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Xu N, Wu K, La T, Cao B. Isolation and whole genomic analysis of mesophilic bacterium Pseudoglutamicibacter cumminsii in epithelial mesothelioma. Heliyon 2024; 10:e35617. [PMID: 39170262 PMCID: PMC11336841 DOI: 10.1016/j.heliyon.2024.e35617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/23/2024] Open
Abstract
The relationship between bacteria and tumors has been the hot spot of clinical research in recent years. Pseudoglutamicibacter cumminsii is an aerobic Gram-positive bacterium commonly found in soil. Recent studies have identified P. cumminsii in patients with cutaneous and urinary tract infections. However, little is known on its pathogenesis as well as involvement in other clinical symptoms. In this study, we first report the isolation of P. cumminsii in blood of an epithelial mesothelioma patient. The clinical and laboratory characteristics of P. cumminsii were first described and evaluated. The pure colony of P. cumminsii was then identified using automated microorganism identification system and mass spectrum. The whole genome of the newly identified strain was sequenced with third generation sequencing (TGS). The assembled genome was further annotated and analyzed. Whole genomic and comparative genomic analysis revealed that the isolated P. cumminsii strain in this study had a genome size of 2,179,930 bp and had considerable unique genes compared with strains reported in previous findings. Further phylogenetic analysis showed that this strain had divergent phylogenetic relationship with other P. cumminsii strains. Based on these results, the newly found P. cumminsii strain was named P. cumminsii XJ001 (PC1). Virulence analysis identified a total of 71 pathogenic genes with potential roles in adherence, immune modulation, nutrition/metabolism, and regulation in PC1. Functional analysis demonstrated that the annotated genes in PC1 were mainly clustered into amino acid metabolism (168 genes), carbohydrate metabolism (107 genes), cofactor and vitamin metabolisms (98 genes), and energy metabolism (68 genes). Specifically, six genes including yodJ, idh, katA, pyk, sodA, and glsA were identified within cancer pathways, and their corresponding homologous genes have been documented with precise roles in human cancer. Collectively, the above results first identified P. cumminsii in the blood of tumor patients and further provide whole genomic landscape of the newly identified PC1 strain, shedding light on future studies of bacteria in tumorigenesis.
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Affiliation(s)
- Nan Xu
- Department of Clinical Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Kunyi Wu
- Core Research Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Ting La
- National-Local Joint Engineering Research Center of Biodiagnosis & Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Bo Cao
- Department of Clinical Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
- Core Research Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
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Yin Y, Cui Q, Zhao J, Wu Q, Sun Q, Wang HQ, Yang W. Integrated Bioinformatics and Machine Learning Analysis Identify ACADL as a Potent Biomarker of Reactive Mesothelial Cells. THE AMERICAN JOURNAL OF PATHOLOGY 2024; 194:1294-1305. [PMID: 38657836 DOI: 10.1016/j.ajpath.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/05/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024]
Abstract
Mesothelial cells with reactive hyperplasia are difficult to distinguish from malignant mesothelioma cells based on cell morphology. This study aimed to identify and validate potential biomarkers that distinguish mesothelial cells from mesothelioma cells through machine learning combined with immunohistochemistry. It integrated the gene expression matrix from three Gene Expression Omnibus data sets (GSE2549, GSE12345, and GSE51024) to analyze the differently expressed genes between normal and mesothelioma tissues. Then, three machine learning algorithms, least absolute shrinkage and selection operator, support vector machine recursive feature elimination, and random forest were used to screen and obtain four shared candidate markers, including ACADL, EMP2, GPD1L, and HMMR. The receiver operating characteristic curve analysis showed that the area under the curve for distinguishing normal mesothelial cells from mesothelioma was 0.976, 0.943, 0.962, and 0.956, respectively. The expression and diagnostic performance of these candidate genes were validated in two additional independent data sets (GSE42977 and GSE112154), indicating that the performances of ACADL, GPD1L, and HMMR were consistent between the training and validation data sets. Finally, the optimal candidate marker ACADL was verified by immunohistochemistry assay. Acyl-CoA dehydrogenase long chain (ACADL) was stained strongly in mesothelial cells, especially for reactive hyperplasic mesothelial cells, but was negative in malignant mesothelioma cells. Therefore, ACADL has the potential to be used as a specific marker of reactive hyperplasic mesothelial cells in the differential diagnosis of mesothelioma.
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Affiliation(s)
- Yige Yin
- School of Basic Medical Sciences, Anhui Medical University, Hefei, China; Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, China
| | - Qianwen Cui
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, China; Science Island Branch, Graduate School of University of Science and Technology of China, Hefei, China
| | - Jiarong Zhao
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, China; Medical Pathology Center, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, China
| | - Qiang Wu
- School of Basic Medical Sciences, Anhui Medical University, Hefei, China; Department of Pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qiuyan Sun
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, China; Medical Pathology Center, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, China
| | - Hong-Qiang Wang
- Biological Molecular Information System Laboratory, Institute of Intelligent Machines, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, China
| | - Wulin Yang
- School of Basic Medical Sciences, Anhui Medical University, Hefei, China; Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, China; Science Island Branch, Graduate School of University of Science and Technology of China, Hefei, China.
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Mathew JK, Rajan GN, Kunju AK. Diagnostic analysis of pleural fluid cell blocks using relevant immunohistochemical markers in clinically suspicious cases of malignancy. Cytojournal 2024; 21:8. [PMID: 38469399 PMCID: PMC10927224 DOI: 10.25259/cytojournal_40_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 06/24/2023] [Indexed: 03/13/2024] Open
Abstract
Objective Thoracocentesis is a less invasive and expensive procedure than pleural biopsy, enabling sample collection for cytological evaluation. Cell blocks prepared from these samples provide histopathological diagnoses; further, immunohistochemistry (IHC) can be performed for subtyping malignancies, guiding the clinician in choosing the appropriate treatment modality for the patient. We aimed to determine the various histological subtypes of malignancies using cell block IHC and compare the cell block and conventional cytology methods for diagnosing malignant pleural effusion. Material and Methods All pleural fluid samples from the clinically suspicious cases of malignancy collected at the Department of Pathology, Government Medical College Kottayam, India, during 18 months, except duplicate and inadequate samples, were included in this prospective observational study. IHC was performed on cell blocks that were positive for malignancy. Results This study analyzed 630 samples, of which 121 cell blocks demonstrated the presence of malignancy. Overall, 80%, 13%, and 7% of cases were negative, suspicious, and positive for malignancy based on conventional cytology, and 81%, 0%, and 19% were negative, suspicious, and positive for malignancy based on cell blocks, respectively. Among all malignancies, adenocarcinomas from the lung (56%) were the most common, followed by adenocarcinomas from the breast (6%), squamous cell carcinomas (5%), and adenocarcinomas from the ovary (3%). Cell blocks helped detect more malignancies (19%) than conventional cytology (7%), despite a moderate agreement between both methods. Conclusion Adenocarcinomas were the most common cause of malignant pleural effusions, and the most frequent site of origin was the lungs. Cell blocks helped diagnose more malignancies than conventional cytology.
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Affiliation(s)
- Jules Kurian Mathew
- Department of Pathology, Government Medical College Kottayam, Kottayam, Kerala, India
| | - Gopalan Nair Rajan
- Department of Pathology, Government Medical College Kottayam, Kottayam, Kerala, India
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Hjerpe A, Demir E, Abd-Own S, Dobra K. Utility of BerEp4/calretinin and desmin/epithelial membrane antigen (EMA) dual immunocytochemical staining in effusion cytology. Cancer Med 2023; 12:5334-5340. [PMID: 36259232 PMCID: PMC10028146 DOI: 10.1002/cam4.5353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/18/2022] [Accepted: 10/04/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Pleural mesothelioma (PM) is typically diagnosed late during the disease. Earlier detection can increase the chance of effective therapy. Recurrent pleural effusions are the earliest symptoms displaying an array of cytomorphological changes from reactive atypia to malignancy. Diagnosis is possible on effusion cytology by applying molecular and immunocytochemical markers, the main difficulty being when to suspect PM and to differentiate PM from metastatic adenocarcinoma and reactive mesothelial proliferations. METHODS We evaluated the diagnostic performance of two immunocytochemical dual stains (BerEp4/Calretinin and Desmin/Epithelial Membrane Antigen (EMA)) on 149 ethanol-fixed cytospin preparation as an initial step to solve the mentioned diagnostic difficulty. The immunocytochemical reactivity pattern was evaluated by two independent investigators. The final diagnosis corresponded to PM (n = 20), metastatic adenocarcinoma (n = 83), and mesotheliosis (n = 46) in these cases. RESULTS Calretinin had 99% specificity and 98% sensitivity for indicating a mesothelial phenotype, while BerEp4 distinguished the adenocarcinoma cases with 98% specificity and 99% sensitivity. EMA displayed 96% specificity and 99% sensitivity in malignant cases, while Desmin without EMA present showed 99% specificity and 96% sensitivity for indicating benign mesothelial proliferation. CONCLUSIONS Interpretation of the four immunoreactions is improved when performed as dual stains. The dual staining is a useful tool in the initial handling of atypical effusions and guides the subsequent choice of antibody panels for more detailed subclassification of malignant effusions.
