CYTOLOGY FOR

VETERINARY TECHS

Dr. Jennifer L. Brazzell, DVM, MRCVS, Dipl. ACVP (Clin Path)

Anatomic Pathology Resident and Graduate Student
Western College of Veterinary Medicine
University of Saskatchewan, CANADA

1
 Overview

What sample to collect

How to collect it
How to process it
How to submit it
In-House Cytology:
How to evaluate a slide
Inflammatory lesions
Mycobacterium sp. in a
Neoplastic lesions multinucleated macrophage
2
 Background

Interpretation of cytologic specimens

dependent on:
Quality of sample submitted
Mast cell
History provided
Veterinary techs are paramount because
sample processing +/- collection and
filling out the laboratory requisitions are
most often left in your hands
Eosinophil
This lecture is aimed to help maximize the
diagnostic yield of cytologic specimens
3
 Cytology vs. Histology

C ytology: The study of cells.

Implies the use of light or
electron microscopic methods
for the study of cellular
morphology.
H istology: The department Histiocytoma cytology

of anatomy dealing with the

minute structure,
composition, and function of
tissues; the study of
microscopic changes in
diseased tissues. Histiocytoma histology 4
 Cytology vs. Histology

C ytology Indications:
Superficial soft tissue masses/inflammatory lesions
Intra-abdominal masses
Peripheral and mesenteric lymph nodes
Internal organs
Body cavity effusions
H istology Indications: Sebaceous adenoma
Firm lesions (you can still aspirate these but make sure that
expectations are appropriate)
Diagnoses where architecture is needed to make the
diagnosis (e.g. small cell lymphoma, inflammation in
hemodiluted samples) 5
 Pros Cons
Cytology  Non-invasive, relatively  Screening test
atraumatic  More susceptible to sampling
 Quick, immediate (in-house) to bias
24-48 hour turnaround time  Unable to evaluate tissue
(send-out) architecture
 Relatively inexpensive  Cytologic criteria of malignancy
 Anesthesia/analgesia often not overlap with hyperplasia
required  Few immunostains available
 May forego the need for surgical  Possible transplantation of tumor
biopsy cells
Histology  Often more definitive  Invasive
 Less susceptible to sampling  Slower, 48-72 hour turnaround
bias time
 Tissue architecture can be  More costly
evaluated  Anesthesia/analgesia required
 Ability to evaluate metastatic
potential based on nearby
tissue/vessel invasion
 Many immunostains available to
help categorize lesions
definitively
6
 Overview

What sample to collect

How to collect it
How to process it
How to submit it
In-House Cytology:
How to evaluate a slide
Inflammatory lesions
Mycobacterium sp. in a
Neoplastic lesions multinucleated macrophage
7
 Sample Collection

Collection and interpretation of

cytologic specimens complicated
by several factors:
Poorly exfoliating lesions
Blood contamination
Breaking/distortion of cells
Sampling bias

Keratin containing cyst

8
 Sample Collection

Minimize these by:

Preparing more slides from
multiple sites/aspiration
attempts (reduce sampling
bias)
Using less suction to reduce
blood contamination
Making scrapes or
impression smears of biopsy
specimens Blastomyces dermatitidis and mixed
neutrophilic-macrophagic inflammation
Preparing adequate smears
9
 Sample Collection
A. Fine needle aspirate:
Appropriate for majority of
lesions
Small gauge needle (</= 20
gauge) of appropriate length
for the lesion being
aspirated, 12 or 20 mL
syringe
Insert into mass, apply 6-8
mL of suction 3 or 4 times
Redirect (maintain suction)
10
 Sample Collection

A. Fine needle aspirate:

Release suction
Withdraw needle
Remove needle
Draw air into syringe
Reattach needle
Expel small volume of
sample onto clean slide
Prepare slides

