PART TWO
Diagnostic Cytology
Fig. 30.4 Chronic radiation change in the lung. The smear contains a
loose aggregate of epithelial cells with enlarged nuclei, irregular chromatin
distribution, and multiple nucleoli. Bronchial epithelial cells are seen in the
background. Bronchial brushing (Papanicolaou x MP).
ratio , hyperchrom asia, irreg ular c lum p ing o f c hrom a tin , and
p ro m in e n t n u c le oli (Fig. 3 0.4) . M etaplastic changes m ay affect
b ron c hial subm ucosal serom ucous glands. O b ta in in g a patient's
h is to ry o f irra d ia tio n is o f critical im p ortance to avoid m aking
a diagnosis o f m alig nancy based on o n ly a few h ig h ly atypical
cells. T he changes associated w ith ra d ia tio n p n e u m o n itis m ay
be present in som e fields n o t d irectly in the ra d ia tio n ports.
These changes are th o u g h t to be secondary to the elab oration
o f cytokines. These includ e alveolar exudates, m ig ra tory organ-
izin g p neum onia, and b ilateral in te rs titia l p neum onia. Radia-
tio n o f pleura and m e sothe lium does n o t produce long -lasting
effects th a t are lik e ly to be confused w ith carcinom a.34 The
chronic ra d ia tio n changes are s im ila r to the chem otherapeutic
changes fo u n d w ith b leom ycin, busulfan, and o th e r p u lm o n a ry
toxic antineop lastic drugs. I f chem otherap y fo llo w s rad ia tio n,
th is m ay lead to a recall p n eum onitis.
Urinary Tract
T he u rin a ry bladder is affected w h e n irra d ia tio n is given fo r u ri-
n ary bladder cancer and o th e r pelvic m alignancies. R ad iation
changes o f the u ro th e liu m occur relative ly early, as soon as the
second day o f tre a tm e n t.35,36 Benign u ro th e lia l cells show p ro-
nounced cellular enlargem ent accom panied b y nuclear sw elling
and cytoplasm ic vacuolation. O th e r nuclear changes include
hyperchrom asia, irreg ular shapes, pyknosis, karyorrhexis, and
m u ltin u c le a tio n . These features are m ost easily visualized in
superficial u ro th e lia l cells (Fig. 3 0.5) . C ytoplasm ic vacuola-
tio n and m u ltin u c le a tio n are n o t specific fo r ra d ia tio n effect.
T he y can be fo u n d in non irrad ia ted bladder e p ith e liu m sec-
ond ary to chronic cystitis o r calculi. Recognition o f unaffected
high-grade m a lig n a n t cells is o fte n n o t very d iffic u lt in u rin e
cytology. T he y m a in ta in a h ig h nucleocytoplasm ic ratio , w ith
hyp erchrom atic nuclei having p ro m in e n t irreg ular nucleoli. The
nuclear hyperchrom asia o f m a lig n a n t cells is m arked com pared
w ith reactive u ro th e lia l cells in the same specim en. Irradiated
u ro th e lia l cells m ay m im ic squam ous cell carcinom a, causing a
diagnostic p rob lem w h en the ra d ia tio n therapy is given fo r car-
cinom a o f the cervix.37 T he d istin c tio n between a lo c a lly invasive
cervical carcinom a and a high-grade u ro th e lia l cell carcinom a
Fig. 30.5 Radiation change in the urinary bladder. The affected
urothelial cells have vacuolated cytoplasm, nuclear enlargement,
finely granular chromatin, and small nucleoli. Catheterized urine
(Papanicolaou x MP).
w ith squam ous d iffe re n tia tio n m ay be d iffic u lt and m ay need a
detailed clinical h is to ry to resolve.
U rin e cytology is a useful m eth od fo r the fo llo w -u p o f patients
w ith irradiated bladder cancer. Esposti and associates reported
89% accuracy in detecting persistent o r recurrent carcinom a.38
O n ly one p a tie nt o f 25 w ith rad ioresistant tu m o r had negative
cytology findings. O f 54 patients w ith recurrences, u rin e cytol-
ogy revealed fra n k ly m a lig n a n t cells in 46 cases. O f patients w ith
recurrence, 17 had p ositive u rin e cytology find ing s 3 -2 4 m on ths
preceding the clinical recog nition o f recurrence.
As a com p lica tion o f radiotherapy, m a lig n a n t neoplasm s can
develop in the u rin a ry bladder. T he lead tim e fo r second m alig -
nancies fo llo w in g ra d ia tio n is fro m 2 to 10 years. U ro th e lia l cell
carcinom a, squam ous cell carcinom a, and sarcom a have been
reported.37
Breast
R adiation-induced change in the breast cytology is a som ew hat
n e w ly recognized p rob lem because o f the greater tendency to
treat sm all localized breast cancer conservatively w ith lum pec-
to m y o r quadrantectom y com bined w ith rad iation.
S c hn itt and coworkers studied the ra d ia tio n effect o n breast
tissue o f 30 patients w ith breast cancer.39 E p ith e lia l atypia in the
te rm in a l duct lo b u la r u n it associated w ith lo b u la r sclerosis and
atrop hy was the characteristic find ing . E p ith e lia l atypia in large
ducts, strom a l changes, and vascular changes were less frequent.
The atypical e p ith elial cells s till m ainta ine d p o la rity and cohe-
sio n w ith o u t evidence o f cellular p leo m o rp hism o r p ro life ra tio n .
These changes could easily be distinguished fro m m alignancy.
Fat necrosis m ay be present as a palpable breast lesion fo llo w in g
breast-conserving therapy. Surgery can be avoided by using fine-
needle asp iration (FN A ) to evaluate such lesions. Radiated breast
and a xilla ry tissue are at risk fo r developing angiosarcom a.
Cytology
In te rp re ta tio n o f the FN A b iopsy sam ple o f a recurrent breast
mass after irra d ia tio n m ay be m ore intrig uing . N o rm a l breast
ductal and lo b u la r e p ithelia m ay have dyscohesion and severe
atypia w ith large, p leom orp hic, hyp erchrom atic nuclei and o n ly
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