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Affiliation(s)
- Anders Hjerpe
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Enes Demir
- Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Sulaf Abd-Own
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Katalin Dobra
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Zhang X, Pang S, Liu Y. Cytomorphology and immunocytochemical features of ovarian granulosa cell tumors in ascites or peritoneal washings: A retrospective review. J Obstet Gynaecol Res 2023; 49:1255-1263. [PMID: 36640051 DOI: 10.1111/jog.15552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 12/30/2022] [Indexed: 01/15/2023]
Abstract
AIM To summarize the cytomorphology and immunocytochemistry features of OGCT in ascites or peritoneal washings. METHODS All cases of histology sections, cytology smears, cell block slides and immunohistochemical staining were reviewed. A panel of immunohistochemistry antibodies consisting of Inhibin, Calretinin, BerEP4 and MC was performed for diagnosis and differential diagnosis. RESULTS Seven positive cases (21.2%) in ascites and peritoneal washings were identified in 33 patients with OGCT, which is higher than early studies with positive rate of 7.4%. Clinicopathologic features including tumor size and the incidence of endometrial atypical hyperplasia or carcinoma (EAH/EC) displayed no statistical difference between groups with positive and negative cytology. Immunocytochemical results usually showed typical staining pattern with α-inhibin, calretinin positive and BerEP4, MC negative. Features of granulosa cells, including nuclear hyperplasia and overlapping, can be observed in all seven positive cases. Nuclear grooves or small conspicuous nucleoli were occasionally observed in the smear. However, features of cell clusters mimicking Call-Exner bodies, cytoplasmic vacuoles or single cell necrosis were not found on smear. Call-Exner bodies and mitosis can only be found on cell blocks. All cases of follow-up information were available and three cases displayed progression and there was a statistical difference between groups with positive and negative cytology. CONCLUSION OGCT with positive cytology in ascites and peritoneal washings tend to have a larger tumor size and higher rates of disease progression. A panel of complementary biomarkers can greatly increase the detection rate and help in differential diagnosis in ascites or peritoneal washings of OGCT.
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Affiliation(s)
- Xinying Zhang
- Department of Pathology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - Shujie Pang
- Department of Pathology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - Yixin Liu
- Department of Pathology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
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Ahuja S, Malviya A. Categorisation of serous effusions using the International System for Reporting Serous Fluid Cytopathology and assessment of risk of malignancy with diagnostic accuracy. Cytopathology 2021; 33:176-184. [PMID: 34913541 DOI: 10.1111/cyt.13089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/24/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT The International System for Reporting Serous Fluid Cytopathology (ISRSFC) standardises the reporting of serous effusion cytology under five categories: Non-Diagnostic (ND), Negative for Malignancy (NFM), Atypia of Undetermined Significance (AUS), Suspicious for Malignancy (SFM), and Malignant (M). Very few studies have been conducted so far to confirm the risk of malignancy of the different categories. AIMS The main objectives of our study were to classify serous effusions according to the ISRSFC categories and assess their risk of malignancy (ROM) and performance parameters. MATERIALS AND METHODS All serous effusion samples received from January 2019 to December 2020 were reclassified according to the ISRSFC. Using histopathological diagnosis as the gold standard, ROM and performance parameters were calculated. RESULTS A total of 831 pleural effusion samples were reclassified as follows: ND, 3 (0.4%); NFM, 635 (76.4%); AUS, 65 (7.8%); SFM, 60 (7.2%); and M, 68 (8.2%). For 457 peritoneal effusion samples, the reclassifications were ND, 5 (1.1%); NFM, 368 (80.5%); AUS, 19 (4.2%); SFM, 17 (3.7%); and M, 48 (10.5%). All 12 (100%) pericardial effusions belonged to the NFM category. The ROM for the ND, NFM, AUS, SRM, and M categories was 0%, 2.1%, 33.3%, 94.1%, 100%, respectively, in pleural effusions, and 50%, 4.8%, 22.2%, 83.3%, 100%, respectively, in peritoneal effusions. The ROM was 0% for NFM in pericardial effusions. CONCLUSION The ISRSFC is an excellent system for accurately classifying serous effusions with greater reproducibility of reports and better communication between pathologist and clinician.
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Affiliation(s)
- Sana Ahuja
- Department of Pathology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttrakhand, India
| | - Avneesh Malviya
- Department of Pathology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttrakhand, India
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Milne EM, Piviani M, Hodgkiss-Geere HM, Piccinelli C, Cheeseman M, Cazzini P, Ressel L, Marcos RJ, Marrinhas CS, Santos MS, Thomas EK, Drummond D, Martinez Pereira Y. Comparison of effusion cell block and biopsy immunohistochemistry in mesothelial hyperplasia, mesothelioma, and carcinoma in dogs. Vet Clin Pathol 2021; 50:555-567. [PMID: 34590335 DOI: 10.1111/vcp.13002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/08/2021] [Accepted: 02/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Determining the cause of effusions is challenging and might require a biopsy. Whether cell blocks from effusions are representative of biopsies requires investigation. A previously developed immunohistochemical panel aids in the differentiation of hyperplastic and neoplastic mesothelium in canine biopsies but has not been investigated in effusions. OBJECTIVES The study aimed to assess cell blocks as an alternative to biopsies and determine whether immunohistochemistry helps distinguish hyperplastic mesothelium, mesothelioma, and carcinoma. METHODS Effusions and biopsies were collected from five dogs with mesothelial hyperplasia (group MH), six with mesothelioma (group M), and five with carcinoma (group C). Immunohistochemistry (IHC) for cytokeratin, vimentin, Wilm's tumor protein 1 (WT1), desmin, glucose transporter 1 (GLUT1), and insulin-like growth factor II mRNA-binding protein 3 (IMP3) was performed. Sections were scored for staining intensity and the percentage of positively stained cells. RESULTS In paired cell blocks and biopsies, vimentin and WT1 staining were positively correlated for intensity and the percentage of positive cells, although not all paired results were identical. The intensity of IMP3 staining in cell blocks was higher in group M than in group C (P = 0.012), and WT1 staining was higher in group MH than in group C (P = 0.020). For biopsies, the intensity of WT1 staining was higher in group MH than in group C (P = 0.031). In group C, WT1 was negative in all cell blocks and biopsies, and desmin was negative in four of five cases. CONCLUSIONS IHC results for the cell blocks and biopsies were comparable for potentially useful markers, such as WT1, which helped discriminate between groups. IHC provided additional information, although results were not always definitive. Further studies on a larger population are required.
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Affiliation(s)
- Elspeth M Milne
- Department of Veterinary Pathology, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Martina Piviani
- Department of Small Animal Clinical Sciences, Institute of Veterinary Science, University of Liverpool, Neston, UK
| | - Hannah M Hodgkiss-Geere
- Department of Small Animal Clinical Sciences, Institute of Veterinary Science, University of Liverpool, Neston, UK
| | - Chiara Piccinelli
- Department of Veterinary Pathology, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Michael Cheeseman
- Department of Veterinary Pathology, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Paola Cazzini
- Department of Veterinary Pathology, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Lorenzo Ressel
- Department of Veterinary Pathology and Public Health, Institute of Veterinary Science, University of Liverpool, Neston, UK
| | - Ricardo J Marcos
- Cytology Diagnostic Services, Laboratory of Histology and Embryology, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Carla S Marrinhas
- Cytology Diagnostic Services, Laboratory of Histology and Embryology, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Marta S Santos
- Cytology Diagnostic Services, Laboratory of Histology and Embryology, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Emily K Thomas
- Hospital for Small Animals, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Dawn Drummond
- Department of Veterinary Pathology, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Yolanda Martinez Pereira
- Hospital for Small Animals, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
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Mneimneh WS, Jiang Y, Harbhajanka A, Michael CW. Immunochemistry in the work-up of mesothelioma and its differential diagnosis and mimickers. Diagn Cytopathol 2021; 49:582-595. [PMID: 33675675 DOI: 10.1002/dc.24720] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Wadad S Mneimneh
- Department of Pathology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio, USA
| | - Yuying Jiang
- Department of Pathology, Firelands Regional Medical Center, Sandusky, Ohio, 44857, USA
| | - Aparna Harbhajanka
- Department of Pathology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio, USA
| | - Claire W Michael
- Department of Pathology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio, USA
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Díaz Del Arco C, Saiz-Pardo Sanz M, Ortega Medina L, Fernández Aceñero MJ. Ber-EP4 staining in effusion cytology: A potential source of false positives. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2020; 54:114-122. [PMID: 33726887 DOI: 10.1016/j.patol.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/21/2020] [Accepted: 04/25/2020] [Indexed: 10/23/2022]
Abstract
The distinction between reactive mesothelium and carcinoma in serous effusions can be very difficult. Immunocytochemistry (ICC) is the most widely used tool to improve the diagnostic accuracy of body fluid cytology, with several ICC markers being proposed. Ber-EP4 antibody has shown high sensitivity and specificity rates for diagnosing metastatic carcinoma. In our department, we have detected Ber-EP4 positivity in mesothelium in some cytological specimens. We reviewed all articles on Ber-EP4 staining in effusion cytology, summarized current findings and analyzed the staining pattern of all cases expressing Ber-EP4. Some cases showing Ber-EP4 positivity in mesothelium have been reported, most of which showed only weak Ber-EP4 staining or staining of less than 50% of mesothelial cells. However, some cases may show strong positivity both in cytological and histological specimens. Clinicians and pathologists should be aware of this source of misdiagnosis, and ICC results in mesothelium should be always interpreted cautiously and correlated with clinical tests, other ICC markers and patient's previous history.
