Serous effusion Objectives. Cytology of Serous Effusions From basics to challenges

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Cytology of Serous Effusions From basics to challenges Cytology of Serous Effusions From basics to challenges Pınar Fırat,

the evaluation of serous effusions Differential diagnosis between reactive mesothelial proliferations, metastatic

effusion Transudates Exudates Chylous Increased viscosity CHF Infections suggests mesothelioma Trauma Cirrhosis Nephrotic

Meigs` syndrome Collagen vascular disease Embolism/ infarction Uremia Pancreatitis Hemorrhage, fistulas, perforation

stands, thick bottom layer develops, rich in cells At least 20-50 ml for optimal assesment Plazma ultrafiltrate /

Predominant cell type Lymphocyte Neutrophil Eosinophil Underlying disease CHF Renal failure Cirrhosis Infections /TBC, viral

1 Cytology of Serous Effusions From basics to challenges Cytology of Serous Effusions From basics to challenges Pınar Fırat, MD, MIAC Department of Pathology, İstanbul University, İstanbul Faculty of Medicine, TURKEY Objectives Basic principles in the evaluation of serous effusions Differential diagnosis between reactive mesothelial proliferations, metastatic carcinomas, and malignant mesotheliomas Role of immunohistochemistry for correct interpretation Use of other ancillary tests when needed. Serous effusion Systemic / local disease Common Frequently reactive Any type of tumor may cause malignant effusion Serous effusion Transudates Exudates Chylous Increased viscosity CHF Infections suggests mesothelioma Trauma Cirrhosis Nephrotic syndrome Malnutrition Vena cava obst. Meigs` syndrome Collagen vascular disease Embolism/ infarction Uremia Pancreatitis Hemorrhage, fistulas, perforation Malignancies Gross appearence is important Malignancies Large amount is suspicious for malignancyre-prep further slides If stands, thick bottom layer develops, rich in cells At least ml for optimal assesment Plazma ultrafiltrate / hypercellular- rich in protein / lipid-rich Clear, yellowish / blurred, bloody / white, milky Cell blocks BENIGN EFFUSIONS Predominant cell type Lymphocyte Neutrophil Eosinophil Underlying disease CHF Renal failure Cirrhosis Infections /TBC, viral Collagen vascular diseases Malignancy Infections/ empyema, pneumonia Embolism, infarction GIS rupture Collagen vascular diseases Idiopathic Air / repeated asp, pneumothorax Infections/ parasitic, fungal Hypersensitivity/ asthma, drugs Embolism, infarction Asbestosis Malignancy Courtesy of Koray Ceyhan and Claire Michael Rheumatoid Artritis Lupus Erythematosus 1

Determines the stage of the disease and the appropriate therapy Not always

Initial presentation of an unknown malignancy Primary site? Sensitive!

Clinical features of malignant effusions Most common histologic type is

Burkitt Rhabdomyosarcoma Clinical features of malignant effusions Most

Female- Breast, lung, genital tract, lymphoma/leukemia, GI tract Peritoneal

2 Main question is. Is it malignant? A malignant effusion may be the manifestation of a known malignancy Determines the stage of the disease and the appropriate therapy Not always malignant in cancer patients! Initial presentation of an unknown malignancy Primary site? Sensitive! Specific! Clinical features of malignant effusions Most common histologic type is adenocarcinoma In children hematopoetic and small round cells tumors Burkitt Rhabdomyosarcoma Clinical features of malignant effusions Most common primary sites are: Pleural Male- Lung, lymphoma/leukemia, GI tract Female- Breast, lung, genital tract, lymphoma/leukemia, GI tract Peritoneal Male- GI tract, lymphoma/leukemia, pancreas, lung Female- Ovary, uterus, breast, GI tract, lymphoma/leukemia Pericardial Breast, lung, lymphoma/leukemia Differential diagnosis in the land of mesothelial cells Mesothelial hyperplasia Metastatic carcinoma 2

3 Mesothelial cells Mesothelial cells Firat P. Benign Effusions in Serous effusions, Ed. Davidson B, Firat P, Michael C, Springer, New York, 2012 Mesothelial cells Vacuolation in mesothelial cells Degeneration Vacuoles in cytoplasms Vacuoles overlap the nucleus w/o pushing or distorting it No mucin Same nuclear morphology in both vacuolated and non-vacuolated cells No malignant nuclear features Larger vacuoles in chronic effusions Mesothelium Adenocarcinoma Macrophage 3

