TIMELY REVIEW
Section Editor: Zubair Baloch, M.D.
Intranuclear Peudoinclusions:
Morphology, Pathogenesis, and Significance
Sandeep Kumar Arora, M.D. and Pranab Dey, M.D.*
Intranuclear pseudoinclusions represent invaginations of the
cytoplasm into the nucleus. The nuclear pseudoinclusions are
generally easier to appreciate in cytological preparations than
frozen sections or histopathology thus forming an important
cytological feature. In the present article we have reviewed the
morphology, pathogenesis, differential diagnosis, and clinical
significance of intranuclear cytoplasmic pseudoinclusion. Diagn.
Cytopathol. 2012;40:741–744. ' 2011 Wiley Periodicals, Inc.
Key Words: pseudoinclusion; nucleus
Intranuclear pseudoinclusions, also known as ‘‘nuclear
cytoplasmic inclusions,’’ represent an invagination of the
cytoplasm into the nucleus and are seen frequently in pap-
illary carcinoma of thyroid as well as other types of
tumors.1,2 The nuclear pseudoinclusions are generally eas-
ier to appreciate in cytological preparations than frozen
sections or histopathology sections and thus forming an
important cytological feature. Over or under interpretation
of a pseudoinclusion on a cytology slide can lead to diag-
nostic error. In the present article we have reviewed the
morphology, pathogenesis, differential diagnosis, and clin-
ical significance of intranuclear cytoplasmic pseudoinclu-
sion (INCI).
Morphology of Nuclear Pseudoinclusions
The intranuclear inclusion often appears as a discrete vari-
able-shaped structure within the nucleus just like a true
inclusion. INCIs are described either as round or oval
areas of pallor in the nucleus. Other shapes, like oval,
tear drop/flask-shaped, irregular, planoconvex/semicircu-
lar, and rectangular forms are less commonly seen.1
Department of Cytology, Postgraduate Institute of Medical Education,
and Research, Chandigarh, India
*Correspondence to: Pranab Dey, M.D., Department of Cytology,
Postgraduate Institute of Medical Education and Research, Chandigarh,
India. E-mail: deypranab@hotmail.com
Received 6 January 2011; Accepted 15 March 2011
DOI 10.1002/dc.21714
Published online 4 May 2011 in Wiley Online Library
(wileyonlinelibrary.com).
' 2011 WILEY PERIODICALS, INC.
The INCI appears as a pink/magenta staining in May
Grunwald-Giemsa (MGG)-stained smears because of the
nuclear envelope and/or when the cytoplasm itself is red-
dish in color (Figs. 1a and b). It has a grayish/light-green-
ish hue with a touch of hyaline or ground glass appear-
ance in Papanicolaou-stained material. The intensity of
staining varies depending on the thickness of the nuclear
envelope over the inclusion. When the envelope is very
thin, especially when the INCI bulges out of the nuclear
surface, it may be quite translucent and homogeneous in
Papanicolaou’s stained smears. In MGG-stained smears,
the colorful cytoplasm may be clearly visible through the
thin nuclear membrane but when the nuclear envelope is
relatively thicker, the nuclear material may have lines
resembling those of a finger printing. Several characteris-
tics of INCI have been highlighted in the schematic
diagram of Figure 2.
Ancillary Techniques Used to Demonstrate
Intranuclear Pseuoinclusions
Other than light microscopy various other techniques can
be used to demonstrate INCI.
Electron microscopy. With the help of electron micros-
copy, the exact nature of INCI has been identified. It has
been noted that INCI is surrounded by the nuclear mem-
brane.3 The inner contents of the INCI were all cytoplas-
mic organelles such as rough endoplasmic reticulum,
Golgi apparatus, and secretary granules.
Confocal microscopy. With the help of confocal mi-
croscopy the deep invaginations of the nuclear membrane
have been demonstrated.4 The same technology therefore
can also be used to demonstrate the INCI.
Immunocytochemistry. INCI can also be demonstrated
by immunocytochemistry. The INCIs are positive for
cytoplasmic secretory granules such as prolactin in pitui-
tary adenoma3 or vimentin in meningioma due to abnor-
mal accumulation of intermediate filaments.5
Diagnostic Cytopathology, Vol 40, No 8 741
Diagnostic Cytopathology DOI 10.1002/dc
ARORA AND DEY
Fig. 1. A: Intranuclear pseudoinclusions seen as round-shaped structure
within the nucleus on cytology smear of a case of papillary carcinoma of
thyroid (MGG, 31,200). B: Intranuclear pseudoinclusions (H&E,
31,200). [Color figure can be viewed in the online issue, which is avail-
able at wileyonlinelibrary.com.]
Fig. 2. Schematic diagram of intranuclear pseudoinclusion highlighting
the salient characteristics. [Color figure can be viewed in the online
issue, which is available at wileyonlinelibrary.com.]
