Atypical cells in a background of reactive and hyperplastic bronchial epithelium and some inflammatory cells (atypical category III according to The Papanicolaou Society of Cytopathology System for Reporting Respiratory Cytology)
- Some loose and some cohesive cellular clusters
- Some tissue fragments imparting a appearance of pseudopapillary tissue fragments
- Minimal overcrowding and overlapping
- Minimal disorganisation/ loss of polarity
- Few dispersed epithelial cells show large nuclei with moderate variation in size and elevated N/C ratio and nuclear hyperchromasia
- Minimal nuclear border irregularity and nucleoli is not apparent
- Easily evident terminal bars and cilia in many of cells, which show hyperchromatic nuclei, loss of polarity and occasional with nuclear border irregularity
- Few cohesive fragment of relative monomorphic cells with high N:C ratio, mild hyperchromasia, which are surrounded by ciliated bronchial cells are indicative of reserve cell hyperplasia
- Background shows inflammatory cells along with few macrophages and blood
- Necrotic debris are not seen
Points of pathoclinics:
- Present case shows some of the architectural and nuclear abnormalities that are more than those seen in benign/reactive conditions. Also these findings are insufficient to call it as a suspicious for malignancy or confirm malignancy.
- Minimal anisonucleosis, mild degree of loss of polarity along with disorganized placement of cells in a detached strip, minimal overlapping and scattered large cells with high N/C ratio, nuclear border irregularity and focal chromatin clearing put this case in atypical category. In addition features like presence of terminal bards and cilia, clusters of reserve cells hyperplasia and inflammatory background prevent this case to put into suspicious category. Absence of chromatin clumping, marked nuclear border irregularity and very minimal variation in size and shape prevent the over diagnosis of malignancy.
- Moderate to marked degree of anisonucleosis, disorganized arrangement of cells, significant overlapping and crowding of cells, nuclear border irregularity and hyperchromasia are features of malignant process
- High N/C ratio due to decrease amount of cytoplasm and prominent nucleoli can be seen in reactive epithelium.
- Chronic smoking can induce squamous metaplasia, high N/C ratio and even moderate to marked pleomorphism, abnormal chromatin pattern and even disorganized tissue fragments; however, consideration of all features in appropriate clinical and radiological context may prevent the misinterpretation.
- Atypical category includes insufficient qualitative criteria as well as insufficient quantity of abnormal cells for designation of malignancy. Atypical category should not include a reactive atypia, later is considered in a benign category.
- Risk of malignancy in atypical category ranges from approximately 50 -60%
- Close consideration here are organizing pneumonia, diffuse alveolar damage/acute lung injury, as well as well-differentiated adenocarcinoma, in a patient with history of smoking and lung mass.
- Lepidic pattern of adenocarcinoma may show lower N/C ratio due to relative large amount of cytoplasm with mucinous vacuoles, bland chromatin pattern, hobnail appearance of nuclei and intranuclear grooves and inclusions.
- Significant number of ciliated bronchial cells with terminal bar favors reactive process over malignant process.