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Salivary gland fine needle aspiration using the ThinPrep technique: diagnostic accuracy hypertension differential diagnosis order betapace 40 mg amex, cytologic artifacts and pitfalls blood pressure chart health canada order betapace 40 mg line. A study of fine needle aspiration cytology of salivary gland lesions with histopathological corroboration how quickly do blood pressure medication work cheap 40mg betapace free shipping. Fine-needle aspiration cytology of lymphoproliferative lesions involving the major salivary glands blood pressure number meanings generic 40mg betapace visa. Role of fine needle aspiration cytology in the diagnosis of swellings in the salivary gland regions: a study of 712 cases. Parotid gland fine-needle aspiration cytology: an approach to differential diagnosis. Comparison of ThinPrep versus conventional smear cytopreparatory techniques for fineneedle aspiration specimens of head and neck masses. The value of fine-needle aspiration biopsy in the cytodiagnosis of salivary gland lesions. Evaluation of clinician-operated sonography and fine-needle aspiration in the assessment of salivary gland tumours. Fine-needle aspiration in the diagnosis of head and neck lesions: A review and discussion of problems in differential diagnosis. Diagnostic accuracy and pitfalls in fine needle aspiration cytology of salivary glands: a study of 113 cases. Fine-needle aspiration biopsy in the diagnostic of the tumors and non-neoplastic lesions of salivary glands. Fine-needle aspiration of cystic parotid glands lesions: an institutional review of 46 cases with histologic correlation. Diagnostic difficulties in the interpretation of fine needle aspirates of salivary gland lesions: the problem revisited. Accuracy of fine-needle aspiration cytology of salivary gland lesions in the Netherlands cancer institute. Relative accuracy of fine-needle aspiration and frozen section in the diagnosis of lesions of the parotid gland. Diagnostic problems in fine needle aspiration Cytopathology of the salivary glands. The keratin layer imparts a pale pink colour and if the keratin layer increases in thickness due to chronic irritation or trauma, the mucosa appears white and slightly spongy. Lining mucosa this covers the ventral tongue, floor of mouth, soft palate and the buccal, labial and vestibular surfaces of the oral cavity. Again, the microanatomy of lining mucosa is related to its functions, shaping food for chewing and swallowing, and allowing movement for speech and other oral functions. Consequently, lining mucosa appears clinically red in colour due to blood in the vessels of the lamina propria. Floor of mouth mucosa has poorly developed connective tissue papillae and the epithelium is thin. This contrasts with buccal mucosa where the connective tissue papillae are long, slender and curved, extending through a much thicker squamous epithelium. Most lining mucosa is located over a submucosa that contains minor mucus salivary glands. Introduction Exfoliative cytology is increasingly being used for oral diagnosis and has been the subject of intense research over the last 5 years. Mucosal biopsy is widely regarded as the gold standard for oral diagnosis but exfoliative cytology is also a valuable technique for the diagnosis of a range of pre-neoplastic, cancerous, infective and inflammatory mucosal disorders. The mucosa is covered by filiform papillae and there are also larger fungiform, foliate and circumvallate papillae at specific locations. The dorsal lingual epithelium is keratinising and bacterial biofilm can be abundant on the surface of the filiform papillae. Sampling methods Normal oral mucosa Oral mucosa is heterogeneous and can be divided into masticatory, lining and specialised types. Collection devices suitable to obtain cells from the superficial and intermediate layers may be conventional brushes, such as the CytoBrush, Orca-brush or others. Signs of dysplasia will be detected in the upper layers due to the principle of disturbed cell maturation that occurs in dysplasia in which a degree of nuclear abnormality (dyskaryosis) in the surface layers reflects the degree of disturbance of maturation of the whole thickness of the epithelium, i. It is the task of a cytopathologist to identify nuclear abnormalities in the cells collected in this way to predict the histological grade of dysplasia. The diagnostic criteria used are similar to cervical exfoliative cytology and are well known (Figs 6. Screening for oral cancer and precursor lesions can be performed by dentists and other healthcare professionals. The microanatomy of masticatory mucosa is related to its function of resisting compressive forces. Exfoliative cytology of oral lesions may replace tissue biopsy in lesions that are clinically not obviously suspicious for malignancy but nevertheless need surveillance. As tissue biopsy is associated with low compliance (9%) and brush-biopsy not (100%),5 this approach may lead to a higher rate of oral cancers identified in early stages. Oral precursor lesions Oral carcinogenesis proceeds through a stepwise accumulation of genetic damage over time. Because the oral cavity is easy to examine and risk factors for oral cancer are known, there is great opportunity to improve patient outcomes through diagnosis and treatment of pre-malignant lesions before the development of invasive oral carcinoma.