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Affiliation(s)
| | | | - Luis Ortega Medina
- Department of Surgical Pathology, Hospital Clínico San Carlos, Madrid, Spain
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Abd Own S, Höijer J, Hillerdahl G, Dobra K, Hjerpe A. Effusion cytology of malignant mesothelioma enables earlier diagnosis and recognizes patients with better prognosis. Diagn Cytopathol 2020; 49:606-614. [PMID: 32049443 DOI: 10.1002/dc.24395] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/16/2020] [Accepted: 01/30/2020] [Indexed: 12/19/2022]
Abstract
A conclusive diagnosis of malignant mesothelioma (MM) can be based on effusion cytology using the guidelines for the cytopathologic diagnosis of epithelioid and mixed-type MM. Briefly, the diagnosis is obtained when the mesothelial phenotype of malignant cells is established by ancillary techniques. This study is based on the comparison of the overall survival rates of patients with MM when diagnosed by effusion cytology, histopathology, or a combination of both. A total of 144 patients were diagnosed with epithelioid and mixed-type pleural MM at Karolinska University Hospital between 2004 and 2013. The diagnosis was obtained by histopathology in 74 cases and by cytological examination of pleural effusion in 70 cases. In 29 of the latter cases, a diagnostic biopsy was obtained simultaneously. A total of 104 patients received chemotherapy. All diagnoses were supported by clinical findings, including computer tomography scans. The median time between first symptoms and diagnosis was similar for cytology and histopathology. However, a delay of more than 6 months after first symptoms was seen in many patients in the histopathology group, resulting in late onset of treatment. The overall survival and proportion of long-term survival were significantly better for cases diagnosed by cytology. Similarly, a better survival, following a cytological diagnosis, was also seen in patients who were only provided the best supportive care. Accurate cytological diagnosis enables conclusive diagnosis of MM. Our finding enables the initiation of treatment as soon as the cytological diagnosis is established, avoiding further delay and deterioration of patient survival and possibilities for treatment.
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Affiliation(s)
- Sulaf Abd Own
- Department of Laboratory Medicine, Division of Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Gunnar Hillerdahl
- Department of Pulmonary Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Katalin Dobra
- Department of Laboratory Medicine, Division of Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Hjerpe
- Department of Laboratory Medicine, Division of Pathology, Karolinska University Hospital, Stockholm, Sweden
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Chen F, Dai L, An J, Zeng N, Chen L, Shen Y. Diagnostic accuracy of E-cadherin for malignanteffusions: a systematic review and meta-analysis. Postgrad Med J 2019; 96:530-536. [PMID: 31818872 DOI: 10.1136/postgradmedj-2019-137025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/17/2019] [Accepted: 11/17/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The differential diagnosis of malignant effusion remains a clinical challenge. We aim to summarise all relevant literature studies in order to determine the overall clinical value of E-cadherin in the diagnosis of malignant effusion by meta-analysis. METHODS PubMed, the Cochrane Library Database, Medline (Ovid), Web of Science, CNKI, WANFANG and WEIPU databases are thoroughly searched up to 15 March2018. The calculated pooled sensitivity, specificity, likelihood ratio (LR), diagnostic OR(DOR) and the summary receiver operating characteristic (SROC) curve were plotted. RESULTS A total of 15 studies were included in the analysis. The sensitivity and specificity of E-cadherin in the diagnosis of malignant effusion were determined to be high, with a sensitivity of 0.83(95%CI0.79 to 0.87) and a specificity of 0.96(95%CI0.90 to 0.98). The positive LR was determined to be 21.10(95%CI 8.54 to 52.11), the negative LR was determined to be 0.17(95% CI 0.14 to 0.22) and the DOR was determined to be 121.34(95%CI 49.11 to 299.80). The SROC curve exhibited a high overall diagnostic, with the area under the curve measured to be 0.91(95% CI 0.89 to 0.93). Subgroup analysis showed the method (cell blocks or smears), sample size (≥100 or<100), geographical location (Asia, Europe or USA) and impact factor of each article (≥3 or<3) were not the sources of overall heterogeneity. CONCLUSION E-cadherin exhibits very good diagnostic accuracy for the diagnosis for malignant effusion; thus, it can be helpful in the process of clinical decisions.
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Affiliation(s)
- Fangying Chen
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China.,Department of Tuberculosis, The Third People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China
| | - Luqi Dai
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jing An
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Ni Zeng
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Lei Chen
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China ,
| | - Yongchun Shen
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China ,
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Bozdag Z, Tutar E, Dizibuyuk OF, Bakir K. Monoclonal Caveolin 1 Expression in the Differential Diagnosis of Malignant Pleural Mesothelioma and Pulmonary Adenocarcinoma: Is it Useful? Pathol Oncol Res 2019; 26:1651-1656. [PMID: 31512057 DOI: 10.1007/s12253-019-00751-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/05/2019] [Indexed: 10/26/2022]
Abstract
In this study we aim to demonstrate the value of monoclonal Caveolin 1 expression in distinguishing between malignant pleural mesothelioma and pulmonary adenocarcinoma. Total of 129 cases, consisting of 68 cases of malignant pleural mesothelioma (51 epitheloid, 12 biphasic, and 5 sarcomatoid type) and 61 cases of pulmonary adenocarcinoma were examined and stained with monoclonal Caveolin-1. Caveolin 1 expression with a membranous and /or cytoplasmic pattern was detected only in 32.35% (n:22/68) of malignant pleural mesothelioma and 6.5% (n:4/61) of pulmonary adenocarcinoma cases. This finding suggests that the choice of poly/monoclonal antibody for Caveolin 1 in the differential diagnosis of malignant pleural mesothelioma and pulmonary adenocarcinoma is important.
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Affiliation(s)
- Zehra Bozdag
- Department of Pathology, Gaziantep University, Medical School, Gaziantep, Turkey.
| | - Ediz Tutar
- Department of Pathology, Gaziantep University, Medical School, Gaziantep, Turkey
| | - Omer Faruk Dizibuyuk
- Department of Pathology, Gaziantep University, Medical School, Gaziantep, Turkey
| | - Kemal Bakir
- Department of Pathology, Gaziantep University, Medical School, Gaziantep, Turkey
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13
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Valerio E, Nunes W, Cardoso J, Santos A, Bovolim G, Domingos T, De Brot L, Saieg M. A 2-year retrospective study on pleural effusions: A cancer centre experience. Cytopathology 2019; 30:607-613. [PMID: 31306514 DOI: 10.1111/cyt.12755] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/11/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cytopathological examination of pleural effusions is a fast and minimally invasive method for verification of the presence of neoplastic cells. We report our 2-year experience using a categorised diagnostic system and reporting risks of malignancy (ROMs) for each defined category. METHODS Cytological reports of patients between November 2016 and October 2018 were collected, with results primarily classified into a five-tiered classification scheme. Immunohistochemistry markers used in cytology and their results were also recorded. Final agreement to histology and overall test performance was calculated for cases with available concomitant (up to 3 months) pleural biopsies. RESULTS A total of 519 samples from 385 patients were collected, being 29 (5.6%) classified as non-diagnostic, 291 (56%) as negative, 28 (5.4%) as atypical, 30 (5.8%) as suspicious and 141 (27.2%) as positive. Most requested markers were calretinin, TTF1, Ber-EP4 and Gata-3, being conclusive in 45 (76.3%) cases. Total cyto-histological agreement was achieved in 49 (80.3%) specimens, with an overall sensitivity and specificity of 69.4% and 93.3%, respectively. Positive predictive value was 96.2% and negative predictive value was of 56%. ROM for each diagnostic category was 50% for non-diagnostic, 44% for negative, 50% for atypical, 83.3% for suspicious and 96.2% for positive. CONCLUSIONS Our 2-year retrospective study has shown a high specificity and positive predictive value for pleural cytology. The use of a five-tiered system has also shown to be highly effective, with a concordantly progressive higher ROM for the assigned diagnostic categories.
