Diagnostic effects of prolonged storage on fresh effusion samples

Minimally Invasive, Maximally Effective: The Power of Precision Cytoanalysis on Effusion Samples-A Comprehensive Exploration from Traditional Methods to Innovative Approaches

Precision medicine translates through molecular assays and in minimally invasive diagnosis, evident in analyses of effusions that serve therapeutic and diagnostic purposes. This cost-effective and low-risk approach provides advantages, playing a pivotal role in late-stage oncology and frequently standing as the primary resource for cancer diagnosis and treatment pathways. This article outlines the workflow for managing serous fluid and explores how cytology effusion analysis extends beyond immunocytological diagnosis. Combined with current molecular tests it showcases the potential to be a skillful tool in precision cytopathology.

The cytological features of effusions with mesothelioma in situ: A report of 9 cases

INTRODUCTION

The diagnosis of mesothelioma in situ (MIS) is now accepted by the WHO as a pre-invasive neoplastic mesothelial proliferation and considered a diagnosis based on histologic evaluation only. Although the definition of MIS includes recurrent effusions, little is known about the cytologic features of such effusions. Since mesothelioma is usually diagnosed at an advanced stage and has a poor prognosis, early detection of a neoplastic mesothelial population in such effusions can potentially have a positive impact on the management of such a dire disease.

MATERIALS AND METHODS

We reviewed a total of 18 pleural effusions from nine patients with recurrent effusions. Of these, five patients had follow-up biopsies diagnosed as MIS and the remaining four cases had negative radiology and malignant cytology proven by molecular markers (BAP1, MTAP or CDKN2A deletion) and at least 1 year follow-up with no overt mass identified by radiology.

RESULTS

Initial effusions may mimic reactive mesothelial hyperplasia or exhibit atypia. As effusions recur, the cellularity and atypia increase and the mesothelial proliferation becomes morphologically indistinguishable from mesothelioma. Molecular alterations diagnostic of mesothelioma can be detected in these effusions, even in the initial-benign/reactive appearing ones. The cellularity and atypia detected in such effusions surpassed those noted on the biopsies, raising questions regarding the cause of such discrepancy.

CONCLUSION

The diagnosis of MIS can be suspected based on malignant effusion cytology supported by molecular alterations. We propose that the proliferation of neoplastic mesothelial clones represent a clinically silent "liquid phase MIS stage" corresponding to in situ stage in other organs.

Storage Artifact Masquerading as Yeast: Presenting a Diagnostic Pitfall

Abnormal cell morphology can result from prolonged specimen storage, both for red and white blood cells. In particular, nuclear pyknosis of segmented neutrophils can occur in both peripheral blood and body fluids and may represent a diagnostic pitfall as it can mimic intracellular yeast or bacteria morphology. Pathologists are frequently asked to examine body fluid smears which are thought to contain microorganisms, and the presence of an unexpected organism can be especially concerning. Morphologic changes from prolonged storage may be encountered infrequently, and it is important to be aware of them in order to avoid misrepresentation, as additional work-up may be required for a suspected case of an unexpected fungal infection.

Molecular cytology of the respiratory tract and pleura

There is growing evidence that molecular testing is feasible on all types of cytological preparation, which is fortunate as more diagnostic markers and biomarkers for targeted therapies are discovered for use in pulmonary and pleural malignancies. In this article we will discuss the pre-analytic, analytic, and post-analytic (interpretive) considerations for successful implementation of molecular tests for diagnostic and predictive markers in respiratory and pleural cytology. The vast majority of laboratories are familiar with, and have validated their molecular protocols for, formalin-fixed paraffin-embedded surgical specimens, which are not directly applicable to cytology specimens. Thus, rigorous validation must be performed for each type of fixative and cytology preparation before it is implemented in the clinical setting.

Immunochemistry in the work-up of mesothelioma and its differential diagnosis and mimickers

The differential diagnosis in cellular effusions with cytological atypia often includes malignant mesothelioma (MM), reactive mesothelial proliferation, and malignancies of metastatic origin, particularly carcinomas. The International Reporting System for Serous Fluid recently established guidelines for reporting MM. In conjunction with the cytomorphologic evaluation, the role of immunochemistry (IC) was emphasized as a very useful tool in the workup of serous fluids, especially with the availability of novel markers. Utilizing a panel of markers, IC allows the characterization of the cells, whether mesothelial or not, and when mesothelial origin is established, IC can frequently assist in delineating its benign or malignant nature. IC can also confirm metastatic disease, allowing the identification of the primary origin in most cases. This review summarizes the current status of IC and its role in the diagnosis of MM and its differential diagnosis in serous fluids.

