed of superficial & intermediate squamous cells → Abundant cytoplasm & small pyknotic nuclei (superficial cells) → Abundant cytoplasm & vesicular nuclei (intermediate cells) 18 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological findings in esophagus Infections Esophageal infections occur most often in immunocompromised patients. Fungal infection – the most common: Candida sp. 19 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological findings in esophagus Infection by Herpes simplex virus Multinucleation Nuclear molding Ground-glass nuclei Cowdry A bodies (eosinophilic intranuclear inclusion) 20 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Epithelial repair in esophagus Any injury to the mucosa can evoke a nonspecific inflammatory or reactive epithelial change Cytological features Cohesive sheets with a flowing or streaming pattern (direct smear) Uniform nuclei with enlargement, smooth & thin nuclear borders, fine chromatin, prominent nucleoli (nuclei not hyperchromatic) Evident mitoses Background inflammation Atypical stromal cells 21 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Epithelial repair Nuclei are enlarged but round and regular with prominent nucleoli. Cells are somewhat crowded but very cohesive (Esophageal brushing, Pap stain, LBC) 22 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Epithelial repair Radiation-induced changes Cellular & nuclear enlargement, multi-nucleation & vacuolization of cytoplasm & nuclei are characteristic (Esophageal brushing, Pap stain, LBC) 23 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Barrett’s esophagus (BE) An acquired condition as a complication of patients with chronic gastroesophageal reflux. Normal stratified squamous epithelium of distal esophagus is replaced by columnar epithelium. Increased risk of adenocarcinoma from BE is associated with intestinal-type epithelium → characterized by presence of goblet cells. 24 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Barrett’s esophagus (BE) 25 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Barrett’s esophagus (BE) - Findings Goblet cells Single large cytoplasmic vacuole displacing the nucleus → shaping the nucleus into a crescent against cell membrane Multiple goblet cells appear as Swiss cheese appearance or honeycomb sheet Not diagnostic for BE → require mucin staining to demonstrate acid mucin, pale blue; pseudogoblet cells – neutral mucin, pink 26 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Barrett’s esophagus (BE) Barrett’s epithelium with goblet cells Displaced nucleus → Shaped into a crescent against the basal cell membrane (Pap stain, LBC) 27 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Dysplasia of Barrett’s esophagus (BE) Cytology is useful in identifying & grading dysplasia of BE. Low-grade esophageal High-grade esophageal dysplasia dysplasia Crowded groups with Crowded groups or isolated stratification cells Mild nuclear atypia & Higher degree of nuclear pleomorphism atypia & pleomorphism 28 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Low-grade dysplasia in BE A fragment of glandular epithelium with stratified elongated nuclei Slight nuclear enlargement, significant nuclear atypia is absent 29 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  High-grade dysplasia in BE A sheet of irregularly arranged cells with variably enlarged nuclei is present, without evident dyshesion ↑ NCR, nuclear membrane irregularities & slight hyperchromasia → yet insufficient for a definitive diagnosis of malignancy 30 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Adenocarcinoma of esophagus Most of the carcinoma are located in the mid- or distal 3rd of esophagus (presumably arising from BE). Distinction between reactive, dysplastic & malignant lesions is challenging. In adenocarcinoma: More abnormal cells Nuclear atypia is more marked Endoscopic finding: fungating, ulcerating lesion 31 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytomorphology of esophageal adenocarcinoma ✓ Increased cellularity ✓ Atypical nuclear features Enlargement ✓ Abnormal cellular Hyperchromasia arrangement Uneven & irregular nuclear membrane Numerous isolated cells Pleomorphism Feathering at the edges of cellular groups ✓ Various amount of Haphazard crowded vacuolated cytoplasm arrangement Gland formation ✓ Tumor diathesis 32 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytomorphology of esophageal adenocarcinoma Dyshesion is evident Nuclei show significant hyperchromasia with chromatin clumping and clearing & large prominent nucleoli (Direct smear, Pap stain) 33 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Squamous cell carcinoma of esophagus Squamous cell carcinoma is the most common malignancy of the esophagus. Cellular features depend on the degree of differentiation. Well-differentiated SCC Poorly differentiated SCC Hyperchromatic or pyknotic nuclei Less keratinization, nuclear Completely obscured chromatin angularity, pyknosis Variable cell shapes (round, oval, Indistinct cell borders spindle) Coarsely textured chromatin Irregular, angulated nuclei Prominent nucleoli Keratinized cytoplasm Sharp cytoplasmic border Prominent necrosis or tumor diathesis 34 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Well-differentiated squamous cell carcinoma of esophagus Spindled-shaped keratinized squamous cells Orangeophilic cytoplasm Hyperchromatic nuclei show markedly abnormal chromatin distribution (Pap stain, LBC) 35 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Poorly-differentiated squamous cell carcinoma of esophagus Cells show scant cytoplasm Nuclei show markedly abnormal chromatin distribution & prominent nucleoli (Pap stain, LBC) 36 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination in stomach Dysplasia & Infections adenoma Adenocarcinoma of stomach 37 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Normal morphology of stomach A sheet of gastric surface mucous cells Honeycomb pattern & columnar cells in palisading arrangement (Gastric brushing) 38 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Infections in stomach Helicobacter pylori ~ unique to the stomach May be a cofactor in the development of gastric carcinoma & lymphoma H. pylori is faintly basophilic, S-shaped rod (Pap stain) Atypical mycobacteria Accumulate within macrophages → presence of many isolated foamy macrophages should raise suspicion of atypical mycobacterial infection 39 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Infections in stomach Helicobacter pylori Isolated macrophage with foamy cytoplasm in atypical mycobacteria infection 40 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Gastric dysplasia & gastric adenoma Cytologic appearance of g. dysplasia = g. adenoma Both are precursor lesions to carcinoma (but rare lesions) Flat lesion – dysplasia Polypoid lesion – adenoma Cytomorphology depends on the degree of dysplasia 41 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Gastric dysplasia & gastric adenoma Cytomorphology Cohesive 3D clusters Uniformly enlarged nuclei Increased NCR Crowded but regular nuclear spacing Absent or inconspicuous nucleoli *Some dyshesion, irregular cellular arrangement & nuclear atypia – high-grade dysplasia 42 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Gastric adenocarcinoma Resembles esophageal & colorectal adenocarcinoma Gastric adenocarcinoma Intestinal type Highly cellular, many isolated cells, tight & loose cells clusters Composed predominantly of signet ring cells Diffuse / Signet ring cell type Quite difficult to detect on cyto/histo preparations 43 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Gastric adenocarcinoma Cytomorphology of gastric adenocarcinoma, signet ring cell type Small groups or isolated cells Vacuolated cytoplasm, often a single large vacuole Crescent-shaped, angulated, hyperchromatic nucleus 44 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Cytological examination in small intestine Adenoma & Infections adenocarcinoma 45 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Normal morphology of small intestine The lining cells of the small intestine can be easily distinguished from gastric surface mucous cells by the presence of goblet cells Typically has a Swiss cheese appearance; “holes” representing either goblet cells or gland openings of the crypts Absorptive cells have either finely granular or vacuolated cytoplasm; Goblet cells have single large mucin vacuoles & crescent-shaped nuclei with rounded contours 46 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Normal morphology of small intestine 47 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Infections in small intestine Giardia lamblia Brush cytology is useful for detection of Giardia lamblia. → Flat, gray, pear-shaped & binucleate with 4 pairs of flagella 48 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Infections in small intestine Microsporidium Opportunistic infection Appear in aggregates as brightly eosinophilic rod-shaped or ovoid organisms, 1-3 µm diam. Can be detected in other cytologic specimens – urine, stool, nasal secretions 49 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Duodenal adenoma & adenocarcinoma Cytomorphology of Cytomorphology of duodenal adenoma duodenal adenocarcinoma Cohesive 3D clusters of Greater cellularity crowded cells More dyshesion Increased NCR More marked nuclear Absent goblet cells atypia & pleomorphism Palisading & molding of elongated nuclei Fine chromatin & absent or small nucleoli *Duodenal adenoma resembles gastric adenoma 50 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Anal lesions Anal squamous cell carcinoma – uncommon. Rectum – simple columnar Anal canal – stratified squamous Screening for anal cancer & its precursor was implemented in 1990s (US) → Anal pap test Anal squamous intraepithelial lesions & SCC are morphologically identical to cervical. The Bethesda terminology is used for reporting – NILM, ASC-US, ASC-H, LSIL, HSIL Adequacy criteria: 2000 to 3000 nucleated squamous cells 51 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  HSIL (Anal Pap smear) Cells show: ✓ Nuclear enlargement ✓ Nuclear membrane irregularity ✓ Chromatin coarsening ~ analogous to the changes seen in cervical specimen 52 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Comparison of cytologic features Features Reactive Dysplasia & Adenocarcinoma adenoma Tight 3D Absent to rare Absent to Moderate to clusters moderate many Loose clusters Absent to rare Absent to Moderate to moderate many Dyshesion Absent to slight Absent to Prominent moderate Single atypical None to few None to Moderate to cells present moderate many 53 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Comparison of cytologic features Features Reactive Dysplasia & Adenocarcinoma adenoma Mitoses Present Present Present Atypical None None to few Present mitoses Chromatin Vesicular Variable Variable Nuclear Absent to slight Slight to Moderate to pleomorphism moderate marked 54 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Comparison of cytologic features Features Reactive Dysplasia & Adenocarcinoma adenoma Nuclear overlap Absent to slight Slight to Moderate to moderate marked Irregular Absent to slight Slight to Moderate to nuclear spacing moderate marked within tight clusters Necrosis Absent Absent Occasionally present 55 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY THANK YOU UNIVERSITI KUALA LUMPUR © Copyright of Universiti Teknikal MARA Sdn. 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