Milan classification.1st edition(2018) برای بزرگنمایی عکسها کلیک را روی ان نگه دارید..... ■■■Terminology&Reporting【1】 Fig. 1.1 Anatomic relationship of the parotid gland and surrounding structures, including branches of the facial nerve, masseter muscle, Stensen's duct, and submandibular gland. (From Faquin and Powers [21], with permission) Fig. 1.2 (a) Standard FNA equipment showing a Cameco syringe holder with a 10 cm3 syringe and attached 25 G needle. One hand should be used to palpate and fix the nodule, while the other hand grasps the Cameco holder to place the needle and perform the biopsy using suction. (b) Schematic showing the use of the Zajdela technique to aspirate a parotid gland lesion using a needle without suction. (Courtesy of Ms. Antonia Conti, CMI) ■■■Non Diagnostic【2】 Fig. 2.1 Non-Diagnostic. (a) Blood, debris, and rare inflammatory cells are present, but insuffi- cient for classification (smear, Romanowsky stain). (b) Hypocellular aspirate showing background blood and scant non-lesional cells (smear, Papanicolaou stain) Fig. 2.2 Non-Diagnostic The aspirate contains dense nonspecific material, background debris, and extensive air-drying artifact (smear, Romanowsky stain) Fig. 2.3 Non-Diagnostic. Hypocellular aspirate with background proteinaceous material and debris with ferning artifact. There are insufficient lesional cells present for classification (smear, Romanowsky stain) Fig. 2.4 Non-Diagnostic. (a) This aspirate in a patient with a discrete mass consists only of blood and non-neoplastic (normal) salivary gland elements. (smear, Romanowsky stain). (b) This aspi- rate shows non-neoplastic (normal) salivary gland acini in a lobular arrangement with focal ductal cells. This aspirate would not be considered representative of a clinically defined mass lesion (smear, Papanicolaou stain). (c) This aspirate shows scattered fragments of skeletal muscle, blood, and debris (smear, Romanowsky stain) Fig. 2.5 Non-Diagnostic. Non-mucinous cyst contents showing histiocytes, debris, and few inflammatory cells (smear, Papanicolaou stain) Fig. 2.6 Atypia of Undetermined Significance (AUS). This aspirate of a cyst shows histiocytes and two rare clusters of atypical epithelial cells. The presence of atypia precludes the classification of this aspirate as Non-Diagnostic. Depending upon the number of epithelial cells and degree of atypia, this aspirate would be best classified as either "Atypia of Undetermined Significance," "Salivary Gland Neoplasm of Uncertain Malignant Potential," or "Suspicious for Malignancy" (smear, Papanicolaou stain) Fig. 2.7 Neoplasm: Benign. This aspirate consists of abundant acellular metachromatic matrix only. This finding is indicative of a neoplasm, and is characteristic of pleomorphic adenoma (smear, Romanowsky stain) Fig. 2.8 Non-Diagnostic. Aspirates showing only necrosis and few inflammatory cells should be classified as "Non- Diagnostic". A note can be added to the case that the presence of necrotic debris raises the possibility of an infarcted neoplasm (smear, Romanowsky stain) ■■■【3】Non Neoplstic Fig. 3.1 Non-Neoplastic. This aspirate of sialolithiasis contains a cluster of metaplastic ductal cells with background acute and chronic inflammation(smear, Papanicolaou stain) Fig. 3.2 Non-Neoplastic. This aspirate of sialolithiasis shows stone fragments and a multinucleated giant cell (smear, Papanicolaou stain) Fig. 3.3 Non-Neoplastic. This smear shows metaplastic ductal cells from an aspirate of sialolithiasis (smear, Papanicolaou stain) Fig. 3.4 Non-Neoplastic. These aspirates of acute sialadenitis (a) (smear, Romanowsky stain) and (b) (Papanicolaou stain) show abundant acute inflammation with occasional histiocytes and back- ground debris, but no evidence of a neoplastic process. Clinical follow-up and radiologic correla- tion are needed to ensure that the aspirate is representative Fig. 3.5 Non-Neoplastic. This smear shows focal ductal cells (upper right) with reactive atypia in a background of marked acute sialadenitis (smear, Papanicolaou stain) Fig. 3.6 