Difference between revisions of "Mesothelial cytopathology"

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Mesothelial cytopathology (view source)

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[[Image:Benign mesothelial cells - pleural fluid -- high mag.jpg|thumb|right|300px|Benign mesothelial cells from a pleural fluid specimen.]]
[[Image:Benign mesothelial cells - pleural fluid -- high mag.jpg|thumb|right|300px|Benign mesothelial cells from a pleural fluid specimen. (WC)]]
[[Image:Lung_adenocarcinoma_-_pleural_fluid_--_very_high_mag.jpg|thumb|right|300px|Adenocarcinoma (lung) and benign mesothelial cells in a pleural fluid specimen. (WC)]]
'''Mesothelial cytopathology''' is a large part of cytopathology.  The article deals with cytopathology specimens from spaces lined with mesothelium, i.e. it deals with pericardial fluid, peritoneal fluid and pleural fluid.
'''Mesothelial cytopathology''' is a large part of cytopathology.  The article deals with cytopathology specimens from spaces lined with mesothelium, i.e. it deals with pericardial fluid, peritoneal fluid and pleural fluid.


An introduction to cytopathology is in the ''[[cytopathology]]'' article.   
An introduction to cytopathology is in the ''[[cytopathology]]'' article.   


''Pleural fluid'' redirects to here.
A general [[differential diagnosis]] of pleural effusion is given in the ''[[pleural effusion]]'' article.


=Specimen types=
''Pleural fluid'', ''pleural cytopathology'', ''peritoneal fluid'', and ''peritoneal cytopathology'' redirect to here.
 
=Overview=
*[[Sensitivity]] moderate for malignancy (60%).<ref name=pmid>{{Cite journal  | last1 = Karoo | first1 = RO. | last2 = Lloyd | first2 = TD. | last3 = Garcea | first3 = G. | last4 = Redway | first4 = HD. | last5 = Robertson | first5 = GS. | title = How valuable is ascitic cytology in the detection and management of malignancy? | journal = Postgrad Med J | volume = 79 | issue = 931 | pages = 292-4 | month = May | year = 2003 | doi =  | PMID = 12782778 }}</ref>
 
===Specimen types===
*'''Wash''', e.g. ''peritoneal wash'': expect sheets of (benign squamous) cells.
*'''Wash''', e.g. ''peritoneal wash'': expect sheets of (benign squamous) cells.
*'''Spontaneous''', e.g. ''pleural fluid'': usually no large sheets.
*'''Spontaneous''', e.g. ''pleural fluid'': usually no large sheets.


Note:
Note:
This distinction is important as ''wash'' specimens may have pseudopapillae.  
This distinction is important as ''wash'' specimens may have pseudopapillae.


=Approach=
===Approach===
Look for:
Look for:
#Two cell populations.
#Two cell populations.
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#Small cells with high [[NC ratio]].
#Small cells with high [[NC ratio]].


==Features of malignancy==
===Features of malignancy===
Strongly suggestive of malignancy:
Strongly suggestive of malignancy:
*3-D clusters.
*3-D clusters.
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*High NC ratio.
*High NC ratio.


=Differential diagnosis=
===Differential diagnosis===
*[[Adenocarcinoma]] not otherwise specified (NOS) - most common.
*[[Adenocarcinoma]] not otherwise specified (NOS) - most common.
*Reactive mesothelium.
*Reactive mesothelium.
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*[[Small cell carcinoma]].
*[[Small cell carcinoma]].


===Peritoneal cavity specific===
====Peritoneal cavity specific====
*[[Hepatocellular carcinoma]] (HCC) may be associated with ascites... but it is rarely positive for malignant cells.<ref name=Ref_APBR679>{{Ref APBR|679}}</ref>
*[[Hepatocellular carcinoma]] (HCC) may be associated with ascites... but it is rarely positive for malignant cells.<ref name=Ref_APBR679>{{Ref APBR|679}}</ref>
**HCC in ascites fluid is super rare -- ''I haven't seen a case''.<ref>SB. 8 January 2010.</ref>
**HCC in ascites fluid is super rare -- ''I haven't seen a case''.<ref>SB. 8 January 2010.</ref>