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Affiliation(s)
- Ediel Valerio
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Warley Nunes
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Jaqueline Cardoso
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Aline Santos
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Graziele Bovolim
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Tabata Domingos
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Louise De Brot
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Mauro Saieg
- Department of Pathology, AC Camargo Cancer Center, São Paulo, Brazil.,Department of Pathology, Santa Casa Medical School, São Paulo, Brazil
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14
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Histological and immunohistochemical analyses of splenic epidermoid cysts. Ann Diagn Pathol 2019; 41:51-56. [DOI: 10.1016/j.anndiagpath.2019.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 05/15/2019] [Indexed: 11/19/2022]
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15
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Halimi M, BeheshtiRouy S, Salehi D, Rasihashemi SZ. The Role of Immunohistochemistry Studies in Distinguishing Malignant Mesothelioma from Metastatic Lung Carcinoma in Malignant Pleural Effusion. IRANIAN JOURNAL OF PATHOLOGY 2019; 14:122-126. [PMID: 31528168 PMCID: PMC6679666 DOI: 10.30699/ijp.14.2.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/11/2019] [Indexed: 12/17/2022]
Abstract
Background and Objective Early diagnosis of malignant pleural mesothelioma (MPM) is the key point of its treatment. The main problem is the precise diagnosis of mesothelioma and its differentiation from metastatic lung adenocarcinoma. Mesothelioma exhibits complex immunohistochemical characteristics. The aim of this study was to study hybrid immunohistochemistry in the differential diagnosis of primary malignant pleural effusion from metastatic pulmonary cancers. Material and Methods Twenty tissue samples in paraffin blocks from the pathology department of Imam Reza Hospital in Tabriz whose pathology reports cited mesothelioma or metastatic lung adenocarcinomas, were included in the studies. These tissues were deemed appropriate for IHC in terms of tissue quality and quantity. They were studied and evaluated for pathological markers. Results In patients with adenocarcinoma CK7 in 100% of patients (13 patients), TTF1 in 61.5% of patients (8 patients) and CEA in 53.8% of patients (7 patients) were positive, but HBME1 and Calretinin were negative for all patients. In patients with mesothelioma, HBME1 and Calretinin were positive in 100% of patients (7 patients) and TTF1, CEA and CK7 were negative. Conclusion The results of this study showed that CEA, CK7, TTF1, Calretinin and HBME1 are suitable criteria for differentiating between metastatic lung adenocarcinoma and mesothelioma, and can differentiate the mesothelioma and adenocarcinoma with high accuracy.
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Affiliation(s)
- Monireh Halimi
- Department of Pathology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad BeheshtiRouy
- Department of Cardiothoracic Surgery, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Davood Salehi
- Department of Cardiothoracic Surgery, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Ziaeddin Rasihashemi
- Department of Cardiothoracic Surgery, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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16
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Sundling KE, Cibas ES. Ancillary studies in pleural, pericardial, and peritoneal effusion cytology. Cancer Cytopathol 2018; 126 Suppl 8:590-598. [DOI: 10.1002/cncy.22021] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Kaitlin E. Sundling
- Wisconsin State Laboratory of Hygiene, Department of PathologyUniversity of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Edmund S. Cibas
- Department of PathologyBrigham and Women's Hospital, Harvard Medical School Boston Massachusetts
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17
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Shivkumar V, Patil B, Gangane N. Utility of MOC-31 monoclonal antibody in differentiating metastatic adenocarcinoma cells and reactive mesothelial cells in effusion cytology. INDIAN J PATHOL MICR 2018; 61:90-93. [DOI: 10.4103/ijpm.ijpm_86_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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18
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Zhang X, Chen L, Liu Y, Xu Y, Zhang X, Shi Y, Wang C, Zhang PL, Liu Y. Improving the cytological diagnosis of high-grade serous carcinoma in ascites with a panel of complementary biomarkers in cell blocks. Cytopathology 2017; 29:247-253. [PMID: 29280203 DOI: 10.1111/cyt.12514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Precise cytological diagnosis of pelvic high-grade serous carcinoma (HGSC) in ascites is important for tumour staging, therapeutic decision-making and prognostic evaluation. However, it can often be difficult to distinguish metastatic HGSC cells from reactive mesothelial cells based on morphology alone. Immunocytochemical analysis of ascites cell blocks has been used to obtain accurate diagnosis and provide a reliable basis for treatment decisions in the clinic. This study was performed to determine whether a panel of antibodies is necessary to achieve high specificity and sensitivity for the identification of HGSC cells. METHODS Ascites samples from 70 cases (70/253, 27.7%) of histologically confirmed HGSC were postoperatively collected from 2012 to 2015 and were immunocytochemically analysed. RESULTS The sensitivity and specificity of Ber-EP4 (a marker of HGSC) for detecting HGSC was 85.7% and 82.1%, respectively, whereas the sensitivity and specificity of HBME-1 for identifying mesothelial cells was 100% and 68.3%, respectively. To improve the rate of detection further of HGSC, 29 cases of ascites were also stained for E-cadherin (a marker of HGSC) and calretinin (a marker of mesothelial cells). The combination of Ber-EP4 and E-cadherin as markers of adenocarcinoma cells increased the sensitivity and specificity for HGSC detection to 100% and 88.9%, respectively. Meanwhile, the sensitivity and specificity for mesothelial cell identification increased to 100% and 90%, respectively, when HBME-1 and calretinin were combined. CONCLUSION This panel of complementary biomarkers is valuable and ideal for the differential diagnosis of HGSC based on ascites cytology.
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Affiliation(s)
- X Zhang
- Department of Cytology, Tianjin Medical University Clinical Hospital of Gynecology Obstetrics, Tianjin, China
| | - L Chen
- Department of Pathology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - Y Liu
- Department of Cytology, Tianjin Medical University Clinical Hospital of Gynecology Obstetrics, Tianjin, China.,Department of Pathology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - Y Xu
- Department of Cytology, Tianjin Medical University Clinical Hospital of Gynecology Obstetrics, Tianjin, China
| | - X Zhang
- Department of Cytology, Tianjin Medical University Clinical Hospital of Gynecology Obstetrics, Tianjin, China
| | - Y Shi
- Department of Pathology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - C Wang
- Department of Pathology, QEII Capital Health, Dalhousie University, Halifax, NS, Canada
| | - P L Zhang
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Y Liu
- Department of Cytology, Tianjin Medical University Clinical Hospital of Gynecology Obstetrics, Tianjin, China.,Department of Pathology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
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19
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Chaini E, Athanassiadou AM, Vassias A, Tsipis A, Gonidi M, Hainis KD, Charpidou A, Athanassiadou P. Immunocytochemical expression of a panel of markers in pleural effusions from patients with primary lung adenocarcinoma. Pathol Res Pract 2017; 213:502-508. [DOI: 10.1016/j.prp.2017.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 11/28/2022]
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20
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Cao S, Jin S, Cao J, Shen J, Zhang H, Meng Q, Pan B, Yu Y. Malignant pericardial mesothelioma : A systematic review of current practice. Herz 2017; 43:61-68. [PMID: 28130567 DOI: 10.1007/s00059-016-4522-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/11/2016] [Accepted: 11/26/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Malignant mesothelioma is a rare but aggressive tumor, with a high misdiagnosis rate and overall bleak prognosis. In 0.7% of all cases, the origin is the pericardium. METHODS The present study is a review of the literature published in recent decades focusing on the advances in clinical manifestations, radiological findings, diagnosis, differential diagnosis, and treatment of malignant pericardial mesothelioma (MPM). RESULTS No clear relationship has been established between the etiologies and the development of MPM. Clinical symptoms and signs are nonspecific when present. The main presentations are chest pain and dyspnea. Imaging plays an important role in the detection, characterization, staging, and posttreatment follow-up. The definitive diagnosis is made on the basis of pathological findings. Chest radiography and echocardiography are common techniques used initially, but their roles are limited. Computed tomography and magnetic resonance imaging have an advantage in depicting the thickened pericardium, mediastinal lymph node, tumor, and the extension of adjacent structures. Surgery is the most important treatment modality and remains palliative in most cases, while the roles of chemo- and radiotherapy are unsatisfactory. CONCLUSION Clinical trials of malignant pleural and peritoneal mesothelioma remain important for MPM management. Multimodality treatment of surgery, chemotherapy, radiotherapy, and immunotherapy is expected to have a role in the treatment of MPM.