Update on diagnosis and management of neoplastic pericardial disease

INTRODUCTION

Pericardial neoplasms are uncommon, mostly due to secondary involvement of the pericardium by extracardiac tumors. Clinical presentation is nonspecific, frequently leading to a delayed diagnosis. Moreover, both benign and malignant pericardial tumors may be associated with myocardial infiltration and mechanical compression of cardiac chambers, possibly precipitating clinical conditions. Pericardial tumors are indeed a diagnostic and therapeutic clinical challenge.

AREAS COVERED

This review aims to provide an overview of the main clinical characteristics of pericardial tumors, along with their management in clinical practice.

EXPERT COMMENTARY

Multimodality imaging (echocardiography, chest X-ray, CT, CMR, and PET) enable full characterization of pericardial neoplasms. An individualized strategy should be developed by a multidisciplinary team including cardiologists, oncologists, radiologists, and cardiac surgeons.

Pericardial diseases in patients with cancer: contemporary prevalence, management and outcomes

Neoplastic pericardial effusion is a common and serious manifestation of advanced malignancies. Lung and breast carcinoma, haematological malignancies, and gastrointestinal cancer are the most common types of cancer involving the pericardium. Pericardial involvement in neoplasia may arise from several different pathophysiological mechanisms and may be manifested by pericardial effusion with or without tamponade, effusive-constrictive pericarditis and constrictive pericarditis. Management of these patients is a complex multidisciplinary problem, affected by clinical status and prognosis of patients.

Effects of the Storage Solution Type and Prolonged Storage on the Immunoreactivity of Cells

INTRODUCTION

In effusion cytology, immunocytochemistry is a useful staining approach to provide important information for diagnosis. Effusion cytology is performed not only for pleural effusions and ascites but also for peritoneal and needle washing from fine needle aspirations or instruments. Although various solutions are used for washing cytology, the effect of the solution type on immunocytochemical reactivity is not fully understood. In this study, we examined the immunocytochemical reactivity of cytological samples after storage in various solutions.

METHODS

Cell block specimens were obtained from ascites of patients with peritoneal cancer and pleural effusions of patients with diffuse malignant mesothelioma. Various solutions, including physiological saline (PS), Ringer solution, a low-molecular-weight dextran L injection, Voluven 6% solution, Mixid L injection, RPMI-1640 medium, and horse serum were added to the sediment layers of aliquots. All samples were kept at 4°C, and aliquots were subsequently processed at specific time points (0, 1, 2, 4, 7, and 14 days). Formalin-fixed, paraffin-embedded, cell block samples were prepared for immunocytochemical staining. Immunocytochemical results were analyzed for differences in the percentages of positive cells, using the effusion sample stored for 1 h as standard (100%).

RESULTS

For all solutions other than PS, the median and central 50% of values were <100% (with respect to the effusion sample as a standard) after 1 h of storage. Immunoreactivity decreased for most solutions as time progressed.

CONCLUSION

Of note, immunocytochemistry results obtained using a washing solution are different from those using an effusion sample. For cytology, when a washing solution was used or when a sample was stored for a long time, the accuracy of the immunocytochemical results was low.

Characterizing the Effect of Automated Cell Sorting Solutions on Cytomorphological Changes

INTRODUCTION

Liquid-based cytology has become a widely adopted, automated screening system for gynecologic and nongynecologic cytology. Automated screening systems function by distinguishing atypical cells based on their cytoplasmic and nuclear areas, densitometric measurement, and so on. However, the morphological influence of the washing solution has not been fully considered. Here, we examined the morphological effect and temporal change resulting from saving the cytologic samples in various solutions.

METHODS

Cytologic specimens were obtained from the ascites (AS) of patients with peritoneal cancer. Various solutions of a physiological saline, a Ringer's solution, a low-molecular dextran L injection, VOLUVEN 6% solution, MIXID L injection (ML), RPMI-1640 medium, and horse serum (HS) were added to aliquot sediments. All samples were refrigerated at 4°C, and aliquots were subsequently processed at specific time points (0, 1, 2, 4, 7, and 14 days). For all samples, cytoplasmic and nuclear size of the Papanicolaou-stained specimens were measured.

RESULTS

In terms of cytoplasmic and nuclear areas, samples stored in ML and HS showed no significant difference compared to the AS sample; in contrast, the other samples were significantly larger in both cytoplasmic and nuclear areas than the AS sample. In examining the temporal change among the solutions, we found that the cytoplasms and nuclei became small over the time course for all of the tested solutions.

CONCLUSION

We showed that cells swell in the solution after 1 h of storage and contract as time progresses. Together, our findings have important implications for how mathematical analysis is applied during the automated screening process.

