POST-MORTEM CYTOPATHOLOGY�[adapted from IAC presentation, 2010]

Sebastian Lucas

Dept of Histopathology

St Thomas’ Hospital

London SE1, UK

MRCPath pt2 - 1978

• Non-gynae cytology slide
• CSF

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• ‘Botryomycosis’
• Staph aureus meningitis

In 2009, I only knew about brain smears for malaria

…then Ash Chandra asked me to prepare a plenary talk for Edinburgh 2010 IAC

AT-05-466

• Female 35 yr, Nigerian
• Two days of feeling unwell
• Found dead in bed by her partner

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• Recent visit home

• Autopsy
• No gross lesions to see

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• Question
• Cause of death:
• Partner violence?
• Natural cause of death?
• ?cerebral malaria

AT-05-466

GIEMSA

AT-05-466

• Pathognomonic of cerebral malaria
• Plasmodium falciparum

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• Brain slicing – no lesions, but a little darker than normal
• Sequestation of parasitised RBC
• No inflammation

...and only this week�AT-12-191

• 9 yr old Nigerian girl, recent return from Lagos
• Admitted in extremis
• Hb = 2g/dL
• PLT = 15
• Hypoglycaemic
• Blood smear +ve for P.falciparum
• Known HbSS, but not on transfusion programme
• Died of cardio-pulmonary failure

Brain smears

• ...negative
• Tissue histology
• No malaria
• Blood smear to be reviewed at the London Malaria Reference Laboratory

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• She died of hepato-splenic sequestration crisis due to HbSS sickle

Contents�

• Literature search
• Results of a loose study
• Comparison of imprint dab cytology with fixed tissue histopathology
• Conclusion on utility
• Tumours and infections
• Pneumonia
• Avoiding tissue histology taking?
• Speed = clinician satisfaction

Literature search – not a lot

• Suen et al [Canada]
• The use of imprint technic for rapid diagnosis in postmortem examinations. A diagnostically rewarding procedure
• Am J Clin Pathol 1976, 65:291

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• Survarna & Start [UK]
• Cytodiagnosis and the necropsy
• J Clin Pathol 1995, 48:443

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• Schnadig et al [USA]
• Cytodiagnosis in the autopsy suite
• APLM 2007, 131:1056

• Diagnostic utility of postmortem FNA cultures [Spain]
• APLM 1998, 122:650

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• Percutaneous needle autopsy sampling
• Mod Pathol 1996, 9:1101

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• Clinician-oriented and cytology-oriented autopsy: Respiratory & Hepato-biliary systems
• Japanese journal 1985

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• Usefulness of rapid cytological diagnosis at autopsy
• Japanese journal 2005

The usual range of tumours, infections and benign lesions

Quoted Reasons for doing it

• Autopsy quality improvement
• Resident/trainee education
• BMS/lab scientist education
• Obtain material for microbiology
• Low cost, little equipment needed
• Quick – little delay for autopsy diagnosis

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• Resource-poor setting – no histopathology

Overview of tissue sampling at autopsy

Histopathology samples

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Frozen section Fixed tissue

Dab imprints

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Air dry Alcohol-fix

FNA samples

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Cytology Microbiology

Fluid, Tissue

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Microbiology

Core biopsy tool

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Percutaneous sampling

Tissue

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Electron

microscopy

Protocol

• St Thomas’ Hospital mortuary + others
• Focal lesions & pneumonias

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• Dab imprints
• Air dry + alcohol fix (~4+)
• Giemsa + Pap
• Special stains, IHC

• In most cases, histo-pathology also

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• Compare the modalities
• Qualitative
• Subjective
• Not statistical

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AT-10-33

• Female 48 yr
• Admitted with left arm weakness & headache
• HIV test +
• CT scan: multiple white matter lesions, non-enhancing.

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• Radiologic DD:
• TB
• Metastases
• Toxoplasmosis
• Viral encephalitis

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• Died one week later without a CNS diagnosis

• Autopsy

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• Brain swollen
• Multiple soft necrotic lesions throughout the cerebrum
• Largest 5cm

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• Question
• What are they?

AT-10-33 - brain

Pap

AT-10-33

• CRYPTOCOCCUS NEOFORMANS

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• Many other organs involved
• Heart
• Kidney
• Lungs
• etc

Giemsa

Grocott

PAS

Mucicarmine

Histopathology

AT-10-25

• Female 37 yr
• Diagnosed HIV+ >10 years
• On cART, but stopped a year ago
• Re-presented with PCP
• CD4 = 6; VL = 146,490
• Progressive lung and multi-organ failure
• No diagnosis in life

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• Autopsy
• Lungs consolidated
• Multiple grey-tan lesions in all 5 lobes
• Similar lesions in the brain

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• Question
• ?diagnosis

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Lung

Giemsa

PAS

Grocott

Lung histology

AT-10-25

• Disseminated aspergillosis in HIV disease

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• Many dab slides had little or no fungus

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• Giemsa better than Pap

AT-10-226

• Male 70 yr
• HCV+, ESRD
• On haemodialysis

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• Feeling unwell for a month

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• CXR abnormal (!)
• Died before tests identified the cause

AT-10-226

CXR 2007

CXR 5 days before death

CT before death

Report:

? Malignant

? TB

AT-10-226

• Cirrhosis of the liver

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• Lungs – miliary lesions

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• Small kidneys

AT-10-226

Mycobacteria++

M.Tb cultured

• Confirm species
• Drug resistance

“Can histopathologists diagnose bronchopneumonia at autopsy?”

