1. Speaker : 黃筱琪 Advisor : 聶鑫 主任 李修南 學姊 Date : 3.15.2006
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 :

2. 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

3. Schematic representation of the three body cavities

4. 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 Transudate Exudate
Gross appearance Watery, clear Cloudy, reddish
Specific gravity < >1.015
Protein <3.0 g/dl >3.0 g/dl
Clots No Yes
Cells Few; usually benign Many; can be malignant

5. Collection and preparation of specimen
Heparinized bottles
(3 units heparin/ml)
Unfixed
Cell block
Adding plasma and thrombin solution
Wrapped in filter paper
Placed in a cassette
Embedded in paraffin
Cut and H&E stain
Alcohol-fixed
Papanicolaou-stained
Cytocentrifuge preparation
Air-dried cytocentrifuge preparation
Diff-Quik
(Hematologic malignancy is suspected)

6. 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

7. 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 Adenocarcinoma
Papillae Papillary adenocarcinoma
Indian files Breast, small cell carcinoma
Cell in cell Squamous cell carcinoma
Signet ring Breast, stomach cancer
Single cell Lymphoma

8. 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

9. 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

10. 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

11. Systemic lupus erythematosus
Cytology preparation: Lupus erythematosus cell (LE cell)
LE cell

12. 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)

13. Cell-in-cell pattern
“More and bigger cells,
in more and bigger clusters”

14. Malignant effusions---metastatic tumors
The Most Common Tumor that Cause Malignant Effusion, by Site and Sex
Type of Malignant Men Women
Pleural Lung Breast
Gastrointestinal tract Lung
Pancreas Ovary
Peritoneal Intestinal Ovary
(includes gastric and pancreatic)
Pancreas Breast
Prostate Uterus

15. Adenocarcinoma Increased N/C ratio Irregular nuclear membranes
Large nucleoli
Secretory vacuoles
Three dimensional aggregates
The patterns of Adenocarcinoma
Breast cancer
Ovarian cancer
Stomach cancer
Kidney cancer
Thyroid cancer
Cannonball (no vacuole)
Indian files
Signet ring cells (small)
Psammoma bodies
Cannonball (vacuole)
Signet ring cells (large)
Clear cells

16. Cannonballs:
Tight packed large balls of cells
Smooth borders
Indian files
Breast cancer
Lung cancer

17. Irregular clusters of cells
Large and clear vacuoles
Ovarian carcinoma
Signet ring cell pattern
Gastric carcinoma

18. Clear cell carcinoma of kidney cancer
Clear or granular and
vacuolated cytoplasm
Papillary carcinoma of the thyroid
Psammoma bodies

19. 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

20. 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

21. lymphoblastic lymphoma
Small to medium sized lymphocytes
Fine powdery chromatin
Scant cytoplasm
Small lymphocytic lymphoma
Differential diagnosis:
chronic inflammation (tuberculosis)

22. Hodgkin lymphoma Multiple myeloma 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 (+)

23. Melanoma Sarcomas Isolated round cells with prominent nucleoli
Fine brown cytoplasmic pigmentation
Intranuclear pseudoinclusions
Immunocytochemistry stain: S-100(+), HMB-45(+)
Sarcomas
Isolated cells
Pleomorphic sarcoma
Osteosarcoma
Liposarcoma
Large and bizarre shaped
Round cell sarcoma
Rhabdomyosarcoma
Neuroblastoma
Small and uniform shaped
Spindle cell sarcoma
Fibrosarcoma
Leiomyosarcoma
Spindle shaped

24. Differences Between Adenocarcinoma and Mesothelioma
Cytologic Differences Between Adenocarcinoma and Mesothelioma
Adenocarcinoma Mesothelioma
Groupings Community borders irregular knobby outline
Windows unusual Windows common
Cells Columnar shape Blebs, skirts
Nucleus Usually eccentric Usually central
Pleomorphic and bizarre Less pleomorphic and not bizarre
Cytoplasm Delicate, homogeneous Dense with lacy edges
Uniform stain Two-tone staining
Vacuoles Secretory Degenerative
Multinucleated Rare Common
Giant cells

25. - + + - + - + - + - + - + - + - + + - + - + - +
Distinguishing Between Mesothelioma and Metastatic Adenocarcinoma with Immunocytochemistry
Stain Staining patterns Adenicarcinoma Mesothelioma
Mucicarmine C
Carcinoembryonic antigen C
CA C
Leu M C+M
E-cadherin C+M
BerEP C+M
B M
Thyroid transcription factor N
(TTF-1)
Keratin protein M (peripheral) (perinuclear)
Calretinin C+N
Vimentin C
Wilms’ tumor(WT1) protein N - + + - + - + - + - + - + - + - + + - + - + - +
C: cytoplasm; M: membrane; N: nuclear

26. Thank you for your attention
THE END
Thank you for your attention

27. E-cadherin

28. BerEP4

29. B72.3

30. Calretinin