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RESPIRATORY Course Objectives

CYTOLOGY • Appreciate the anatomy, histology and
cytology of the respiratory system.
• Describe the pathology and cytology of
benign respiratory conditions evaluated on
sputum and FNA specimens.
• Distinguish between the different
ML 301 Cytology malignant conditions seen in the
Dr Pritinesh Singh
Department of Pathology respiratory system and the appearance of
School of Health Sciences
Fiji School of Medicine
this in smears

THE RESPIRATORY SYSTEM

Introduction
• Respiratory cytology consists of 3 basic types of exfoliative
specimens
CELLULAR – Sputum, bronchial cytology (including washings & brushings) and
COMPONENTS bronchoalveolar lavage (BAL)
OF THE
• In general large central tumors are more readily detected by
RESPIRATORY
SYSTEM
exfoliative methods then small peripheral ones
• Squamous & Small cell carcinomas are more accurately
diagnosed then adenocarcinomas
• Poorly differentiated cancers are more easily detected then
well differentiated ones
• Benign tumors may not shed any diagnostic cells
• Most diagnostic problems relate to sampling (false negative)
& inflammation (false positive)

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SPUTUM
• Composed predominantly of mucus but also contains
cells & other elements
• Significant spontaneous sputum production indicates the
presence of pulmonary disease
• Most smokers & p patients with bronchogenic
g carcinoma
have a cough & can produce sputum
• Sputum production can also be induced
• Sputum screening unable to prevent lung cancer in the
way pap smear has prevented cervical cancer
• Most readily accessible pulmonary cytology specimen,
cannot be used to localize lesion
SPUTUM
• Specimens can be prepared by the
Saccomanno (blender) technique or by the “pick
and smear” technique
– Advantage of Saccomanno
• is that it concentrates cells, increasing diagnostic yield
– Disadvantages
Di d t iinclude:
l d
• fragmentation of fungal organisms, disruption of glands,
dispersion of cells of small cell carcinoma & creation of
potentially infectious aerosols
• Post bronchoscopy sputum has the highest
sensitivity of any exfoliative respiratory cytology
specimen.
BRONCHOALVEOLAR
LAVAGE
• Often used to diagnose opportunistic infections in immuno-compromised
hosts (AIDS or transplants)
• Helpful in diagnosis of interstitial lung disease, granulomatous disease
includign sarcoid, hypersensitivity pneumonia, drug induced pulmonary
toxicity, asbestosis, pulmonary hemorrhage & cancer (particularly when
peripherally located)
• It’s important to look for fungus, Pnuemocystis, viral changes,
hemosiderin laden macrophages & malignant cells; some specimen
should also be cultured
• Can help separate inflammatory processes in which lymphocytes
predominate (eg. Sarcoid, hypersensitivity pneumonia including drug
reaction, berylliosis) from those in which neutrophils or macrophages
predominate (eg pneumonia, idiopathic pulmonary fibrosis, cytotoxic drug
reaction, Langerhans histiocytosis)
• Haemosiderin laden macrophages suggest pulmonary hemorrhage but
also can be seen in infection & cancer.
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SPUTUM
• To look for cancer in spontaneous sputum specimens, its
best to examine pooled morning secretion.
• At least 3 specimens should be submitted to diagnose
cancer, single specimen is unreliable in tumor detection
• Fresh specimens are preferred
• It can be preserved in alcohol but is not recommended
as it can shrink the cells making them difficult to interpret
• It can fail to penetrate the mucus, leaving embedded
cells poorly fixed & can make smearing difficult because
it coagulates the mucus
BRONCHIAL CYTOLOGY
– Patients with abnormal sputum cytology
should undergo bronchoscopy
– Bronchial cytology including bronchial
washings and brushings is better suited for
diagnosis of peripheral lung lesions than
sputum cytology
– Bronchoscopy is also useful in diagnosing
patients with central lesions & negative
sputum cytology who are not candidates for
surgery
THE CELLS
• Cells obtained in bronchial washings & brushings are
better preserved than those in sputum
• Cells from squamous cell carcinoma in sputum are
usually keratinized (differentiated) than those found in
bronchial washing or brushing specimens of the same
tumor
• All cell types of bronchogenic carcinoma tend to appear
less mature in bronchial brush specimens
• Although single tumor cells are an important feature of
malignancy, occasionally they are not present in
bronchial brushing specimens of malignant tumors.
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SQUAMOUS CELLS
• Most squamous cells come from the mouth as
contaminants
• Cytologic appearance is similar to those in the pap
smear with a predominance of superficial cells
• Anucleate squames & intermediate cells may also be
present
• Benign pearls & occasional spindle squamous cells may
be seen
• Reactive/ degenerative changes are common
• Squamous cells originating in the mouth often show
cytologic atypia that can cause diagnostic problems
Glandular Cells
• Tracheobronchial tree is lined by
pseudostratified glandular epithelium composed
predominantly of ciliated columnar & mucous
goblet cells, normally in a ratio of at least 5:1
• Other cell types include Clara cells, reserve cells
& Kulchitsky cells. Lymphoid cells are present in
the walls of the bronchi (bronchial associated
lymphoid tissue, BALT)
Ciliated columnar cells -
bronchial
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Pearl Squamous cells
Ciliated columnar cells
• Most characteristic feature of ciliated cells is presence of
cilia on the apical surface, anchored into a terminal bar
• At the other end the cells have a cytoplasmic tail by
which they attach to the basement membrane
• Cytoplasm
y p is basophilic
p & homogenous
g with basally
y
oriented, round to oval nuclei.
• Chromatin ranges from fine – mildly coarse – dark
• Small nucleoli may be present
• Ciliary tufts become detached from cells as a non
specific reaction to injury.
Mucous Goblet Cells
• Degenerate rapidly in sputum
• Commonly seen in bronchial cytology
• Have abundant, vacoulated cytoplasm, filled with
mucin
• Nuclei are uniform & basally located
• Are numerous in asthma, chronic bronchitis,
bronchiectasis & allergic conditions
• When in abundance, consider mucinous
bronchioalveolar carcinoma (BAC)
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Bronchial Irritation Cells –