Pathogenesis
The genesis of the nuclear invagination is unknown, how-
ever, several hypotheses have been presented by various
742 Diagnostic Cytopathology, Vol 40, No 8
Table I. Possible Pathogenesis of Pseudoinclusion
Causes References
Altered ratio of nuclear surface to volume Leduc EH6
Swollen excess cytoplasm Sobel HJ7
Consequence of aging process Serber BJ8
Nuclear grooves followed by inclusion Deligeorgi-Polit H2
authors (Table I).2,6–8 Some authors found the inclusions
in large cells which contained much cytoplasm. Leduc
and Wilson consider that the invagination develops as an
attempt to maintain the normal ratio of nuclear surface to
nuclear volume,6 while Sobel et al. consider that the ma-
jority of inclusions can be explained by the swollen cyto-
plasm extruding into the nucleus.7 Serber studied the de-
velopment of cytoplasmic intranuclear inclusions in the
pituitary gland of experimental animals and found that
they were related to the process of ageing and probably
developed due to a deficiency of sex hormones.8
An active protein synthesis with consequent increase in
cytoplasmic volume could lead to the cytoplasmic invagi-
nation of the nuclear membrane. Because of the finding
of inclusions of different shape and size in sections of the
same tumor, it is reasonable to conclude that there is a
continuous process producing the inclusions.
Deep intranuclear cytoplasmic invaginations are often
associated with INCIs. These invaginations result in the
appearance of intranuclear inclusions under the light
microscope. Infolding of the nuclear membrane most
probably results in the nuclear creases observed in FNAC
preparations of papillary thyroid carcinoma (PTC). Per-
haps the infolding of nuclear membrane is the early stage
of the deep cytoplasmic invaginations that are responsible
for the formation of the intranuclear inclusions.2
Significance
In thyroid pathology, INCIs have been recorded in many
other types of lesions and in non-thyroid pathology they
have also been observed in several neoplastic lesions.
Among thyroid tumors, nuclear pseudoinclusions are
characteristic of but not specific for papillary carcinoma.
In cytologic smears, such pseudoinclusions are found in
50–100% of cases.1 In a study by Das et al., intranuclear
inclusions were found in the range of 5–20 per 1,000
cells. Intranuclear inclusions coexisted with the nuclear
creases in 33 of 34 PTC cases.1 Nuclear creases and intra-
nuclear inclusions did not exist in the same cell. In the
appropriate context, the presence of nuclear pseudoinclu-
sions would strongly favor a diagnosis of papillary carci-
noma. Nuclear pseudoinclusions, however, were more
prominent in tall cell variant than in usual variant of
PTC.9 Hyalinizing trabecular adenoma is another thyroid
neoplasm showing frequent nuclear pseudoinclusions.10
Among the neoplasms of the neck region, intranuclear
cytoplasmic invaginations are reported in papillary

carcinoma, medullary carcinoma, follicular thyroid carci-
noma, and paranganglioma. The delicate, pink, vacuolated
cytoplasm with indistinct borders, delicate chromatin, nu-
clear pleomorphism, and architectural characteristics of
paraganglioma should alert the pathologist that papillary
thyroid carcinoma is unlikely.11,12
Malignant melanoma is another entity which shows
intranuclear inclusions and INCIs are found more com-
monly in spindle cell variant of malignant melanoma than
in other variants. There are variable-shaped INCIs like
spindle, spherical, and bizarre form.13 Inclusions are
stained with eosin with a varying degree of intensity and
are PAS-positive both before and after diastase treatment.
Electron microscopic sections clearly show that the inclu-
sions are of cytoplasmic origin. INCIs contain cytoplas-
mic structures such as mitochondria, premelanosomes,
melanosomes, microfilaments, ribosomes, rough endoplas-
mic reticulum, and annulate lamellae, and are separated
from the nuclear matrix by a double-layered membrane.13
The pathognomonic diagnostic hallmark of a meningi-
oma is the combination of nuclear pseudoinclusions,
psammoma bodies, together with whorling and syncytial
arrangement of cells. The presence of nuclear INCI
strongly favors a diagnosis of meningioma over other tu-
mor types, such as schwannoma and astrocytoma.14
In the setting of salivary gland tumors intranuclear
pseudoinclusion has also been reported in myoepithelial
carcinoma.15 However amelanotic melanoma should be
included in the differential diagnosis. A loosely cohesive
pattern of spindle or polygonal tumor cells, plasmacytoid
appearance, prominent nucleoli, and bi-nucleation are fea-
tures of myoepithelial neoplasms. Occasional case reports
of scattered nuclear pseudoinclusions are described in
pleomorphic adenoma of the submandibular gland and
mucoepidermoid carcinoma of parotid.16,17
Nuclear inclusions are an independent prognostic factor
for clear cell renal cell carcinoma because nuclear
inclusions are histologic components of RCCs, especially
chromophobe and papillary carcinomas. Furthermore the
intranuclear inclusions are found more frequently in chro-
mophobe and papillary types than in clear cell carcinoma.