Non-Neoplastic. (a) This aspirate of chronic sialadenitis shows a sheet of cytologically bland ductal cells. (b) This aspirate of chronic sialadenitis demonstrates reactive ductal atypia (smear, Papanicolaou stain) Fig. 3.7 Non-Neoplastic. This smear of chronic sialadenitis demonstrates a smaller atrophic ductal group with basaloid qualities and background chronic inflammation; avoid misinterpreting this as a basaloid neoplasm (smear, Papanicolaou stain) Fig. 3.8 Non-Neoplastic. Amylase crystalloids (a, b) are non-birefringent crystalline structures with rectangular, needle-shaped, rhomboid, and platelike shapes. They are most commonly associated with non-neoplastic inflammatory conditions as in this case (smear, Papanicolaou stain) Fig. 3.9 Non-Neoplastic. (a) This aspirate of granulomatous sialadenitis shows a large group of epithelioid histiocytes; an infectious agent should be excluded. (b) Aspirates of sarcoidosis yield loose collections of epithelioid histiocytes, and usually lack background necrosis (noncaseating) (smear, Papanicolaou stain) Fig. 3.10 Non-Neoplastic. These aspirates of reactive lymph node hyperplasia (a) (smear, Romanowsky stain) (Courtesy of William Geddie, MD, Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Canada) and (b) (smear, Papanicolaou stain) show a mixed popula- tion of mostly small and intermediate-size lymphocytes admixed with follicular dendritic cells. Flow cytometry can be used to confirm a polyclonal population Fig. 3.11 Non-Neoplastic. These aspirates of reactive lymph node hyperplasia show (a) a cohe- sive group of lymphocytes and follicular dendritic cells representing a germinal center fragment. (b, c) Tingible body macrophages are present in a background of predominantly small mature lymphocytes and occasional follicular dendritic cells (smear, Papanicolaou stain) Fig. 3.12 Atypia of Undetermined Significance (AUS). This lymph node aspirate shows an increased proportion of larger lymphocytes. In the absence of flow cytometry to exclude lymphoma, such aspirates should be classified as AUS (smear, Romanowsky stain) Fig. 3.13 Non-Neoplastic. This aspirate demonstrates the lymphoepithelial lesion of lymphoepithelial sialadenitis, which consists of a bland sheet of ductal epithelial cells with admixed small lymphocytes (smear, Papanicolaou stain) Fig. 3.14 Non-Neoplastic. (a, b) The lymphoepithelial lesions of lymphoepithelial sialadenitis (LESA) are sheets of ductal cells that can exhibit squamous metaplastic features. (c) The associated lymphoid population in LESA is a mixed pattern with a predominance of small mature lym- phocytes (smear, Papanicolaou stain) Fig. 3.15 Non-Neoplastic. (a) Aspirates of lymphoepithelial cysts consist of a mixed population of lymphocytes and variable numbers of dendritic cells. (b) Some cases may show only cyst contents with abundant bland nucleate and anucleate squamous cells. Clinical context is important to exclude a squamous cell carcinoma (smear, Papanicolaou stain) Fig. 3.16 Non-Neoplastic. This aspirate of sialadenosis shows a cluster of large vacuolated acinar cells. Clinical correlation is needed to interpret this aspirate (smear, Romanowsky stain) Fig. 3.17 Non-Neoplastic. This aspirate of oncocytosis from a multinodular gland shows a sheetlike collection of oncocytes merging with a small fragment of ductal epithelium (smear,Papanicolaou stain) ■■■AUS【4】 Fig. 4.1 Atypia of Undetermined Significance. These two images (a, b) show rare atypical cells in an inflammatory background, indefinite for a neoplasm (smears, Papanicolaou stain) Fig. 4.2 Atypia of Undetermined Significance. Group of epithelioid cells, indefinite for a neoplasm (smear, Papanicolaou stain) Fig. 4.3 Atypia of Undetermined Significance. The aspirate shows occasional epithelial cells with oncocytic features in a background with numerous lymphocytes, indefinite for a neoplasm (smear, Papanicolaou stain). The surgical follow-up was a Warthin tumor Fig. 4.4 Atypia of Undetermined Significance. This aspirate contains occasional groups of bland epithelial cells with oncocytic