Benign Reactive Atypia
• Can include nuclear enlargement & pleomorphism
with abnormally coarse dark chromatin &
prominent nucleoli
• Multinucleation is common
• Reactive changes seen more in bronchial than
sputum cytology
• In contrast with cancer, benign cells have good
intercellular cohesion with fewer single cells
• There is a range of atypia in benign conditions,
Goblet cells with abundant mucin filled cytoplasm
whereas in malignant neoplasms there is usually
a discrete population of abnormal cells

Reparative/ Regenerative
Bronchial Cells
• Similar to that seen in the pap smear
• Atypia can range from mild – severe, mimicking cancer
• Repair is characterized by cohesive, orderly, flat sheets of
cells with adequate cytoplasm, single cells are absent or rare
• Although nuclei can be enlarged & pleomorphic with large or
irregular nucleoli,
nucleoli the nuclei are not significantly crowded or
disorderly & the NC ratio remain WNL.
• Chromatin is fine but nuclei can degenerate, undergoing
karyopyknosis, karyorrhexis or karyolysis
• Cancer is characterised by crowded disorderly groups &
single atypical cells with hyperchromatic coarse chromatin.
Reactive bronchial cells showing marked
nuclear size variation. Note the cilia is
retained evidence of their benign nature

Pneumocytes
• Alveoli are lined by 2 kinds of pneumocytes:
Type I & Type II
• Type I alveolar pneumocytes are flat cells
(squamous) & cover > 90% of the alveolar
surface. Not recognized
g in cytologic
y g specimens
p

• Type II granular pnuemocytes are columnar

cells that are normally found scattered in the
alveoli & secrete surfactant, usually recognized
when they are hyperplastic (reactive)
Reactive bronchial cells

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Type II Reactive Pneumocytes • Can closely mimic

Adenocarcinoma
• Reactive cells occur singly & in
clusters
• Cytoplasm finely – coarsely
vacuolated & lacks inclusions
• ↑ NC ratio, angular membranes,
chromatin clumping or clearing,
macronucleoli & can be
multinucleated
• Primary DDX is with
adenocarcinoma (BAC)

BAC is characterised by the presence of numerous well preserved tumor cells

While reactive are fewer & may be degenerated. Benign groups have scalloped
borders & less dept of focus. Cilia if present point to benign diagnosis

Alveolar Macrophages Alveolar Macrophages

• Bone marrow derived histiocytes found in free • Identical to other histiocytes
alveolar space • Vary in size
• Presence is necessary but not sufficient • Have round – oval – bean shaped nuclei
condition for adequacy of sputum specimen • May be mono – bi – multi nucleated
• Indicate that some of the peripheral, alveolar • Giant cell histiocytes mainly found in granulomatous
di
diseases such
h as sarcoidid & TB
part has been sampled.
• Chromatin has salt & pepper texture
• Ciliated respiratory cells are insufficient • One or more nucleoli may be present
evidence of deep lung sample in sputum • Cytoplasm is foamy & stains variably
• In BAL alveolar macrophages should be • Cells are phagocytic & contain various particles such as
abundant carbon
• Cells named according to particles found in them

