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[[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. | ||
== | A general [[differential diagnosis]] of pleural effusion is given in the ''[[pleural effusion]]'' article. | ||
=== | |||
''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: | |||
This distinction is important as ''wash'' specimens may have pseudopapillae. | |||
=== | ===Approach=== | ||
* | Look for: | ||
* | #Two cell populations. | ||
#Large dark objects. | |||
#Boerner's red flags. | |||
Boerner's red flags: | |||
#3-D clusters. | |||
#*Doublet & triplets common. | |||
#*Quads-to-Quints - sweat breaks-out. | |||
#*Sextuplets... very nervous. | |||
#"Busy" slide: | |||
#*Nuclear pleomorphism. | |||
#*Too many "intermediate cells". | |||
#*Mitoses - 1-2/slide is "many". | |||
#Vacuolated cytoplasm. | |||
#Small cells with high [[NC ratio]]. | |||
=== | ===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. | ||
==Normal mesothelium== | ===Differential diagnosis=== | ||
*[[Adenocarcinoma]] not otherwise specified (NOS) - most common. | |||
*Reactive mesothelium. | |||
*Malignant mesothelioma. | |||
*[[Serous carcinoma]]. | |||
*[[Lymphoma]]. | |||
Less common: | |||
*[[Squamous carcinoma]]. | |||
*[[Rheumatoid pleuritis]]. | |||
*[[Systemic lupus erythematosus pleurisy]]. | |||
*[[Endosalpingiosis]]. | |||
*[[Endometriosis]]. | |||
*[[Small cell carcinoma]]. | |||
====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> | |||
**HCC in ascites fluid is super rare -- ''I haven't seen a case''.<ref>SB. 8 January 2010.</ref> | |||
=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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*Nucleoli (in reactive cells). | *Nucleoli (in reactive cells). | ||
Note - abnormal features: | |||
* | *Large clusters of cells, e.g. 150+ micrometres. | ||
===Images=== | |||
<gallery> | |||
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:Benign mesothelial cells - pleural fluid -- high mag.jpg | Pairs of mesothelial cells with an intercellular window. (WC) | |||
</gallery> | |||
=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=== | |||
<pre> | |||
Pleural Fluid, Right, Thoracentesis: | |||
- Negative for malignant cells. | |||
- Reactive mesothelial cells present in a background of abundant lymphocytes. | |||
Comment: | |||
Additional sampling should be considered within the clinical context. | |||
</pre> | |||
=Specific diagnoses - benign= | |||
*Large | ==Eosinophilic pleuritis== | ||
===General=== | |||
This has a large DDx: | |||
*Trauma with air in the pleural cavity. | |||
**Repeated tap in the context of [[pneumothorax]]. | |||
*[[Pulmonary infarct]]. | |||
*[[Pneumonia]]. | |||
*Parasitic infections. | |||
*[[Hodgkin lymphoma]]. | |||
*Idiopathic - most common cause. | |||
===Cytology=== | |||
Features: | |||
*Eosinophils >10%. | |||
==Rheumatoid pleuritis== | |||
===General=== | |||
*History of [[rheumatoid arthritis]]. | |||
*Cytologic appearance considered to be ''pathognomonic''.<ref name=pmid2197838/> | |||
===Cytology=== | |||
Features:<ref name=pmid2197838>{{Cite journal | last1 = Naylor | first1 = B. | title = The pathognomonic cytologic picture of rheumatoid pleuritis. The 1989 Maurice Goldblatt Cytology award lecture. | journal = Acta Cytol | volume = 34 | issue = 4 | pages = 465-73 | month = | year = | doi = | PMID = 2197838 }}</ref> | |||
*Large (single) multinucleated cells - classically spindled. | |||
**May have epithelioid morphology. | |||
*Necrotic debris - fluffy orange-to-blue crap. | |||
Note: | |||
*Necrotizing granulomatous inflammation. | |||