=Normal mesothelium=
=Normal mesothelium=
===General===
Often seen in the context of:
*Gynecologic surgeries - done to exclude malignancy.
*Taps for ascites.
===Cytology===
Features:<ref name=Ref_APBR674>{{Ref APBR|674}}</ref>
Features:<ref name=Ref_APBR674>{{Ref APBR|674}}</ref>
*"Window" or "space" between attached cells (due to microvilli).
*"Window" or "space" between attached cells (due to microvilli).
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Image:Mesothelium_peritoneal_wash_intermed_mag.jpg | Peritoneal wash - benign mesothelial cells in sheets (WC)
Image:Mesothelium_peritoneal_wash_intermed_mag.jpg | Peritoneal wash - benign mesothelial cells in sheets (WC)
Image:Mesothelium_peritoneal_wash_high_mag.jpg | Peritoneal wash - benign mesothelial cells in sheets - high mag. (WC)
Image:Mesothelium_peritoneal_wash_high_mag.jpg | Peritoneal wash - benign mesothelial cells in sheets - high mag. (WC)
Image:Benign mesothelial cells - pleural fluid -- high mag.jpg | Pairs of mesothelial cells an intercellular window. (WC)
Image:Benign mesothelial cells - pleural fluid -- high mag.jpg | Pairs of mesothelial cells with an intercellular window. (WC)
</gallery>
</gallery>


=Reactive mesothelium=
=Reactive mesothelium=
===General===
*May be due to any number of causes.
*Can be severe in the context of [[chronic renal failure|(peritoneal) dialysis]].<ref name=pmid2323293>{{Cite journal  | last1 = Selvaggi | first1 = SM. | last2 = Migdal | first2 = S. | title = Cytologic features of atypical mesothelial cells in peritoneal dialysis fluid. | journal = Diagn Cytopathol | volume = 6 | issue = 1 | pages = 22-6 | month =  | year = 1990 | doi =  | PMID = 2323293 }}</ref>
===Cytology===
:''See [[Mesothelial_cytopathology#Malignant_mesothelioma|mesothelioma]]''.
====Images====
<gallery>
Image: Peritoneal fluid - post-DC insertion -- high mag.jpg | PF - high mag. (WC)
Image: Peritoneal fluid - post-DC insertion -- very high mag.jpg | PF - very high mag. (WC)
Image: Peritoneal fluid - post-DC insertion - alt -- very high mag.jpg | PF - very high mag. (WC)
</gallery>
===Sign out===
===Sign out===
<pre>
<pre>
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This has a large DDx:
This has a large DDx:
*Trauma with air in the pleural cavity.
*Trauma with air in the pleural cavity.
**Repeated tap in the context of pneumothorax.
**Repeated tap in the context of [[pneumothorax]].
*[[Pulmonary infarct]].
*[[Pulmonary infarct]].
*[[Pneumonia]].
*[[Pneumonia]].
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===Cytology===
===Cytology===
Features:
Features:
*Lupus erythematosus cells, usually abbreviated ''LE cells'':<ref>URL:[http://www.tabers.com/tabersonline/ub/view/Tabers/143167/34/L_E__cell http://www.tabers.com/tabersonline/ub/view/Tabers/143167/34/L_E__cell]. Accessed on: 12 April 2012.</ref>
*Lupus erythematosus cells, usually abbreviated ''[[LE cell]]s'':<ref>URL:[http://www.tabers.com/tabersonline/ub/view/Tabers/143167/34/L_E__cell http://www.tabers.com/tabersonline/ub/view/Tabers/143167/34/L_E__cell]. Accessed on: 12 April 2012.</ref>
**Pink blobs (representing a denatured nuclei) - phagocytosed by macrophages or [[PMN]]s.<ref>URL: [http://library.med.utah.edu/WebPath/IMMHTML/IMM008.html http://library.med.utah.edu/WebPath/IMMHTML/IMM008.html]. Accessed on: 12 April 2012.</ref>
**Pink blobs (representing a denatured nuclei) - phagocytosed by a [[neutrophil]].<ref>URL: [http://library.med.utah.edu/WebPath/IMMHTML/IMM008.html http://library.med.utah.edu/WebPath/IMMHTML/IMM008.html]. Accessed on: 12 April 2012.</ref>


Image:  
Image:  
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===IHC===
===IHC===
*Calretin +ve.
*[[Calretinin]] +ve.
*WT-1 +ve.
*WT-1 +ve.
*[[D2-40]] +ve.
*[[D2-40]] +ve.
*[[TTF-1]] -ve.
*[[TTF-1]] -ve.
*CEA -ve.
*CEA -ve.
*[[p63]] -ve.<ref name=pmid18064689>{{Cite journal  | last1 = Pu | first1 = RT. | last2 = Pang | first2 = Y. | last3 = Michael | first3 = CW. | title = Utility of WT-1, p63, MOC31, mesothelin, and cytokeratin (K903 and CK5/6) immunostains in differentiating adenocarcinoma, squamous cell carcinoma, and malignant mesothelioma in effusions. | journal = Diagn Cytopathol | volume = 36 | issue = 1 | pages = 20-5 | month = Jan | year = 2008 | doi = 10.1002/dc.20747 | PMID = 18064689 }}</ref>


