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1
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Diagnostic Cytopathology
Hotel O, Pune, IndiaJanuary 7, 2012
of Effusion FluidsShort course
Vinod B. Shidham, MD, FRCPath, FIACVice-chair & ProfessorVice-chair & ProfessorDirector of Cytopathology, Cytotechnology School, Cytopathology fellowshipDept of Pathology, Wayne State University Medical SchoolDetroit, MI 48201, USA
Co-editor-in-chief & Executive editor, CytoJournal (www.cytojournal.com)
This presentation is available on web for all conference attendees at- http://alturl.com/3ucwx
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
DisclosureI do not have conflict of any financial interest in the
product if cited any in the course.
I am the co-editor of the book *and
C th f th h t **Co-author of the chapter**on the same topic.
*Shidham VB and Atkinson BF. Editors and contributors ‘Cytopathologic Diagnosis of Serous Fluids’ Multi-author book with 15 chapters, Elsevier (W. B. Saunders Company), 2007 (ISBN-13: 9781416001454).
** Shidham VB, Falzon M. Serous effusions: reactive, benign and malignant. In Gray & Kocjan, ed. Diagnostic Cytopathology, Elsevier, 3rd edition, Chapter 3.
2
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology Acknowledgment
Many images and tables are based on chapters in:
Shidham VB and Atkinson BF.Cytopathologic Diagnosis of SerousFluidsElsevier (W. B. Saunders Company) Firstedition, 2007.
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology OutlinePart I :
Anatomy, histology, cytology, and effusions
Collection, transportation, and processing
Factors leading to potential diagnostic pitfalls
Approach to diagnostic cytopathology of effusions
The panorama of different faces of mesothelial cells
Part II :
Immunocytochemistry of effusion fluids: SCIP (Subtractive Coordinate Immunoreactivity Pattern) approach
Evaluation of unknown primary sites of origin-Where do they come from?
3
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Anatomy, histology, cytology, and effusions
a. Peritoneal cavityy
b. Left & right pleural cavities
c. Pericardial cavity
Four major serous cavities
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Anatomy, histology, cytology, and effusions (continued)
1
Hi t l f li i
32a b
Histology of serous lining(inguinal hernia sac). Themesothelial cells lining thefibrous tissue are flat (1).Focal reactive changes areseen as hypertrophy ofsome cells which assume acuboidal contour (2,3).
dc
( ,3)[a-d, HE stain (a, 10X; b-d,100X)].
4
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Peripheral light ectoplasm (1) Mesothelial cells (peritoneal
Anatomy, histology, cytology, and effusions (continued)
Inner darker endoplasm (2)
Slightly off-center nucleus
Nucleolus
1
fluid): show outer faintly stainedectoplasm (1) with inner denserendoplasm (2) rich inintermediate filaments. Thenucleus is usually central or nearcentral (a), but may be eccentric(b). Nucleoli are readilyobserved The vacuolation1
2
1
2
a b
observed. The vacuolationgenerally begins at the peripheryin ectoplasm (1).[a,b, Papanicolaou stainedSurePath® Preparation (a,b,100XZoomed)]
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Peripheral ectoplasm
Anatomy, histology, cytology, and effusions (continued)
Peripheral ectoplasm
Inner endoplasm
Central to slightly eccentric nucleus
Ruffled cell border with blebs
Mesothelial cell (pleural fluid): shows outer ectoplasm which is denser than the innerendoplasm. The nucleus is central to slightly eccentric but not touching the cellperiphery. The cell margin shows blebs and is ruffled.[Diff-Quik stained Cytospin preparation (100XZoomed)]
5
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Bloody effusions(Hemothorax hemopericardium and hemoperitoneum)
Anatomy, histology, cytology, and effusions (continued)
Homogenously red or dark brown with hemosiderin pigment and the hematocrit of the effusion is 10% or more than that of the plasma hematocrit. (Occasional blood tinged fluids may be associated with a procedure trauma). Bloody effusions are more likely to be associated with an underlying malignancy.
Reactive conditions associated with Bloody Effusions
(Hemothorax, hemopericardium and hemoperitoneum)
Para pneumonic effusionsPost traumatic effusions
-Post cardiothoracic procedures / surgeries-Thoracic cavity vascular damage
Pulmonary embolismAsbestos exposure associated pleural effusion
PancreatitisAcute aortic dissectionEndometriosisSarcoidosisIntralobar pulmonary sequestrationSome Infections –e.g B. Anthrax
underlying malignancy
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Biopsy vs effusion cytologyCollection, transportation, and processing
6
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Collection, transportation, and processing (continued)
To prevent clotting: Collected in anticoagulant such as-EDTA (sodium or potasium salts) in final concentration of 4.55+0.85 µmol/ml[e g di sodium EDTA dihydrate (EDTA Na 2H O) 1 4 mg per ml of effusion fluid][e.g. di-sodium EDTA dihydrate (EDTA Na2, 2H2O) 1.4 mg per ml of effusion fluid]
Amount of fluid sample: Variable (less than 1 ml to 100 ml or more).For optimum cellularity of cytology preparations and cell blocks, it is recommend to submit as
much specimen as possible (up to 1000 ml).Each laboratory follows its own protocol for determining the amount of sample to be used.
Submit as a fresh, unfixed sample:If delay is expected in transporting to the laboratory-
refrigerate at 4oC (with precaution not to freeze the specimen).g ( p p )Alternatively, although not recommended, it may be preserved in a weak fixative
Fluids collected in fixative- require a wash prior to instrument processing.
