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Blistering Skin Diseases

A blister is a fluid-filled space within or beneath the epidermis. Blisters may occur as a secondary event caused by factors such as infections (e.g., viral, bacterial), ischemia (e.g., vasculitis), burns, or inflammation leading to disruption of the dermal-epidermal junction (e.g., erythema multiforme) or as a primary event in which a genetic mutation or immunologic event affects the structural integrity of the basement membrane zone (BMZ)…

Cutaneous Vasculitis

Vasculitis is a histologic diagnosis defined as inflammatory cell infiltration and destruction of blood vessels. Vasculitis is generally classified as primary vasculitis (idiopathic e.g., cutaneous leukocytoclastic angiitis [CLA], granulomatosis with polyangiitis [GPA]); secondary vasculitis (a manifestation of connective tissue diseases [CTDs], infections, adverse drug eruptions, or a paraneoplastic phenomenon); or incidental vasculitis, a histologic finding that is the consequence of another pathologic process such as traumatic…

Infectious Diseases of the Skin

Viral Infections Human Papilloma Virus Warts (Verrucae) The human papilloma virus (HPV) is the most prominent member of the papovaviruses group. There are more than 100 distinct HPV genotypes, some of which have oncogenic potential. Clinical Findings Different HPV strains have different clinical manifestations. Verruca vulgaris (common wart) may present as solitary or multiple, rough-surfaced (verrucous) papules on exposed surfaces, frequently affecting fingers ( Fig. 3-1…

Panniculitis

This chapter reviews inflammatory diseases involving the subcutaneous fat tissue (panniculitis). Although panniculitis is typically centered on the subcutis, many forms of panniculitis are associated with internal organ involvement or represent a manifestation of an associated systemic disease. The focus here will be on the most distinctive and commonly encountered histopathologic features of the major forms of panniculitis. Panniculitis is classically divided into mostly septal (i.e.,…

Inflammatory Diseases of the Dermis and Epidermis

Inflammatory disorders of the skin have typically been classified by etiology (suspected or confirmed), clinical features, histologic features (e.g., reaction patterns), location in the skin, or all of the above, as remains the tradition in Foundations in Diagnostic Pathology . As our collective understanding of inflammatory skin disorders continues to evolve, no single uniform classification of disease has been or is likely to be perfect for…

Laboratory Management

In the United States, the cytology laboratory is one of the most regulated of all the laboratories involved in clinical testing. To effectively manage and work in a cytology laboratory, personnel must be familiar with the relevant regulatory agencies and professional organizations (“the players”) and their licensure, accreditation, quality control, billing, and safety regulations (“the rules”). Agencies and Organizations Centers for Medicare and Medicaid Services The…

Bone

Introduction Primary bone tumors are relatively common, and the majority are benign and clinically silent. Bone lesions that have a characteristic radiologic appearance or are predominantly sclerotic, such as osteochondroma and fibrous dysplasia, are monitored clinically and radiologically and are not usually amenable to needle biopsy. Malignant bone tumors are rare, accounting for only 0.2% of all neoplasms. The cortical destruction and soft tissue extension of…

Soft Tissue

Few areas in cytology arouse such passionate discourse as fine-needle aspiration (FNA) of soft tissue masses. Critics jump at the opportunity to point out the limitations of the technique but pose few valid arguments along with outdated fallacies and academic concerns that do not necessarily consider the best interests of individual patients. Because needle core biopsy has largely replaced incisional biopsy as the initial diagnostic modality…

Ovary

Fine-needle aspiration (FNA) is a safe, minimally invasive, and relatively inexpensive procedure for the diagnosis of selected ovarian lesions. Indications for fine-needle aspiration of the ovary Confirm the benign nature of an incidental cyst discovered during: An infertility workup Pregnancy Confirm malignancy in a patient with a suspicious pelvic mass Confirm recurrence of an ovarian tumor treated conservatively Drain a tuboovarian abscess FNA of the ovary…

Kidney and Adrenal Gland

The Kidney Indications and Sampling Methods Fine-needle aspiration (FNA) of the kidney is a useful technique for the diagnosis of selected renal lesions. FNA, as it turns out, is not necessary for most renal masses. In adults, the great majority of renal lesions are either radiologically benign cysts requiring no treatment or radiologically malignant masses for which FNA is redundant. Cross-sectional imaging such as ultrasonography (US),…