HepPar-1 positivity supports a hepatic primary over other small round blue cell tumours of non-hepatic origin blood pressure medication that starts with m order cheap betapace. Hepatoblastomas will stain with high-molecular-weight cytokeratin hypertension 40 mg buy genuine betapace line,146 whereas tumour cells of most hepatocellular carcinomas do not blood pressure viagra betapace 40 mg otc. All but the intraductal type form a firm prehypertension with low heart rate generic 40 mg betapace with mastercard, white-tan mass that can become quite large when intrahepatic, but is usually small in the hilar or extra-hepatic locations due to obstruction causing early detection. This is due to the difficulty in obtaining a specimen of quality and quantity sufficient for a confident malignant diagnosis. Processing bile duct brushings in a liquid-based medium has shown improvement in diagnostic sensitivity and specificity. Smears are variably cellular and demonstrate irregular, variably sized sheets of atypical to malignant appearing glandular cells that resemble bile duct epithelium. Clusters of tumour cells may show cytoplasmic vacuolisation and focal mucin production. Cell block preparations are particularly helpful in this diagnosis because the characteristic common histological pattern described above may be recognised. Ancillary tests A simple mucin stain demonstrating the production of mucin will define the neoplasm as an adenocarcinoma and, with the rare exception of a mixed cholangiocarcinoma-hepatocellular carcinoma, exclude the diagnosis of hepatocellular carcinoma. The basic immunohistochemical panel discussed above under hepatocellular carcinoma will also help in this differential diagnosis. Distinguishing cholangiocarcinoma from metastatic adenocarcinomas relies primarily on clinical history, but a panel of immunohistochemical markers may be helpful for specific tumours (see Ch. Histologically these neoplasms are single or multiple nodules of vascular channels lined by malignant endothelial cells. The malignant cells range from being widely spaced lining dilated sinusoidal channels to more solid growth filling the sinusoids and causing atrophy of the surrounding hepatocytes. An epithelioid appearance to the endothelial cells may also occur creating a pitfall and misdiagnosis of a carcinoma. They have elongated, spindled-shaped hyperchromatic nuclei that are easier to appreciate in small clusters. Embryonal sarcoma Embryonal sarcoma is a rare malignancy of children typically between 6 and 10 years of age. Tumour cells also stain for vimentin, alpha-1-antitrypsin and alpha-1-antichymotrypsin. Cell block preparations of tissue fragments often demonstrate the characteristic angulated glands invading dense sclerosis (H&E). Tumour cells are large, anaplastic often multinucleated tumour giant cells (smear, rapid H&E). Cytoplasm is delicate, frequently vacuolated, sometimes wispy Intracytoplasmic mucin may be seen; mucicarmine or other mucin stains can help identify focal mucin production. Past medical history is of vital importance as most patients have a known history of a primary malignancy elsewhere. Metastatic tumours tend to recapitulate their appearance in the primary organ, and specific tumour types such as small cell carcinoma and lymphoma generally maintain a consistent cytological appearance. Adenocarcinoma, although frequently recognisable as an entity, presents the most difficulty in making a specific diagnosis as to site of origin. Other metastatic malignancies commonly encountered in the liver include those from the pancreas (adenocarcinoma and neuroendocrine tumours), stomach (adenocarcinoma and gastrointestinal stromal tumours), breast, lung (adenocarcinoma, small cell carcinoma and much less commonly squamous cell carcinoma), skin (melanoma) and bladder. Less common but diagnostically more challenging are metastases from the kidney and adrenal gland due to the morphological overlap with hepatocellular carcinoma. The combination of cytological evaluation and flow cytometry immunophenotyping is very often sufficient for diagnosis and subclassification of non-Hodgkin lymphoma. Cytological findings: breast carcinoma, ductal type Often low grade with a monomorphous cell population Flat angulated groups Single flame or cone-shaped cells Target cells (cells with intracytoplasmic lumen) Cell-in-cell arrangement Immunocytochemistry: oestrogen/progesterone and supportive if positive, but non-specific, gross cystic disease protein-15 is supportive if positive. Mostly diffuse large