features. The findings are indefinite for an oncocytoma versus oncocytic metaplasia(smear, Papanicolaou stain) Fig. 4.5 Atypia of Undetermined Significance. This hypocellular aspirate shows a very rare group of mildly atypical epithelial cells with associated "lymphocytic tangles," suggestive but not diagnostic of a neoplasm (smear, Papanicolaou stain) Fig. 4.6 Atypia of Undetermined Significance. The epithelial cells in this aspirate are suggestive of a neoplastic process but abundant blood limits the evaluation (smear, Papanicolaou stain) Fig. 4.7 Atypia of Undetermined Significance. This aspirate contains abundant mucin without any epithelial cells. The differential diagnosis includes a benign mucinous cyst; however, a low-grade mucoepidermoid carcinoma cannot be excluded (smear,Romanowsky stain) Fig. 4.8 Atypia of Undetermined Significance. Mixed population of lymphocytes with background lymphoglandular bodies and increased numbers of larger lymphocytes. A lymphoma cannot be excluded, particularly in the absence of flowcytometry (smear, Romanowsky stain) Fig. 4.9 Atypia of Undetermined Significance. These aspirates (a, b) show groups of basaloid- appearing epithelium that are indefinite for a neoplastic process versus reactive or metaplastic changes (smear, Papanicolaou stain). (Note: These images are purposefully overexposed to capture nuclear detail) Fig. 4.10 Atypia of Undetermined Significance. This hypocellular aspirate contains occasional epithelioid and spindled cells that are suggestive of a neoplasm (smear, Papanicolaou stain) Fig. 4.11 Atypia of Undetermined Significance (AUS). This aspirate shows a mixed lymphoid pattern with an atypical population of intermediate-size lymphocytes. In the absence of flow cytometry, this aspirate can be classified as either "AUS" or "Suspicious for Malignancy" (smear, Romanowsky stain) Fig. 4.12 Atypia of Undetermined Significance. This hypocellular cyst aspirate contains rare atypical epithelial groups that are suggestive of, but not diagnostic of, a cystic neoplasm (smear, Papanicolaou stain) Fig. 4.13 Atypia of Undetermined Significance. This image showing a collection of cytologically bland keratinizing squamous cells raises a differential diagnosis of metastatic squamous cell carcinoma versus reactive squamous atypia in a benign squamous cyst. Clinical context and quality of the fine-needle aspiration sample will influence the cytologic classification (smear, Papanicolaou stain) ■■■【Neoplasm【5 Fig. 5.1 Neoplasm: Benign. Pleomorphic adenoma. Intense metachromatic fibrillary matrix with myoepithelial cells embedded within—(a) (smear, Romanowsky stain), (b) (smear, Papanicolaou stain). FNA of pleomorphic adenoma showing metachromatic fibrillary matrix with embedded myoepithelial cells. Notice the stroma individually surrounds each cell and the so called "troll hair" appearance of the stroma-(c) (smear, Romanowsky stain) Fig. 5.2 Neoplasm: SUMP. FNA of pleomorphic adenoma showing a highly cellular, matrix-poor tumor with a predominance of plasmacytoid myoepithelial cells (a) (smear, Romanowsky stain), (b) (high power, smear, Papanicolaou stain). This pleomorphic adenoma is a cellular, matrix poor specimen with spindled and epithelioid myoepithelial cells (c) (liquid-based preparation, Papanicolaou stain) Fig. 5.3 Neoplasm: Benign. (a, b) Pleomorphic adenoma showing myoepithelial cells and very delicate, pale-staining matrix (smear a, Romanowsky stain, smear b, Papanicolaou stain) Fig. 5.4 Neoplasm: SUMP. FNA of pleomorphic adenoma having adenoid cystic carcinoma-like areas(smear, Papanicolaou and Romanowsky stains) Fig. 5.5 Pleomorphic adenoma. The stroma lacks the usual fibrillary character and mimics thick mucin (smear, Romanowsky stain) Fig. 5.6 Neoplasm: SUMP. FNA of pleomorphic adenoma showing squamous metaplasia (smear, Papanicolaou stain) Fig. 5.7 Neoplasm: SUMP. (a, b) This aspirate of a pleomorphic adenoma has a predominance of spindled myoepithelial cells mimicking a salivary gland neoplasm of mesenchymal origin (smear, Papanicolaou stain) Fig. 5.8 