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ADVNCED CYTOPATHOLOGY

MEDS2135Case study 3: Non-Gynae

Coordinator: Karin Bradshaw

Student Name: Abdullah Bandar Almutiri

Student Number: 3276950

Date Submitted: 14/05/2013

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Student Name: Abdullah Bandar Almutiri, Student Number: 3276950 Page 2

Introduction

The cytology laboratory is considered as one of the most important tool to help in diagnosis of

many diseases. Many ancillary tests work as complementary to get a final diagnosis. In this case

study of 64 years old female, Respiratory cytology is used to get the precise diagnosis. Which is the

study of the cells that exfoliate within the respiratory tract whether they are originating from

respiratory system or they belong to a tumor that metastasis to the lung or other parts of the

respiratory tract.

The use of endoscope to sample cells from the lower portion of respiratory tract lead to an

improvement in the result that can be obtained compared to the conventional sputum sample (4).

Bronchial wash is mainly dependent on the use of a bronchoscope through washing the mucosa by

saline and consequent aspirate of that saline which contains the cells that can be centrifuged and

smeared into the slide. By examining the wash return fluid, the doctor can identify any

abnormality such as bleeding, fungal infections and different kinds of lung tumor. Patients

undergoing bronchial washing usually have mild side effects which include coughing, sore throat

and a sleepy feeling from being sedated (4, 8).

Case Report

CLINICAL DETAILS

Type of specimen: Bronchial washing.

Age: 64 years old.

Gender: Female.

Clinical notes: The patient has a mass in the upper right lobe of the lung.

Material and Method

The specimen collected from the upper right lobe of the lung by using bronchoscopetechnique.

Bronchial washing or bronchoscopy is a procedure used to investigate diseases in the lung.During the procedure, the patient is injected with saline into the lung through a fiberoptic

bronchoscope (4). The bronchial wash then sucked out and sent to the cytology laboratory

for the investigation. Bronchial washings are easily obtained and are useful in diagnosis of

many respiratory diseases including the centrally located lesions, but in bronchial washing

the cytology must prepare the smear without any delay because the cells in the saline can

undergo degenerative changes.

One slide was reserved for screening any abnormality.

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CASE DESCRIPTION

Microscopic description:

The smear of bronchial washing is satisfactory, because at low power the smear ishypercellular and containing crowded branching groups Cells present in acinar groups. Thesmears show abundant ciliated bronchial cells in significant numbers. Macrophages and

red blood cell present. The background of the slide is mucoid (Figure 1A, 1B).

Bronchial cells (ciliated bronchial cells) are seen in significant numbers in bronchialwashing specimens. Columnar shaped cells with cytoplasmic tail present singly and in

loosely cohesive groups, basally located nucleus, Round / oval nuclei, Smooth, fire to mildly

coarse dark chromatin, Nucleoli is also seen (Figure 1B).

Macrophages have round shaped nuclei which are centric or eccentric, finely granularchromatin; some have more nuclei and other bi nuclei, foamy cytoplasm (Figure 1C).

Squamous cells present in very few numbers which reflect contamination from the upperrespiratory tract in sputum or bronchial washings. Predominately superficial squamous

cells (Figure 1D).

Small cell carcinoma:

Small cells presents singly and in groups lined up with scant to absent cytoplasm (Figure2A, 2B).

Nuclear molding is prominent, which is feature of small cell carcinoma (Figure 2C, 2D).

A high N\C ratio. Small cell nuclear staining ranges from dark to pale. Hyperchromatic, Nucleoli is invisible

(Figure 2A, 2D).

In the cropped image of C (Figure 2D) it show elongated groupings of small cell with Scantcytoplasm or absent cytoplasm and irregular moulded nuclei; dark chromatin,

inconspicuous nucleoli; very high N\C ratios.

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Figure 1. A At low power the smear is hypercellular and containing crowded branching groups

Cells with mucoid background Pap stain x20. B Shows bronchial cells with cilia Pap stain x20. C

Macrophages and other material are present in the background Pap stain x20. D Squamous cells

present in very few numbers Pap stain x20.