BAL – Alveolar macrophages

Alveolar Macrophages
• Carbon histocytes
– Common in smokers & urban dwellers
– Known as “dust cells” and contain black carbon pigment
• Siderophages
– Occur in reaction to bleeding, contain blood pigment hemosiderin.
– Presence usually indicates old bleeding associated with benign
conditions such as infarcts,
infarcts heart failure,
failure & hemosiderosis or with
malignant conditions
• Lipophages
– Have lacy bubbly cytoplasm due to lipid content. Lipid source can be
endogenous (tissue destruction) or exogenous (nasal drops)
– Can be seen in conditions such as lipid pneumonia, fat embolism,
acute pancreatitis. In children may be associated with aspiration
pneumonia
– When present particularly in adults, malignant conditions must be
considered.

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BAL – Dust macrophages Siderophages

Acellular Material Curschmann’s

Ferriginous Bodies
spiral
• Found in conditions with • Form when iron salts
excess mucus production precipitated onto tiny
eg asthma & smoking rounded or fibrous
• Formation due to intrinsic inhaled dust
property of mucus • Fiber is often asbestos
• Have dark stained center but can be other particles
p
with lighter stained eg fiberglass, carbon, or
periphery & usually spiral other minerals
like a corkscrew • Typically golden brown,
• Maybe associated with beaded and have
eosinophils or neutrophils bulbous tips. Frequently
engulfed by
macrophages.

Charcot – Leyden Crystals Other acellular material

• Bi-pyramidal or needle • Alvelolar proteinosis – due to enzymatic
like red crystals
composed of condensed disorder of macrophages, results in
granules derived from coarsely granular, periodic acid – schiff
eosinophils.
p
• Eosinophils are usually
y (PAS) – positive debris.
present near the crystals
• Are particularly
associated with asthma • Amyloid is dense, acellular, waxy material
but can occur in other
allergic reactions that has a characteristic “apple green”
birefringence under polarized light after
congo red staining.

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• Corpora amylacea are concentrically laminated, Psammoma bodies are concentrically laminated, calcified
non-calcified, alveolar casts associated with bodies associated with BAC but can also be seen in benign
preceding pulmonary edema disease (eg TB or microlithiasis)

Starch – from glove powder typically has a cracked

Contaminants center & a maltese cross polarization

• Food particles –
common in sputum
and source of
diagnostic error.
• Meat is recognized by
cross striations.
• Vegetable cells have
translucent refractile
cell walls (cellulose) Vegetable Cells

Pollen – appears as colorful bodies with Benign Proliferation

cell walls and spikes
• The bronchial epithelium can undergo a series
of transformations including reserve cell
hyperplasia, squamous metaplasia & bronchial
hyperplasia in response to a variety of chronic
irritations or inflammations ranging from air
pollution to infections to cancer
• Squamous epithelium is more mechanically
resistant but less specialized than the respiratory
epithelium
• Not premalignant, squamous metaplasia is the
mileu in which cancer may arise

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Reserve Cell Hyperplasia Reserve Cell hyperplasia

• Most commonly observed in bronchial brush specimens
• Exfoliates as tightly cohesive groups of small uniform
cells, often lined on one surface by ciliated columnar
cells
• Individual reserve cells resemble
l
lymphocytes/histiocytes
h t /hi ti t
• Have small dark round nuclei with a thin rim of
basophilic cytoplasm & high NC ratio
• Nuclei may show some molding
• Nucleoli are usually absent unless cells are irritated
• Background is clean
• Dif Dx: small cell carcinoma (nuclear pleomorphism,
nuclear molding, crush artifact, tumor diathesis)

Squamous Metaplasia Parakeratosis & Atypical Parakeratosis

• Essentially normal & ranges from focal – extensive • Similar to that of pap smear
• Frequently associated with reserve cell hyperplasia
• Can be similar to that seen in pap smear with rounded • Usually results from severe irritation
parabasal sized cells.
• When immature has smaller cells with angulated, polygonal
• Atypical parakeratosis can occur with
outlines squamous cell dysplasia or carcinoma
• Cells appear in a loose cobblestone sheet – Is also known as pleomorphic parakeratosis
• Metaplastic cytoplasm is dense with distinct cell borders & mimicking keratinizing squamous cell
usually stains cyanophilic (blue-green)
carcinoma
• Nuclei round with granular chromatin, nucleoli present when
cell is irritated – Look for clear-cut malignant cells to diagnose
• Degenerative changes include cytoplasmic eosinophilia or cancer
orangeophilia & nuclear karyorrhexis or pyknosis. (May be
difficult to distinguish from parakeratosis)

