Fine Needle Aspiration Cytology Other books in this series: Neuropathology Gastrointestinal and Liver Pathology Head and Neck Pathology Breast Pathology Other books coming soon in this series: Dermatopathology Bone and Soft Tissue Pathology Genitourinary Pathology Hematopathology Gynecologic Pathology Pulmonary Pathology Fine Needle Aspiration Cytology A Volume in the Series Foundations in Diagnostic Pathology Edited by Mary K Sidawy, MD Professor of Pathology, Director of Anatomic Pathology Georgetown University Washington, DC USA Syed Z Ali, MD Associate Professor of Pathology and Radiology Associate Director, Division of Cytopathology Johns Hopkins University School of Medicine Baltimore, MD USA Series Editor John R Goldblum MD, FCAP, FASCP, FACG Chairman, Department of Anatomic Pathology The Cleveland Clinic Foundation Cleveland Clinic Lerner College of Medicine Case Western Reserve University Cleveland Ohio, USA An imprint of Elsevier Inc. FINE NEEDLE ASPIRATION CYTOLOGY © 2007, Elsevier Inc. All rights reserved. ISBN-13: 978-0-443-06731-0 ISBN-10: 0-443-06731-7 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103–2899, USA: phone: (+1) 215 239 3804; fax: (+1) 215 239 3805; or, e-mail: healthpermissions@ elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www. elsevier.com), by selecting ‘Support and contact’ and then ‘Copyright and Permission’. NOTICE Medical knowledge is constantly changing. 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The Publisher First published 2007 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Commissioning Editor: Michael Houston Project Development Manager: Claire Bonnet Project Manager: Cheryl Brant Design Manager: Louis Forgione Marketing Manager(s) (USA/UK): Kathleen Neely/Leontine Treur Working together to grow libraries in developing countries Printed in China www.elsevier.com | www.bookaid.org | www.sabre.org Last digit is the print number: 9 8 7 6 5 4 3 2 1 List of Contributors Fadi W Abdul-Karim, MD Shahla Masood, MD Professor of Pathology Professor and Associate Chair Department of Pathology University of Florida University Hospitals of Cleveland Chief of Pathology Cleveland, OH Department of Pathology USA Shands Jacksonville Medical Center Jacksonville, FL Syed Z Ali, MD USA Associate Professor of Pathology and Radiology Associate Director, Division of Cytopathology Ritu Nayar, MD Johns Hopkins University School of Medicine Associate Professor and Director of Cytopathology Baltimore, MD Department of Pathology USA Feinberg School of Medicine Northwestern University Ema A Berbescu, MD Chicago, IL Assistant Professor of Pathology USA Division of Anatomic Pathology Medical College of Virginia Marlo M Nicolas, MD Virginia Commonwealth University Health System Genitourinary Fellow Richmond, VA Department of Pathology USA University of Texas, MD Anderson Cancer Center Houston, TX Katherine Berezowski, MD USA Assistant Professor Department of Pathology Anil V Parwani, MD, PhD The George Washington University Assistant Professor Washington, DC Department of Pathology USA University of Pittsburgh Medical Center Pittsburgh, PA Martha Bishop Pitman, MD USA Associate Professor of Pathology Harvard Medical School Celeste N Powers, MD, PhD Assistant Director of Cytopathology Professor and Chair Director of the Fine Needle Aspiration Biopsy Service Division of Anatomic Pathology Massachusetts General Hospital Medical College of Virginia Boston, MA Virginia Commonwealth University Health System USA Richmond, VA USA Yener S Erozan, MD Professor of Pathology Natasha Rekhtman, MD, PhD Department of Pathology Assistant, Department of Pathology The Johns Hopkins University School of Medicine Division of Surgical Pathology Baltimore, MD Johns Hopkins University USA Baltimore, MD USA Michael O Idowu, MD Assistant Professor of Pathology Mary K Sidawy, MD Division of Anatomic Pathology Professor of Pathology, Director of Anatomic Pathology Medical College of Virginia Georgetown University Virginia Commonwealth University Health System Washington, DC Richmond, VA USA USA Sana O Tabbara, MD Igor Jovanovic, MD, PhD Professor of Pathology Cytopathology Fellow The George Washington University Department of Pathology Washington, DC George Washington University USA Washington, DC USA vi LIST OF CONTRIBUTORS Paul E Wakely Jr, MD Maureen F Zakowski, MD Department of Pathology Attending Pathologist The Ohio State University Department of Pathology College of Medicine Memorial Sloan-Kettering Cancer Center Columbus, OH New York, NY USA USA Foreword The study and practice of anatomic pathology is both only written extensively in these areas, but, more exciting and overwhelming. Surgical pathology, with importantly, have been practicing cytopathologists with all of the subspecialties it encompasses, and cytopathol- vast practical experience. As with other editions in the ogy have become increasingly complex and sophisti- Foundations in Diagnostic Pathologyseries, the informa- cated, and it is not possible for any individual to master tion is presented in a straightforward and accessible the skills and knowledge required to perform all of manner, including numerous practical tables and these tasks at the highest level. Simply being able to impressive photomicrographs. Where appropriate, the make a correct diagnosis is challenging enough, but the authors seamlessly integrate ancillary diagnostic standard of care has far surpassed merely providing a techniques including