11
 Sample Collection
B. Fine needle core/non-aspirate
technique:
Preferred for vascular masses/organs
and masses that contain fragile cells
Normal aspiration results in marked
hemodilution and/or cellular lysis Intact neoplastic lymphocytes
Small gauge needle (</= 20g), with or
without an attached air-filled syringe
Inserted and removed from the
tissue/lesion rapidly, several times in
succession, may redirect
Air-filled syringe attached to needle and
contents expelled onto a glass slide Smeared neoplastic lymphocytes
12
 Sample Collection
C. Impressions/scrapings:
Generally represent
superficial pathology
Most often reveal
superficial inflammation
and/or infection while
underlying, primary
pathology missed
Use if lesion flat/not
amenable to aspiration Blue fungal hyphae and neutrophils
13
 Sample Collection
Superficial crust/exudates should
be removed (cytology ONLY)
Impressions collected by pressing
slide directly onto lesion
Scraping sometimes allows
exfoliation of deeper pathology
Use scalpel blade to scrape
surface
Scraped material transferred to
glass slide and smeared
Superficial squamous cells
14
 Sample Collection

D. Swabs:
Ear canals/vaginasites not
amenable to aspirate or EarMalassezia sp.

impression
Use sterile (+/-pre-moistened)
cotton swab Vaginasuperficial cells
Gently roll swab over surface of
slide
Avoid smearing/sliding
Vaginaintermediate15
cells
 Overview

What sample to collect

How to collect it
How to process it
How to submit it
In-House Cytology:
How to evaluate a slide
Inflammatory lesions
Mycobacterium sp. in a
Neoplastic lesions multinucleated macrophage
16
 Sample Processing

Make sure to label slides with indelible ink

or pencil!!
Preferable to label prior to sample collection
Name, date, and source

17
 Sample ProcessingSmears
Simonsiella sp. on a superficial
Helpful tips: squamous cell

Clean slides first

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your bare hands
'RQWOHWVDPSOHFORW
Pools of blood cells need
to be dispersed
Dry rapidly without heat

18
 Sample Processing--Smears

Preparing smears:
Push smears
Pull/slide-over-slide smears
Roll preparations

Spindle cells
19
 Sample Processing--Smears

Push smears
Like making a blood smear
Ideal for bloody/fluid samples

20
 Sample Processing--Smears
Pull/slide-over-slide smears:
Good for fragile tissues like lymph nodes, cellular,
thick samples

21
 Sample Processing--Smears

Roll preparations:
Method of concentrating cells without sediment

30-450

22
 Sample Processing--Fluids
Submit fluids from body cavities (with known cellular and
protein content) for full fluid analysis
Total solids, WBC count, and RBC count.

Fluids from cystic masses or from washings (e.g. tracheal

wash) should be submitted for cytologic evaluation
Urine
Cells very susceptible to lysis in vivo and in vitro

Let patient void, collect 2-3 hours later via cystocentesis

23
 Sample Processing--Fluids
Clear, transparent fluids unlikely to clot
can be submitted in a sterile red-topped
serum tube
Bloody or turbid fluid should be
aliquoted into sterile LTT +/- RTT
If culture also submitted, aliquot
separate portion into a sterile non-
anticoagulated container/tube.
Whenever possible, fresh direct smears,
+/- sediment smears, +/- roll
preparations should be submitted
24
 Sample Processing--Staining

Staining one slide for evaluation of

sample quality is recommended
Heat fixation/other fixation
techniques are not required prior to
staining
Any Romanowski-type stain (e.g.
Diff-Quick) acceptable
Slides stained with vital dyes (e.g.
methylene blue, Sedi-Stain) cannot
be reevaluated
Keep away from formalin
25
 Evaluating Sample Quality

Inadequate samples:
No or only rare cells
All cells broken
Cells obscured by
lubricating/US gel
Smears too thick
Smears clotted
Formalin exposure
Ultrasound gel
26
 Increasing Diagnostic Yield
Submit several slides
Use appropriate collection technique
Limit blood contamination
Disperse sample adequately
Prevent drying out or clotting of sample
prior to slide prep dries out or clots prior
to/during slide preparation
Keep away from formalin
Wipe off excess lubricating gel/US gel
27
 Overview

What sample to collect

How to collect it
How to process it
How to submit it
In-House Cytology:
How to evaluate a slide
Inflammatory lesions
Mycobacterium sp. in a
Neoplastic lesions multinucleated macrophage
28
 Filling out the Requisition

Interpretation cytologic
specimens occurs in the
context of the
signalment, history, and
clinical findings!!!