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Affiliation(s)
- S Cao
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China
| | - S Jin
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China
| | - J Cao
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China
| | - J Shen
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China
| | - H Zhang
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China
| | - Q Meng
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China
| | - B Pan
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China
| | - Y Yu
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Haping Road, 150081, Harbin, China.
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21
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Rossi E, Bizzarro T, Martini M, Longatto-Filho A, Schmitt F, Fagotti A, Scambia G, Zannoni GF. The Role of Liquid Based Cytology and Ancillary Techniques in the Peritoneal Washing Analysis: Our Institutional Experience. PLoS One 2017; 12:e0168625. [PMID: 28099523 PMCID: PMC5242474 DOI: 10.1371/journal.pone.0168625] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/02/2016] [Indexed: 01/04/2023] Open
Abstract
Background The cytological analysis of peritoneal effusions serves as a diagnostic and prognostic aid for either primary or metastatic diseases. Among the different cytological preparations, liquid based cytology (LBC) represents a feasible and reliable method ensuring also the application of ancillary techniques (i.e immunocytochemistry-ICC and molecular testing). Methods We recorded 10348 LBC peritoneal effusions between January 2000 and December 2014. They were classified as non-diagnostic (ND), negative for malignancy-NM, atypical-suspicious for malignancy-SM and positive for malignancy-PM. Results The cytological diagnosis included 218 ND, 9.035 NM, 213 SM and 882 PM. A total of 8048 (7228 NM, 115SM, 705 PM) cases with histological follow-up were included. Our NM included 21 malignant and 7207 benign histological diagnoses. Our 820 SMs+PMs were diagnosed as 107 unknown malignancies (30SM and 77PM), 691 metastatic lesions (81SM and 610PM), 9 lymphomas (2SM and 7PM), 9 mesotheliomas (1SM and 8SM), 4 sarcomas (1SM and 3PM). Primary gynecological cancers contributed with 64% of the cases. We documented 97.4% sensitivity, 99.9% specificity, 98% diagnostic accuracy, 99.7% negative predictive value (NPV) and 99.7% positive predictive value (PPV). Furthermore, the morphological diagnoses were supported by either 173 conclusive ICC results or 50 molecular analyses. Specifically the molecular testing was performed for the EGFR and KRAS mutational analysis based on the previous or contemporary diagnoses of Non Small Cell Lung Cancer (NSCLC) and colon carcinomas. We identified 10 EGFR in NSCCL and 7 KRAS mutations on LBC stored material. Conclusions Peritoneal cytology is an adjunctive tool in the surgical management of tumors mostly gynecological cancers. LBC maximizes the application of ancillary techniques such as ICC and molecular analysis with feasible diagnostic and predictive yields also in controversial cases.
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Affiliation(s)
- Esther Rossi
- Division of Anatomic Pathology and Histology - Università Cattolica del Sacro Cuore, “Agostino Gemelli” School of Medicine, Rome, Italy
- * E-mail:
| | - Tommaso Bizzarro
- Division of Anatomic Pathology and Histology - Università Cattolica del Sacro Cuore, “Agostino Gemelli” School of Medicine, Rome, Italy
| | - Maurizio Martini
- Division of Anatomic Pathology and Histology - Università Cattolica del Sacro Cuore, “Agostino Gemelli” School of Medicine, Rome, Italy
| | - Adhemar Longatto-Filho
- Department of Pathology, University of São Paulo School of Medicine, Sao Paolo, Brazil
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B’s Laboratory of Medical Investigation (LIM)- PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Molecular Oncology Research Center, Barretos Cancer Hospital, Pio XII Foundation, Barretos, Brazil
| | - Fernando Schmitt
- Medical Faculty, Porto University, Porto, Portugal
- Laboratorie National de Sante, Luxembourg, Luxembourg
| | - Anna Fagotti
- Gynecological Oncology, Catholic University, Rome, Italy
| | | | - Gian Franco Zannoni
- Division of Anatomic Pathology and Histology - Università Cattolica del Sacro Cuore, “Agostino Gemelli” School of Medicine, Rome, Italy
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22
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Kim NI, Kim GE, Lee JS. Diagnostic Usefulness of Claudin-3 and Claudin-4 for Immunocytochemical Differentiation between Metastatic Adenocarcinoma Cells and Reactive Mesothelial Cells in Effusion Cell Blocks. Acta Cytol 2016; 60:232-9. [PMID: 27387183 DOI: 10.1159/000447008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/20/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Claudin-3 and claudin-4 have recently been reported as promising targets for the detection and diagnosis of cancer. This study was designed to evaluate the diagnostic value of claudin-3 and claudin-4 immunoreactivity to distinguish metastatic adenocarcinoma cells (MAC) from reactive mesothelial cells (RMC) in effusions. STUDY DESIGN Claudin-3 and claudin-4 immunocytochemical staining was performed on 234 cell block specimens, including 194 malignant effusions with MAC and 40 benign effusions with RMC. Any degree of membranous staining was considered positive. RESULTS Claudin-3 was positive in 190 (97.9%) out of 194 cases with MAC and in 3 (7.5%) out of 40 cases with RMC. Claudin-4 immunoreactivity was seen in all 194 (100%) cases with MAC and in 11 (27.5%) out of 40 cases with RMC. In all claudin-3- or claudin-4-positive RMC samples, the area of positive staining was <25% of the cells. Claudin-3 and claudin-4 efficiently discriminated between MAC and RMC (p < 0.001 for both), and claudin-3 was more specific than claudin-4 in differentiating between MAC and RMC (p < 0.05). CONCLUSION These results suggest that claudin-3 and claudin-4 are good candidates to be included as MAC markers in the panel of antibodies to distinguish MAC from RMC in effusion specimens.
