CAP Non GynecologicCAP Non GynecologicCytologyCytology

Unknown Case Presentation -Unknown Case Presentation -# 7# 7

Theodore R. Miller, M.D.Theodore R. Miller, M.D.University of California Medical CenterUniversity of California Medical Center

San Francisco, CASan Francisco, CA

Case History:Case History:

The patient is a 58 y/o male with a 2.5 cmThe patient is a 58 y/o male with a 2.5 cmmass in the right parotid. There was facialmass in the right parotid. There was facialnerve dysfunction. A fine needle aspirationnerve dysfunction. A fine needle aspirationwas performed. was performed. Figures 1-3 display theFigures 1-3 display thefindings.findings.

The mass was removed.The mass was removed.

Figure 1Figure 1

Figure 2Figure 2

Figure 3Figure 3

What is your interpretation?*What is your interpretation?*

* Next slide contains the answer.* Next slide contains the answer.

FNA Right parotid: High gradeFNA Right parotid: High gradeneoplasm.neoplasm.

Comment:Comment:The differential diagnosis in this high gradeThe differential diagnosis in this high gradecarcinoma (HGCa) includes HGCa (NOS), HGcarcinoma (HGCa) includes HGCa (NOS), HGmucoepidermoid carcinoma, squamous cellmucoepidermoid carcinoma, squamous cellcarcinoma, salivary duct Ca and a metastaticcarcinoma, salivary duct Ca and a metastaticneoplasm.neoplasm.The lesion was removed for histological examination.The lesion was removed for histological examination.

Next slide contains histological diagnosis.Next slide contains histological diagnosis.

Right Parotidectomy:Right Parotidectomy:Salivary duct carcinomaSalivary duct carcinoma

Figures 4-5 demonstrate H and EFigures 4-5 demonstrate H and Ehistologyhistology

Figure 4Figure 4

Figure 5Figure 5

Salivary duct carcinomaSalivary duct carcinomaCytological findingsCytological findings

•• Cellular sample.Cellular sample.•• Flat sheets of cells, less often thick groups,Flat sheets of cells, less often thick groups,

may have cribriform pattern.may have cribriform pattern.•• Comedo necrosis.Comedo necrosis.•• High grade neoplastic eccentric placedHigh grade neoplastic eccentric placed

nuclei.nuclei.•• Dense cytoplasm, may be granular.Dense cytoplasm, may be granular.

Salivary duct carcinomaSalivary duct carcinomaCytological findings (continued)Cytological findings (continued)

•• There are no pathognomonic features.There are no pathognomonic features.•• Best to offer a differential Best to offer a differential DxDx. to include. to include

Salivary duct Ca, Mucoepidermoid Ca,Salivary duct Ca, Mucoepidermoid Ca,Squamous cell Ca, Poorly diff. Ca, andSquamous cell Ca, Poorly diff. Ca, andMetastatic Ca..Metastatic Ca..

•• Staining for androgen receptor may beStaining for androgen receptor may behelpful.helpful.

An Approach to SalivaryAn Approach to SalivaryGland FNAGland FNA

•• Differential Diagnosis Outline Based on:Differential Diagnosis Outline Based on:

•Site, intrinsic/extrinsic•Cell type•Extra cellular material•Degree of nuclear abnormality*

* (slides 14-18)(slides 14-18)

1. Myxoid-Hyaline Lesions1. Myxoid-Hyaline Lesions

••Polymorphous low gradePolymorphous low gradeCa (PLGCa)Ca (PLGCa)

••Myxoid neurofibromaMyxoid neurofibroma••Adenoid cystic CaAdenoid cystic Ca

••MyxomaMyxoma••Ca ex BMTCa ex BMT

••SchwannomaSchwannoma••Benign mixed tumorBenign mixed tumor(BMT)(BMT)

ExtrinsicExtrinsicIntrinsicIntrinsic

2. Basaloid Lesions2. Basaloid Lesions

••RhabdomyosarcomaRhabdomyosarcoma••Small cell anaplasticSmall cell anaplastic

••Olfactory neuroblastomaOlfactory neuroblastoma••PLGCaPLGCa

••EwingEwing’’s/PNETs/PNET••Adenoid cystic CaAdenoid cystic Ca solid varient solid varient

••Small cell anaplasticSmall cell anaplastic••Basal cell CaBasal cell Ca

••Skin adnexal tumorsSkin adnexal tumors••Basal cell adenomaBasal cell adenoma

ExtrinsicExtrinsicIntrinsicIntrinsic

3. Oncocytoid Lesions3. Oncocytoid Lesions

•• Melanoma Melanoma

•• Medullary Ca Medullary Ca

•• Renal cell CA Renal cell CA•• Oncocytic Ca Oncocytic CaMod/MarkedMod/Marked••Acinic cell CaAcinic cell Ca

•• BMT BMT

••ChronicChronicsialadenitissialadenitis

••Granular cellGranular celltumortumor

•• Oncocytoma Oncocytoma

••ParagangliomaParaganglioma•• Warthins’ Warthins’None/ModNone/ModExtrinsicExtrinsicIntrinsicIntrinsicAtypiaAtypia

4. Lymphoid Lesions4. Lymphoid Lesions

•• Same Same•• HD HD

•• Same Same•• NHL, high grade NHL, high gradeMod/MarkedMod/Marked

•• Warthins’ Warthins’

•• NHL, low grade NHL, low grade

•• Cystic lesion of HIV Cystic lesion of HIV

•• Lymph node with Lymph node withmetastasismetastasis

•• Benign BenignLymphoepithelialLymphoepitheliallesionlesion

•• Reactive hyperplasia Reactive hyperplasia•• Chronic sialadenitis Chronic sialadenitisNone/ModNone/ModExtrinsicExtrinsicIntrinsicIntrinsicAtypiaAtypia

5. Squamoid Lesions5. Squamoid Lesions

••Sq Ca,Sq Ca, PDCa PDCa

••Salivary duct CaSalivary duct Ca••Ca ex BMTCa ex BMT

••Sq Ca,Sq Ca, PDCa PDCa, Met, Met••Mucoepidermoid Ca,Mucoepidermoid Ca,high gradehigh grade

Mod/MarkedMod/Marked

••Sq Ca, Sq Ca, PDCaPDCa, Met, Met

••Dermoid cystDermoid cyst

••Thymic cystThymic cyst••Mucoepidermoid Ca,Mucoepidermoid Ca,low gradelow grade

••Thyroglossal cystThyroglossal cyst•• BMT BMT

••Epidermal cystEpidermal cyst••Cystic lesion of HIVCystic lesion of HIV

••Branchial cleft cystBranchial cleft cyst••Chronic sialadenitisChronic sialadenitisNone/ModNone/ModExtrinsicExtrinsicIntrinsicIntrinsicAtypiaAtypia