Cytology of Body Fluid
Edmund S, Cytology, Chapter 4: Pleural, pericardial, and peritoneal fluid
Richard M DeMay, The art & science of cytopathology, Chapter 8: Fluid
Leopold G.Koss, Koss’ diagnostic cytology, Chapter 26: Effusion in the presence of cancer
Speaker : 黃筱琪
Advisor : 聶鑫 主任 李修南 學姊
Date
: 3.15.2006
Outline
• Representation of the three body cavities
• Collection and preparation of specimen
• Benign elements
• Non-neoplastic conditions
• Malignant effusions---primary tumors
---metastatic tumors
• Differences Between Adenocarcinoma and Mesothelioma
Schematic representation of the three body cavities
Accumulation of fluids in body cavities
Transudates
• Increased hydrostatic pressure: Congestive heart failure
• Decreased oncotic pressure: cirrhosis, nephrosis, and malnutrition
(decreased albumin)
Exudate
• Inflammation: Infection, infarction, hemorrhage
• Tumor
Differences Between a Transudate and an Exudate
Feature
Gross appearance
Specific gravity
Protein
Clots
Cells
Transudate
Watery, clear
<1.015
<3.0 g/dl
No
Few; usually benign
Exudate
Cloudy, reddish
>1.015
>3.0 g/dl
Yes
Many; can be malignant
Collection and preparation of specimen
Cell block
Heparinized bottles
(3 units heparin/ml)
Adding plasma and thrombin solution
Wrapped in filter paper
Cytocentrifuge preparation
Alcohol-fixed
Unfixed
Papanicolaou-stained
Placed in a cassette
Air-dried cytocentrifuge preparation
Embedded in paraffin
Diff-Quik
(Hematologic malignancy is suspected)
Cut and H&E stain
Benign elements
Mesothelial cells
• Usually dispersed as isolated cells
• Binucleation and multinucleation
• Occasional small clusters with “windows”
• Dense cytoplasm with clear outer rim (lacy skirt)
Mesothelial cells
Reactive mesothelial cell
• Pleomorphic and enlarged nuclei
• Hyperchromasia
• Prominent nucleoli
• Mitotic figures
Benign Mesothelial cells that mimic cancer cells
Benign Formation
Mimics
Three Dimensional cells balls, or rosettes
Papillae
Indian files
Cell in cell
Signet ring
Single cell
Adenocarcinoma
Papillary adenocarcinoma
Breast, small cell carcinoma
Squamous cell carcinoma
Breast, stomach cancer
Lymphoma
Histiocytes
• Nuclei often kidney shape
• Cytoplasm granular and vacuolated
• No window between cells
• CD68 positive
Other blood cells
• Lymphocytes
• Eosinophils
• Neutrophils
• Plasma cells
• Red blood cells
Non-neoplastic conditions
Acute serositis
• Bacterial infection: pleural empyema, bacterial peritoneal
• Color of the fluid: creamy pale yellow (purulent)
• Cytology preparation: high cellular and polymorphonuclear leukocytes
Eosinophilic effusions
• Thoracic trauma, pneumothorax, hemothorax, pulmonary infarcts
• Cytology preparation: high number of eosinophils
• Eosinophilic pleural effusions more common
• Charcot-Leyden crystals
Eosinophilic pleural fluid
Tuberculous pleuritis
• Color of the fluid: turbid and greenish-yellow
• Cytology preparation: high cellular of lymphocytes (T cells)
• Differential diagnosis: inflammatory effusion of non-tuberculous origin
Tuberculous pleuritis
Rheumatoid pleuritis
• Necrotizing granulomatous inflammation (joint disease)
• Cytology preparation: clumps of granular debris
multinucleated macrophages
Multinucleated macrophages
Systemic lupus erythematosus
• Cytology preparation: Lupus erythematosus cell (LE cell)
LE cell
Malignant effusions---primary tumors
Malignant mesothelioma
• Clinical history: asbestos exposure, persistent pleural effusions, chest pain
• Epithelial (carcinomatous) pattern
Malignant Mesothelioma
“More and bigger cells, in more and bigger
clusters”
Group
• Irregular papillae and
Knobby three-dimensional clusters
• Cell-in-cell arrangements