Neoplasm: SUMP. This case of pleomorphic adenoma shows marked nuclear atypia of the myoepithelial cells; in such cases, malignant transformation needs to be excluded (smear, Papanicolaou stain) Fig. 5.9 Neoplasm: Benign. (a–c) FNA of Warthin tumor (WT) showing classic cytomorphologic features consisting of background lymphocytes and groups of oncocytic epithelial cells (smear, Romanowsky stain); (d) This case of WT only shows oncocytic cells arranged in papillary groups. Notice the lack of lymphocytes; such cases may be classified as "oncocytic/oncocytoid neoplasm" (liquid-based preparation, Papanicolaou stain) Fig. 5.10 Neoplasm: Benign. This classic aspirate of Warthin tumor consists of oncocytic cells with abundant granular cytoplasm and well- defined borders in a background of lymphocytes (smear, Papanicolaou stain) Fig. 5.11 Neoplasm: Benign. FNAS of oncocytoma showing various patterns of a monotonous population of oncocytic cells with abundant granular cytoplasm and well-defined borders arranged in cohesive groups-(a) (smear, Romanowsky stain), (b-d) smear, Papanicolaou stain Fig. 5.12 Neoplasm: Benign. FNA of lipoma showing lacelike group mature adipocytes with abundant clear cytoplasm and small dark nuclei (smear, Romanowsky stain) Fig. 5.13 Neoplasm: Benign. This FNA contains a group of adipocytes from a lipoma characterized by large cells with abundant clear cytoplasm. The small dark nuclei are often displaced to the edge of the cell (smear, Romanowsky stain) Fig. 5.14 Neoplasm: Benign. This aspirate of schwannoma shows a group of bland spindle cells with wispy cytoplasm. The cytoplasmic borders are indistinct. Nuclei are spindle-shaped and display bends or curves (smear,Romanowsky stain) Fig. 5.15 Neoplasm: Benign. Smears obtained from hemangiomas are characteristically bloody, but may contain small aggregates of bland spindle-shaped endothelial cells. Rarely, sheet-like structures composed of oval or spindle-shaped endothelial cells will be present. Clinical and radiologic correlation is needed in the evaluation.(smear, Romanowsky stain) Fig. 5.16 Neoplasm: SUMP. (a, b) FNA of cellular basaloid neoplasms showing a predominant population of cells with scanty cytoplasm with hyaline stroma (smear, Romanowsky stain); (c, d) This FNA contains a monotonous population of basaloid cells arranged in cohesive groups with scanty hyaline stroma (smear, Papanicolaou stain) Fig. 5.17 Neoplasm: SUMP. (a) This FNA shows basaloid tumor cells associated with well- demarcated hyaline stroma. Depending upon the cellularity and cytomorphologic features com- bined with clinical findings, the diagnosis of cases such as this can range from "SUMP-basaloid neoplasm" to "suspicious for adenoid cystic carcinoma" (smear, Romanowsky stain). (b) This aspirate shows basaloid tumor cells arranged in a 3-dimensional cohesive group with nuclear crowding and minimal to no stroma (liquid-based preparation, Papanicolaou stain) Fig. 5.18 Neoplasm: SUMP. (a, b) In this FNA of a cellular basaloid neoplasm there is a cohesive group of basaloid cells with no stroma. On histologic follow-up this case was diagnosed as solid variant of adenoid cystic carcinoma (smear, Papanicolaou stain) Fig. 5.19 Neoplasm: SUMP. (a, b) This aspirate shows neoplastic cells with oncocytic/oncocytoid cytoplasm arranged in a cohesive clusters with associated crystalline material. The cells demon- strate eccentrically placed nuclei (plasmacytoid appearance). On histologic follow-up this case was diagnosed as myoepithelioma (smear, Romanowsky stain) Fig. 5.20 Neoplasm: SUMP. FNA of cellular oncocytic/oncocytoid neoplasm showing loose groups and dispersed neoplastic cells with bland oncocytic features. On histologic follow-up this case was diagnosed as acinic cell carcinoma (smear, Romanowsky stain) Fig. 5.21 Neoplasm: SUMP. (a, b) FNA of a cellular neoplasm with clear cell to oncocytoid fea- tures showing sheets of epithelial cells with finely vacuolated cytoplasm. Nuclei are enlarged, but retain smooth nuclear membranes. The histologic follow-up of this case was acinic