For blood rich specimens- start with smaller aliquots (such as 10 ml) of fresh fluid.Concentration of cells and removal of excess erythrocytes in the blood rich specimenmay be achieved by density gradient centrifugation with Ficoll
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Concentrate theeffusion fluid specimen
Collect fresh effusion fluid with or without anticoagulant
Collection, transportation, and processing (continued)
Concentrate the remaining fluid similar to specimen without clotSpecimen
with clot
Concentrate by centrifugation (at 600g for 10 minutes)
Use homogenized specimen after mixing(For paucicelluar fluids: Use cell-rich sediment)
Direct smear of unconcentrated specimen for semi-quantitative evaluation
Remove the clot and process for
Cell-block preparation Histogel Plasma-Thrombin Celloidin bag
Pour off supernatant and vortex to resuspend cell pellet
Process for paraffin-embedding after formalin fixation.
cell-block preparation
• Direct smears• Cytospin
• SurePrep (Autocyte) • ThinPrep• Other methods
Smear preparation
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Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Different alternatives available for preparing permanent cytology preparations.a. Direct smears
Collection, transportation, and processing (continued)
(Spreading a drop of specimen directly on slide. The specimen may be before concentration OR after concentration as sediment)
i. Wet fixed- Pap stainii. Air-dried-
Diff-Quik stain*Pap stain: After rehydration in saline and
post-fixation in 95%ethanol with 5% acetic acid (28) b. Cytospin preparations (Shandon EZ Megafunnel™ with Shandon Cytospin®) (31)
i. Wet fixed- Pap stainii Ai d i dii. Air-dried-
Diff-Quik stainPap stain: After rehydration in saline and
post-fixation in 95%ethanol with 5% acetic acid (28) c. Filters
i. Wet fixed- Pap staind. Liquid based cytology (SurePathTM or ThinPrepTM or other non-proprietary methods)
i. Wet fixed- Pap stain
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Preparation Purpose
Collection, transportation, and processing (continued)
A Diff-Quik stained direct smearof the undiluted specimen
Semiquantitative evaluation of cellularity.
B Diff-Quik stained air-dried Shandon EZ Megafunnel™ preparation
Rapid initial detection of second population and cytomorphologic evaluation of hematopoietic cells.
C Pap stained preparation Cytomorphologic evaluation especially nuclear detailsespecially nuclear details.
D Cell-block preparation in HistoGelTM
Evaluation of-
a. Immunoprofile,
b. Other special stains,
c. Architecture,
8
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Approach to diagnostic cytopathology of effusions
► GENERAL FEATURES
► PROCESSING RELATED
► INTERPRETATION STRATEGY
► CYTOMORPHOLOGY
► IMMUNOCYTOCHEMISTRY
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Approach to diagnostic cytopathology of effusions (continued)
► GENERAL FEATURESA l h l l b i ff i ll l h l i dAny general pathology laboratory may receive effusion- all general pathologists andcytopathologists should be conversant with the diagnostic challenges and pitfallsof effusion fluid cytology.
►
Finding neoplastic cells in effusion specimens not only reveals that a patient hascancer, but it also denotes the advanced nature of the disease which at this stage isalmost always incurable.
►
The morphologic features of most of the cancer cells in effusion smears arediff t f th i f li ti b hi d FNA t l
►different from those seen in exfoliative, brushing, and FNA cytology.
The standard cytologic criteria of malignancy based on evaluation of single cellmorphology are not applicable for most of the effusion cytology specimens(except in cases with high-grade neoplasms with pleomorphic cells).
►
Since cells in a fluid medium ‘round up’ because of surface tension, the nativeshapes of cancer cells cannot be a guiding feature.
►
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Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
► PROCESSING RELATED
Approach to diagnostic cytopathology of effusions (continued)
1. Second population of foreign cells
2. Nuclear details of the ‘second population’.
3. Semiquantitative evaluation
4. Objective confirmation and differential diagnosis of primary neoplasm.
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
► INTERPRETATION STRATEGY
Approach to diagnostic cytopathology of effusions (continued)
a. Reactive mesothelial cells- morphologic overlap with neoplastic cellsb. A single population- favor mesothelial cellsc. Second foreign population consistent with metastatic neoplasm d. Sarcomas- previous history knowne. Romanowsky stains highlight the ‘second population’ f. Immunocytochemistry- objective confirmation of ‘second population’y yg. Identical orientation of serial sections for immunocytochemistryh. Quantitative and qualitative clues for mesotheliomai. Apoptosis
10
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
► CYTOMORPHOLOGY
Approach to diagnostic cytopathology of effusions (continued)
1. Cell groups and intercellular cohesionNon-cohesive, good intercellular cohesion, proliferation spheres
2. Arrangement of neoplastic cellsPapillary configurations
3. Cytoplasm of neoplastic cells
4. Special structures and cytological features
5. Other features
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Algorithm for evaluation of ‘second foreign population’
Reactive-Usually single cells without large 3-D groups
4
Cells in effusion fluid 1
Non mesothelial cells 3
Mesothelial cells 2
groups
Hematopoietic cells(Non-cohesive cells)
6
Neoplastic-L h
6b
Reactive-Inflammatory cells
6a
Neoplastic- Mesothelioma♦Quantity- Many cells ♦Quality- Many large groups
5
Non-mesothelial cells 3 Lymphoma
Neoplastic-8
(2nd foreign population)Carcinoma (Cohesive cells)Sarcoma(Spindle cells may be present. Known history of sarcoma is usually crucial for proper interpretation) Melanoma (Non-cohesive cells)
7 ¶Metastatic cancer cells may be the predominantcells without being seen as a ‘second population’.They may be present as scattered solitary cells withcytomorphology overlapping with floridly reactivemesothelial cells. If indicated, immunocytochemistrywould facilitate confirmation of these cells as non-mesothelial.
