Serous Effusion Cytology - eoepathology.comeoepathology.com/pdf handouts/small files_cytology... ·...
Transcript of Serous Effusion Cytology - eoepathology.comeoepathology.com/pdf handouts/small files_cytology... ·...
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Serous Effusion Cytology Dr J Chan
16th September 2019
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Effusion cytology
● Review clinical history and additional fluid findings
● Algorithmic approach
● Practical tips
● Review illustrative cases
● Present model answer
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Clinical history & other findings
● Large unilateral effusions in elderly – malignant until proven otherwise
● Malignant effusions – may show reactive features only. Ask for repeat, at least 50ml. (P124)
● If persistent, have a low threshold for performing immunocytochemistry
● Transudate (<3g/dl), systemic problem e.g. cardiac, liver, renal failure
● Exudate (>3g/dl), inflammatory V neoplastic
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Algorithmic approach
● Low power view (?hypercellular ?other abnormal elements i.e. mucin)
● If hypercellular, is it mesothelial or is there a second population?
● Identify nuclear atypia if mesothelial – can be subtle
● Assess 2nd population if present, is it cohesive – epithelial or discohesive- lymphoid or melanocytic?
● Formulate immunopanel (calretinin, EMA, desmin, Ber-EP4 & MOC31, CD45, melan-A, S100) with more specific panels to assess for metastatic disease
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Practical tips
● If suspicious of an atypical population, perform immunostains
● Large papillary groups (>50 cells) in pleural fluid should always raise concern of a neoplastic process
● Necrosis & apoptosis abnormal, look for viable atypical cells
● Beware of hypercellular single cell appearance of mesothelioma
● Always perform calretinin, EMA & desmin to assess for an atypical mesothelial proliferation with follow up biopsy to confirm invasion
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Practical tips
● If the atypical population is wildly pleomorphic, unlikely to be mesothelioma, think poorly differentiated carcinoma, high grade lymphoma, melanoma, sarcoma
● Beware of settling for a diagnosis of reactive lymphocytic effusion without ruling out a lymphoproliferative disorder (CD3, CD5, CD20, MIB-1). Correlate with flow cytometry results
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Neutrophilic Effusion
● Empyema
● Infarction
● Fistula (broncho/oesophageal) – beware squamous cell carcinoma
● SBP
● Bowel perforation
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Lymphocytic Effusion
● Chronic pleurisy
● TB
● Viral pneumionia
● Malignancy (haematological/solid organ)
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Eosinophilic Effusion
● Recurrent pleural intervention
● Allergy
● Autoimmune disorders
● Pneumonia
● Pulmonary infarction
● Infection (parasitic/fungal/mycobacterial)
● Haemo/pneumothorax
● Neoplasms
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Differential for 2nd benign population
● Endosalpingiosis/endometriosis
● Fallopian tube epithelium
● Ruptured cysts
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Metastatic melanoma
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Model Answer ● MICROSCOPY: Moderately cellular sample with dispersed atypical single cells displaying anisonucleosis with rare multinucleate forms. There is moderate amounts of cytoplasm containing coarse pigment.
● DIAGNOSIS: METASTATIC MALIGNANT MELANOMA
● COMMENT:
● Make a clot prepara,on and confirm diagnosis with immunostaining (melan-‐A, S100, SOX10)
● Perform BRAF V600E IHC: ● If posi,ve eligible for combined vemurafenib (TKI) and MEK inhibitor ● If nega,ve proced to NGS to assess for other targetable BRAF musta,ons
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CLL/SLL CD3 CD5
CD20 CD23
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DLBCL
CD79a MIB1
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Plasma cell neoplasm CD138
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Metastatic small cell lung carcinoma
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Metastatic ovarian carcinoma
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Metastatic lung adenocarcinoma
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Metastatic breast carcinoma
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Metastatic pleomorphic rhabdomyosarcoma
Desmin Thigh Bx
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Metastatic urothelial carcinoma
CK7 CK20
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Atypical mesothelial proliferation Calre,nin EMA
Desmin
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Empyema
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Sarcina ventriculi – oesophageal perforation
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Eosinophilic effusion
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Pseuomyxoma peritonei
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Vacuolated cells