cell carcinoma (smear, Papanicolaou stain) Fig. 5.22 Neoplasm: SUMP. This aspirate contains loosely cohesive groups of cells with indis- tinct finely vacuolated, pale-staining cytoplasm imparting a clear quality. Nuclei are small to medium-sized with even chromatin. No nuclear pleomorphism is seen. The histologic follow-up was acinic cell carcinoma. (a) (smear, Papanicolaou stain) and (b) (smear, Papanicolaou stain). This case could also be classified as "Suspicious for Malignancy" based on one's level of suspicion of acinic cell carcinoma Fig. 5.23 Neoplasm: SUMP. This FNA shows a neoplastic proliferation of cells with delicate pale cytoplasm containing variably-sized clear vacuoles and round nuclei with inconspicuous nucleoli and minimal nuclear pleomorphism. (a) (smear, Romanowsky stain) and (b) (smear, Papanicolaou stain). The histologic follow-up was acinic cell carcinoma Fig. 5.24 Neoplasm: SUMP. FNA of a neoplasm with variably oncocytoid to clear cell features. A monotonous population of neoplastic cells arranged in cohesive groups with finely granular cytoplasm. The background shows thin mucin and clear histiocytic-type cells that raise a differential diagnosis of mucoepidermoid carcinoma (a) (smear Romanowsky stain and (b) (smear, Papanicolaou stain) Fig. 5.25 Neoplasm:SUMP. FNA of a neoplasm with scattered large cells with finely vacuolated clear to pale cytoplasm (smear, Papanicolaou stain) ■■■Suspicious for Malignancy【6】 Fig. 6.1 Suspicious for Malignancy. The smear shows rare markedly atypical cells suggestive of carcinoma, but the classification is limited by scant cellularity (smear, Papanicolaou stain) Fig. 6.2 Suspicious for Malignancy. Thesmear contains markedly atypical cells suspicious for high-grade carcinoma, but with obscuring blood limiting the assessment (smear, Romanowsky stain) Fig. 6.3 Suspicious for Malignancy. The smear shows a group of epithelial cells suggestive of acinic cell carcinoma, but hypocellularity and background blood in the absence of ancillary studies limits the evaluation (smear, Papanicolaou stain) Fig. 6.4 Suspicious for Malignancy. This smear is composed of basaloid cells and abundant matrix spheres with a pattern suspicious for adenoid cystic carcinoma (smear, Papanicolaou stain) Fig. 6.5 Suspicious for Malignancy. The smear consists of epithelial cells with epidermoid features, suggestive of mucoepidermoid carcinoma (smear, Romanowsky stain) Fig. 6.6 Suspicious for Malignancy. The smear shows presence of markedly atypical (upper left) cytologic features in a subset of cells admixed with features of pleomorphic adenoma (smear, Papanicolaou stain) Fig. 6.7 Suspicious for Malignancy. This aspirate is hypocellular but contains occasional small groups of markedly atypical cells suspicious for carcinoma. The corresponding resection showed a high-grade mucoepidermoid carcinoma (smear, Papanicolaou stain) Fig. 6.8 Suspicious for Malignancy. This smear shows neoplastic cells containing nuclei with "salt and pepper" chromatin suggestive of neuroendocrine differentiation (smear, Papanicolaou stain) Fig. 6.9 Suspicious for Malignancy. This smear shows a population of enlarged atypical lymphoid cells suspicious for a large cell lymphoma (smear, Papanicolaou stain) Fig. 6.10 Suspicious for Malignancy. This aspirate shows a monotonous population of intermediate- size lymphocytes that, based upon cytomorphology alone, are highly suspicious for lymphoma. Additional ancillary studies including immunophenotyping are needed for classification (smear, Papanicolaou stain) Fig. 6.11 Suspicious for Malignancy. This smear shows a polymorphous pattern with a predominance of intermediate-size lymphoid cells as can be seen in marginal zone lymphomas. Ancillary studies are needed for further classification (smear, Papanicolaou stain) Fig. 6.12 Suspicious for Malignancy. This smear shows cytologic features that are highly suspicious for adenoid cystic carcinoma, but the specimen is limited to a single Papanicolaou- stained smear (smear, Papanicolaou stain) ■■■Malignant【7】 Fig. 7.1 