==Adenocarcinoma==
==Adenocarcinoma==
===General===
*[[Diagnosis]] represent a large number of distinct entities - see ''[[adenocarcinoma NOS]]''.
===Cytology===
===Cytology===
Adenocarcinoma in fluid - features:<ref name=Ref_APBR675>{{Ref APBR|675}}</ref>
Adenocarcinoma in fluid - features:<ref name=Ref_APBR675>{{Ref APBR|675}}</ref>
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====Images====
====Images====
=====Case 1=====
<gallery>
<gallery>
Image: Adenocarcinoma - pleural fluid  -- high mag.jpg | Adenocarcinoma - high mag. (WC)
Image: Adenocarcinoma - pleural fluid  -- high mag.jpg | Adenocarcinoma - high mag. (WC)
Image: Adenocarcinoma - pleural fluid  -- very high mag.jpg | Adenocarcinoma - very high mag. (WC)
Image: Adenocarcinoma - pleural fluid  -- very high mag.jpg | Adenocarcinoma - very high mag. (WC)
</gallery>
<gallery>
Image: Lung adenocarcinoma - pleural fluid -- high mag.jpg | Lung adenocarcinoma - high mag. (WC)
Image: Lung adenocarcinoma - pleural fluid -- very high mag.jpg | Lung adenocarcinoma - very high mag. (WC)
Image: Lung adenocarcinoma - pleural fluid - 2 -- high mag.jpg | Lung adenocarcinoma - high mag. (WC)
Image: Lung adenocarcinoma - pleural fluid - 2 -- very high mag.jpg | Lung adenocarcinoma - very high mag. (WC)
</gallery>
=====Case 2=====
<gallery>
Image: Adenocarcinoma - pleural fluid 3 -- high mag.jpg | Adenocarcinoma - high mag. (WC)
Image: Adenocarcinoma - pleural fluid 3 -- very high mag.jpg | Adenocarcinoma - very high mag. (WC)
Image: Adenocarcinoma - pleural fluid 3 - alt -- very high mag.jpg | Adenocarcinoma - very high mag. (WC)
Image: Adenocarcinoma - pleural fluid 3 - TTF-1 -- high mag.jpg | Adenocarcinoma - TTF-1 - high mag. (WC)
Image: Adenocarcinoma - pleural fluid 3 - TTF-1 -- very high mag.jpg | Adenocarcinoma - TTF-1 - very high mag. (WC)
</gallery>
</gallery>
===IHC===
Breast:
*ER +ve/-ve.
*Calretinin -ve.
Colon:
*CK20 +ve.
*CDX2 +ve.
*Calretinin -ve.
Lung:
*TTF-1 +ve.
*Calretinin -ve.


==Colorectal adenocarcinoma==
==Colorectal adenocarcinoma==
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**Pseudostratified cells.
**Pseudostratified cells.
**Columnar cells.
**Columnar cells.
Note:
*See ''adenocarcinoma'' section above for other types of adenocarcinoma.


==Serous carcinoma==
==Serous carcinoma==
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===IHC===
===IHC===
*WT-1 +ve.
*WT-1 +ve.
*CA-125 +ve.
*[[CA-125]] +ve.
*D2-40 +ve.
*D2-40 +ve.
==Lymphoma==
===General===
*Can only be reasonably certain for ''large cell lymphomas'', e.g. ''[[DLBCL]]''.
**The diagnosis of [[small cell lymphomas]] relies on architecture and immunostains.
===Cytology===
Features:
*Dyscohesive cells ~2x a resting lymphocyte - usually with scant blue cytoplasm.
DDx:
*[[Small cell carcinoma]].
*Other [[small round cell tumours]].
====Images====
<gallery>
Image: Lymphoma - pleural fluid -- intermed mag.jpg | Lymphoma - intermed. mag.
Image: Lymphoma - pleural fluid - alt -- high mag.jpg | Lymphoma - high mag.
Image: Lymphoma - pleural fluid - alt -- very high mag.jpg | Lymphoma - very high mag.
Image: Lymphoma - pleural fluid - DQ -- high mag.jpg | Lymphoma - high mag.
Image: Lymphoma - pleural fluid - DQ -- very high mag.jpg | Lymphoma - very high mag.
</gallery>


=See also=
=See also=
Michael
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