B cell lymphoma, predominantly secondary but can be primary Discohesive, single cell population; may have pseudogroups. Large polygonal cells mimic hepatocellular carcinoma with polygonal cell shape, macronucleoli, intranuclear inclusions and abundant cytoplasm. This cell block preparation demonstrates the remarkable architectural similarity to hepatocellular carcinoma with large polygonal cells forming trabeculae with endothelial wrapping (H&E). Assuming that a nodule in the liver in a patient with a known extrahepatic malignancy represents metastatic disease can lead to patient mismanagement and over-treatment. Even with classic clinical and radiological evidence of metastatic disease from a known primary malignancy, confirmation with tissue diagnosis is essential for patient enrollment in research protocols and for patients to qualify as candidates for new therapies such as ethanol ablation47 and targeted gene therapy. When performed by experienced interventional radiologists and interpreted by experienced pathologists, the accuracy rivals that of frozen section. As such, concomitant core biopsy improves accuracy, specificity and sensitivity, and both are better than either alone. Metastatic colon cancer should be high in the differential diagnosis with or without a known primary colon cancer as it is the most common malignancy in the liver. Recognition of the typical smear pattern of an adenocarcinoma with palisading columnar cells in a background of dirty necrosis. Familiarity of the typical appearance of extrahepatic malignancies is of benefit as most metastases recapitulate their appearance in the primary organ, and specific tumour types such as small cell carcinoma and lymphoma generally maintain a consistent cytological appearance. If not already a routine practice, procurement of tissue for cell block should be requested of the radiologist in anticipation of ancillary studies. Fine needle aspiration biopsy in pediatric spaceoccupying lesions of liver: a retrospective study evaluating its role and diagnostic efficacy. Diagnostic value and complications of fine needle aspiration for primary liver cancer and its 19.
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Most galactoceles are so characteristic clinically that no further investigation is undertaken and the majority resolve spontaneously arteria y vena histologia cheap betapace american express. Tumours and tumour-like lesions that occur during pregnancy and lactation are usually benign heart attack blood pressure purchase 40mg betapace with mastercard. However arrhythmia on ecg generic betapace 40 mg visa, carcinomas do occur arrhythmia quiz online order discount betapace on line, and tend to be high grade and oestrogen receptor negative. Evaluation of mammograms during pregnancy and lactation may be difficult because the breast tissue is usually very dense. The nuclei are large and round with active vesicular chromatin and a distinct large nucleolus. The nucleolus in lactating epithelial cells is larger than in most malignant breast tumours (Figs 4. However, the presence of lipid-laden secretory material in the background is a helpful feature. The number of naked myoepithelial cell nuclei will mirror the amount of epithelial cell groups and sheets. Skeletal muscle fibres are seen rarely, particularly if the 184 the aspirate may be moderately or markedly cellular the cells are single and well dispersed in a lipid rich foamy or granular background the cells and their nuclei are large; there is abundant vacuolated or wispy cytoplasm Bare nuclei are common 4 the breast Galactocele Galactoceles are often easily diagnosed clinically without need for further investigation. However, occasionally a galactocele can accumulate abundant inspissated milk to form a large mass, even up to 80 mm in diameter, and this can be clinically worrying. The diagnosis may be readily made from the history, confirmed by the aspiration of milk, a procedure both diagnostic and therapeutic. In the light of the clinical details the diagnosis should be benign, not inadequate. Milk granuloma Milk granuloma is thought to arise when milk leaks into the mammary stroma. When arising before the age of 25, it is usually due to pubertal hormonal changes and commonly reverses spontaneously. In later life, the most common causes are drug therapy, androgenic steroid abuse, hormone producing tumours and cirrhosis of the liver with resulting failure to metabolise endogenous oestrogen. The superficial nature of the mass in gynaecomastia generally makes sampling easy but it should be noted that the procedure is particularly painful in the male breast and good technique, even combined with the use of local anaesthetic, is important. The nuclei are round and uniform with active granular or vesicular, but evenly distributed chromatin. Single prominent nucleoli Cytological findings: gynaecomastia Diagnostic pitfalls: pregnancy-related changes the main risk is that the low-power impression