• Indian files
Nuclei
• Increased bi/multinucleation
• Nuclear enlargement and pleomorphism
• Macronucleoli
Cytoplasm
• Windows, skirts (lacy appearance)
• Dense, many two-tone staining
• Fine vacuoles (lipid, glycogen)
Cell-in-cell pattern
“More and bigger cells,
in more and bigger clusters”
Malignant effusions---metastatic tumors
The Most Common Tumor that Cause Malignant Effusion, by Site and Sex
Type of Malignant
Men
Women
Pleural
Lung
Gastrointestinal tract
Pancreas
Breast
Lung
Ovary
Peritoneal
Intestinal
(includes gastric and pancreatic)
Pancreas
Prostate
Ovary
Breast
Uterus
Adenocarcinoma
• Large nucleoli
• Increased N/C ratio
• Secretory vacuoles
• Irregular nuclear membranes
• Three dimensional aggregates
The patterns of Adenocarcinoma
Breast cancer
• Cannonball (no vacuole)
• Indian files
• Signet ring cells (small)
Ovarian cancer
• Psammoma bodies
• Cannonball (vacuole)
Stomach cancer
• Signet ring cells (large)
Kidney cancer
• Clear cells
Thyroid cancer
• Psammoma bodies
Breast cancer
• Cannonballs:
Tight packed large balls of cells
Smooth borders
• Indian files
Lung cancer
Ovarian carcinoma
• Irregular clusters of cells
• Large and clear vacuoles
Gastric carcinoma
• Signet ring cell pattern
Clear cell carcinoma of kidney cancer
• Clear or granular and
vacuolated cytoplasm
Papillary carcinoma of the thyroid
• Psammoma bodies
Squamous cell carcinoma
• Keratinized or non-keratinized
• Tadpoles and bizarre shape
F4.27
Small cell carcinoma
• Isolated and molded cells
• Scant cytoplasm, inconspicuous nucleoli
F4.28
Non-Hodginkin lymphoma
Large cell lymphoma
• Nuclei large than histiocyte
• Eccentric nuclei
• Abundant blue cytoplasm
• Best appreciated in Diff-Quik
Follicular lymphoma
• Irregular nuclear contours
• Scant cytoplasm
lymphoblastic lymphoma
• Small to medium sized lymphocytes
• Fine powdery chromatin
• Scant cytoplasm
Small lymphocytic lymphoma
• Differential diagnosis:
chronic inflammation (tuberculosis)
Hodgkin lymphoma
• Reed-Sternbery cells:
Multinucleated cell with
huge inclusion-like nucleoli
Multiple myeloma
• Single, lack cohesive aggregate
• Numerous malignant plasma cells
• Immunocytochemistry stain:
kappa and lambda light chain (+)
CD138 (+)
Melanoma
• Isolated round cells with prominent nucleoli
• Fine brown cytoplasmic pigmentation
• Intranuclear pseudoinclusions
• Immunocytochemistry stain: S-100(+), HMB-45(+)
Sarcomas
• Isolated cells
Pleomorphic sarcoma
Round cell sarcoma
Spindle cell sarcoma
Osteosarcoma
Rhabdomyosarcoma
Fibrosarcoma
Liposarcoma
Neuroblastoma
Leiomyosarcoma
Large and bizarre shaped
Small and uniform shaped
Spindle shaped
Differences Between Adenocarcinoma and Mesothelioma
Cytologic Differences Between Adenocarcinoma and Mesothelioma
Adenocarcinoma
Mesothelioma
Groupings
Community borders
Windows unusual
irregular knobby outline
Windows common
Cells
Columnar shape
Blebs, skirts
Nucleus
Usually eccentric
Pleomorphic and bizarre
Usually central
Less pleomorphic and not bizarre
Cytoplasm
Delicate, homogeneous
Uniform stain
Dense with lacy edges
Two-tone staining
Vacuoles
Secretory
Degenerative
Multinucleated
Giant cells
Rare
Common
Distinguishing Between Mesothelioma and Metastatic Adenocarcinoma with Immunocytochemistry
Stain
Staining patterns
Adenicarcinoma
Mesothelioma
Mucicarmine
C
+
-
Carcinoembryonic antigen
C
+
-
CA19-9
C
+
-
Leu M-1
C+M
+
-
E-cadherin
C+M
+
-
BerEP4
C+M
+
-
B27.3
M
+
-
Thyroid transcription factor-1
(TTF-1)
N
+
-
Keratin protein
M
+ (peripheral)
+ (perinuclear)
Calretinin
C+N
-
+
Vimentin
C
-
+
Wilms’ tumor(WT1) protein
N
-
+
C: cytoplasm; M: membrane; N: nuclear
E-cadherin
BerEP4
B72.3
Calretinin