Fig. 2.1
Nondiagnostic. Tissue is uninterpretable due to obscuring blood clot. Tissue casts and clots expressed onto glass slides should be picked up off the glass slide with the needle tip and placed in formalin for processing as a cellblock. (Direct smear; Hematoxylin and Eosin)
Fig. 2.2
Nondiagnostic. Normal pancreatic acinar tissue. When an FNA is performed to evaluate a discrete solid or cystic mass lesion, normal pancreatic tissue does not explain the mass and indicates a sampling error. Benign tissue may be present in the setting of chronic pancreatitis where fibrosis forms a mass lesion, but normal appearing acinar tissue is nondiagnostic. (Direct smear; Papanicolaou)
Fig. 2.3
Nondiagnostic. Few gastric epithelial cells only. Recognizing gastric and duodenal epithelial contamination is critical to accurate interpretation of EUS-FNAs. Benign gastric epithelial cells from the EUS-FNA of a solid mass lesion are easily recognized as contamination. It is more challenging to differentiate gastric epithelium from low-grade dysplasia of a mucinous cyst. The organ traversed (duodenum versus stomach), ancillary testing results (CEA and KRAS or GNAS mutations), and quality and quantity of the gastric-type epithelium all contribute to the decision to classify an FNA as nondiagnostic. (Direct smear; Papanicolaou)
Fig. 2.4
Nondiagnostic. Stripped naked nuclei consistent with gastric contamination. Gastric epithelial cells may loose their cytoplasm and form a sea of naked nuclei, some with nuclear grooves, entrapped in a mucoid background. The phenomenon is not a feature of mucinous cystic lesions. (Direct smear; Diff-Quik)
Fig. 2.5
Nondiagnostic. Thin, clear cyst fluid with rare histiocytes, CEA of 85 ng/ml, which is not elevated above our cutoff level of 192 ng/ml to support a mucinous cyst and no KRAS or GNAS mutations to support a mucinous etiology. (Cytospin; Papanicolaou)
Preparation artifact precludes evaluation of the cellular component.
Obscuring artifact precludes evaluation of the cellular component.
Gastrointestinal epithelium only.
Normal pancreatic tissue elements in the setting of a clearly defined solid or cystic mass by imaging.
Acellular aspirates of a solid mass or pancreaticobiliary brushing.
Acellular aspirate of a cyst without evidence of a mucinous etiology such as thick colloid-like mucus, elevated CEA or KRAS or GNAS mutation (See Chap. 6).
Explanatory Notes
It is very important for the pathologist to take into consideration the imaging characteristics of the lesion being sampled and all ancillary testing performed on the specimen when determining whether a biopsy is nondiagnostic. This is particularly important for pancreatic cysts . Cyst fluid analysis with biochemical and molecular testing is a vital component of the overall evaluation of the specimen and should be incorporated into and reported with the specimen when available, just like with any pathology specimen where ancillary testing refines the diagnosis (see Chap. 6 and sample reports below). CEA and amylase testing should be available at the time of sign out whereas molecular testing usually takes longer. A low CEA and unavailable molecular result may well lead to a nondiagnostic report.
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