4 Adenocarcinoma Atypia in mesothelial cells Pulmonary infart, uremia, pancreatitis, radiation, chemotherapy, cirrhosis, heart failure, BerEp4 mucicarmin Firat P. Benign Effusions in Serous effusions, Ed. Davidson B, Firat P, Michael C, Springer, New York, 2012 Differential diagnosis in the land of mesothelial cells Mesothelial hyperplasia Pattern Cellular features IHC Metastatic carcinoma Pattern / Dual cell population Metastatic carcinoma Unless all the cells are neoplastic 4

5 Not all the foreigners are tumor cells Pattern / Tight 3-D clusters Endometrial cells Endosalpingiosis Tuba epithelium Megakaryocyts Colonic mucosa Hepatocytes Lung parenchyma Striated muscle Skin Cartilage Mesothelium Metastatic carcinoma Megakaryocyte Mesothelium Carcinoma Intracytoplasic mucin Psammoma bodies 3.7% (Parwani, et al. Cancer 2004) Most often in peritoneal effusions ~ 2/3 is malignant ~ 1/3 is benign Alarming if it is in pleura or pericardium Mucin in the background 5

Pitfalls Cellular features Mesothelial cells may mimic malignant cells Some carcinomas may look rather bland Golden standart.

Metzgeroth, 2007 84 92 Metzgeroth, 2007 84 94 92 100 Grefte, 2008 78 73 Grefte, 2008 78 96 73 91 Grefte JM, de Wilde PC, Salet-van de Pol MR,

Cytopathology 2008; 19: 205-11 Grefte JM, de Wilde PC, Salet-van de Pol MR, Cytopathology 2008; 19: 205-11 Non- mesothelial markers Mesothelial

- - - - p63 - - -/+ + - Pax8 - + - - + Claudin4 - + + + +/- + Metastatic carcinoma Pattern Any discrete cell population? 3-D tight, crowded groups?

6 Pitfalls Cellular features Mesothelial cells may mimic malignant cells Some carcinomas may look rather bland Golden standart...? Metastatic carcinoma Accuracy in effusion cytology Accuracy in effusion cytology Immuno stains Sensitivity Specificity Sensitivity Specificity Metzgeroth, Metzgeroth, Grefte, Grefte, Grefte JM, de Wilde PC, Salet-van de Pol MR, Tomassen M, Raaymakers-van Geloof WL, Bulten J. Acta Cytol. 2008; 52(1): Metzgeroth G, Kuhn C, Schultheis B, Hehlmann R, Hastka J. Cytopathology 2008; 19: Grefte JM, de Wilde PC, Salet-van de Pol MR, Tomassen M, Raaymakers-van Geloof WL, Bulten J. Acta Cytol. 2008; 52(1): Metzgeroth G, Kuhn C, Schultheis B, Hehlmann R, Hastka J. Cytopathology 2008; 19: Non- mesothelial markers Mesothelial cell Lung adeno Ovarian carcinoma Breast carcinoma SqCC RCC MOC /- - Ber-EP /- - CEA /- - B TTF p /+ + - Pax Claudin /- + Metastatic carcinoma Pattern Any discrete cell population? 3-D tight, crowded groups? Cellular features Nuclear? Cytoplasmic? Cell block- IHC 6

7 Serous effusion ER TTF-1 If it is malignant where is the primary? Cell balls Breast Lung Ovary calretinin 81y, M Followed-up with prostate carcinoma Mediastinal LAP, Nodules in the lung, Pleural effusion PSA Ovary Papillary groups Ovary Lung GIS... Lung Ovary Pancreas Pancreas Pancreas Ovary Vacuolization Ovary Pancreas Lung Renal cell Renal cell Giant cells Pancreas Lung Ovary... Lung 7

8 GIS Breast Single small cells: Lymphoma/leukemia Small cell carcinoma Breast Stomach Small round cell tmrs Single large cells: Melanoma Poorly diff adenocarcinoma Germ cell tumors M.Myeloma Single cells GI tract Breast Lung Lymphoma/ leukemia... DLBCL Lung adenoca Squamous Ca Stomach Breast Breast Indian files Breast Small cell GI tract p63 Small cell Ca Small cell carcinoma Urothelial carcinoma Syn CD56 8