of a cellular aspirate of single, large cells is taken as evidence of malignancy when the pathologist is not aware of the pregnant or lactational state of the patient. The distinctive granular background and critical assessment of the nuclear features should prevent this error. It is important for the cytopathologist to be informed about pregnancy or lactation when the aspirate is performed by others, to lessen the likelihood of interpretive errors; one must also remember that foci of lactational change can occur unassociated with pregnancy and generalised lactation. Scanty or moderately cellular smears Small- to medium-sized epithelial fragments that may be hyperplastic and three-dimensional Small to moderate numbers of bipolar cells. Diagnostic pitfalls: gynaecomastia In florid hyperplasia there may be marked anisokaryosis that can be misinterpreted as atypia Fibrocystic change may rarely occur in the male breast60 as can most benign/reactive and malignant lesions that occur in the female breast. This aspirate contained numerous foamy macrophages (upper arrowhead) and amorphous debris (lower arrowhead). Mammary duct ectasia Histologically there is dilatation of large or intermediate ducts that are filled with secretion, and to a variable extent foamy macrophages, siderophages and cholesterol crystals that form the inspissated, pasty material seen on gross examination. Epithelial proliferation is not a feature, but reparative changes in epithelium next to areas of inflammation may give rise to a spurious impression of atypia both histologically and cytologically. Rupture of the epithelial layer and basement membrane cause chronic inflammation, fibrosis and scarring of the surrounding stroma. Macroscopically the aspirated material often appears thick, creamy and homogeneous. Inflammatory conditions the breast is susceptible to a limited range of inflammatory conditions, a few of which have a recognised infective aetiology. Trauma and extravasation of duct contents account for a proportion, but in some conditions, no obvious tissue insult is recognised. Inflammation is characteristically manifest by the presence of dolor, calor, rubor and tumor. It is the formation of a mass in the breast with or without pain that results in the patient with an inflammatory condition seeking medical assistance. Inflammatory lumps may frequently mimic malignancy both to the patient and on initial clinical assessment. Occasionally, particularly in cases of old or membranous fat necrosis, an aspirate may contain only oily lipid material, with few or no cells visible. Cytological findings: fat necrosis (A) Foamy macrophages and multinucleate giant cells with foamy cytoplasm Small irregular groups of (reactive) histiocytic cells Fragments of normal as well as degenerate fatty tissue Variable numbers of other inflammatory cells but usually sparse Few if any epithelial cells Free lipid droplets, seen as empty spaces that may be surrounded by blood or as empty spaces in a granular background Granular background debris. Diagnostic pitfalls: fat necrosis Aspirates from tuberculosis or other causes of panniculitis may be mistaken for fat necrosis Epithelioid cells in fat necrosis and granulation tissue can imitate carcinoma closely Vacuolated histiocytic cells may be mistaken for lobular carcinoma cells Fat necrosis is often found in the periphery of a tumour in areas where the carcinoma cells infiltrate fatty tissue. If the aspirated cells are from the periphery only, cells from the underlying tumour may not be seen. Plasma cell mastitis (periductal mastitis, comedo mastitis) Clinically, this lesion may mimic carcinoma, as there can be retraction of the nipple associated with a well-defined lesion, usually centrally located. The aetiology is not clear but the basic abnormality is stagnation of secretion, possibly due to loss of elastin support in duct walls, leading to ectasia.
Adequate interpretive skills are also required and particularly so in maximising the true positive rate heart attack 21 year old female buy betapace 40mg amex. The most common sites of origin are breast heart attack lyrics demi order 40 mg betapace visa, kidney pulse pressure hypovolemia order cheapest betapace and betapace, lung hypertension in 9th month of pregnancy betapace 40mg line, the gastrointestinal tract and squamous carcinomas of the head and neck region. Clinical presentation with a secondary malignancy in the thyroid is, however, rare. To be considered of adequate epithelial cellularity, samples from solid lesions should have at least six groups of thyroid follicular epithelial cells across all the submitted slides, each with at least 10 well-visualised epithelial cells. The reason for sample insufficiency should be clearly stated in the cytology report. Thy1c Cyst-fluid specimens which do not reach the epithelial cell adequacy criterion above and which contain mostly macrophages but without abundant colloid. Comment: There is a recognised risk of