PART TWO
Diagnostic Cytology
Fig. 28.26 Liver cell adenoma. The tumor is composed of monotonous
population of normal-appearing polygonal hepatocytes. No portal triads or
bile ducts are present. FNA smear (Papanicolaou x HP).
Fig. 28.27 Pleomorphism of hepatocytes in cirrhosis or
macroregenerative nodules of the liver. Liver cells that have nuclei
showing variation in size and prominent nucleoli in cohesive groupings.
FNA smear (Papanicolaou x HP).
the previously m en tio n ed cytologic finding s
coupled w ith
clinical h isto ry are in keeping w ith a liv e r cell adenom a.
Key features of liver cell adenoma
• C lin ic a l: h is to ry o f lo n g -te rm use o f o ra l contraceptive.
• C T scan: circum scribed, so m e tim e s encapsulated mass
w ith lo w d e n sity o n n o n c o n tra s t and a m arked c entrip etal
p a tte rn o f e n h a n c e m e n t o n a rte ria l phase. T h e le s io n can
have a central n e c ro tic area o r calcifications.
• P hysical features o f th e aspirate: fin e -n e e d le cores d iffic u lt
to sm ear.
• M o n o to n o u s p o p u la tio n o f p o ly g o n a l hepatocytes w ith
n o rm a l n u c le a r to c yto p la sm ic ( N /C ) ra tio .
Cirrhosis
C irrho sis is a chronic, diffuse process characterized by extensive
in te rs titia l fibrosis and the conversion o f n o rm a l liv e r architec-
ture in to struc tu rally ab norm al nodules. Grossly, the n o d u la r
pattern m ay be m ic ro n o d u la r o r m acronod ular. In the m ic ro -
n o d u la r category, the nodules o f a c irrh o tic liv e r are o f the same
size, n o larger th a n 0.3 m m in th e ir greatest d im ension. In the
m ac ron od u la r category, the nodules are m uch m ore variable in
size and m an y exceed 1 cm in the greatest d im ension. A m acro-
nodular, h ea vily fib ro tic liv e r is typical o f the late stage o f cir-
rhosis, w hatever its etiology. M icroscopically, round ed nodules
are w e ll demarcated and separated b y dense fib rous septa. The
regenerative nodules are com posed o f hepatocytes e xh ib iting
m arked variatio ns in size and shape. B in uc lea tio n is a c om m o n
find ing . Focal areas o f necrosis m ay be seen. B ile d uctular p ro lif-
e ration and a m ixed in fla m m a to ry in filtra te occur in som e n od -
ules. However, in inactive cirrhosis, in fla m m a to ry in filtra tio n is
m ild , d uctular p ro life ra tio n is inconspicuous, and hepatocytes
show little o r no necrosis. V a ria tio n in activity fro m one part o f
a c irrho tic liv e r to a no the r is com m on.
Cytology
Fine-needle aspiration biopsy o f c irrhotic liv e r nodules is d iffic u lt
to sm ear due to intact reticulum fib er n e tw o rk.25 A com b in atio n
o f regenerative changes, fibrosis, degenerative changes, and fa tty
Fig. 28.28 Pleomorphism of hepatocytes in cirrhosis
macroregenerative nodules of the liver. Large hepatocytes that
have marked variations in nuclear size and shape and prominent nucleoli.
FNA smear (Papanicolaou x HP).
m etam orphosis is seen. Regenerative changes are represented by
p leom orp hism o f hepatocytes and an increase in the n um b er o f
m ito tic figures and binucleated hepatocytes. The nuclei o f hepa-
tocytes often show variatio n in size and have p ro m in e n t nucle-
o li (Fig. 28.27) . The hepatocytes are enlarged. T h e ir nuclei are
irregular, w ith p ro m in e n t nucleoli and m arked variations in size
(Fig. 28.28) . This is a p otential p itfa ll in the in te rp reta tion o f live r
aspirates at hig h-p ow er exam ination because it m ay be m istaken
fo r hep atocellular carcinom a b y inexperienced exam iners.32
However, the rig id cores' appearance o n smears and the intact
re tic u lin fib er n etw ork on cell b loc k w ill prevent the overcall.
Degenerative changes are represented b y necrosis o f hepa-
tocytes appearing as ghost cells in FN A smears. Fibroblasts are
present in variable num bers and are in te rm in g le d w ith hepa-
tocytes. Hepatocytes are o fte n seen embedded in fragm ents
o f fib rous tissue. Fatty changes o f hepatocytes are a c om m on
find ing . N e u tro p h ils and lym phocytes are present in variable
am ounts in d iffe re n t specimens. Because o f variatio ns in activity
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