==Systemic lupus erythematosus pleurisy== | |||
{{Main|Systemic lupus erythematosus}} | |||
*[[AKA]] ''systemic lupus erythematosus pleuritis''. | |||
===General=== | |||
*Not common. | |||
*Distinctive cytology. | |||
===Cytology=== | |||
Features: | |||
*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 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: | |||
*[http://library.med.utah.edu/WebPath/IMMHTML/IMM008.html LE cell (utah.edu)]. | |||
*[http://www.tabers.com/tabersonline/ub/view/Tabers/143167/34/L_E__cell LE cell (tabers.com)]. | |||
== | =Specific diagnoses - malignant= | ||
==Malignant mesothelioma== | |||
{{Main|Malignant mesothelioma}} | |||
===General=== | ===General=== | ||
*Can be challenging to diagnose. | *Can be challenging to diagnose. | ||
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#*Multiple nucleoli. | #*Multiple nucleoli. | ||
#*Irregular nucleoli (strong). | #*Irregular nucleoli (strong). | ||
Notes: | Notes: | ||
*Single cells/small clusters - suggestive of mesothelioma vs. serous carcinoma. (???) | *Single cells/small clusters - suggestive of mesothelioma vs. serous carcinoma. (???) | ||
Mesothelioma versus reactive mesothelium:<ref name=Ref_DCHH359-60>{{Ref DCHH|359-60}}</ref> | |||
{| class="wikitable sortable" | |||
{| class="wikitable" | |||
|- | |- | ||
! | ! Characteristic | ||
! Reactive mesothelial cells | ! Reactive mesothelial cells | ||
! Mesothelioma | ! Mesothelioma | ||
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*Best assessed on single cells. | *Best assessed on single cells. | ||
== | ====Images==== | ||
www: | |||
*[http://www.acta-cytol.com/feature/2006/feature062006.php IHC mesothelioma (acta-cytol.com)]. | |||
*[http://www.nature.com/modpathol/journal/v17/n4/fig_tab/3800067f2.html IHC mesothelioma (nature.com)]. | |||
<gallery> | |||
Image:Mesothelioma_cytology_1.jpg | Mesothelioma - 1 (WC) | |||
Image:Mesothelioma_cytology_2.jpg | Mesothelioma - 2 (WC) | |||
</gallery> | |||
===IHC=== | |||
*[[Calretinin]] +ve. | |||
*WT-1 +ve. | |||
*[[D2-40]] +ve. | |||
*[[TTF-1]] -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== | |||
===General=== | |||
*[[Diagnosis]] represent a large number of distinct entities - see ''[[adenocarcinoma NOS]]''. | |||
===Cytology=== | |||
Adenocarcinoma in fluid - features:<ref name=Ref_APBR675>{{Ref APBR|675}}</ref> | |||
*Classically large morules (clusters of cells that are heaped/are "3-dimensional"), known as ''cannonballs'', with "community borders". | *Classically large morules (clusters of cells that are heaped/are "3-dimensional"), known as ''cannonballs'', with "community borders". | ||
**"Community border" = smooth, low surface area border; should be differentiated from a "knobby" border seen in mesothelioma. | **"Community border" = smooth, low surface area border; should be differentiated from a "knobby" border seen in mesothelioma. | ||
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*GI. | *GI. | ||
==Colorectal adenocarcinoma | ====Images==== | ||
=====Case 1===== | |||
<gallery> | |||
Image: Adenocarcinoma - pleural fluid -- high mag.jpg | Adenocarcinoma - 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> | |||
===IHC=== | |||
Breast: | |||
*ER +ve/-ve. | |||
*Calretinin -ve. | |||
Colon: | |||
*CK20 +ve. | |||
*CDX2 +ve. | |||
*Calretinin -ve. | |||
Lung: | |||
*TTF-1 +ve. | |||
*Calretinin -ve. | |||
==Colorectal adenocarcinoma== | |||
{{Main|Colorectal adenocarcinoma}} | |||
*May be abbreviated ''CRA''. | |||
===General=== | |||
*Cytology may be distinctive. | |||
===Cytology=== | |||
Features: | Features: | ||