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Affiliation(s)
- Nah Ihm Kim
- Department of Pathology, Chonnam National University Medical School, Gwangju, Republic of Korea
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23
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Cheng F, Wang Q, Zhong D. [Value of Cell Block in the Diagnosis of Malignant Pleural Effusion]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2016; 18:652-5. [PMID: 26483339 PMCID: PMC6000087 DOI: 10.3779/j.issn.1009-3419.2015.10.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
背景与目的 恶性胸腔积液(malignant pleural effusion, MPE)是由原发于胸膜的恶性肿瘤或者是转移至胸膜的恶性肿瘤造成的胸腔积液。对于不明原因的单侧胸腔积液, 首要任务是排除或者是确诊恶性胸腔积液。胸腔积液沉淀物是将送检胸腔积液细胞学剩余的胸腔积液进行离心或者是自然静置所获得的细胞块。此技术具有操作简单、有创性小、重复性高、对恶性胸腔积液的诊断率相对较高等特点, 在恶性胸腔积液的诊断、治疗等方面起着重要的作用。本文主要从沉淀物的制作方法、免疫组织化学染色检查的鉴别诊断价值、沉淀物的诊断优势及沉淀物行基因检测的临床应用价值等方面来论述胸腔积液沉淀物对恶性胸腔积液的诊断价值。
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Affiliation(s)
- Fangyuan Cheng
- Department of Medical Oncology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qian Wang
- Department of Medical Oncology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Diansheng Zhong
- Department of Medical Oncology, Tianjin Medical University General Hospital, Tianjin 300052, China
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Hiroshima K, Wu D, Hasegawa M, Koh E, Sekine Y, Ozaki D, Yusa T, Walts AE, Marchevsky AM, Nabeshima K, Tada Y, Shimada H, Tagawa M. Cytologic Differential Diagnosis of Malignant Mesothelioma and Reactive Mesothelial Cells With FISH Analysis ofp16. Diagn Cytopathol 2016; 44:591-8. [DOI: 10.1002/dc.23490] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 03/01/2016] [Accepted: 03/30/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Kenzo Hiroshima
- Department of Pathology; Tokyo Women's Medical University, Yachiyo Medical Center; Yachiyo Japan
| | - Di Wu
- Department of Pathology; Tokyo Women's Medical University, Yachiyo Medical Center; Yachiyo Japan
| | - Mizue Hasegawa
- Department of Respirology; Tokyo Women's Medical University, Yachiyo Medical Center; Yachiyo Japan
| | - Eitetsu Koh
- Department of Thoracic Surgery; Tokyo Women's Medical University, Yachiyo Medical Center; Yachiyo Japan
| | - Yasuo Sekine
- Department of Thoracic Surgery; Tokyo Women's Medical University, Yachiyo Medical Center; Yachiyo Japan
| | - Daisuke Ozaki
- Department of Pathology; Chiba Rosai Hospital; Ichihara Japan
| | - Toshikazu Yusa
- Department of Thoracic Surgery; Chiba Rosai Hospital; Ichihara Japan
| | - Ann E. Walts
- Department of Pathology and Laboratory Medicine; Cedars-Sinai Medical Center; Los Angeles California
| | - Alberto M. Marchevsky
- Department of Pathology and Laboratory Medicine; Cedars-Sinai Medical Center; Los Angeles California
| | - Kazuki Nabeshima
- Department of Pathology; Fukuoka University Hospital and School of Medicine; Fukuoka Japan
| | - Yuji Tada
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Hideaki Shimada
- Department of Surgery, School of Medicine; Toho University; Tokyo Japan
| | - Masatoshi Tagawa
- Division of Pathology and Cell Therapy; Chiba Cancer Center Research Institute; Chiba Japan
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25
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Oda T, Ogata S, Kawaguchi S, Minabe S, Dokyu M, Takahashi H, Kumazawa F, Shimazaki H, Takano M, Hase K, Ozeki Y, Kanoh S, Nakanishi K. Immunocytochemical utility of claudin-4 versus those of Ber-EP4 and MOC-31 in effusion cytology. Diagn Cytopathol 2016; 44:499-504. [DOI: 10.1002/dc.23476] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 02/15/2016] [Accepted: 03/09/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Tomohiro Oda
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Sho Ogata
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Saki Kawaguchi
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Shinya Minabe
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Misaki Dokyu
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Hiromi Takahashi
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Fumihiko Kumazawa
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Hideyuki Shimazaki
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
| | - Masashi Takano
- Department of Obstetrics and Gynecology; National Defense Medical College; Tokorozawa Japan
| | - Kazuo Hase
- Department of Surgery; National Defense Medical College; Tokorozawa Japan
| | - Yuichi Ozeki
- Department of Surgery; National Defense Medical College; Tokorozawa Japan
| | - Soichiro Kanoh
- Department of Medicine; National Defense Medical College; Tokorozawa Japan
| | - Kuniaki Nakanishi
- Department of Laboratory Medicine; National Defense Medical College Hospital; Tokorozawa
- Department of Pathology and Laboratory Medicine; National Defense Medical College; Tokorozawa Japan
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26
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Diagnostic accuracy of epithelial membrane antigen for malignant effusions: a meta-analysis. Int J Biol Markers 2016; 31:e11-6. [PMID: 26743333 DOI: 10.5301/jbm.5000181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Body cavity fluid examination sometimes presents a diagnostic challenge in cytology practice. This meta-analysis was undertaken to comprehensively assess the diagnostic potential of epithelial membrane antigen (EMA) in malignant effusions. MATERIALS AND METHODS All relevant original articles about EMA in the diagnosis of malignant effusions published up to July 1, 2014 were retrieved. The overall sensitivity, specificity, positive and negative likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristic (SROC) curve were pooled to evaluate the diagnostic value of EMA for malignant effusions using the Meta-Disc 1.4 and STATA 12.0 statistical software. RESULTS Eleven studies met the inclusion criteria for the meta-analysis and the summary estimates for EMA in the diagnosis of malignant effusions were as follows: sensitivity 0.9 (95% CI 0.83-0.87), specificity 0.87 (95% CI 0.96-0.99), positive likelihood ratio 5.8 (95% CI 15.59-36.37), negative likelihood ratio 0.15 (95% CI 0.07-0.20) and diagnostic odds ratio 52.63 (95% CI 20.91-132.49). The SROC curve indicated that the maximum joint sensitivity and specificity (Q-value) was 0.88; the area under the curve was 0.94. CONCLUSION The present meta-analysis indicated that EMA may be a useful diagnostic tool with good sensitivity and specificity for differentiating malignant effusions from benign effusions.
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Cappellesso R, Nicolè L, Caroccia B, Guzzardo V, Ventura L, Fassan M, Fassina A. Young investigator challenge: MicroRNA-21/MicroRNA-126 profiling as a novel tool for the diagnosis of malignant mesothelioma in pleural effusion cytology. Cancer Cytopathol 2016; 124:28-37. [DOI: 10.1002/cncy.21646] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/14/2015] [Accepted: 10/16/2015] [Indexed: 12/24/2022]
Affiliation(s)
- Rocco Cappellesso
- Department of Medicine, Surgical Pathology and Cytopathology Unit; University of Padua; Padua Italy
| | - Lorenzo Nicolè
- Department of Medicine, Surgical Pathology and Cytopathology Unit; University of Padua; Padua Italy
| | - Brasilina Caroccia
- Department of Medicine, Surgical Pathology and Cytopathology Unit; University of Padua; Padua Italy
| | - Vincenza Guzzardo
- Department of Medicine, Surgical Pathology and Cytopathology Unit; University of Padua; Padua Italy
| | - Laura Ventura
- Department of Statistical Sciences; University of Padua; Padua Italy
| | - Matteo Fassan
- Department of Medicine, Surgical Pathology and Cytopathology Unit; University of Padua; Padua Italy
| | - Ambrogio Fassina
- Department of Medicine, Surgical Pathology and Cytopathology Unit; University of Padua; Padua Italy
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BAP1 (BRCA1-associated protein 1) is a highly specific marker for differentiating mesothelioma from reactive mesothelial proliferations. Mod Pathol 2015; 28:1043-57. [PMID: 26022455 DOI: 10.1038/modpathol.2015.65] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 04/20/2015] [Accepted: 04/24/2015] [Indexed: 01/18/2023]
Abstract
The distinction between malignant mesothelioma and reactive mesothelial proliferation can be challenging both on histology and cytology. Recently, variants of the BRCA1-associated protein 1 (BAP1) gene resulting in nuclear protein loss were reported in hereditary and sporadic mesothelioma. Using immunohistochemistry, we evaluated the utility of BAP1 expression in the differential diagnosis between mesothelioma and other mesothelial proliferations on a large series of biopsies that included 212 mesotheliomas, 12 benign mesothelial tumors, and 42 reactive mesothelial proliferations. BAP1 stain was also performed in 70 cytological samples (45 mesotheliomas and 25 reactive mesothelial proliferations). BAP1 was expressed in all benign mesothelial tumors, whereas 139/212 (66%) mesotheliomas were BAP1 negative, especially in epithelioid/biphasic compared with sarcomatoid/desmoplastic subtypes (69% vs 15%). BAP1 loss was homogeneous in neoplastic cells except for two epithelioid mesotheliomas showing tumor heterogeneity. By fluorescence in situ hybridization, BAP1 protein loss was paralleled by homozygous deletion of the BAP1 locus in the vast majority of BAP1-negative tumors (31/41, 76%), whereas 9/10 BAP1-positive mesotheliomas were normal. In biopsies interpreted as reactive mesothelial proliferation BAP1 loss was 100% predictive of malignancy, as all 6 cases subsequently developed BAP1-negative mesothelioma, whereas only 3/36 (8%) BAP1-positive cases progressed to mesothelioma. On cytology/cell blocks, benign mesothelial cells were invariably positive for BAP1, whereas 64% of mesotheliomas showed loss of protein; all 6 cases showing BAP1 negativity were associated with histological diagnosis of BAP1-negative mesothelioma. BAP1 stain also showed utility in the differential of mesothelioma from most common pleural and peritoneal mimickers, such as lung and ovary carcinomas, with specificity and sensitivity of 99/70% and 100/70%, respectively. Our results show that BAP1 protein is frequently lost in mesothelioma, especially of epithelioid/biphasic subtype and is commonly associated with homozygous BAP1 deletion. BAP1 immunostain represents an excellent biomarker with an unprecedented specificity (100%) in the distinction between benign and malignant mesothelial proliferations. Finding BAP1 loss in mesothelial cells should prompt to immediately reevaluate the patient; moreover, it might be useful in mapping tumor extent and planning surgical resection.