29
 Filling out the Requisition
Provide pertinent information:
Signalment including: species, breed, age, sex
Clinical history including: duration, previous treatment &
effects, previous cytology/histology, pertinent lab data
Gross appearance including (specific location, size,
moveable or fixed, firm or soft, painful/warm,
haired/hairless, ulcerated/inflamed, cystic/not)
Other pertinent information (e.g. the mass bled
profusely, CBC findings if hemodiluted)
Clinical differentials/impressions

30
 Be efficient!

Taking a little more time to collect, process,

and submit samples well will increase
efficiency!!!

31
 Good History vs. Bad History

)LQHQHHGOHDVSLUDWHRID
x 3 x 2 cm subcutaneous
mass on the ventral
abdominal wall. Mass is
soft, freely moveable.
6XVSHFWOLSRPD
$EGRPLQDOPDVVDVSLUDWH

32
 Good History vs. Bad History
FNA of ~2 cm diameter, non-
painful superficial semi-firm
sparsely haired raised SQ
nodule right caudal hip of 13
y.o. MN Collie mix dog.
Mass present for less than 1
month. Opaque gray fluid
aspirated. 4 slides submitted.

33
 Good History vs. Bad History
Runny eyes and nose started 6/16/08. Started
sneezing a month ago. Started coughing 10 days
ago. Trouble eating. Other cats in household are
asymptomatic. Sample is from the post-extraction
site of the upper right canine tooth.

34
 Overview

What sample to collect

How to collect it
How to process it
How to submit it
In-House Cytology:
How to evaluate a slide
Inflammatory lesions
Mycobacterium sp. in a
Neoplastic lesions multinucleated macrophage
35
 Evaluation of Cytologic
Specimens
Not every sample needs to be sent in to
referral lab but remember:
1. Interpret cytologic findings in light of
clinical knowledge
2. Cytologic continuum between
normalhyperplasticdysplasticneop
lastic
3. -XVWEHFDXVH\RXKDYHDKHDGDFKH
GRHVQWPHDQ\RXFDQWKDYHGLDUUKHD
WRR
4. :KHQLQGRXEW---VHQGLWRXW
5. 1HYHUDPSXWDWHVROHO\RQWKHEDVLVRI 36
F\WRORJLFILQGLQJV
 Evaluating Cytologic Specimens
Methodical, step-by-step approach to evaluating the
slide constituents will help decipher what
pathological process(es) is/are present so that you
can present this information to the veterinarian to
aid in making a diagnosis.

37
 Step 1: Low power exam

Describe what you see at low power

(4-10x)
Quality of slide

Background material: mucus,

protein, blood, matrix material

Organisms: large ones may be

seen at this magnification

38
 Evaluating Sample Quality

Inadequate samples:
No or only rare
cells
All cells broken

Cells obscured by
lubricating/US gel
Smears too thick

Smears clotted

Formalin
exposure
39
 Step 1: Low power exam

Cells: Degree of cellularity?

z Variability in cell type: >1
cell type, variation within
cell populations?
z Are cells alone or in
clusters?
z Shapes of cells: round,
spindle, oval?

40
 Step 2: High power exam

Describe what you see at high power (40-100x).

Are the cells inflammatory cells, tissue cells, or
both?

Atypical spindle cells and neutrophils 41

 Inflammatory Cells

Identify the cells and characterize the

reaction: neutrophils, macrophages,
lymphocytes, plasma cells, and eosinophils
Think about etiologic agents that could cause
this type of reaction
Look for etiologic agents

Neutrophils surrounding bacteria 42

 Tissue Cells
Type of cell
Epithelial, mesenchymal, round cell
Features of cells (outside to inside)
Cell margins, cytoplasm, nucleus,
nucleoli, N:C ratio
Criteria of malignancy

43
 Tissue Cells
Evaluate everything you can about the
cells:
Shape and degree of pleomorphism
Cytoplasm: color, amount, texture
borders (indistinct, defined)
N:C ratio
Nucleus: location in cell, shape,
size, number, staining
Nuclear chromatin: pattern,
abnormal mitotic figures
Nucleoli: number, shape, size, variability 44
 Adequate cellularity/quality?
Background

Inflammatory cells Inflammatory and non- Non-inflammatory cells

Neutrophils inflammatory cells
Macrophages Inflammation due to neoplasia
Lymphocytes/plasma cell Inflammation with normal cells
Eosinophils Inflammation with other lesions
(hyperplasia/dysplasia)
C ell Type Benign vs.
M alignant
Epithelial Criteria of
Bacteria? Mesenchymal malignancy
Fungi? Round
Yeast? Other
Parasites?
Foreign body?