9 Differential diagnosis in the land of mesothelial cells Main difficulty! Mesothelial hyperplasia Metastatic carcinoma IHC Cytology of malignant mesothelioma Absence of a discrete cell population Morphologic continuum between native mesothelial cells and malignant cells More and bigger cells in more and bigger clusters DeMay Complex groups, three dimentional aggregates Cell-in cell arrangements more common 9

10 Cytology of malignant mesothelioma Cytology of malignant mesothelioma If sufficiently well differentiated to be easily recognized as mesothelial, difficult to call them malignant calretinin CK 5/6 Ber-Ep4 CEA TTF-1 D2-40 WT-1 2 mesothelial + 2 carcinoma related markers 10

Marker Calretinin Keratin 5/6 Positive mesothelial markers Useful Differential Diagnosis Not useful (?

Pathology 2013; 44: 1-19 Marker MOC-31 Ber-EP4 CEA TAG-72 BG-8 CD15 Useful Positive carcinoma markers Adenocarcinoma (limited) Differential Diagnosis Not useful Modified from Ordonez NG, Human

Squamous cell carcinoma vs. CEA Lung adenocarcinoma vs. Breast carcinoma vs. Renal cell Renal carcinoma cell carcinoma TAG-72 BG-8 CD15 vs.

11 Marker Calretinin Keratin 5/6 Positive mesothelial markers Useful Differential Diagnosis Not useful (?) (limited) (limited) Podoplanin/D2-40 WT1 Thrombomodulin Mesothelin s Adenocarcinoma (limited) (limited) Negative staining strongly indicates against a mesothelioma Modified from Ordonez NG, Human Pathology 2013; 44: 1-19 Marker MOC-31 Ber-EP4 CEA TAG-72 BG-8 CD15 Useful Positive carcinoma markers Adenocarcinoma (limited) Differential Diagnosis Not useful Modified from Ordonez NG, Human Pathology 2013; 44: 1-19 Positive carcinoma markers Marker Useful Differential Diagnosis Not useful MOC-31 Adenocarcinoma New Marker Breast : carcinoma Ber-EP4 Claudin-4: vs. Squamous cell carcinoma vs. CEA Lung adenocarcinoma vs. Breast carcinoma vs. Renal cell Renal carcinoma cell carcinoma TAG-72 BG-8 CD15 vs. (limited) Modified from Ordonez NG, Human Pathology 2013; 44: AdenoCa, 75 MM Membranous staining 99% AdenoCa 0% MM Marker Positive Organ Negative TTF-1 (75-85%) Napsin A (80-90%) Clear cell RCC (40%) Papillary RCC (75%) PAX 8 PAX 2 (non-mucinous ovarian) Epithelial thymic tumors Thyroid tumors GCDFP-15 (70%) Mammaglobin (50-85%) CDX2 Gastrointestinal Pancreatobiliary Organ specific markers P63 (80-100%) Differential diagnosis in the land of mesothelial cells? Mesothelial hyperplasia Metastatic carcinoma Modified from Ordonez NG, Human Pathology 2013; 44:

12 p53 EMA Desmin Glut-1 E-cadherin Expected immun pattern in malignant mesothelioma Sensitivity, specificity, and positive and negative predictive values for detection of MM by FISH were 79%, 100%, 100%, and 72%, Cyto+Bx (TMA) Homozygote deletion Effusion cytology the role of morphology Not to miss Not to overcall If in doubt IMMUNOCYTOCHEMISTRY ANCILLARY TESTS...morphology is our first line of defense, and if the case passes through this, we have already lost the battle Where is the primary? Is it mesothelioma? IMMUNOCYTOCHEMISTRY ANCILLARY TESTS 12

13 ...morphology is our first line of defense, and if the case passes through this, we have already lost the battle...immunocytochemistry adds great value to our interpretation, and may be the only tool to save the patient NOT always 13

Effusion Cytology: Diagnostic Challenges

Effusion Cytology: Diagnostic Challenges Tarik M. Elsheikh, MD Professor and Medical Director, Anatomic Pathology Cleveland Clinic Outside Consult Case 45 year old woman, presented with nausea, dyspnea,