Pancreas and Biliary Tree

Indications An unexplained pancreatic mass and a bile duct stricture are the major indications for cytologic evaluation of the pancreas and bile ducts. Imaging studies contribute useful information on the location, distribution (solitary, multiple, or diffuse), and nature (cystic vs solid) of a lesion, but a cell sample is usually necessary for definitive diagnosis. In the case of a potentially resectable mass that is malignant by…

Liver

Fine-needle aspiration (FNA) and small core needle biopsy are mainstays in the evaluation of liver masses. They are usually performed percutaneously with guidance by computed tomography (CT), ultrasonography, or magnetic resonance imaging (MRI), and its principal value is in the diagnosis of malignancies. FNA can also be performed with the aid of endoscopic ultrasonography (EUS). The large core needle biopsy is generally reserved for diffuse liver…

Lymph Nodes

Enlarged lymph nodes are a prime target for fine-needle aspiration (FNA). In an adult, lymph nodes greater than 1 to 2 cm are an immediate source of concern, and, unless the cause is evident, the enlarged node should be aspirated. Although FNA is readily applicable to children also, lymphadenopathy in children and young adults is common and usually due to reactive hyperplasia; for this reason, it…

Salivary Gland

Rationale, Indications, and Technical Considerations Any unexplained salivary gland mass is an indication for fine-needle aspiration (FNA). FNA is the preferred biopsy method because incisional biopsy is associated with an increased risk of infection and potential contamination of surgical planes. FNA, in contrast, is a cost-effective technique that poses minimal risk to the patient. The few relative contraindications to FNA are a bleeding disorder (which might…

Thyroid

Discovering a thyroid nodule in a patient raises the specter of malignancy. The usual workup includes an ultrasound examination, followed by fine-needle aspiration (FNA) if the nodule meets biopsy criteria. Thyroid nodules are very common, although the prevalence depends on how carefully one looks for them. Palpable nodules are found in only 5% of adult women and 1% of men, but the prevalence is much higher…

Breast

Specimen Types Breast cytology includes the nipple discharge and fine-needle aspiration (FNA). The more common specimen by far is the FNA. Fine-Needle Aspiration FNA is used to evaluate palpable breast masses and cysts, as well as nonpalpable mammographic abnormalities. FNA is highly accurate for palpable lesions, although its accuracy is limited with lesions smaller than 1 cm. Despite competition from the automated core needle biopsy (CNB)…

Fine Needle Aspiration Biopsy Technique and Specimen Handling

Acknowledgments Thank you to Olga Pozdnyakova, MD, for her contributions to the video. Thank you to Jessica L. Wang, MD, and Bonnie Choy, MD, for assistance with preparing visual material for this chapter. Introduction Fine needle aspiration (FNA) is widely used for evaluating palpable superficial masses and cysts, as well as deep-seated, nonpalpable radiologic abnormalities with image guidance. The capabilities and limitations of FNA specific to…

Gastrointestinal Tract

The advent of improved sampling and visualization devices cemented cytology as a valuable method for the detection of gastrointestinal (GI) malignancies, premalignant lesions, and infections. Direct endoscopic visualization of the mucosa, coupled with ultrasound imaging of submucosal structures, allows for the collection of mucosal brushings, submucosal fine needle aspirates (FNAs), and mucosal biopsies, all with a single procedure. Indeed, GI cytology is a rapid, efficient, and…

Cerebrospinal Fluid

The lumbar puncture (spinal tap) was introduced in 1891, , and in 1904 a French neurologist first described malignant cells in cerebrospinal fluid (CSF). Since then, preparatory methods have been refined and diagnostic features described in a number of monographs and atlases, attesting to the importance of CSF cytology for excluding leptomeningeal metastasis in a patient with neurologic symptoms. Anatomy and Physiology The brain contains four…

Peritoneal Washings

Peritoneal washing cytology (PWC) was introduced in the 1950s as a way to identify microscopic spread of cancer not visible by gross inspection of the peritoneal surface. In some cancer patients, positive PWC may be the only evidence of metastatic disease to the peritoneum. Because positive results correlate with poorer prognosis, cytologic findings are included in the staging system for ovarian and fallopian tube cancers. The…