8
11
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
The panorama of different faces of mesothelial cellsREACTIVE MESOTHELIAL CELLS
Binucleation and multinucleation-Binucleation and multinucleationGigantic nucleiPhagocytic activityCohesive Clusters and/or Papillary Structures‘The two cell population approach’Cell-in-cell configurationCells in sheetsGroups of reactive mesothelial cells
I) Hepatomegaly, II) Ischemic conditions such as pulmonary infarction, ischemic colitis, and occlusion of mesenteric blood vessels, III) Trauma to organs covered with mesothelium such as spleen, liver, and lung etc, IV) Large retroperitoneal masses- Slowly growing retroperitoneal masses, V) Postoperative- following laparotomy and thoracotomy.
‘ATYPICAL’ MESOTHELIAL CELLS
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
The panorama of different face of mesothelial cells (continued)
a b cMesothelial cells with central to slightly eccentric nuclei (ascitic fluid). The cytoplasm shows a two-zone staining pattern. [a-c, Diff-Quik stained cytospin preparation (a-c, 100x Zoomed)].
12
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Panorama of mesothelial cells(ascitic fluid). Central to near
The panorama of different face of mesothelial cells (continued)
a cb
hg
fed
lkji
(asc t c u d) Ce t a to eacentral nuclei. Rare mesothelialcells may show eccentric nucleitouching the cell membrane,but usually there is a narrowrim of cytoplasm separating thenucleus from the cell border(arrows).[ Diff Q ik t i d t i
ponm
xwvuts
rq
[a-x, Diff-Quik stained cytospinpreparations (a-x, 100xZoomed)].
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
1
The panorama of different face of mesothelial cells (continued)
a b c
Mesothelial cells with central to slightly eccentric nuclei (ascitic fluid). The cytoplasm shows a two-zone staining pattern with peripheral vacuolation (red arrow 1). [a-c, Papanicolaou stained ThinPrep preparation (a-c, 100x Zoomed)].
13
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Mesothelial cells with central tot i l i ( iti fl id)
The panorama of different face of mesothelial cells (continued)
a cb
hg
fed
l
kji
eccentric nuclei (ascitic fluid).Spectrum of cytomorphologicalfeatures.[a-zc, Papanicolaou stainedThinPrep preparation (a-zc, 100xZoomed)]
ponml
x
wvutsr
q
zy za zb zc
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
The panorama of different face of mesothelial cells (continued)
Mesothelial cells witheccentric nuclei (asciticfluid). Careful scrutinyusually shows a
l x
ynarrow rim ofcytoplasm separatingthe nucleus from thecell border (arrows).[Papanicolaou stained ThinPrep preparation, 100XZoomed].
14
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
NC NCRM
The panorama of different face of mesothelial cells (continued)
RM
RM
ICIC
DQ Pap
a bMetastatic adenocarcinoma (pleural fluid). An example with morphologically identifiable unequivocal‘second foreign population’ (red arrow NC) other than mesothelial cells (blue arrow RM) and inflammatorycells (brown arrow ‘IC) in DQ and PAP stained preparations. This ‘second population’ of cells ’ (redarrow NC) is easy to be identified in DQ stain (a) as compared to that in PAP stain (b).[a, Diff-Quik stained cytospin preparation; b, Papanicolaou stained ThinPrepTM preparation (a,b, 100xZoomed)]
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
The panorama of different face of mesothelial cells (continued)
a b c da b c dPulmonary adenocarcinoma (pleural fluid). The non-cohesive metastatic cancer cellsis the predominant cell population without being seen as a ‘second population’ (a-d).Some apoptotic tumor cells (arrows in c & d) are present. Differential includesanaplastic large cell lymphoma[a-d: PAP stained Cytospin preparation (a, 10X; b, 40X; c,d, 100X)].
15
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Factors leading to potential diagnostic pitfallsa. Surface tension related alterations in cytomorphology b Improper specimen processingb. Improper specimen processingc. Many faces of reactive mesothelial cellsd. Proliferation related features
i) Proliferation spheres ii) Increased number of mitotic figuresiii) Prominent nucleoli
e. Degenerative changesNuclear hyperchromasia C l i l iCytoplasmic vacuolation
f. Presence of some unexpected patterns and unusual structuresi) Reactive lymphoid population ii) Polymorphic lymphocytesiii) Single population of cells due to predominance of tumor cellsiv) Psammoma bodiesv) Three dimensional benign cell groups
Benign papillary inclusions, Gland-like epithelial structures, Mullerian inclusionsvi) Megakaryocytes
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Factors leading to potential diagnostic pitfalls (continued)
TRUE NEGATIVE RESULTS IN EFFUSIONS CAUSED BY CANCER
a. Blockage of lymphatics without exfoliation of neoplastic cells
b. Increased capillary permeability due to VEGF.
c L k f f li ti b l d d i dl ll th li
TRUE NEGATIVE RESULTS IN EFFUSIONS CAUSED BY CANCER
c. Lack of exfoliation by low-grade sarcomas and spindle cell mesotheliomas.
d. Organized thick fibrin serosal covering preventing exfoliation of neoplastic cells.
e. Decrease or total disappearance of neoplastic cells over a time
16
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Part II
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
The most important issue to be considered when applyingimmunocytochemistry to effusion fluids is the significantvariation in results due to the many variables incurredfrom the time of collection of the specimen to its finalimmunostaining.
17
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
C fi ti f ‘ d f i ’ i fl t l ti f ll th th
UNIQUENESS OF EFFUSION IMMUNOCYTOCHEMISTRY
Immunocytochemistry of effusion fluids
Intricacies of finding and locating the cells of interest in cell-block sections may adversely affect the final results.