A B

C D

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Figure 2. A Small cell carcinoma presents singly and in groups Pap stains x40. B small cell

carcinoma seen in a linear Pap stain x20. C The molding of nuclei around each other; which is

feature of small cell carcinoma Pap stain x40. D cropped image of C to show the molding, PAP

stain.

A B

C D

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DIAGNOSIS AND RECOMMENDATION

Diagnosis: Bronchial washing/ Malignant cells present (Small cell carcinoma).

Recommendation: Referralfor oncologist; chemotherapy or combination chemotherapy with

concurrent chest radiotherapy (RT) for treatment (9, 10).

DISCUSSIONSmall-cell carcinoma

Small cell lung cancer (SCLC) is a malignantcancer which is most commonly arises inside the lung,

commonly called Small cell carcinoma. This tumor usually occurs centrally and metastasizes very

early to the hilary lymph nodes, bones, brain, and liver. Also it can infrequently happen in otherbody sites, like for example the gastrointestinal tract and prostate in man. When SCLC infects the

lung, it is sometimes called "oat cell carcinoma" due to the scanty cytoplasm and flat cell shape (6).

In the cytology definition of the small cell carcinoma characteristics is small cells with finely

granular nuclear chromatin and not easily seen nucleoli, scant cytoplasm. There are a high mitotic

count and nuclear molding (7).

Small cell carcinomas are smaller than normal cells, and the primary stage of this cancer is too

difficult to diagnose because the cell is too small and difficult to find. Small cell carcinoma belongs

to a group of tumors know as (bronchial neuroendocrine tumors). As they arise from

neuroendocrine cells in the bronchus. Neuroendocrine cells found throughout the body and they

release hormones when they stimulate by neural stimulus (1, 6). Pulmonary neuroendocrine cells

involved in the regulation of oxygen levels. By detecting increase oxygen or increased carbon

dioxide levels and sending chemical message to help the lung adjust to these changes. The people

who living at high altitudes, where oxygen levels are lower, have a higher number of

neuroendocrine cells in their lungs.

The main cause of small cell cancer is tobacco smoking and the majority of patients how infected

have strong smoking history of all histological types of lung cancer, Squamous cell carcinoma and

SCLC have the strongest relationship to tobacco. Approximately 98% of patients with SCLC have a

smoking history. Patients with SCLC should be encouraged to stop smoking, as smoking cessation

is associated with improved survival (6).
http://en.wikipedia.org/wiki/Malignanthttp://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Prostatehttp://en.wikipedia.org/wiki/Cytoplasmhttp://en.wikipedia.org/wiki/Cytoplasmhttp://en.wikipedia.org/wiki/Prostatehttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Malignant

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DIFFRENTIAL DIAGNOSIS

Problems in diagnosis are to differentia between small cell and poorly differentiated non-small

cell carcinomas and a tendency to include tumors with larger than expected nuclei in the non-small cell category. In general, if the nuclear features of a problematical tumor are those of small

cell carcinoma- that is, granular chromatin without prominent nucleoli- the neoplasm will fall into

the small cell carcinoma group Histologically; vesicular nuclei with prominent nucleoli would

generally be evidence of non-small cell tumor. Also, immunocytochemistry is also helpful in

differentiating between non- small cell lung cancer and small cell; small cell carcinomas are

reactive with CD 56, and other neurondocrine markers, whereas non-small cell carcinomas are

generally unreactive(2, 3).

In addition, it is sometimes very difficult to distinguish small cell carcinoma from lymphomas,particularly those of follicular center cell origin with pronounced cell polymorphism and nuclear

irregularity. Cell dispersal together with a rim or tail of intact cytoplasm in individual cells and a

background of round, cytoplasmic fragments staining blue with MGG (lymphoid globules\ lymph

glandular bodies) are helpful features in making a diagnosis of lymphoma. Dispersed cells of small

cell carcinoma are usually bare nuclei. Some low-grade lymphomas can show pseudomoulding

due to clustering of the nuclei. However, significant true nuclear moulding is not seen in

lymphoma and cytoplasm is usually maintain while, small cell carcinoma usually do not maintain

cytoplasm (2, 9).

