Pathology MCQs for various entrance exams

A summary of adequacy criteria for various cytology specimens.

CYTOLOGY SPECIMENS

1. Cervical cytology

2. Anal cytology

3. Fine needle aspiration cytology for thyroid nodules

4. Urinary cytology

5. Salivary gland cytology

6. Pancreaticobiliary cytology

7. Serous fluid cytology

8. Sputum cytology

9. Fine needle aspiration cytology of breast

10. Fine needle aspiration biopsy of breast

11. Summary

12. Multiple choice questions on this topic

CERVICAL CYTOLOGY:

Adequacy criteria: based on 2014 Bethesda system of reporting cervical cytology

Satisfactory:
- Adequate number of well visualized or preserved squamous or squamous metaplastic cells
- Conventional smear: minimum 8,000 – 12,000 cells
- Liquid based preparation: minimum 5,000 cells
- Woman’s postchemotherapy, radiotherapy, postmenopausal, atrophic changes or posthysterectomy may have < 5,000 cells and be deemed adequate at laboratory’s discretion (if > 2,000 cells)
- Exception: adequate if any abnormal cells are present
Unsatisfactory:
- More than 75% of cells obscured by inflammation, bacteria or interfering substances (lubricants and blood)
- 50 – 75% of cells obscured, include a disclaimer describing how and the percentage of cells obscured

2. ANAL CYTOLOGY

Specimen adequacy is based primarily upon specimen cellularity and morphological quality of the sample.

As outlined in The Bethesda System,

A minimum cellularity for conventional anal-rectal cytology smears is 2,000 to 3,000 nucleated squamous cells (image) for conventional smears,

1–2 nucleated squamous cells per high power field (hpf) for ThinPrep specimens, and 3–6 nucleated squamous cells per hpf for SurePath specimens.

Specimens composed primarily of anucleate squamous cells and specimens that do not meet minimum criteria for cellularity should be considered unsatisfactory for evaluation; provided that no abnormal cells are identified, no diagnostic interpretation/result should be rendered for such specimens.

Obscuring factors such as fecal material, bacteria, and inflammation may hinder evaluation, and when the majority of nucleate squamous cells are obscured, specimens should be considered unsatisfactory for evaluation.

While the presence of a transformation zone component is not required for a satisfactory specimen, presence or absence of glandular columnar cells should be noted.

3. FINE NEEDLE ASPIRATION CYTOLOGY OF THYROID NODULES

Adequacy criteria based on The Bethesda system for reporting thyroid cytopathology 2017 2nd edition.

FNA smear should contain ≥ 6 groups of well visualized follicular cells (≥ 10 cells/group), preferably on a single slide

Exceptions (a minimum number of follicular cells is not required)

✅Solid nodules with cytologic atypia, which qualify into categories III – VI

✅Solid nodules with inflammation are considered benign

✅Only numerous inflammatory cells

✅Lymphocytic thyroiditis, thyroid abscess or granulomatous thyroiditis

✅Nodules with abundant colloid are placed in the benign category even in the absence of follicular epithelium

4. URINARY CYTOLOGY

According to The Paris System for Reporting Urinary Cytology

Voided urine: >30 ml without non-urothelial features obscuring urothelial morphology

Instrumented urine: 2600 cells or at least 20 cells in 10 HPF may be taken as adequacy criteria.

5. SALIVARY GLAND CYTOLOGY

According to The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) : More than 60 lesional cells are required for a cytologic diagnosis.

Any atypical cells or sign of features such as mucin is also considered adequate.

6. PANCREATICO-BILIARY CYTOLOGY

According to The Papanicolaou Society of Cytopathology (PSC) developed in 2014

Contains adequate cellular or extracellular tissue to evaluate or define a lesion that is identified on imaging

Only GI contamination, or benign pancreatic tissue indicates missed lesion and is considered non diagnostic.

NOTE: MUCIN is considered adequate in MILAN( Salivary gland cytology) but not in pancreatico-biliary cytology.

7. SEROUS FLUID CYTOLOGY

According to The international system standardized reporting of serous fluid cytology

Volume of fluid: There is no specific cutoff but volume >50 mL to 75ml is considered adequate

Cellularity: There is no definitive criteria of number of mesothelial cells for adequacy and the criteria might vary depending on the pathologic process.

Quality of preparation: poor cell preservation, degeneration, hemorrhage, artifacts and contaminants can impair interpretation and is considered inadequate,

8. SPUTUM CYTOLOGY

Presence of alveolar macrophages are a must for sputum cytology specimens to be deemed adequate

9. FINE NEEDLE ASPIRATION CYTOLOGY OF BREAST

✅No definite criteria for adequacy in breast FNA cytology

✅MD Anderson Cancer Center Group proposed that 4 – 6 well visualized cell groups with 10 or more cells / flat sheets as an adequacy criteria.

✅Samples that lack epithelial cells are considered inadequate in general

✅If the lesion is suspected to be lipoma or fat necrosis, the absence of epithelial clusters doesn’t indicate inadequacy

10. FINE NEEDLE ASPIRATION BIOPSY OF BREAST

According to Yokohama system for reporting Fine needle aspiration biopsy

✅If there is a mass lesion on palpation or imaging, which does not decrease in size on FNAB, the presence of seven tissue fragments, each of 20 or more epithelial cells, are suggested as a measure of adequacy.

11. SUMMARY OF CYTOLOGIC ADEQUACY CRITERIA- ALL SPECIMENS