►Orient the serial sections identically on all slides
Confirmation of a ‘second-foreign’ non-inflammatory population of cells other than mesothelial cells in effusions correlate with metastatic cancer with objectivity.
It is crucial to:
(to identify more precisely the same cell (or small group of cells) in different sections). ►Know the sequence of these serial sections
(to evaluate their co-ordinate immunoreactivity pattern).
►Immunocytochemistry does not have significant role in evaluation of peritoneal washings.
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Cell-blocks are the preferred choice.
Immunocytochemistry of effusion fluids
Formalin-fixed cell-block sections are recommended-Other protocols such as the evaluation of various cytology preparations
(direct smears- wet fixed in alcohol or acetone, air-dried fixed with alcohol, air-driedsmears rehydrated and post-fixed in formol alcohol, liquid based cytologypreparations- SurePath or ThinPrep, cytospin preparations, etc) should beavoided.
For reproducible results a standardized protocol with stepscomparable to the processing of formalin-fixed paraffin-embeddedtissue sections is essential.
18
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Critical issues leading to the best result with cell blocksthe best result with cell blocks
of cytology specimens with singly scattered cells
Aligning the cells along the cutting surfaceAligning the cells along the cutting surface
Monitor the depth of section cutting
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Varsegi GM, Shidham V (2009)Journal of Visualized Experiments (JoVE) 2009 Jul 21;(29). pii: 1316.doi: 10.3791/1316. PMID: 19623160
19
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
From:Varsegi GM, Shidham V (2009)Journal of Visualized Experiments(JoVE) 2009 Jul 21;(29). pii: 1316.doi: 10.3791/1316. PMID: 19623160
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
From:Varsegi GM, Shidham V (2009)Journal of Visualized Experiments(JoVE) 2009 Jul 21;(29). pii: 1316.doi: 10.3791/1316. PMID: 19623160
20
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Modified from:Varsegi GM, Shidham V (2009)Journal of Visualized Experiments(JoVE) 2009 Jul 21;(29). pii: 1316.doi: 10.3791/1316. PMID: 19623160
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
From:Varsegi GM, Shidham V (2009)Journal of Visualized Experiments(JoVE) 2009 Jul 21;(29). pii: 1316.doi: 10.3791/1316. PMID: 19623160
21
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
The video article is available FREE on the web under open access at:
http://www.jove.com/index/Details.stp?ID=1316Vid f J VE ti l (8 i t 15 )
Video of JoVE article (8 minutes 15 sec)
Video of JoVE article (8 minutes 15 sec)
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunophenotyping and cell blocks-Factors affecting immunoreactivity-Factors affecting immunoreactivity-
Loss, reduction, or enhancement of antigen immunoreactivityExposure to different reagents and fixative(s)TemperatureStorage of specimen with or without fixative
Subtractive Coordinate Immunoreactivity Pattern (SCIP) approachShidham & AtkinsonCh 5 Imm noc tochemistr of eff sion fl ids introd ction to SCIP approachCh 5. Immunocytochemistry of effusion fl uids: introduction to SCIP approach. ‘Cytopathologic Diagnosis of Serous Fluids’Elsevier (W. B. Saunders Company)
Shidham VB.Effusion Fluid Evaluation Made Simple: A brief review of cytomorphologic and SCIP approachCytoJournal (In press).
22
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Discrepant results between formalin-fixed paraffin-embedded tissue sections of surgical pathology material and effusion fluid cell-block sections are not uncommon
Immunocytochemistry of effusion fluids
surgical pathology material and effusion fluid cell block sections are not uncommon.
Reasons for variable reports:
The variables responsible for such discrepancies include: sample size (tiny cell groups or single cells), selection of fixatives, antigen retrieval methods
(i e heat induced epitope retrieval enzyme digestion etc )
The proteinaceous effusion fluid around suspended cells may contribute to unexpected nonspecific immunoreactivity.
(i.e., heat-induced epitope retrieval, enzyme digestion, etc.), antibody clones used, antibody titer, and other variations in immunostaining protocols.
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
If findings are equivocal:
Immunocytochemistry of effusion fluids
It is prudent to be conservative and recommend to repeat.Malignant effusions usually re-accumulate quickly.Acquiring a new sample is generally not a problem.
However, it is not uncommon to submit only a small fraction of a large volume ofeffusion fluid collected.
To avoid inadequate resubmission, it may be specifically communicated in therecommendation as comment :
“Recommend submission of most of the drained effusion fluid (up to1000 mL). Larger volume of specimen facilitates retrieval of adequatecellular material in cell-block sections for immunocytochemicalevaluation”.
23
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
I t t ti
Immunocytochemistry of effusion fluids
All aspects of individual and complimentary immunomarkersshould be considered collectively rather than applying areflexive positive-negative approach.
Evaluation of co-ordinate immunoreactivity in different cell
Interpretation:
ypopulation.
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
MicrovillousMembranousCytoplasmicNuclear &NuclearNoneImmunostaining
Immunocytochemistry of effusion fluids
WT-1
Vimentin
Cytokeratin*
D2-40 (Podoplanin)
Calretinin
MicrovillousMembranousCytoplasmicNuclear & cytoplasmic
NuclearNoneImmunostaining
pattern
Immunomarker
X
X
X
X
X
X
X
PGM1 (CD68)
HBME-1
EMA
LCA (CD45)X
X AdCa
X AdCa
X
X meso
X meso
24
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
MicrovillousMembranousCytoplasmicNuclear &NuclearNoneImmunostaining
Immunocytochemistry of effusion fluids
MicrovillousMembranousCytoplasmicNuclear & cytoplasmic
NuclearNoneImmunostaining
pattern
Immunomarker
MOC-31
BerEP4
Cadherins
CD44S
B72.3 X
X
X
X
X
CA19.9
Ttf-1
Mesothelin
CD15 (Lue-M1)
CK 5/6
mCEA
X
X
X
X
X
X
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
EMA
Immunoreactivitypattern with EMA(epithelioid mesothelioma,pleural fluid).Mesothelioma cells withmembranous (arrow) andmembranous (arrow) andcytoplasmicimmunostaining. Note themicrovilli (arrowhead).[Immunostained cell-blocksection (100XZoomed)].