*Cannonballs (non-specific). | *Cannonballs (non-specific). | ||
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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== | ||
General | {{Main|Serous carcinoma}} | ||
* | ===General=== | ||
*S. Boerner believes one can and ought to separate ''adenocarcinoma'' from ''serous carcinoma''. | |||
===Microscopic=== | |||
Features: | Features: | ||
*Large nucleoli.<ref name=pmid2916358>{{Cite journal | last1 = Kuebler | first1 = DL. | last2 = Nikrui | first2 = N. | last3 = Bell | first3 = DA. | title = Cytologic features of endometrial papillary serous carcinoma. | journal = Acta Cytol | volume = 33 | issue = 1 | pages = 120-6 | month = | year = | doi = | PMID = 2916358 }}</ref> | *Large nucleoli.<ref name=pmid2916358>{{Cite journal | last1 = Kuebler | first1 = DL. | last2 = Nikrui | first2 = N. | last3 = Bell | first3 = DA. | title = Cytologic features of endometrial papillary serous carcinoma. | journal = Acta Cytol | volume = 33 | issue = 1 | pages = 120-6 | month = | year = | doi = | PMID = 2916358 }}</ref> | ||
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**Large clusters of cells / micropapillae (?). | **Large clusters of cells / micropapillae (?). | ||
**Nuclear overlap. | **Nuclear overlap. | ||
**+/-True papillae.<ref> | **+/-True papillae.<ref name=scott>Boerner, S. 12 January 2010.</ref> | ||
Note 1 - classic features of serous (see ''[[gynecologic pathology]]'' article): | Note 1 - classic features of serous (see ''[[gynecologic pathology]]'' article): | ||
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*Cilia. | *Cilia. | ||
*Papillae. | *Papillae. | ||
*Psammoma bodies. | *[[Psammoma bodies]]. | ||
DDx of serous carcinoma (found in ascites fluid): | DDx of [[serous carcinoma]] (found in ascites fluid): | ||
*Cervix. | *Cervix. | ||
*Endometrium. | *[[Serous endometrial carcinoma|Endometrium]]. | ||
**Intravacuolar neutrophils are erroneously believed to be indicative of this.<ref> | **Intravacuolar neutrophils are erroneously believed to be indicative of this.<ref name=scott>Boerner, S. 12 January 2010.</ref> | ||
*Uterine tube. | *Uterine tube. | ||
*Ovary. | *[[Ovarian serous carcinoma|Ovary]]. | ||
*Primary peritoneal. | *Primary peritoneal. | ||
IHC | ====Images==== | ||
www: | |||
*[http://pathy.med.nagoya-u.ac.jp/atlas/misc/serous.html Ascites fluid serous adenocarcinoma (nagoya-u.ac.jp)]. | |||
<gallery> | |||
Image:Serous_carcinoma_cytology.jpg | Serous carcinoma - cytology - low mag. (WC) | |||
Image:Uterine_serous_carcinoma_high_mag.jpg | Serous carcinoma - histology - high mag. (WC) | |||
</gallery> | |||
===IHC=== | |||
*WT-1 +ve. | *WT-1 +ve. | ||
*CA-125 +ve. | *[[CA-125]] +ve. | ||
*D2-40 +ve. | *D2-40 +ve. | ||
==See also | ==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= | |||
*[[Cytopathology]]. | *[[Cytopathology]]. | ||
*[[Urine cytopathology]]. | *[[Urine cytopathology]]. | ||
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*[[Urothelium]]. | *[[Urothelium]]. | ||
=References= | |||
{{reflist|2}} | {{reflist|2}} | ||
=External links= | |||
*[http://www.histopathology-india.net/MesoCyto.htm Mesothelioma (histopathology-india.net)]. | *[http://www.histopathology-india.net/MesoCyto.htm Mesothelioma (histopathology-india.net)]. | ||
*[http://www.cytology-asc.com/cec/respiratory/respneopl.htm Respiratory cytopathology (Australian Society)]. | *[http://www.cytology-asc.com/cec/respiratory/respneopl.htm Respiratory cytopathology (Australian Society)]. | ||
[[Category:Cytopathology]] | [[Category:Cytopathology]] |
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