In multivariate analysis, higher inclusion scores and
advanced tumor stages (III/IV) are correlated with worse
outcomes of clear cell RCC.18
Ultrastructurally nuclear pseudoinclusions are important
features in choroid plexus carcinoma and human ovarian
surface epithelial cells.19,20
Intranuclear cytoplasmic inclusions can be found in
some cases of pigmented villonodular synovitis (PVNS)
along with the characteristic cytological features such as
mononuclear histiocytes, coarse, refractile, golden brown
crystals of hemosiderin within the cells and, a small num-
ber of multinucleated giant cells.21 In the presence of
these inclusions, it is essential to rule out the possibilities
Diagnostic Cytopathology DOI 10.1002/dc
INTRANUCLEAR PSEUDOINCLUSIONS
of other neoplasms that usually show intranuclear cyto-
plasmic inclusions. In view of the simultaneous presence
of pigment and intranuclear inclusions, a diagnosis of
malignant melanoma had to be excluded. Melanin and
hemosiderin pigment may mimic each other in MGG and
Papanicolaou staining. Special stains are necessary to
determine the nature of the pigment. Prussian blue reac-
tion may confirm haemosiderin pigment. Further, the
bland nuclear features of the cells help to eliminate the
diagnosis of malignant melanoma and other soft tissue
neoplasms that may show INCIs.
Dahl et al. have reported a correlative cytological and his-
tological study of 28 cases of schwannoma, four of which
had intranuclear cytoplasmic invaginations (‘‘kernloche’’)
along with structures resembling Verocay bodies.22
INCIs are also seen in papillary carcinoma of lung,23
spindle and epithelioid cell nevus,24 angiomyolipoma of
kidney,25 and Hepatocellular carcinoma.26
Discussion
Nuclear inclusions represent accumulation of substances
in the nucleus. True nuclear inclusions represent actual
accumulation of a foreign substance such as viral par-
ticles27 or it may be due to the abnormal accumulation of
the cytoplasmic substances in nucleus, for example, sur-
factant in pulmonary adenocarcinomas, immunoglobulin
(Dutcher bodies) in lymphoplasmacytic lymphoma, and
glycogen in hepatocytes.28 Only after the introduction of
the electron microscope the true nature of INCI was
known. In addition there are ‘‘bubbly’’ nuclei which can
be mistaken for the ground-glass nuclei characteristic of
papillary thyroid carcinoma. These ‘‘bubbly’’ nuclei are
believed to arise as a result of incomplete fixation, or ex-
cessive drying, and although their occurrence is often spo-
radic it is difficult to pinpoint where the fault is located.29
The nuclear pseudo-pseudoinclusions can be distinguished
from nuclear pseudoinclusions by the following features:
single or multiple, empty-looking intranuclear ‘‘holes’’
that are not delimited by membranes and fuzzy appear-
ance of the chromatin granules. The nuclear pseudoinclu-
sions are generally easier to appreciate in cytological
preparations than frozen sections or histopathology
because freezing artifacts and nuclear bubbles in the latter
material can make distinction from genuine pseudoinclu-
sions difficult.
Nuclear holes are fixation artifact and often show as
clear spaces within the nucleus. This may be mistaken as
INCI. However the nuclear holes are of variable sized
clear spaces and the outer boundary of the hole is not
sharp.30
Electron microscopy and immunostaining were used to
demonstrate the origin of the intranuclear inclusion. These
INCIa are due to cytoplasmic invagination because (1)
the inclusions are continuous with the cytoplasm, (2) all
Diagnostic Cytopathology, Vol 40, No 8 743
Diagnostic Cytopathology DOI 10.1002/dc
ARORA AND DEY
cytoplasmic organelles, such as the endoplasmic reticu-
lum, the Golgi apparatus, and the secretory granules are
found in the inclusions, (3) immunoreactivity of the intra-
nuclear inclusion is the same as that of the cytoplasm.3,13
Different degrees of irregularity of the nuclear membrane
were found in papillary thyroid carcinomas by using im-
munofluorescence and immunoperoxidase techniques by
tagging with anti-emerin antibodies. In addition to the
typical nuclear pseudoinclusion, different stages of transi-
tion such as simple groove to complex pockets were
noted.31 Nuclear grooves or membrane indentations might
be an earlier phenomenon which later on advances into
fully formed pseudoinclusions.
Nuclear pseudoinclusions are cytoplasmic invaginations
commonly present in papillary carcinoma of the thyroid,
and many other tumors. Lack of familiarity with the vari-
ous types of pseudoinclusions and their mimickers in cy-
tology may lead to errors in diagnosis.
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