25
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
a b HBME-1HBME-1
HBME-1 immunoreactivity pattern (epithelioid mesothelioma, pleural fluid).Mesothelioma cells with membranous (arrow in a) and cytoplasmic immunostaining.Note the microvilli (arrowhead in b).
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Pan-cytokeratin
Immunocytochemistry of effusion fluids
immunoreactivity pattern(pleural fluid).Reactive mesothelial cellswith cytoplasmicimmunostaining (arrow ininset). Some reactivemesothelial cells may showa concentrici t i i tt
Pan-cytokeratin
immunostaining patternaround the nucleus betterappreciated by adjustingfine focus.
26
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
Cytokeratin 7 immunoreactivity pattern(epithelioid mesothelioma, pleural fluid). Neoplastic mesothelial
Cytokeratin 7
Neoplastic mesothelial cells with cytoplasmic immunostaining. Note the bushy microvilli (arrowhead).
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
12
a b CalretininCalretinin
Calretinin immunoreactivity pattern (epithelioid mesothelioma, pleural fluid).Mesothelioma cells (arrow in a) show nuclear (arrowhead 1) immunoreactivity usually withcytoplasmic immunostaining (arrowhead 2) imparting the so called ‘fried-egg’ appearance.
27
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Calretinin immunoreactivity
Immunocytochemistry of effusion fluids
RM
immunoreactivity pattern (pleural fluid).
Reactive mesothelial cells (blue arrows). The effusion also contains metastatic mammary
NC
Calretnin
ycarcinoma cells (red arrow NC).
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
WT-1 immunoreactivity pattern
Immunocytochemistry of effusion fluids
p(Metastatic colonic adenocarcinoma, peritoneal fluid).Reactive mesothelial cells(arrow RM) show nuclearimmunoreactivity (arrowheadin inset) with somecytoplasmic immunostaining.
RM
WT-1
y p gRare adenocarcinoma cellsdemonstrating nuclearimmunoreactivity for CDX2were also seen in othersection.
28
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
B72.3 immunoreactivity pattern(Metastatic mammary adenocarcinoma, pleural fluid).Metastatic adenocarcinoma
NC
B72.3
Metastatic adenocarcinomacells (red arrow NC) show acytoplasmic immunoreactivitypattern.
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Vimentin
Immunocytochemistry of effusion fluids
Vimentin immunoreactivity pattern (peritoneal wash).Reactive mesothelial cells(arrow RM) show cytoplasmicimmunoreactivity pattern(arrowhead in inset)
RM
vimentin
(arrowhead in inset).
29
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
RM
LCA (CD45 ) immunoreactivity pattern (pleural fluid).Reactive mesothelial cells (blue arrow RM) with chronic inflammatory cells (redRM
LCA
inflammatory cells (red arrows). The inflammatory cells show a strong cytoplasmic immunoreactivity pattern obscuring the nucleus (arrowhead in inset).
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
CD 68 (PGM1 ) immunoreactivity
tt (M i
Immunocytochemistry of effusion fluids
H
H
H
pattern (Metastatic mammary adenocarcinoma with proliferation spheres (red arrow NC), pleural fluid).Histiocytes show CD68 immunoreactivity (blue arrows H). In our experience, PGM1 does not show non
NC
HCD68
PGM1 does not show non-specific immunostaining usually associated with KP1. Inset- Histiocytes (blue arrow H) with cytoplasmic immunoreactivity pattern around the nucleus.
30
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
NC
Immunocytochemistry of effusion fluids
NC
NC
a b BerEP4BerEP4
BerEP4 immunoreactivity pattern (Metastatic mammary adenocarcinoma, pleural fluid).a. The neoplastic cells in proliferation spheres (red arrow NC)- membranous immunostainingwith a honey comb-like pattern. b. Solitary adenocarcinoma cells (red arrow NC)- membranousimmunostaining pattern along the cell membrane (arrowhead in inset).
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
NCNCComparison of immunoreactivity with
Immunocytochemistry of effusion fluids
BerEP4a b BerEP4
NC
NC
NCNC
immunoreactivity with BerEP4 and B72.3(Metastatic mammary adenocarcinoma, pleural fluid).As Compared to B72.3, most of the adenocarcinoma cells (red arrows NC) show strong
c dB72.3 B72.3
NC) g
membranous BerEP4 immunoreactivity.
31
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Monoclonal CEA
Immunocytochemistry of effusion fluids
m
(mCEA) immunoreactivity pattern(Metastatic ovarian carcinoma, peritoneal
fluid).Metastatic adenocarcinoma
mCEA
c
cells show cytoplasmic (c) and membranous (m) immunostaining.
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
CDX2 immunoreactivity
Immunocytochemistry of effusion fluids
NC
ypattern(Metastatic colonic adenocarcinoma,
peritoneal fluid).The adenocarcinoma cells show nuclear immunoreactivity (arrow
CDX2
NC). Compare with non-immunoreactive nuclei with blue hematoxylin counterstain (arrowhead).