45
 Overview

What sample to collect

How to collect it
How to process it
How to submit it
In-House Cytology:
How to evaluate a slide
Inflammatory lesions
Mycobacterium sp. in a
Neoplastic lesions multinucleated macrophage
46
 Inflammatory Lesions

General categories:
Neutrophilic
Pyogranulomatous (mixed
neutrophilic-macrophagic)
Granulomatous
(macrophagic)
Eosinophilic
Lymphocytic +/- plasmacytic
Mixed inflammation with
spindle cells 47
 Neutrophilic

>85% neutrophils
Degenerate: nuclear
swelling/karyolysis
Degenerate neutrophil with
z Rule out bacterial etiology intracellular rods

Non-degenerate
z Rule out causes of sterile Degenerate neutrophil
inflammation
Indicates more acute
inflammatory process
Non-degenerate neutrophil48
 Mixed/Pyogranulomatous

Predominantly neutrophils but

>10% macrophages +/-
lymphocytes, plasma cells
Subacute to chronic inflammation
Rule out foreign bodies, fungal
infection, mycobacterial infection,
infection with higher order bacteria
(Actinomyces/Nocardia),
panniculitis, lick granulomas
49
 Macrophagic/Granulomatous

Predominance of
macrophages
Chronic inflammation
Often see multinucleate
giant cells, activated
HSLWKHOLRLGPDFURSKDJHV
Foreign bodies,
mycobacterial infections
50
 Eosinophilic

>10% eosinophils
Rule out
hypersensitivities/allergies,
paraneoplastic, parasitic
Rarely see secondary to
protozoal, fungal, or
foreign body

51
 Lympho(plasma)cytic

Predominance of
lymphocytes +/- plasma
cells
Immune reactions
Contact allergies/vaccine
reactions

52
 Overview

What sample to collect

How to collect it
How to process it
How to submit it
In-House Cytology:
How to evaluate a slide
Inflammatory lesions
Mycobacterium sp. in a
Neoplastic lesions multinucleated macrophage
53
 Neoplastic Lesions

General tumor types

1. Epithelial tumors
Neuroendocrine tumors
2. Mesenchymal tumors
3. Round cell tumors
4. Other
Melanoma

54
 Tumor Type General Cell General Cell Schematic Cellularity of Clumps of
Size Shape Representation Aspirates Clusters
Common
Epithelial Large Round to Usually high Yes
caudate

M esenchymal Small to Spindle to Usually low No

(spindle cell) medium stellate

Discrete round Small to Round Usually high No

cell medium

(Modified From Diagnostic Cytology and Hematology of the Dog and Cat, Cowell and Tyler, 2nd
edition)
55
 Epithelial Tumors

Tend to cluster
Can see intercellular
junctions
Generally have round
nuclei

56
 Epithelial Tumors

Neuroendocrine tumors

57
 Mesenchymal Tumors

Tend to exfoliate
singly
Often are spindle
shaped
May produce
matrix material

58
 Mesenchymal Tumors

Fibroma Fibrosarcoma

59
 Round Cell Tumors
Round and exfoliate singly
Only 5 kinds!
Lymphoma
Histiocytoma
Mast cell tumor
Plasma cell tumor
Transmissible venereal tumor
Beware that any anaplastic tumor can
exfoliate round cells!! 60
Lymphoma

61
Histiocytoma

62
Mast Cell Tumor

63
Plasma Cell Tumor

64
Transmissible Venereal Tumor

65
 Round Cells

Lymphocyte Plasma C ell H istiocyte M ast C ell TVT

66
 Benign vs. Malignant?

Not as easy as it sounds

Cytologic continuum
between normal,
hyperplastic/dysplastic,
and malignant

67
 Cytologic Criteria of Malignancy

General criteria:
Uniform population

Lymphoma

Pleomorphic cells

Pulmonary Adenocarcinoma
68
 Cytologic Criteria of Malignancy

Large cell size

Histiocytic Sarcoma

Abnormal location

Pancreatic adenocarcinoma in liver69

 Cytologic Criteria of Malignancy

Hypercellularity

Transitional Cell Carcinoma

70
 Cytologic Criteria of Malignancy

Nuclear criteria:
Macrokaryosis
(a.k.a. karyomegaly)
Increased N:C ratio
Anisokaryosis