Malignant. Acinic cell carcinoma. Cellular smear with loosely cohesive groups of fragile acinar cells adherent to a delicate capillary meshwork. Note the presence of stripped nuclei in the flocculent background and the conspicuous absence of ductal cells (smear, Romanowsky stain) Fig. 7.2 Malignant. Acinic cell carcinoma. Dyshesive well-preserved tumor cells with delicate granular cytoplasm and stripped nuclei. The cells are polygonal with low N:C ratio (smear, Romanowsky) Fig. 7.3 Malignant. Acinic cell carcinoma. Aspirate showing a sheet of cells with abundant delicate cytoplasm with scattered small coarse granules (smear, Papanicolaou stain) Fig. 7.4 Malignant. This acinic cell carcinoma has three-dimensional clusters of acinar cells with abundant delicate cytoplasm; low N:C ratio; uniform, round to oval nuclei, with distinct nucleoli (smear,Papanicolaou stain) Fig. 7.5 Malignant. This acinic cell carcinoma has loosely cohesive groups of cells with a somewhat higher N:C ratio imparting more of a non-specific glandular appearance (smear, Papanicolaou stain) Fig. 7.6 Malignant. This aspirate of acinic cell carcinoma with high-grade transformation shows a loose cluster of epithelial cells with nuclear pleomorphism (smear, Papanicoloau stain) Fig. 7.7 Malignant. Secretory carcinoma (mammary analogue secretory carcinoma [MASC]). These aspirates (a-c) show different architectural patterns of microcystic, tubular, microfollicular, and solid sheets of glandular cells with eosinophilic colloid-like secretory material (smear, Papanicolaou and Romanowsky stains) Fig. 7.8 Malignant. This aspirate of secretory carcinoma consists of cells with low-grade vesicular nuclei with finely granular chromatin and distinct nucleoli (smear, Papanicolaou stain) Fig. 7.9 Malignant. This FNA of secretory carcinoma shows cells with moderate to abundant pale, markedly vacuolated cytoplasm (smear, Romanowsky stain) Fig. 7.10 Malignant. Epithelial-myoepithelial carcinoma. The aspirate shows a biphasic tumor with inner cuboidal ductal cells and prominent outer myoepithelial cells (smear, Papanicolaou stain) Fig. 7.11 Malignant. Aspirate of epithelial- myoepithelial carcinoma showing biphasic cells organized in pseudopapillary tubules and sheets (smear, Papanicoloau stain) Fig. 7.12 Malignant. This aspirate of epithelial- myoepithelial carcinoma has a prominent biphasic pattern of ductal cells and abundant pale myoepithelial cells as well as focal proteinaceous material (smear,Papanicolaou stain) Fig. 7.13 Malignant. This epithelial-myoepithelial carcinoma has prominent concentrically laminated proteinaceous secretions that should be distinguished from the matrix material of adenoid cystic carcinoma (smear,Papanicolaou stain) Fig. 7.14 Malignant. Salivary duct carcinoma. The aspirate is cellular with three-dimensional groups of epithelial cells with moderate amounts of cytoplasm and hyperchromatic nuclei in a background of blood and necrosis (smear,Romanowsky stain) Fig. 7.15 Malignant. This aspirate of salivary duct carcinoma contains groups of high-grade malignant cells with abundant cytoplasm, nuclear pleomorphism, prominent nucleoli, and glandular features (smear, Romanowsky stain) Fig. 7.16 Malignant. The polygonal cells in this FNA of salivary duct carcinoma have large pleomorphic nuclei with prominent nucleoli (smear, Papanicolaou stain) Fig. 7.17 Malignant. This aspirate of salivary duct carcinoma shows abundant background necrosis (smear, Papanicolaou stain) Fig. 7.18 Malignant. Salivary duct carcinoma. (a) The cell block section shows a cluster of tumor cells with nuclear pleomorphism, well-defined cellular borders, relatively abundant granular cyto- plasm, and nuclei with prominent nucleoli. Note the mitotic figure in the upper right corner. (b) Her2neu immunostain showing strong membranous staining in tumor cells (cell block, H&E) Fig. 7.19 Malignant. (a, b) FNA of lymphoepithelial carcinoma showing dyshesive and markedly atypical epithelial cells with background lymphocytes (smear, Romanowsky stain) Fig. 7.20 Malignant. Cell block of