32
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
TTF-1 immunoreactivity
Immunocytochemistry of effusion fluids
NC
ypattern(Metastatic pulmonary carcinoma, pleural fluid).The solitary adenocarcinoma cells as the predominant population (arrows NC) show nuclear immunoreactivity
TTF-1NC
(arrowheads in inset).
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
mMOC-31 immunoreactivity pattern(Metastatic mammary carcinoma, pleural fluid). The adenocarcinoma cells show predominantly
MOC-31
c
membranous (m) with cytoplasmic (c) immunoreactivity.
33
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Diffuse malignant mesothelioma of epithelial
Immunocytochemistry of effusion fluids
EM
A
a b
mesothelioma of epithelial type, (pleural fluid).Neoplastic cells are immunoreactive for EMA (a & b) and HBME-1 (c, d, & e) with a membranous immunostaining pattern (arrows) highlighting long, slender, microvilli (arrowheads).
c d e
HB
ME
-1
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
a bEMA HBME-1
Adenocarcinoma, peritoneal fluid.Cytoplasmic immunostaining pattern (arrows) with focal blotchy immunostaining for EMA (a) and HBME-1 (b) along the cell membrane .
34
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
For reproducible results, it is important to select any
Immunocytochemistry of effusion fluids
immunopanel which will fundamentallyidentify most of the mesothelial and inflammatory cellsto create the basic mapfor confirmation of a ‘second-foreign’ population by ‘SubtractiveCoordinate Immunoreactivity Pattern’ (SCIP) approach
* Shidham VB, Atkinson BF. Immunocytochemistry of effusion fluids: Introduction to the SCIP approach. In: Shidham VB and Atkinson BF. Editors ‘Cytopathologic Diagnosis of Serous Fluids’ First edition, Elsevier (W. B. Saunders Company); 2007. Ch 5, pp. 55-78.
*Shidham VB. Diagnostic Cytopathology of Serous Fluids- A brief review of cytomorphologic and SCIP approach. CytoJournal (In press).
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
Evaluation of‘Subtractive Coordinate Immunoreactivity Pattern’
(SCIP)
35
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Met
asta
sis
(no
n-c
arci
no
ma)
2
3
6
57
2
3
1
6
57
2
3
1
6
57
3
1
6
57
2
3
1
6
57
ZImmunocytochemistry of
effusion fluids
2
6 8
ial &
ry
cel
ls
2
6 8
2
6 8
2
6 8
2
6 8
X
1 54 1 54 1 54 1 541 54
Met
asta
sis
(car
cin
om
a)
21
54
3
7
6
21
54
3
7
6
21
54
3
7
6
21
54
3
7
6
21
54
3
7
6
Y
SCIP approach
3
1
5
4 7
Mes
oth
elin
flam
mat
or
3
1
5
4 7
3
1
5
4 7
3
1
5
4 7
3
1
5
4 7
vim
en
tin
Pan
CK
(Mix
ture
of A
E1/
AE
3 &
CA
M5
.2)
Cal
reti
nin
WT
-1
LC
A(C
D45
)[o
r P
GM
1(C
D68
) o
r m
ixtu
re o
f LC
A
& P
GM
1]
A B C D E
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Immunocytochemistry of effusion fluids
SCIP approachapproach
36
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
SCIP approach
Immunocytochemistry of effusion fluids
a b
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
CIP lret
inin
, D2
-40
)
Carcinoma
Immunoreactive for ‘negative’ mesothelial markers such as-BerEP4, B72.3, MOC-31, mCEA, .
Proceed with:Immunopanel for unknown primary OR
CK+,vim –/+
Immunocytochemistry of effusion fluids
pa
ne
l fo
r e
valu
ati
on
by
SC
K7,
CK
20, B
er/E
P4,
B72
.3, M
OC
31C
al
Without‘second foreign’ population
With‘second-foreign’ population
Qualitative & quantitative features of mesothelioma
CK-,vim+
Lymphoma
Melanoma/Sarcoma
LCA+
LCA–S-100 protein &
Melanoma markers
Lymphoma panelCytogenetics
Gene rearrangement
Restricted panel for known primary
+–
Ba
sic
p(v
imen
tin
, Pan
CK
,CK second-foreign population features of mesothelioma
Negative for malignancy
Absent Present
Sa
rco
ma
Me
lan
om
a
Immunopanel for sarcomaORRestricted panel for known primary
Malignantmesothelioma
EMA/HBME-1: Microvillous pattern
B72.3–, BerEP4–
37
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
SCIP approach
B. Pan-cytokeratinImmunoreactive
A. VimentinNon-immunoreactive
‘Subtractive coordinate immunoreactivity pattern’ (SCIP) in cell block sections
NC
10X 40X
NC
NC
NCapproach
C. LCA (CD45)Non-immunoreactive
D. CalretininNon-immunoreactive(Inset {2}-Mesothelial cell immunoreactivenuclear-cytoplasmic)
RM
10X
10X
10X 40X
40X
40X
NC
NC
NC
NC
NCRM
Metastatic colonic adenocarcinoma, (peritoneal fluid).
F. CDX2Immunoreactivenuclear
HEstained cell blocksection
y p )
E. WT-1Non-immunoreactive(Arrow 2 with inset: Mesothelial cell-immunoreactivenuclear-cytoplasmic)
40X
RM
10X
10X
10X
40X
40X
100X40X
NC
NC
NC
NC
RM
RM
NC
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
B. Pan-cytokeratinImmunoreactive
A. VimentinNon-immunoreactive
‘Subtractive coordinate immunoreactivity pattern’ (SCIP) in cell block sections
10X
NC
RM
Zoomed
SCIP approach
HEstained cell blocksection
C. CalretininNon-immunoreactive[Mesothelial cells (RM) immunoreactivenuclear-cytoplasmic]
D. BerEP4Immunoreactive
10X
10X
10X
Zoomed
NC
RM
Zoomed
NCRM
approach
sect o
E. Cytokeratin 7Immunoreactive
F. Cytokeratin 20Non-immunoreactive
10X
10X
10X
10X
Zoomed
Zoomed
NC
RM
Metastatic ovarian carcinoma, (peritoneal fluid).