Management of cytological material, pre-analytical procedures and bio-banking in effusion cytopathology

Serous effusion fluid is one of the most commonly encountered specimens in routine cytopathology practice. It provides invaluable information about the patient and the clinical status; but to get the most of it, specimen handling and processing must be carried out properly. Cytomorphology is the basis of a successful analysis which should complemented by ancillary tests when needed. A wide spectrum of ancillary techniques - ranging from immunocytochemistry and flow cytometry to different assays of molecular pathology - can be applied to serous effusions. This article describes the acquisition and management of serous effusion fluids, methods for preservation and transportation, different techniques of cytopreparation, application of immunocytochemistry, flow cytometry, and fluorescence in-situ hybridization (FISH), as well as DNA extraction for polymerase chain reaction (PCR) and next generation sequencing (NGS). Principles of bio-banking of effusion samples are also discussed which is getting more important in correlation with the developments in personalized medicine.

Pre-analytical issues in effusion cytology

Effusions or body cavity fluids are amongst the most commonly submitted samples to the cytology laboratory. Knowledge of proper collection, storage, preservation and processing techniques is essential to ensure proper handling and successful analysis of the sample. This article describes how the effusions should be collected and proper conditions for submission. The different processing techniques to extract the cellular material and prepare slides satisfactory for microscopic evaluation are described such as direct smears, cytospins, liquid based preparations and cell blocks. The article further elaborates on handling the specimens for additional ancillary testing such as immunostaining and molecular tests, including predictive ones, as well as future research approaches.

2015 update on the diagnosis and management of neoplastic pericardial disease

The best approach in diagnosis and treatment of neoplastic pericardial disease has not been defined yet. The authors report the most recent literature about the new diagnostic techniques that are useful to improve the diagnosis. The literature about the therapeutic options is critically reviewed, in order to give suggestions of use to the clinical practice. Pericardial effusion may require urgent drainage; the solid component, however, becomes predominant in some cases. Neoplastic pericardial disease should be assessed following oncologic criteria evaluation of the neoplastic burden; outcome classified as complete or partial response, stable or progressive disease and - in cases with progression - event-free survival. Systemic chemotherapy may be effective in lymphomas and possibly in breast carcinomas. Intrapericardial chemotherapy with systemic chemotherapy is the treatment of choice in lung cancer. Pericardial window with systemic chemotherapy is also effective in preventing the accumulation of large amount of fluid.

Sheep (Ovis aries) as a model for cardiovascular surgery and management before, during, and after cardiopulmonary bypass

Because of its similarity to humans in important respects, sheep (Ovis aries) are a common animal model for translational research in cardiovascular surgery. However, some unique aspects of sheep anatomy and physiology present challenges to its use in these complicated experiments. In this review, we discuss relevant anatomy and physiology of sheep and discuss management before, during, and after procedures requiring cardiopulmonary bypass to provide a concise source of information for veterinarians, technicians, and researchers developing and implementing protocols with this model.

Neoplastic pericardial disease: Old and current strategies for diagnosis and management

The prevalence of neoplastic pericardial diseases has changed over time and varies according to diagnostic methods. The diagnostic factor is usually the detection of neoplastic cells within the pericardial fluid or in specimens of pericardium, but the diagnosis may be difficult. Accurate sampling and cytopreparatory techniques, together with ancillary studies, including immunohistochemical tests and neoplastic marker dosage, are essential to obtain a reliable diagnosis. The goals of treatment may be simply to relieve symptoms (cardiac tamponade or dyspnea), to prevent recurrent effusion for a long-term symptomatic benefit, or to treat the local neoplastic disease with the aim of prolonging survival. Immediate relief of symptoms may be obtained with percutaneous drainage or with a surgical approach. For long term prevention of recurrences, various approaches have been proposed: extended drainage, pericardial window (surgical or percutaneous balloon pericardiostomy), sclerosing local therapy, local and/or systemic chemotherapy or radiation therapy (RT) (external or with intrapericardial radionuclides). The outcomes of various therapeutic approaches vary for different tumor types. Lymphoma and leukemias can be successfully treated with systemic chemotherapy; for solid tumors, percutaneous drainage and the use of systemic and/or local sclerosing and antineoplastic therapy seems to offer the best chance of success. The use of "pure" sclerosing agents has been replaced by agents with both sclerosing and antineoplastic activity (bleomycin or thiotepa), which seems to be quite effective in breast cancer, at least when associated with systemic chemotherapy. Local chemotherapy with platinum, mitoxantrone and other agents may lead to good local control of the disease, but the addition of systemic chemotherapy is probably relevant in order to prolong survival. The surgical approach (creation of a pericardial window, even with the mini-invasive method of balloon pericardiostomy) and RT may be useful in recurring effusions or in cases that are refractory to other therapeutic approaches.