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Diagnostic accuracy of calretinin for malignant mesothelioma in serous effusions: a meta-analysis. Sci Rep 2015; 5:9507. [PMID: 25821016 PMCID: PMC4377575 DOI: 10.1038/srep09507] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 03/04/2015] [Indexed: 02/05/2023] Open
Abstract
Numerous studies have investigated the utility of calretinin in differentiating malignant mesothelioma (MM) from metastatic carcinoma (MC) in serous effusions. However, the results remain controversial. The aim of this study is to determine the overall accuracy of calretinin in serous effusions for MM through a meta-analysis of published studies. Publications addressing the accuracy of calretinin in the diagnosis of MM were selected from the Medline (Ovid), PubMed, the Cochrane Library Database and the Web of Science. Data from selected studies were pooled to yield summary sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), and receiver operating characteristic (SROC) curve. Statistical analysis was performed by Meta-Disc 1.4 and STATA 12.0 softwares. 18 studies met the inclusion criteria and the summary estimating for calretinin in the diagnosis of MM were: sensitivity 0.91 (95%CI: 0.87–0.94), specificity 0.96 (95%CI: 0.95–0.96), positive likelihood ratio (PLR) 14.42 (95%CI: 7.92–26.26), negative likelihood ratio (NLR) 0.1 (95%CI: 0.05–0.2) and diagnostic odds ratio 163.03 (95%CI: 54.62–486.63). The SROC curve indicated that the maximum joint sensitivity and specificity (Q-value) was 0.92; the area under the curve was 0.97. Our findings suggest that calretinin may be a useful diagnostic tool for confirming MM in serous effusions.
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Rossi ED, Bizzarro T, Schmitt F, Longatto-Filho A. The role of liquid-based cytology and ancillary techniques in pleural and pericardic effusions: an institutional experience. Cancer Cytopathol 2015; 123:258-66. [PMID: 25641902 DOI: 10.1002/cncy.21518] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Fine-needle aspiration cytology (FNAC) of serous membrane effusions may fulfil a challenging role in the diagnostic analysis of both primary and metastatic disease. From this perspective, liquid-based cytology (LBC) represents a feasible and reliable method for empowering the performance of ancillary techniques (ie, immunocytochemistry and molecular testing) with high diagnostic accuracy. METHODS In total, 3171 LBC pleural and pericardic effusions were appraised between January 2000 and December 2013. They were classified as negative for malignancy (NM), suspicious for malignancy (SM), or positive for malignancy (PM). RESULTS The cytologic diagnoses included 2721 NM effusions (2505 pleural and 216 pericardic), 104 SM effusions (93 pleural and 11 pericardic), and 346 PM effusions (321 pleural and 25 pericardic). The malignant pleural series included 76 unknown malignancies (36 SM and 40 PM effusions), 174 metastatic lesions (85 SM and 89 PM effusions), 14 lymphomas (3 SM and 11 PM effusions), 16 mesotheliomas (5 SM and 11 SM effusions), and 3 myelomas (all SM effusions). The malignant pericardic category included 20 unknown malignancies (5 SM and 15 PM effusions), 15 metastatic lesions (1 SM and 14 PM effusions), and 1 lymphoma (1 PM effusion). There were 411 conclusive immunocytochemical analyses and 47 molecular analyses, and the authors documented 88% sensitivity, 100% specificity, 98% diagnostic accuracy, 98% negative predictive value, and 100% positive predictive value for FNAC. CONCLUSIONS FNAC represents a primary diagnostic tool for effusions and a reliable approach with which to determine the correct follow-up. Furthermore, LBC is useful for ancillary techniques, such as immunocytochemistry and molecular analysis, with feasible diagnostic and predictive utility.
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Affiliation(s)
- Esther Diana Rossi
- Division of Anatomic Pathology and Histology, "Agostino Gemelli" School of Medicine, Sacred Heart Catholic University, Rome, Italy
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Lv M, Leng JH, Hao YY, Sun Y, Cha N, Wu GP. Expression and significance of MOC-31 and calretinin in pleural fluid of patients with lung cancer. Diagn Cytopathol 2014; 43:527-31. [PMID: 25346242 DOI: 10.1002/dc.23218] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 07/18/2014] [Accepted: 10/06/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Ming Lv
- Department of Pathology; Jilin Cancer Hospital; Changchun 130012 China
| | - Ji-Hong Leng
- Department of Pathology; Jilin Cancer Hospital; Changchun 130012 China
| | - Yan-Yong Hao
- Department of Pathology; Jilin Cancer Hospital; Changchun 130012 China
| | - Yan Sun
- Department of Pathology; Jilin Cancer Hospital; Changchun 130012 China
| | - Na Cha
- Department of Pathology; Changchun Obstetrics Gynecology Hospital; Changchun 130042 China
| | - Guang-Ping Wu
- Department of Pathology; The First Affiliated Hospital and College of Basic Medical Sciences, China Medical University; Shenyang 110001 China
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Diagnostic accuracy of Ber-EP4 for metastatic adenocarcinoma in serous effusions: a meta-analysis. PLoS One 2014; 9:e107741. [PMID: 25229691 PMCID: PMC4168227 DOI: 10.1371/journal.pone.0107741] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/14/2014] [Indexed: 02/05/2023] Open
Abstract
Numerous studies have investigated the utility of Ber-EP4 in differentiating metastatic adenocarcinoma (MAC) from malignant epithelial mesothelioma (MM) and/or reactive mesothelial cells (RM) in serous effusions. However, the results remain controversial. The aim of this study is to determine the overall accuracy of Ber-EP4 in serous effusions for MAC through a meta-analysis of published studies. Publications addressing the accuracy of Ber-EP4 in the diagnosis of MAC were selected from the Pubmed, Embase and Cochrane Library. Data from selected studies were pooled to yield summary sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), and receiver operating characteristic (SROC) curve. Statistical analysis was performed by Meta-Disc 1.4 and STATA 12.0 softwares. 29 studies, based on 2646 patients, met the inclusion criteria and the summary estimating for Ber-EP4 in the diagnosis of MAC were: sensitivity 0.8 (95% CI: 0.78-0.82), specificity 0.94 (95% CI: 0.93-0.96), positive likelihood ratio (PLR) 12.72 (95% CI: 8.66-18.7), negative likelihood ratio (NLR) 0.18 (95% CI: 0.12-0.26) and diagnostic odds ratio 95.05 (95% CI: 57.26-157.77). The SROC curve indicated that the maximum joint sensitivity and specificity (Q-value) was 0.91; the area under the curve was 0.96. Our findings suggest that BER-EP4 may be a useful diagnostic adjunctive tool for confirming MAC in serous effusions.
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Use of circulating tumor cell technology (CELLSEARCH) for the diagnosis of malignant pleural effusions. Ann Am Thorac Soc 2014; 10:582-9. [PMID: 24236662 DOI: 10.1513/annalsats.201303-068oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RATIONALE Cytological analysis of pleural effusions (PEs) has a sensitivity of approximately 60%. We hypothesized that the CELLSEARCH technology (Janssen Research and Development, Huntingdon Valley, PA) currently used to detect circulating tumor cells could be adapted for the identification of tumor cells in PEs. METHODS This was a single-center, prospective, observational study. Pleural fluid from subjects with undiagnosed PEs were analyzed by CELLSEARCH technology, which uses an epithelial cell adhesion molecule antibody-based capture system/cytokeratin antibodies to identify tumor cells. Subjects were prospectively monitored by periodic chart review to determine the etiology of the PE. MEASUREMENTS AND MAIN RESULTS One hundred thirty-two subjects were analyzed. A malignant etiology was established in 81 subjects. The median number of "positive" pleural epithelial cells (PECs) detected per milliliter of pleural fluid was 6 in the benign group. The number of PECs was 52 in the malignant nonepithelial group (NS) and 526 in the malignant epithelial group (P < 0.001). Unlike blood, there was a baseline number of "positive" cells in benign pleural fluids; however, any cutoff greater than 852 positive cells/ml had 100% specificity. The area under the receiver operating characteristic curve was 0.86. Nine percent of our cancer cases had high numbers of PECs (>280/ml) but a negative or nondefinitive cancer diagnosis by cytology. CONCLUSIONS The pleural CELLSEARCH assay may serve as a valuable addition to traditional cytology and provide useful information regarding the diagnosis of malignant effusions. Major advantages include that it is well standardized, relatively inexpensive, has a rapid turnaround, and is easily available. Our data support the conduct of additional studies of this approach to assist in the diagnosis of malignant PEs.