38
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
B. CD68 (PGM1)
A. VimentinNon-immunoreactive
‘Subtractive coordinate immunoreactivity pattern’ (SCIP) in cell block sections
40X
SCIP approach
Metastatic mammary adenocarcinoma, (pleural effusion).
Non-immunoreactive
C. CalretininNon-immunoreactiveMesothelial cell (RM)immunoreactivenuclear-cytoplasmic)
40X
40X
RM
RM
approach
HEstained cell blocksection
D. Cytokeratin 7Immunoreactive
E. BerEP4Immunoreactive
40X40X
40X
NC
NC
RM
NC
RM
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
B. CD68 (PGM1)Non-immunoreactive
A. VimentinNon-immunoreactive(Mesothelial & inflammatory cells are immunoreactive)
‘Subtractive coordinate immunoreactivity pattern’ (SCIP) in cell block sections
20X 40X
Metastatic mammary adenocarcinoma,
SCIP approach
C. CalretininNon-immunoreactive(Rare mesothelial cell [blue arrow] is immunoreactivenuclear-cytoplasmic)
(inflammatory cells are immunoreactive)
20X
20X
40X
40X
RM
mammary adenocarcinoma, (pleural effusion).
approach
D. BerEP4Immunoreactive
E. Estrogen receptorsImmunoreactive
20X
20X
40X
40X
NC
NC
NC
39
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
B. Cytokeratin 20Non-immunoreactive
A. Cytokeratin 7Immunoreactivecytoplasmic
40X 100X
‘Subtractive coordinate immunoreactivity pattern’ (SCIP) in cell block sections
NC
SCIP approach
C. TTF-1Immunoreactive Nuclear
D. ChromograninImmunoreactivecytoplasmic
40X 100X
40X 100X
NC
NC Metastatic small cell carcinoma,(pleural fluid).
approach
F. CD56Immunoreactivecytoplasmic
E. SynaptophysinWeak immunoreactivecytoplasmic
40X 100X
40X 100X
100X40X
NC
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
‘Subtractive coordinate immunoreactivity Pattern’ (SCIP) in cell block sections
A. Cytokeratin 7Non-immunoreactive[Mesothelial cell Immunoreactive (red arrow)Cytoplasmic]
B. CalretininNon-immunoreactive[M th li l ll
PAP stained Cytospin preparation (a-c)
40X
RM
RM
SCIP approach[Mesothelial cell
Immunoreactive (red arrow)nuclear-cytoplasmic]
C. CD 20ImmunoreactiveCytoplasmic (red arrow)
a
b
10X
40X
40X
40X
NC
RM
NC
Large B-cell lymphoma, (peritoneal fluid).
approach(continued)
D. Bcl2ImmunoreactiveCytoplasmic (red arrow)
E. CD3Non-immunoreactive
HE stained cell blockSection (d)
c
d
NC
NC
40X 40X
40X
NC
NC
40
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
SCIP with dual
Vimentin (Brown)-Cytokeratin 7 (Red)Vimentin (Brown)-Cytokeratin 7 (Red)
Immunocytochemistry of effusion fluids
dual staining method
a bVimentin (Brown)-Cytokeratin 7 (Red)Vimentin (Brown)-Cytokeratin 7 (Red)
Mammary carcinoma, (effusion fluid).
dc
Shidham V.B., Varsegi G, D’Amore K.Two-color immunocytochemistry forevaluation of effusion fluids for metastaticadenocarcinoma.CytoJournal 2010 Feb 10;7:1
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
SCIP with dual staining method
C l ti i (B ) B EP4 (R d)Vi ti (B ) C t k ti 7 (R d)
Metastatic mammary adenocarcinoma, pleural fluid.
Immunocytochemistry of effusion fluids
Calretinin (Brown)-BerEP4 (Red)Vimentin (Brown)-Cytokeratin 7 (Red)
a b c
41
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
SCIP with dual staining methodMetastatic gastric adenocarcinoma, peritoneal fluid.
Immunocytochemistry of effusion fluids
Calretinin (Brown)-BerEP4 (Red)Vimentin (Brown)-Cytokeratin 7 (Rred)
a b c
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Evaluation of unknown primary sites of origin- Where do they come from?
Immunocytochemistry of effusion fluids
on
cyt
olo
gy
1 Equivocal for
malignant cells
2
Negativefor
malignant cells
3
Eff
usi
o
Unequivocal for
malignant cells
4
malignant cells
42
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
N t il bl 9
Suspicious for malignant cells with recommendation to
13
Evaluation of unknown primary sites of origin- Where do they come from? (continued)
Evaluation of unknown primary sites of origin
Cell-blockNegative for malignant cells
Report17
Immunocytochemical
Not availableOr insufficient
9submit additional specimen forconfirmation with additional cytopathological evaluation withcell-block preparation if effusion reaccumilatesb.
