PART TWO
Diagnostic Cytology
Fig. 28.55 Angiosarcoma of the liver. Bloody aspirate containing
metachromatic mesenchymal tissue studded with atypical nuclei.
FNA smear (Romanowsky x LP).
Fig. 28.56 Angiosarcoma of the liver. A fragment of mesenchymal tissue
with openings. FNA smear (Papanicolaou x MP).
ro u tin e liv e r fu n c tio n test. CT scan o f the abdom en finds m u ltip le
liv e r masses w ith no k n o w n prim ary. T he e p ith e lio id endothe-
lia l cells are in va ria b ly associated w ith a strom a th a t varies fro m
loose and m yxo id to dense and fibrous. The neoplastic endothe-
lia l cells have ab und ant cytoplasm fo rm in g intracytop lasm ic
lum ens (Fig. 28.5 8 ) th a t express CD31, C D 34, and fa c to rV III.
T he FN A smears are p aucicellular due to the fib ro tic strom a
and contain scattered single cells and occasional sm all tis-
sue fragm ents. There is an ad m ixture o f sm all b lan d cells w ith
scanty cytoplasm , sp indled cells, and large p leo m o rp hic cells
w ith ab und ant cytoplasm . M a n y o f the tu m o r cells are tadpole-
shaped, w ith nuclei at the head and a lon g cytoplasm ic ta il
(Fig. 28.5 9 ) . Scattered cells contain p ro m in e n t nuc le oli, w h ile
others dem onstrate hyperchrom asia. Rare m ultin u clea te d tu m o r
cells are present.66 It is a lm ost im p ossib le to diagnose hepatic
e p ith e lio id h e m an g io en d o the lio m a w ith certainty based on
cytology alone. It is crucial d u ring on-site assessment to request
Fig. 28.57 Angiosarcoma of the liver. Higher examination of the opening
revealed flat endothelial cells surrounded by atypical spindle and ovoid
nuclei. FNA smear (Papanicolaou x HP).
Fig. 28.58 Epithelioid hemangioendothelioma of the liver. On
histology, the epithelioid endothelial cells are associated with abundant
stroma. The neoplastic endothelial cells have abundant cytoplasm forming
intracytoplasmic lumina. Cell block (Trichrome x MP).
a cell b loc k sam ple fo r h isto lo g y and im m un oh istoc he m istry.
E p ith e lio id h e m an g io en d o the lio m a is an im p o rta n t diagnosis,
since lon g -term disease-free survival is possible, especially in the
setting o f o rth o to p ic liv e r tra n sp la n ta tio n .67
Tumors Metastatic to the Liver
The liv e r fre q ue ntly harbors m etastatic growths. A p p roxim a te ly
80% o f the cases o f FN A b iop sy o f the liv e r in the senior author's
series were m a lig n a n t tu m o rs.1 A m o n g them , 90% were can-
cers m etastatic to the liver. The cancer cells m ay reach the liv e r
th rou g h the p ortal vein, hepatic artery, o r h ila r lym p hatics o r by
direct extension. Practically all m a lig n a n t cells grow w e ll in liv e r
parenchym a, and m etastatic carcinom as u su a lly grow rap id ly
in the liver. P rim a ry m a lig n a n t tu m o rs o f the gallbladder, extra-
hepatic b ile ducts, pancreas, and stom ach fre q u e n tly in vo lve the
894
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