71
 Cytologic Criteria of Malignancy
Multinucleation
Coarse chromatin
Nuclear molding
Macronucleoli
Angular nucleoli
Anisonucleoliosis
72
 Cytologic Criteria of Malignancy

Increased/abnormal mitotic figures

73
 Cytologic Criteria of Malignancy

Cytoplasmic criteria:
C ytoplasmic changes may occur secondary
to non-neoplastic stimuli (e.g. inflammation)
Basophilia
Vacuolization
Ill-defined margins

Mesothelial reactivity 74
 Why aspirating all lumps is
LPSRUWDQW
History: Aspirate of a large, soft,
subcutaneous, moveable mass on ventral
abdominal wall, suspect lipoma.

75
 2QWKDWQRWH

Aspirate all masses!!!!

We encourage techs and vets alike to look at
cytologies in-house
Some lesions are amenable to in-house
cytology (lipomas, granulated mast cell tumors,
etc.)
Be aware of sample bias, non-neoplastic atypia
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76
 Lesions to Send Out

Complex lesions with inflammation and tissue cells

0DPPDU\JODQGVLQIDFWGRQWDVSLUDWHWKHVHMXVW
remove them)
Spindle cell proliferationsreactive or neoplastic?
Body cavity fluids with mesothelial reactivity
Bone marrow
Cytologies that do not correlate with clinical suspicions

:KHQLQGRXEWVHQGLWRXW

77
 Lesions Amenable to In-House
Evaluation
1. Inflammatory lesions
2. Lipomas
3. Perianal (circumanal) gland tumors
4. Sebaceous hyperplasia/adenoma
5. Basilar epithelial neoplasms
6. Keratin containing masses/cysts
7. Mast cell tumors
8. Histiocytomas
9. Lymph node aspirates
10. Joint fluids
78
 1.

Low power scan identifies clusters of neutrophils

Numerous non-degenerate neutrophils and
vacuolated, medium sized macrophages
Yeast, characterized by refractile, deeply basophilic
cell wall, broad-based budding and measure 7 15
m

Moderate mixed/pyogranulomatous inflammation with numerous

intralesional yeast consistent with Blastomyces dermatitidis 79
 Blastomyces dermatitidis

Systemic mycotic infection

Yeast:
7-15 m, thick cell wall, deeply basophilic with broad based
budding
Inflammation:
Ranges from suppurative to pyogranulomatous to
granulomatous
Tissues affected varies:
Most common: skin, lungs, eyes and bone
Less common: testes, prostate, kidney, bladder, brain,
mammary gland, joints and nasal passages

80
 Differentials

Cryptococcus spp.
Narrow based budding

Thick capsule

# of organisms may outnumber inflammatory

cells
Coccidiomycosis spp.
Large, measuring up to 200 m

Spherules containing endospores

81
 Additional testing

Histology
Serologic testing
ELISA
Latex agglutination
AGID
Fluorescent antibody
Culture**
Advise lab ZOONOTIC!
Not recommended
PCR

82
 2.

Smears often oleaginous

Single or aggregated lipid-laden adipocytes

Aspiration of cytologically benign adipose tissue; rule out

lipoma 83
 Lipomas

Aspirate all lipomas!!!

Beware the mast cell tumor or liposarcoma that is
disguising as a benign lipoma
Interpretation relies on the history

84
 3.

Uniform clusters of
hepatocyte-like (hepatoid)
epithelial cells
Contain a moderate
amount of basophilic to
amphophilic cytoplasm;
small round nuclei; may
have a single small
prominent nucleolus
Perianal gland tumor 85
 Perianal gland tumor

Said to occur more frequently in intact male dogs

but frequently see in castrated male and spayed
female dogs
May find in dogs with sex-hormone producing
tumors or hyperadrenocorticism
Benignancy vs. malignancy relies on
histopathology so although many look benign
cytologically cannot be definitive
Major differential in this anatomic region is anal
sac adenocarcinomaneuroendocrine appearance 86
Anal sac adenocarcinoma

87
 4.
Described as wart-like
proliferations, often sessile
Older dogs
Clusters of well-
differentiated, vacuolated,
sebum-containing cells
Cannot differentia
hyperplasia from adenoma
grossly or cytologically
Sebaceous hyperplasia/adenoma 88
 5.

