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Course Objectives

RESPIRATORY
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
malignant conditions seen in the
respiratory system and the appearance of
this in smears

ML 301 Cytology
Dr Pritinesh Singh
Department of Pathology
School of Health Sciences
Fiji School of Medicine

THE RESPIRATORY SYSTEM

Introduction
CELLULAR
COMPONENTS
OF THE
RESPIRATORY
SYSTEM

Respiratory cytology consists of 3 basic types of exfoliative

specimens
Sputum, bronchial cytology (including washings & brushings) and
bronchoalveolar lavage (BAL)

In general large central tumors are more readily detected by

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

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

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

SPUTUM

BRONCHIAL CYTOLOGY

Specimens can be prepared by the

Saccomanno (blender) technique or by the pick
and smear technique

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

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)
Its 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.

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

Pearl

Squamous cells

Glandular Cells

Ciliated columnar 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)

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.

Ciliated columnar cells bronchial

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

Goblet cells with abundant mucin filled cytoplasm

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,
whereas in malignant neoplasms there is usually
a discrete population of abnormal cells

Reparative/ Regenerative
Bronchial Cells

Reactive bronchial cells showing marked

nuclear size variation. Note the cilia is
retained evidence of their benign nature

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.

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
Bone marrow derived histiocytes found in free
alveolar space
Presence is necessary but not sufficient
condition for adequacy of sputum specimen
Indicate that some of the peripheral, alveolar
part has been sampled.
Ciliated respiratory cells are insufficient
evidence of deep lung sample in sputum
In BAL alveolar macrophages should be
abundant

Alveolar Macrophages

Alveolar Macrophages

Identical to other histiocytes

Vary in size
Have round oval bean shaped nuclei
May be mono bi multi nucleated
Giant cell histiocytes mainly found in granulomatous
di
diseases
such
h as sarcoid
id & TB
Chromatin has salt & pepper texture
One or more nucleoli may be present
Cytoplasm is foamy & stains variably
Cells are phagocytic & contain various particles such as
carbon
Cells named according to particles found in them

BAL 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 Curschmanns

spiral

Ferriginous Bodies

Found in conditions with

excess mucus production
eg asthma & smoking
Formation due to intrinsic
property of mucus
Have dark stained center
with lighter stained
periphery & usually spiral
like a corkscrew
Maybe associated with
eosinophils or neutrophils

Charcot Leyden Crystals

Bi-pyramidal or needle
like red crystals
composed of condensed
granules derived from
eosinophils.
p
are usually
y
Eosinophils
present near the crystals
Are particularly
associated with asthma
but can occur in other
allergic reactions

Form when iron salts

precipitated onto tiny
rounded or fibrous
inhaled dust
Fiber is often asbestos
p
but can be other particles
eg fiberglass, carbon, or
other minerals
Typically golden brown,
beaded and have
bulbous tips. Frequently
engulfed by
macrophages.

Other acellular material

Alvelolar proteinosis due to enzymatic
disorder of macrophages, results in
coarsely granular, periodic acid schiff
(PAS) positive debris.
Amyloid is dense, acellular, waxy material
that has a characteristic apple green
birefringence under polarized light after
congo red staining.

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Corpora amylacea are concentrically laminated,

non-calcified, alveolar casts associated with
preceding pulmonary edema

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

Psammoma bodies are concentrically laminated, calcified

bodies associated with BAC but can also be seen in benign
disease (eg TB or microlithiasis)

Starch from glove powder typically has a cracked

center & a maltese cross polarization

Vegetable Cells

Pollen appears as colorful bodies with

cell walls and spikes

Benign Proliferation
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
Essentially normal & ranges from focal extensive
Frequently associated with reserve cell hyperplasia
Can be similar to that seen in pap smear with rounded
parabasal sized cells.
When immature has smaller cells with angulated, polygonal
outlines
Cells appear in a loose cobblestone sheet
Metaplastic cytoplasm is dense with distinct cell borders &
usually stains cyanophilic (blue-green)
Nuclei round with granular chromatin, nucleoli present when
cell is irritated
Degenerative changes include cytoplasmic eosinophilia or
orangeophilia & nuclear karyorrhexis or pyknosis. (May be
difficult to distinguish from parakeratosis)

Atypical Parakeratotic cells

Parakeratosis & Atypical Parakeratosis

Similar to that of pap smear
Usually results from severe irritation
Atypical parakeratosis can occur with
squamous cell dysplasia or carcinoma
Is also known as pleomorphic parakeratosis
mimicking keratinizing squamous cell
carcinoma
Look for clear-cut malignant cells to diagnose
cancer

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
On squamous cells causes enlargement of
cytoplasm and nucleus so the NC ratio remains
WNL
Multinucleation is common
Nuclei
N l i may b
be h
hyper/hypochromatic
/h
h
ti &
sometimes vacuolated
Prominent nucleoli or macronucleoli may be
seen
Cytoplasm is thick & dense, vacoulated &
polychromatic

Goblet cell hyperplasia

Chemotherapy
Similar changes to that of radiation
Cells are enlarged, pleomorphic and have large
nuclei with dark chromatin and prominent
nucleoli
Mitotic
Mit ti fifigures can b
be seen
Can be an increase in mucin and goblet cells
Histiocytes and inflammatory cells are frequently
seen in the background
Atypical cells tend to be few, degenerated and
single maintaining their columnar shape

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

Can exfoliate epitheloid histiocytes with bizarre
shapes
Have hyperchromatic, degenereated, smudged
nuclei with variably colored cytoplasm ranging
from blue- red orange
g
Background shows marked inflammation &
necrotic debri
Occasional multi-nucleated giant cells may be
seen
Bizarre cells can mimic keratinizing squamous
cell carcinoma.

Viral Pneumonia
Can cause reactive change in bronchial
cells
Have specific viral changes such as those
due to cytomegalovirus or herpes
Atypical cells usually are sparse in
infection while in BAC are numerous

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.

silver)

Pneumocystis carinii (giemsa)

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Candida

Aspergillosis

Aspergillosis

Aspergillosis

Pulmonary Embolism/ Infarct

Miscellaneous Benign Diseases

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

Asthma: Creola bodies, Cushmann spirals,

Charcot leyden crystals, esoinophils
Silicosis: weakly bifringent, silvery particles.
Lofflers 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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