immunohistochemistry, electron diagnosis. Pathologists are now asked to provide large microscopy and molecular techniques, which are also amounts of ancillary information, both diagnostic and an important part of the cytopathologist’s diagnostic prognostic, often on small amounts of tissue, a task armamentarium. that can be daunting even to the most experienced This edition is organized into ten chapters covering pathologist. the full spectrum of fine needle aspiration cytology in Although large general surgical pathology textbooks an organ-by-organ fashion. The first three chapters are useful resources, they by necessity could not possi- focus on aspiration cytology of salivary glands, thyroid bly cover many of the aspects that pathologists needs to and lymph nodes. Drs. Abdul-Karim and Massood know and include in their reports. As such, the concept provide superb discussions on the finer points of fi ne behind Foundations in Pathology was born. This series needle aspiration of soft tissue tumors and tumors is designed to cover the major areas of surgical and of the breast. Separate chapters covering the lung, cytopathology, and each edition is focused on one major mediastinum, liver, pancreas, kidney and adrenal topic. The goal of every book in this series is to provide gland are also provided. The chapters are uniformly the essential information that any pathologist, whether well organized, concisely written and beautifully general or subspecialized, in training or in practice, photomicrographed. would find useful in the evaluation of virtually any type I wish to extend my sincerest gratitude to Drs. Sidawy of specimen encountered. and Ali for leading this outstanding effort. Clearly, they Dr. Mary Sidawy from Georgetown and Dr. Syed Ali poured their heart and soul into this edition of the from Johns Hopkins Hospital, both outstanding and Foundations in Diagnostic Pathology series, and for this renowned cytopathologists, have edited what I believe I am truly grateful. I would also like to extend my appre- to be an outstanding state-of-the-art book covering the ciation to the authors who took time from their busy essential aspects of fine needle aspiration cytology. This schedules to contribute their expertise and knowledge. book cuts to the essentials of what all pathologists I sincerely hope you enjoy this volume of Foundations who practice the art of cytopathology need to know in Diagnostic Pathology. about this challenging field. The list of contributors is truly impressive and includes authors who have not John R. Goldblum, M.D. To our families, Tony, Michelle, and Nicholas Tehmina, Adeel, and Sabeen Preface In 1930, Martin and Ellis, recognizing the value of referencing the histopathologic characteristics with the cytologic sampling, published a cornerstone article cytologic features reflects our conviction that the two entitled “Biopsy by Needle Puncture and Aspiration.” disciplines are complementary. Fine needle aspiration (FNA) began gaining momen- Cytopathologists enjoy a position at the forefront of tum in Europe in the 1950s; however, it was not until diagnostic anatomic pathology; we intimately interact the 1980s when it became widely accepted in the United with many disciplines of clinical medicine. Therefore, States. FNA of palpable and deep-seated lesions has emphasis was placed on the interpretation of morpho- quickly grown to become a powerful diagnostic tool in logic findings in the proper clinicoradiologic context the diagnosis of neoplastic, reactive, and infectious pro- leading to a more meaningful and valid list of differen- cesses. But as we acquired more experience and knowl- tial diagnoses of FNA interpretation. edge we developed a better appreciation of the pitfalls The book is aimed primarily at pathology residents and limitations in interpreting cytologic samples. and fellows, as well as practicing pathologists looking There is no paucity of published scientific material for a practical overview of FNA cytopathology. Our on aspiration cytopathology; we have seen an exponen- ultimate goal is the best patient care based on timely and tial growth in the cytopathology literature paralleling its accurate FNA interpretation. It is our hope that this widespread success as a medical discipline. This volume book will further the understanding of FNA and its role in the series Foundations in Diagnostic Pathology, offers in patient management. We would like to thank whole- several notable features. FNA of most commonly heartedly the authors that contributed time and effort to sampled sites are presented in ten chapters authored by this project; our mentors who inspired us, and our resi- experts in the field. The template format throughout the dents and fellows for constantly challenging us at the book provides a high degree of consistency in style and microscope. We sincerely hope that this book will presentation. Furthermore, the use of Facts and Fea- convey our enthusiasm to the discipline of cytopathol- turesboxes allows easy access to key information. High ogy, an area that we find exciting, challenging and resolution images are the cornerstone of morphologic fulfi lling in our daily practice and teaching. discussion of any given entity with the text revolving around issues of practical diagnostic and clinical impor- Mary K. Sidawy, M.D. tance. Differential diagnoses, potential pitfalls, and the Syed Z. Ali, M.D. use of ancillary techniques are emphasized. Cross October 2006