non-representative sampling, especially in cystic papillary thyroid carcinomas. It is important not to offer false reassurance on suboptimal epithelial cellularity. Samples in this category should achieve the epithelial cellularity adequacy criterion described above. This non-neoplastic category therefore includes: normal thyroid tissue, thyroiditis, hyperplastic nodules, colloid nodules; these samples will contain easily identifiable colloid with cytologically bland follicular epithelial cells reaching the cellular adequacy criteria outlined above. Thy3a Samples which exhibit cytological atypia or other features which raise the possibility of neoplasia, but which are insufficient to categorise otherwise with confidence into any other category. For further details as to clinical scenarios in which category 3a applies, see ref. The histological possibilities therefore include hyperplastic or other cellular but non-neoplastic nodules, as well as neoplasms, including follicular adenomas and follicular carcinomas. Follicular variants of papillary thyroid carcinoma without clear nuclear features of papillary thyroid cancer may fall into this category. Those samples which are suspicious of malignancy, but which do not allow confident diagnosis of malignancy. This includes specimens of low cellularity and mixed cell types (normal and atypical). The tumour type suspected should be clearly stated, and will often be papillary carcinoma. This category should not be used for samples that exhibit mild atypia, which should be categorised as Thy3a. The evidence available is difficult to assess5 but it has been proposed, on the basis of reviewing large numbers of known false negative cases, that the minimum criteria for adequacy in the examination of thyroid nodules and exclusion of neoplasia should be the presence of at least five or six clusters of 10 cells or more on each of at least two slides taken from separate aspirates. Even with these criteria, false negatives will still occur and a further reduction in that rate will result from further aspirations. If atypia is present it should be described and interpretation attempted even if little material is present. Colloid-rich specimens with scanty follicular cells can, in the appropriate clinical and radiological context, be regarded as diagnostic. Cyst fluid samples where there is no residual mass after aspiration can also be regarded as adequate even if of low cellularity. The unsatisfactory and false negative rate is, of course, dependent on the underlying pathology and upon the skills of the aspirator and interpreter. Inadequate rates of less than 5% have been described in studies including palpation guided, ultrasound guided and thin-layer prepared samples. Aspiration by the pathologist with access to all of the clinical information together with immediate staining 508 and interpretation reduces false negative rates and allows the best judgement as to whether an aspirate is adequate or not and whether further aspirates are advisable. The use of needle aspiration reduces the use of surgery by approximately one-third, doubles the proportion of malignancies among surgical resections and increases costeffectiveness. False positive diagnoses are rare, less than 1% of cases, where the convention of diagnosing follicular neoplasia rather than always attempting to specify adenoma or carcinoma is used. The use of clear and consistent reporting categories with defined follow-up or therapeutic actions decreases errors and ensures appropriate interpretation of needle aspiration results by clinical colleagues. Malignant Papillary thyroid carcinoma Poorly differentiated carcinoma Medullary thyroid carcinoma Undifferentiated (anaplastic) carcinoma Squamous cell carcinoma Carcinoma with mixed features (specify) Metastatic carcinoma Non-Hodgkin lymphoma Other Thy5 Thy4 Thy2c Thy3a Integrated management schemes for thyroid cytology Several classification and integrated management schemes have been proposed and are in use (Tables 17. The various management schemes differ in the terminology used and in follow-up protocols but in common they prescribe a surgical referral for suspicious or definite differentiated thyroid cancer and appropriate further investigation, radiotherapy and/or chemotherapy for anaplastic carcinoma, lymphoma or metastatic malignancy. The distinction between follicular adenoma and carcinoma remains problematic and suspected follicular neoplasms warrant a surgical referral and lobectomy for diagnosis. When there is strong clinical or radiological suspicion the decision to proceed to lobectomy may be made despite a benign cytological diagnosis. A synopsis of the National Cancer Institute thyroid fine-needle aspiration state of the science conference. Comparison of fine-needle-nonaspiration with fine-needle-aspiration technique in the cytologic studies of thyroid nodules. A comparative study of fine needle aspiration cytology versus non-aspiration technique in thyroid lesions.