lymphoepithelial carcinoma showing undifferentiated-appearing epithelial cells in a lymphoid background (H&E stain) Fig. 7.21 Malignant. This aspirate of an adenoid cystic carcinoma with high-grade transformation shows a population of high-grade pleomorphic tumor cells with an undifferentiated appearance (smear, Papanicolaou stain) Fig. 7.22 Malignant. This aspirate of small cell carcinoma shows characteristic tumor cells with high N:C ratio, nuclear molding, and scant cytoplasm (smear, Romanowsky stain) Fig. 7.23 Malignant. This FNA of a small cell carcinoma shows a three-dimensional cluster of tumor cells with high N:C ratio, scant to minimal cytoplasm, mitosis, fine chromatin, and no nucleoli (smear, Papanicolaou stain) Fig. 7.24 Malignant. This cell block of small cell carcinoma exhibits conspicuous nuclear molding and apoptotic bodies (cell block, H&E stain) Fig. 7.25 Malignant. FNA of low-grade mucoepidermoid carcinoma. The aspirate contains abundant mucin in the background and loose sheets of bland epidermoid and mucinous cells (smear, Papanicolaou stain). (Courtesy of William Geddie, MD, Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Canada) Fig. 7.26 Malignant. This aspirate of low-grade mucoepidermoid carcinoma contains bland epi- dermoid cells with moderate amounts of dense cytoplasm and well-defined cell borders, while mucus cells contain abundant delicate pink mucinous cytoplasm (smear, Papanicolaou stain). (Courtesy of William Geddie, MD, Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Canada) Fig. 7.27 Malignant. (a) This aspirate of low-grade mucoepidermoid carcinoma has occasional mucus cells with a large cytoplasmic vacuole indenting the nucleus and occupying the majority of cytoplasm with a central pink mucin droplet; (b) FNA of mucoepidermoid carcinoma, low- to intermediate-grade. The aspirate shows a solid sheet of tumor cells, predominantly composed of epidermoid and intermediate cells with occasional interspersed mucus cells (smears, Papanicolaou stain) Fig. 7.28 Malignant. FNA of high-grade mucoepidermoid carcinoma showing a cluster of pleomorphic cells with dense cytoplasm and rare interspersed glandular cells with intracytoplasmic mucin. Pink material farthest to the right of the image likely represents thick mucin (smear, Romanowsky stain) Fig. 7.29 Malignant. FNA of high-grade mucoepidermoid carcinoma with markedly atypical epidermoid cells and occasional interspersed mucinous cells (smear, Romanowsky stain) Fig. 7.30 Malignant. Adenoid cystic carcinoma. Aspirates show small high N:C ratio basaloid tumor cells surrounding acellular matrix with: a cribriform pattern (a) (smear, Papanicolaou stain) and (b) (smear, Romanowsky stain); or with a matrix-poor solid pattern (c) (smear, Romanowsky stain) Fig. 7.31 Malignant. This aspirate of adenoid cystic carcinoma shows monotonous basaloid tumor cells, with high N:C ratio, some of which are surrounding pale-staining basement membrane-like material (smear, Papanicolaou stain) Fig. 7.32 Malignant. This FNA of adenoid cystic carcinoma shows abundant acellular homogeneous matrix with sharp borders. Basaloid tumor cells often form a syncytial smear surrounding the matrix material (smear, Romanowsky stain) Fig. 7.33 Malignant. (a, b) FNA of the solid subtype of adenoid cystic carcinoma containing sheets of basaloid tumor cells with no matrix and large and monotonous nuclei with scant cyto- plasm (smear, Papanicolaou stain) Fig. 7.34 Malignant. This FNA of adenoid cystic carcinoma shows the acellular tubular matrix pattern (smear, Romanowsky stain) Fig. 7.35 Malignant. (a, b) FNA of polymorphous adenocarcinoma containing bland tumor cells with moderate amounts of cytoplasm, open chromatin, and pseudopapillary structures with mini- mal matrix material (smear, Papanicolaou stain) Fig. 7.36 Malignant. FNA of myoepithelial carcinoma. The aspirate is cellular and contains loosely cohesive highly atypical cells with plasmacytoid morphology, nuclear pleomorphism, and distinct nucleoli. Note the presence of delicate stroma in the background (smear, Papanicolaou stain) Fig. 7.37 Malignant. FNA of myoepithelial carcinoma. The aspirate contains atypical plamacytoid tumor cells with moderate amounts of cytoplasm, oval nuclei, and acellular matrix material (smear, Romanowsky stain) Fig. 7.38 Malignant. (a, b) FNA of high-grade myoepithelial carcinoma showing pleomorphic plasmacytoid and epithelioid cells with large round to oval nuclei and prominent nucleoli (smear, Papanicolaou stain) Fig. 7.39 Malignant. (a, b) FNA of high-grade carcinoma ex pleomorphic adenoma; only the carcinomatous component is seen since in most instances the carcinomatous component overgrows and masks the presence of an underlying pleomorphic adenoma (smear, Papanicolaou stain) Fig. 7.40 Malignant. FNA of high-grade carcinoma ex pleomorphic adenoma. The aspirates show loose groups of high-grade carcinoma cells. Scant background metachromatic material likely represents residual pleomorphic adenoma. (a) (smear, Romanowsky stain) and (b) (smear, Papanicolaou stain) Fig. 7.41 Malignant. (a, b) FNA of extranodal marginal zone lymphoma. The aspirates contain a dispersed mixed population of small- to intermediate-sized lymphocytes with small amounts of preserved cytoplasm, coarse chromatin, and round to irregular nuclei. Scattered larger lympho- cytes and tingible body macrophages are also seen (smear, Papanicolaou stain) Fig. 7.42 Malignant. FNA of diffuse large B-cell lymphoma containing a dispersed population of large atypical lymphocytes >3 times the size of a small mature lymphocyte (smear, Romanowsky stain) Fig. 7.43 Malignant. These FNAS of (a) mantle cell lymphoma and (b) follicular lymphoma show very atypical cytomorphologic features suggestive of lymphoma, but ancillary studies are needed for accurate subclassification of the lymphomas (smear, Romanowsky stain). (Courtesy of William Geddie, MD, Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Canada) Fig. 7.44 Malignant. These aspirates of metastatic melanoma show the characteristic dyshesive FNA pattern of pleomorphic cells as well as background melanophages with fine brown melanin pigment. (a, b) (smear, Papanicoloau stain) and (c) (smear, Romanowsky stain) Fig. 7.45 Malignant. Metastatic squamous cell carcinoma. The cellular aspirate shows high N:C ratio cells as well as dyskeratotic orangeophilic cells in a background of necrotic debris (smear, Papanicolaou stain) Fig. 7.46 Malignant. FNA of a malignant spindle cell neoplasm (myxoid sarcoma) of the parotid gland (smear, Papanicolaou stain) ■■■IHC study【8】 Fig. 8.1 Mucoepidermoid carcinoma. Mucicarmine stain histochemical highlighting a mucin-positive goblet cell Fig. 8.2 Pleomorphic adenoma. PLAG1 immunostain showing strong nuclear expression in the tumor cells in a cell block (Courtesy of Jeffrey F. Krane, MD, PhD, Brigham and Women's Hospital, Boston MA, USA) Fig. 8.3 Pleomorphic adenoma. HMGA-2 immunostain showing moderate nuclear expression in the tumor cells in a cell block (Courtesy of Jeffrey F. Krane, MD, PhD, Brigham and Women's Hospital, Boston MA, USA) Fig. 8.4 Adenoid cystic carcinoma. MYB immunostain showing strong nuclear expression in the tumor cells in a cytologic smear Fig. 8.5 Adenoid cystic carcinoma. CD117 immunostain showing strong cytoplasmic expression in the tumor cells in a cytologic smear Fig. 8.6 Basal cell adenoma. ẞ-catenin immunostain showing strong nuclear expression in the tumor cells (Courtesy of Vickie Y. Jo, MD, Brigham and Women's Hospital, Boston MA, USA) Fig. 8.7 Acinic cell carcinoma. DOG1 immunostain showing strong cytoplasmic expression in the tumor cells in a cell block Fig. 8.8 Acinic cell carcinoma. SOX10 immunostain showing strong nuclear expression in the tumor cells in a cell block Fig. 8.9 Epithelial-myoepithelial carcinoma. Pancytokeratin immunostain showing the biphasic pattern of the tumor Fig. 8.10 Secretory carcinoma of salivary glands. Fluorescent in situ hybridization (FISH) showing rearrangement of the ETV6 locus (separation of red and green signals) (Courtesy of Joaquin J. Garcia, MD Mayo Clinic, Rochester MN, USA)