Exfoliation of cords and sheets of cuboidal,

uniform, quite basophilic cells with high N:C
ratios

Basilar epithelial neoplasm 89

 Basilar epithelial neoplasms

Common skin tumor in dogs (trichoblastoma) and

cats (basal cell tumor)
Basal cell tumors encompass a wide variety of
epithelial tumors of the basilar layer of the skin all
with a similar cytologic appearance
8VHWKHWHUPEDVLODUHSLWKHOLDOQHRSODVPVWR
reflect the broad scope of benign and malignant
epidermal, follicular, sweat gland or sebaceous
gland tumors

90
 6.

Moderate to marked amount of amorphous,

basophilic cellular debris with anuclear
squamous epithelium and keratin bars
Variable numbers of inflammatory cells
No overt infectious agents present
Cholesterol crystals

91
C ystic keratin containing mass 92
 Keratin containing mass

Non-neoplastic, non-inflammatory, tumor-like lesions

May be keratin containing/cystic tumor or true cyst-
lesiondifferentiation requires histopathology
Located on the dorsum or extremities
Occasionally, pore can be seen opening to the surface
Typically benign
Rupture elicits mixed inflammatory response

93
 Keratin containing mass

Cholesterol crystals:
Negatively stained,
irregularly notched,
rectangular plates
Indicate chronic cell
turnover/death
Prognosis:
Excellent

Rupture can lead to localized

pyogranulomatous
inflammation
94
 7.

Quite variable cytologic appearance:

z Well to poorly granulated round cells

z Many to few eosinophils

z Presence or absence of collagenolysis

z Many or few mast cell and eosinophil granules

in the background

M ast cell tumor 95

Beware the agranular mast cell tumor!!
96
 Mast cell tumors

Among most common

cutaneous tumors is cats and
dogs
12- 20% prevalence in cats
~ 7-21% in dogs
Breed predilection:
Dogs:
z Boxer, Boston Terriers, bull
terriers, retrievers
Cats:
z Siamese 97
 8.

Moderately cellular with moderate to marked

hemodilution
Background is finely stippled and faintly eosinophilic
Discrete round cell population
Nuclei are round to ovoid to indented with a finely stippled
chromatin pattern and indistinct nucleoli. Moderate amount of
basophilic cytoplasm
Anisocytosis and anisokaryosis are mild
Low numbers of non-degenerate neutrophils, and
small well-differentiated lymphocytes

98
H istiocytoma 99
 Histiocytoma

Very common, benign

cutaneous lesion in dogs
Seen in animals <4 years of
age
Ulcerated, raised, hairless
masses that frequently
regresses within 3 months
of initial presentation
Commonly occurs on the
head, pinnae, hind leg, feet,
trunk, etc
100
 Differentials
1. Agranular mast cell tumor
2. Plasmacytoma
Significant cytologic overlap

Bi and tri nucleated cells common

Prominent anisocytosis and anisokaryosis

Perinuclear clear zone

Amorphous eosinophilic material seen in <10% of cases

z Represents amyloid

+/- Mott cells

z Plasma cells containing Russell Bodies

Immunoglobulin containing inclusions 101

102
103
104
 Differentials

3. Lymphoma:
Homogeneous population of lymphocytes

z High N:C ratio

z Round to ovoid to indented nucleus with a smudged to

lacy to finely stippled chromatin pattern and multiple,
prominent nucleoli
z Intensely basophilic cytoplasm

Cytoplasmic fragments

Bizarre and abnormal mitotic figures

Accounts for <1% of cutaneous tumors in dogs, 2.8% in

cats 105
106
 Differentials

4. Amelanotic melanoma:
*UHDWPLPLFNHU

Malignant

Pleomorphic

z Ranging from epithelioid to fusiform to occasionally

discrete round cells
Cytologically, a few, cytoplasmic melanin granules can

be seen
z Rice to rod shaped, dark brown to black granules

z Can be seen in the background

107
108
109
 9. Lymph Nodes

Indications for lymph node aspirate:

1. Lymphadenomegaly
2. Detection of metastatic disease
3. Classification of lymphoma

110
 Indications for Lymph Node
Aspiration

Lymphadenomegaly
Enlargement of one or

more lymph nodes

If multiple LNs affected,

sample > 1
Submandibular LNs tend

to be reactive
Aspiration of popliteals a

good choice
111
 <RXKLWVRPH\RXPLVVVRPH

Very easy to aspirate salivary gland when

attempting to aspirate normally sized or
slightly enlarged submandibular lymph node
Perinodal adipose tissue often aspirated
 Indications for Lymph Node
Aspiration

Detection of metastatic disease

Even normal sized LNs can contain evidence of

metastatic disease

113
 Indications for Lymph Node
Aspiration

Classification of Lymphoma
Immunocytochemistry

Flow cytometry

PCR for antigen receptor rearrangement (PARR)

Often done via HISTOPATHOLOGY and IHC

114
 Sample Preparation

Use non-aspirate technique to avoid rupture of

fragile neoplastic cells

115
 Normal

.HHSLQPLQGWKDWQRUPDO
depends on the node
submandibular lymph nodes are
QRUPDOO\UHDFWLYH
Predominantly small well-
differentiated lymphocytes
Few plasma cells, macrophages,
neutrophils, eosinophils, mast cells

116
 Reactive

Relatively increased
numbers of medium and
large lymphocytes,
plasma cells
May also have
increased
neutrophils/eosinophils
if draining an inflamed
site 117
 Beware the monomorphic
medium-sized lymphocytes!!!

118
 Lymphadenitis

True lymphadenitis uncommonusually fungal or

protozoal infections
May see inflammatory cells in nodes draining an
inflamed site

119
 Joint Fluids
Plasma ultrafiltrate with
added mucopolysaccharides
Normally colorless, clear,
mucinous
Cell counts:
z RBC: normal = 0 but often get
few due to iatrogenic blood
contamination
z Nucleated cells = <1,000-
3,000/uL, small, quiescent
mononuclear cells
120
 Joint Effusions

Joint fluids only have a few patterns:

1. Hemorrhagemust differentiate iatrogenic from

true
2. Mononuclear reactivity
3. Inflammation
z Infectious

z Non-infectious

121
 Joint Effusions
Hemorrhage
Blood contaminationstreaks of blood in the tube, see
platelets
Minimize by releasing suction before removing needle

True hemorrhageuniformly red, often less viscous

z >6 hours old erythrophagia and/or hemosiderin-

containing macrophages
z Olderxanthochromia

Rule out trauma, coagulopathies

122
 Joint Effusions

Mononuclear reactivity
Due to degenerative arthropathies caused by

joint instability, OCD

123
 Joint Effusions
Mononuclear reactivity:
Increased number of mononuclear cells;

sometimes aggregated
Increased cytoplasmic basophilic, volume,

and/or vacuolation

Increased cytoplasmic
Normal Increased cytoplasmic vacuolation and volume Aggregates
basophilia
 Joint Effusions
Inflammatory
Neutrophil predominant

Infectious

z Bacterial: usually acute

presentation,
monoarticular (large
joint), heat/pain, history
of penetrating/surgical
wound, neutrophils
usually degenerate
appearing 125
 Joint Effusions

z Rickettsial (Anaplasma phagocytophilum) and

spirochetal (Borrelia burgdorferi): history of
tick exposure in endemic area, polyarticular,
organisms rarely identified, neutrophils often
non-degenerate
z Other: fungal, Mycoplasmal, protozoal, viral

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 Joint Effusions

May not see bacteria, may be culture negative but

antibiotic therapy responsive

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 Joint Effusions

Non-infectious/Immune-mediated
z Also neutrophil predominant, primarily
polyarthritis, smaller joints
z Non-erosive

Idiopathic polyarthritis
SLE
Secondary to some stimulus: distant
focus of infection, IBD, malignancy,
drugs, vaccination
z Erosive

Rheumatoid arthritis
128
Miscellaneous Artifacts

129
Questions?

130