Furthermore, Reserve cell hyperplasia. Reserve cells are rarely seen except in reactive states. They

are small in size (compare the size with adjacent columnar cell), have hyperchromatic nuclei, and

may show evidence of nuclear molding. It is important not to confuse them with small cell

carcinoma.

TREATMENT and PROGNOSIS

Treatment

Treatment options depend on factors such as stage of the cancer, the position of the tumor, andpatients fitness to tolerate the therapy. There are two stages of small cell carcinoma that is usually

determined by the presence or absence of metastases which are extensive stage (ES) and

including limited stage (LS). In cases of LS-small cell carcinoma, combination chemotherapy is

administered together with concurrent chest radiotherapy (RT) for treatment.

Generally, Small cell carcinoma spreads very quickly throughout out the body and patients do not

benefit from surgery. Chemotherapy is the main treatment is given to patients with extensive

disease, to prolong their life and relieve their symptoms (5, 10).

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Prognosis

Lung cancer has one of the worst survival outcomes of any cancer. The outcome is dependent on

the stage and type of lung cancer. Overall, for all types of lung cancers irrespective of the stage atthe time when the cancer is diagnosis, only 25% of patients will live for one year and 8% will live

for five years. For small cell lung cancer the Surviving for five years is 1% for stage 4. Indicators of

poor diagnosis include relapsed disease, weight loss, and poor performance status (5, 10). For all

patients with SCLC, activity should be encouraged and a dietary consultation should be obtained.

SUMMARY

The patient is 64 years old, Female that has a mass in the upper right lobe of the lung the specimen

collected by using bronchoscope technique. One slide was reserved for screening any abnormality.

This case is reported as Malignant cells present (Small cell carcinoma) as there is indication of

abnormality. Chemotherapy is the main treatment for this patient when considering his age as

well, to prolong their life and relieve their symptoms.

Small cell carcinoma is highly aggressive as it usually characterized by aggressive actions, fast

growth, early spread to other sites in the body organs, exquisite sensitivity to chemotherapy and

radiation the survival rate is always low. Therefore advice to avoid the risk factors for

development of disease such as smoking because smoking is the main cause of lung cancer, the

only means of decreasing the occurrence of this disease as well as that of small cell carcinoma

specifically, is to decrease the occurrence of smoking.

Furthermore, development of highly advanced early diagnostic facilities and increase public

awareness of the effects of smoking should be the main primary concern of medical centers and

government.

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REFERENCES

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3. Marluce Bibbo DW. Comprehensive Cytopathology. SAUNDERS2008.4. Collins W. Bronchial Washing Procedures. 2013; Available from:

http://www.livestrong.com/article/161434-bronchial-washing-procedures/.

5. Austin JHM, Yip R, D'Souza BM, Yankelevitz DF, Henschke CI. Small-cell carcinoma of the lungdetected by CT screening: Stage distribution and curability. Lung Cancer. 2012;76(3):339-43.

6. Behded Shambayati. CYTOPATHOLOGY. United States: Oxford University Press; 2011.7. DeMay RM. The pap test: Chicago : ASCP Press c2005 .8. Fernndez-Villar A, Gonzlez A, Leiro V, Represas C, Isabel Botana M, Blanco P, et al. Effect of

Different Bronchial Washing Sequences on Diagnostic Yield in Endoscopically Visible Lung

Cancer. Archivos de Bronconeumologa ((English Edition)). 2006;42(6):278-82.

9. Kocjan WGWG. Diagnostic cytopathology. 3rd ed: Edinburgh : Churchill Livingstone/Elsevier;2010.

10.Sun J-M, Ahn M-J, Ahn JS, Um S-W, Kim H, Kim HK, et al. Chemotherapy for pulmonary large cellneuroendocrine carcinoma: Similar to that for small cell lung cancer or non-small cell lung

cancer? Lung Cancer. 2012;77(2):365-70.
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