Hunt et al

J Clin Pathol 1995

K16.2010

• Male 59 yr

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• Found dead at home

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• History of alcohol abuse

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• No indication of recent antibiotic intake

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• Autopsy
• Pneumonia

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• Question
• Gross ‘natural’ cause of death
• Coroner – “NO histology”

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• With dab imprint?
• Confirm pneumonia?
• Identify the bug?

Giemsa

Gram

K16.2010

• Conclusion

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• Coccal pneumonia

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• Probably Streptococcus pneumoniae
• May be Gram variable

AT-10-98

• Female 17yr
• Pregnant
• Found dead in bath
• Brain death

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• Died four days later in ITU

• Autopsy

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• ? Bronchopneumonia

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Gram

AT-10-98

• Conclusion

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• Polymorphs++

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• Gram+ diplococci

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• Pneumococcal lung infection

• Cf: Group A Strep pyogenes

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AT-10-212

• HIV+ve female
• New diagnosis

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• Sudden respiratory collapse

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• CXR = white out
• Died

• Autopsy

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• Oedematous lung

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• Question
• ?PCP
• ?acute heart failure
• ?what

Giemsa

AT-10-212

• Conclusion
• No acute inflammation
• No PCP

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• Therefore oedema: cause to be determined

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Autopsy 11 days after death

Bacterial contamination, but

no polymorphs

...and another

First conclusion

• Cytodabs good for rapid diagnosis
• Can distinguish pulmonary oedema vs infection (polymorphs +/- bugs)

What about tumours?

Unexpected tumours at autopsy quite common

AT-10-87

• Male 79 yr
• Haemophiliac, HCV+
• Cirrhosis
• Recent presentation with mass under jaw and in axilla
• En route to hospital for scanning, dropped dead.

• Autopsy
• Intra-abdominal haemorrhage
• Splenic rupture due to tumour
• White tumour in neck and axillary nodes

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• Question
• Dab imprint of node
• what is the diagnosis?

Spleen

Neck node

Giemsa

Pap

CD20

MIB-1

AT-10-87

• High grade B-cell non-Hodgkin lymphoma

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• Cytology = Histopathology

AT-10-94

• Male 63 yrs
• Stage IV mediastinal Hodgkin disease
• Nodular sclerosing
• Rx: ABVD

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• Developed neutropaenic sepsis

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• Autopsy
• Mediastinal fibro-necrotic mass 7x4x3cm, contiguous with....
• Lung mass 5x4x3cm

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• Question
• ?residual viable HD?

Giemsa

AT-10-94

• Residual viable HD tumour confirmed

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• Cytology = Histopathology

Case

• Female 49yr
• No medical history; one adult son; new partner

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• Wants to be sterilised

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• Under GA:-
• Tubes clipped and uterine coil removed
• Discharged home

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• Next day, feels unwell
• Goes to A&E Dept
• Clammy, cold
• BP 160/106, PR 155
• Collapses
• Taken to ITU
• Dead 5 hours after arrival
• Clinical diagnoses
• ?Pulmonary embolism or infection

Case 1 - autopsy

Right adrenal tumour

Phaeochromocytoma

Case – autopsy – dab imprint cytology of adrenal tumour

S100

Chromogranin

Giemsa

Pap

And now for something different��Case 2�Male 47yr, found dead at home

Air-dried dab imprint

Giemsa stain

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What solid organ is sampled?

What disease process?

Case

• Is it?
• 1. mucin-secreting adenocarcinoma
• 2. macrophage infiltrate with haemophagocytosis
• 3. sea-blue histiocytosis
• 4. hepatic steatosis
• 5. adrenal adenoma
• 6. cryptococcosis

Case

• Answer: macrovesicular steatosis of the liver

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• Liver: 4260gm,
• Fatty++, not cirrhotic

Conclusions

• Obviously useful, sensitive, specific
• Post-mortem autolysis limitation
• Pyogenic pneumonia vs not - OK
• Fungi – easy (sampling)
• Bacteria – Giemsa better than Pap
• Mycobacterial infections – usually easy
• Tumours
• Lymphoma straightforward

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Can pathologists diagnose bronchopneumonia?

• Hunt et al. J Clin Pathol 1995, 48: 120-123
• Yes and No

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• 279 cases
• ‘bronchopneumonia’ described in gross report, the histology report, or both
• Median lung samples = 2

• Only 74% confirmed by histology
• Consultants more consistent than trainees
• IMPLICATION
• Histology rate is ‘unacceptably high’
• Do coroners want THE diagnosis, or A diagnosis from their autopsies?

Other identifiable lesions

• Survarna & Start
• Cytomegalovirus
• Candida
• Renal fibroma
• Nodular goitre
• Rhabdomyosarcoma
• Carcinoid tumour

• Schnadig et al
• Melanoma
• Herpes virus
• Bacterial cholecystitis
• Acute lung injury (HMD)
• Large epithelial cells around fibrinous debris
• Asbestos bodies

Final Case

• Male 34yr, caucasian
• Suicide pact with non-partner female
• Hydrogen sulphide poison
• Found dead in a van by dog-walker

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• Autopsy
• Normal brain
• Normal heart and lungs etc

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• Spleen 200gm
• Small white nodules

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Dab imprint of spleen

Giemsa

Spleen dab

HIVp24

Cytopathology 2012

Consent issues – Human Tissue Act 2004

• Who owns the tissues?
• Is consent needed & appropriate?

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• Can cytopathology cheat the system?
• Is dab cytology ‘tissue retention’?
• It is ‘human tissue’ – it contains DNA
• What happens to the slides afterwards
• Photographed & discarded, retained, inadvertently lost in the office?

Questions?