Report
13
Eq
uiv
oca
l fo
r al
ign
ant
cell
s
2
5
Positive for malignant cells,depending on results of immunocytochemistry,comment about the primary site
Report
18
for malignant cellscharacterization on cell-block sections to confirm presence of second population by SCIP with characterization of this second population for possible primary site
12
Available8
m
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Evaluation of unknown primary sites of origin- Where do they come from? (continued)
Immunocytochemistry of effusion fluids
Evaluation of Primary
Negativefor
malignant cells
3Negative for malignant cells
Report6
43
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Evaluation of unknown primary sites of origin- Where do they come from? (continued)
Immunocytochemistry of effusion fluids
Evaluation of Primary
Clinical correlationc
7
Possible10 Comparative
review of primary lesion
14
neq
uiv
oca
l fo
rli
gn
ant
cell
s
4
Not possible11
Un
ma
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Cytomorphological patterns Possible primary carcinoma
Cytomorphological features suggestive of a primary site
Evaluation of unknown primary sites of origin
y p g p p y
1 Three dimensional round cell groups-proliferation spheres or ‘cannonballs’
Breast adenocarcinomaOvarian adenocarcinomaMesothelioma of epithelioid typeReactive mesothelial proliferations
2 Acini / glands Adenocarcinomas of Breast, Lung,Colorectum, Stomach, Ovary,Endometrium, etc.Mesothelioma of epithelioid typeMesothelioma of epithelioid type
3 Predominantly scattered isolated malignant cells
Gastric adenocarcinomaNon-cohesive variant of lungadenocarcinomaBreast lobular carcinomaAdrenocortical carcinoma(Also Lymphoma, Melanoma, & Sarcoma)
44
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Cytomorphological patterns Possible primary carcinoma
Cytomorphological features suggestive of a primary site (continued)
Evaluation of unknown primary sites of origin
4 Carcinoma cells in chains and rows (‘Indian file’ pattern)
Breast- Lobular and ductal carcinomaPoorly differentiated small cell carcinomaGastric adenocarcinomaOvarian adenocarcinoma
5 Extensive cytoplasmic vacuolization Renal cell adenocarcinoma (glycogen, fat)Adrenocortical carcinoma (fat)Benign mesothelial cellsPancreatic adenocarcinoma (mucin)( )Ovarian adenocarcinoma (mucin)Lung adenocarcinomaClear cell carcinoma endometrium
6 Signet ring cells Gastric adenocarcinomaColorectal adenocarcinoma
7 Intracytoptasmic lumina Breast adenocarcinoma
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Cytomorphological patterns Possible primary carcinoma
Cytomorphological features suggestive of a primary site (continued)
Evaluation of unknown primary sites of origin
y p g p p y
8 Giant tumor cells Lung large cell carcinoma- giant cell typePancreatic adenocarcinomaThyroid anaplastic carcinomaSquamous cell carcinoma(Also Melanoma & pleomorphic sarcoma)
9 Targetoid intracytoplasmic vacuole containing secretion
Breast adenocarcinoma (especiallylobular)Thyroid carcinoma (colloid)Thyroid carcinoma (colloid)Ovarian carcinomaPancreatic carcinoma
10 Three dimensional groups in papillary configurations
Bronchioloalveolar carcinomaColonic adenocarcinomaEndometrial adenocarcinomaMammary adenocarcinoma
45
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Cytomorphological patterns Possible primary carcinoma
11 Three dimensional papillary groups Ovarian carcinoma- serous papillary
Cytomorphological features suggestive of a primary site (continued)
Evaluation of unknown primary sites of origin
11 Three dimensional papillary groups containing psammoma bodies
Ovarian carcinoma- serous papillaryThyroid papillary carcinomaPancreatic papillary carcinoma
12 Cell groups of tall columnar cells with a picket fence pattern
Colonic adenocarcinomaPancreato-biliary carcinoma
13 Cellular pleomorphism Poorly differentiated carcinomas of lung,pancreas, ovary, thyroid, urothelium
14 Large polyhedral cells Hepatocellular carcinomag p y pTransitional cell carcinomaLarge c ell type squamous cell carcinoma
15 Cytoplasmic pigment Hepatocellular carcinoma- Bile,(Melanoma- melanin)
16 Prominent nucleoli Hepatocellular carcinomaRenal cell carcinomaProstatic adenocarcinoma
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Cytomorphology
Evaluation of unknown primary sites of origin-Where do they come from? (continued)
Positive f li t ll
Report
19
Immunocytochemistry of effusion fluids
Evaluation of Primary
Clinical correlationc
7
Possible10
Cytomorphologynot classical for the known primary neoplasm 16
Cytomorphologyconsistent withprimary site 15Comparative
review of primary lesion
14
Positive for malignant cells with broad
Report26
neq
uiv
oca
l fo
rli
gn
ant
cell
s
4
for malignant cells,consistent withmetastatic cancer from previous neoplasm.
Not possible11
Cell-block20
Available 21
Not availableOr insufficient
22
Immunocytochemical characterization
23
cells with broad cytomorphological characterization (such asnon-small cell carcinoma vs small cell carcinoma vs lymphoma). Recommend additional specimen for cell-blockfor immunocharacterization of neoplastic cells if effusion reaccumilates.
Un
ma
46
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
Evaluation of unknown primary sites of origin- Where do they come from? (continued)
Report
27
Immunocytochemistry of effusion fluids
Evaluation of Primary
Immunoprofile of the 25
Immunoprofile of the second population isconsistent with primary neoplasm.
24
no
cyto
chem
ical
ar
acte
riza
tio
n
23Positive for malignant cells,consistent with XYZ primary.
28Immunoprofile of the second population is not distinct for primary neoplasm.
25
Imm
un
cha
Positive for malignant cells,And suggest a differential diagnosis for the primary sites.
Report
Diagnostic Cytopathology of Effusion Fluids
Short course
International CME on Oncopathology
CytoJournalwww cytojournal com
End
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