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Fluid & Brush Quiz 1 This 59 year-old white male smoker presents to the pulmonary clinic with a history of recent onset of hemoptysis. He has been seen for several years because of COPD. Bronchoscopy reveals an intraluminal mass. A bronchial brush and biopsy are performed. The following images are from the thin prep of the brush. The most probable diagnosis is:
Answer: (D) Malignant, small cell carcinoma.
Diagnostic Features in this case: In general, the thin prep contains clusters to scattered, small cells. Many cells tend to be well scattered. The nuclei are small, without prominent nuclei, and "salt and pepper" like clumpy chromatin which is suggestive of neuroendocrine cells. These features are highly suggestive of small cell carcinoma and the diagnosis is confirmed on biopsy (Panel E).
Discussion: In contrast to biopsy specimens, cells in small cell carcinoma are very well preserved in thin prep solution. They appear different from the biopsy specimen that is frequently smeared and somewhat difficult to interpret. In addition, both benign and malignant cells round up in fluid and they need to be evaluated in this light. Small cell carcinoma cells tend to be separate and not in clumps in this thin prep fluid. However if you look long enough you will always find at least one clump that will confirm your suspicion this is indeed small cell carcinoma and not lymphoma. In addition, the absence of lymphoglandular body does not support the diagnosis of lymphoma.