Atypical Parakeratotic cells Therapeutic Agents

• Radiation & Chemotherapy can induce severe
cytologic atypia which can mimic cancer
• Clinical history is essential in diagnosis.
RADIATION
• Induces changes that are characterized by
cytomegaly of squamous or glandular cells
• Irradiated malignant cells show characterized
malignant cells plus radiation effect
• These induced changes may subside with time
or persist for life

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Radiation Effect Chemotherapy

• On squamous cells causes enlargement of • Similar changes to that of radiation
cytoplasm and nucleus so the NC ratio remains • Cells are enlarged, pleomorphic and have large
WNL nuclei with dark chromatin and prominent
• Multinucleation is common nucleoli
• Nuclei
N l i may b be h
hyper/hypochromatic
/h h ti & • Mitotic
Mit ti fifigures can b
be seen
sometimes vacuolated • Can be an increase in mucin and goblet cells
• Prominent nucleoli or macronucleoli may be • Histiocytes and inflammatory cells are frequently
seen seen in the background
• Cytoplasm is thick & dense, vacoulated & • Atypical cells tend to be few, degenerated and
polychromatic single maintaining their columnar shape

Goblet cell hyperplasia GRANULOMATOUS INFLAMMATION

• Can be seen in TB, fungus, or other infections;
rheumatoid arthritis, sarcoid & as a reaction to cancer
• Granulomas are nodular collections of epitheloid
histiocytes
• Epitheloid histiocytes are found in loose syncytial
aggregates
• The nuclei are usually elongated and have folded
nuclear membranes, fine pale chromatin & tiny nucleoli.
Cytoplasm is more abundant, eccentrically located
around the nucleus & has fibrillar quality with poorly
defined cell borders.
• In foreign body granulomas, phagocytosis is more
prominent.

Tuberculosis SPUTUM - TB

• Epitheliod histiocytes, giant cells,

lymphocytes and a necrotic background
• Acute inflammation can be seen in early
course of disease
• Identification of beaded, red AFB or +ve
culture clinches the diagnosis
• Reactive atypia of bronchial or squamous
metaplasia cells or alveolar pneomocytes
could result in a false +ve diagnosis.

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TB granuloma Sarcoid
• Chronic granulomatous disease of unknown
aetiology
• Non caseating granulomas
• Schaumann bodies or asteroid bodies are
suggestive
ti off sarcoidiosis
idi i
• Schaumann bodies are concentrically laminated
calcifications found in the cytoplasm of giant
cells
• Asteroid bodies are intracytoplasmic, radiate,
crystalline arrays.

Rheumatoid Granuloma of Lung Viral Pneumonia

• Can exfoliate epitheloid histiocytes with bizarre • Can cause reactive change in bronchial
shapes
• Have hyperchromatic, degenereated, smudged cells
nuclei with variably colored cytoplasm ranging • Have specific viral changes such as those
from blue- red – orange
g
• Background shows marked inflammation &
due to cytomegalovirus or herpes
necrotic debri • Atypical cells usually are sparse in
• Occasional multi-nucleated giant cells may be infection while in BAC are numerous
seen
• Bizarre cells can mimic keratinizing squamous
cell carcinoma.

HSV infection

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Other Infections
• Candida/ bacterial colonies –
contamination or overgrowth
• Actinomyces – common saprophyte in
tonsils
• Aspergillus, Pneumocystis – common in
immunocompromised hosts

Pneumocystis carinii Pneumocystis carinii

Pneumocystis carinii (meth. Pneumocystis carinii (giemsa)

silver)

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Candida
Aspergillosis
Pulmonary Embolism/ Infarct
• Solitary pulmonary embolism can mimic a neoplasm
• Some cases exfoliate with markedly reactive cells
• 3 D clusters of pleomorphic cells with enlarged nuclei,
irregular chromatin clearing & macronucleoli can mimic
adenocarcinoma
• Blood, inflammation, siderophages may be seen in the
background
• Squamous metaplasia is common
• Clues to benign nature – sparsity of atypical cells,
variability within groups
• Shallow depth of focus, tight cell grouping, presence of
cilia & smudgy chromatin
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Aspergillosis
Aspergillosis
Miscellaneous Benign Diseases
• Asthma: Creola bodies, Cushmann spirals,
Charcot leyden crystals, esoinophils
• Silicosis: weakly bifringent, silvery particles.
• Loffler’s Pneumonia: also known as eosinophilic
pneumonia. Associated with worm infestations
(ascariasis) with allergy, including drug reactions
& SLE
• Giant cell Interstitial Pneumonia: industrial
exposure to hard metals. Multinucleated giant
cell histiocytes containing phagocytosed cells or
debri
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TB granuloma Creola body

Bronchial asthma – mucous plugs

Strongyloides stercoralis

Cryptococcus Cryptococcus

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