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Rodriguez-Panadero F, Romero-Romero B. Lung cancer coexisting with ipsilateral pleural effusion. Lung Cancer Manag 2014. [DOI: 10.2217/lmt.14.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Invasion beyond the elastic layer of the visceral pleura and/or diffuse pleural metastatic spread affects negatively survival in lung cancer. Presence of pleural effusion is also associated with poor prognosis, and image techniques can be of great help for diagnosis. When pleural fluid cytology is negative, thoracoscopy is advisable before attempting tumor resection, in order to detect unsuspected pleural metastases. If widespread pleural malignancy is confirmed, chemical pleurodesis using graded talc (with particles larger than 20 µm in diameter) is the best option, unless the lung is unable to re-expand. In this case, or when a previous pleurodesis has failed, or there is a short life expectancy, placement of a indwelling pleural catheter is the treatment of choice.
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Affiliation(s)
- Francisco Rodriguez-Panadero
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Unidad Médico–Quirúrgica de Enfermedades Respiratorias (UMQER), Hospital Universitario Virgen del Rocío, Seville, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), I.S. Carlos III, Spain
| | - Beatriz Romero-Romero
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Unidad Médico–Quirúrgica de Enfermedades Respiratorias (UMQER), Hospital Universitario Virgen del Rocío, Seville, Spain
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Conner JR, Cibas ES, Hornick JL, Qian X. Wilms tumor 1/cytokeratin dual-color immunostaining reveals distinctive staining patterns in metastatic melanoma, metastatic carcinoma, and mesothelial cells in pleural fluids: An effective first-line test for the workup of malignant effusions. Cancer Cytopathol 2014; 122:586-95. [DOI: 10.1002/cncy.21439] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/24/2014] [Indexed: 11/10/2022]
Affiliation(s)
- James R. Conner
- Department of Pathology; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
| | - Edmund S. Cibas
- Department of Pathology; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
| | - Jason L. Hornick
- Department of Pathology; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
| | - Xiaohua Qian
- Department of Pathology; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
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Kim HJ, Kim GE, Lee JS, Lee JH, Nam JH, Choi C. Insulin-like growth factor-II mRNA-binding protein 3 expression in effusion cytology: a marker for metastatic adenocarcinoma cells and a potential prognostic indicator in gastric adenocarcinoma. Acta Cytol 2014; 58:167-73. [PMID: 24457229 DOI: 10.1159/000357199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 11/11/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of our study was to identify the diagnostic value of insulin-like growth factor-II mRNA-binding protein 3 (IMP3) in distinguishing metastatic adenocarcinoma cells (MAC) from reactive mesothelial cells (RMC) in effusions. We also investigated the role of IMP3 as a prognostic indicator for patients with malignant effusion. STUDY DESIGN A total of 156 cell block specimens, including 116 malignant effusions with MAC and 40 benign effusions with RMC, were subjected to immunocytochemical staining for IMP3. RESULTS Immunocytochemical studies showed positive staining for IMP3 in 91 of 116 (78.4%) cases of MAC and in 3 of 40 (7.5%) cases of RMC. With regard to distinguishing MAC from RMC, the IMP3 reactivity was found to be 78.4% sensitive and 92.5% specific with a positive predictive value of 96.8% and a negative predictive value of 59.7%. Diffuse IMP3 expression (>25%) in MAC from patients with gastric adenocarcinoma was associated with shorter survival (p = 0.001). CONCLUSION Our data suggest that IMP3 is a helpful marker for differentiating MAC from RMC, and that diffuse IMP3 expression is a poor prognostic indicator in patients with gastric adenocarcinoma and malignant effusion.
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Affiliation(s)
- Hye Jeong Kim
- Department of Pathology, Chonnam National University Medical School, Gwangju, Republic of Korea
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Cho JS, Kim GE, Lee JS, Lee JH, Nam JH, Choi C. Diagnostic usefulness of MUC1 and MUC4 for distinguishing between metastatic adenocarcinoma cells and reactive mesothelial cells in effusion cell blocks. Acta Cytol 2013; 57:377-83. [PMID: 23860190 DOI: 10.1159/000348499] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 01/30/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of our study was to determine the diagnostic value of MUC1 and MUC4 for distinguishing between metastatic adenocarcinoma cells (MAC) and reactive mesothelial cells (RMC) in effusion fluids. STUDY DESIGN A total of 237 cell block specimens from pleural and peritoneal effusions, including 196 malignant effusions with MAC and 41 benign effusions with RMC, were stained with antibodies against MUC1 and MUC4. Membranous staining with or without cytoplasmic staining was considered to be positive. RESULTS MUC1 immunoreactivity was observed in 194 (99.0%) of 196 cases of MAC and in 20 (48.8%) of 41 cases of RMC. MUC4 immunoreactivity was observed in 174 (88.8%) of 196 cases of MAC and in 4 (9.8%) of 41 cases of RMC. For distinguishing MAC from RMC, the MUC1 reactivity was found to be 99.0% sensitive and 51.2% specific with a positive predictive value of 90.7% and a negative predictive value of 91.3%. The sensitivity of MUC4 for MAC was 88.8%, the specificity was 90.2%, the negative predictive value was 62.7%, and the positive predictive value was 97.8%. CONCLUSION Our data suggest that MUC4 appears to be a sensitive and specific marker for differentiating between MAC and RMC.
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Affiliation(s)
- Jin Seong Cho
- Department of Surgery, Chonnam National University Medical School, Gwangju, Republic of Korea
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Henderson DW, Reid G, Kao SC, van Zandwijk N, Klebe S. Challenges and controversies in the diagnosis of mesothelioma: Part 1. Cytology-only diagnosis, biopsies, immunohistochemistry, discrimination between mesothelioma and reactive mesothelial hyperplasia, and biomarkers. J Clin Pathol 2013; 66:847-53. [DOI: 10.1136/jclinpath-2012-201303] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Jiang H, Gupta R, Somma J. EZH2, a unique marker of malignancy in effusion cytology. Diagn Cytopathol 2013; 42:111-6. [DOI: 10.1002/dc.22999] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 03/19/2013] [Indexed: 01/09/2023]
Affiliation(s)
- Huimiao Jiang
- Department of Pathology; SUNY Downstate Medical Center; Brooklyn New York
| | - Raavi Gupta
- Department of Pathology; SUNY Downstate Medical Center; Brooklyn New York
| | - Jonathan Somma
- Department of Pathology; SUNY Downstate Medical Center; Brooklyn New York
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Rodriguez-Panadero F, Romero-Romero B. Current and future options for the diagnosis of malignant pleural effusion. ACTA ACUST UNITED AC 2013; 7:275-87. [PMID: 23550710 DOI: 10.1517/17530059.2013.786038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Malignant pleural effusion (MPE) is a frequent problem faced by clinicians, but tumor pleural involvement can be seen without effusion. AREAS COVERED Imaging, pleural fluid analysis, biomarkers for MPE, needle pleural biopsy and thoracoscopy. To prepare this review, we performed a search using keywords: 'diagnosis' + 'malignant' + 'pleural' + 'effusion' (all fields) in PubMed, and found 4106 articles overall (until 16 January 2013, 881 in the last 5 years). EXPERT OPINION Ultrasound techniques will stay as valuable tools for pleural effusions. Biomarkers in pleural fluid do not currently provide an acceptable yield for MPE. In subjects with past history of asbestos exposure, some serum or plasma markers (soluble mesothelin, fibulin) might help in selecting cases for close follow-up, to detect mesothelioma early. Needle pleural biopsy is justified only if used with image-techniques (ultrasound or CT) guidance, and thoracoscopy is better for both diagnosis and immediate palliative treatment (pleurodesis). Animal models of MPE and 'spheroids' are promising for research involving both pathophysiology and therapy. Considering the possibility of direct pleural delivery of nanotechnology-developed compounds-fit to both diagnosis and therapy purposes ('theranostics')-MPE and mesothelioma in particular are likely to benefit sooner than later from this exciting perspective.
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Affiliation(s)
- Francisco Rodriguez-Panadero
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias (UMQUER), Hospital Universitario Virgen del Rocío, Seville, Spain.
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Rosolen DCB, Kulikowski LD, Bottura G, Nascimento AM, Acencio M, Teixeira L, Vargas FS, Sales RK, Antonangelo L. Efficacy of two fluorescence in situ hybridization (FISH) probes for diagnosing malignant pleural effusions. Lung Cancer 2013; 80:284-8. [PMID: 23453645 DOI: 10.1016/j.lungcan.2013.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/29/2013] [Accepted: 02/03/2013] [Indexed: 01/12/2023]
Abstract
It is difficult to differentiate tumor cells in pleural fluid from reactive benign mesothelium. Fluorescence in situ hybridization (FISH) can increase diagnostic accuracy. Two hundred pleural fluid samples were analyzed by using FISH probes for chromosomes 11 and 17. Histological analysis was used to diagnose cancer. Clinical, radiological, and histological data were used to exclude malignancy. Eighty-two pleural effusion samples had positive cytology, 51 were benign, and 67 were atypical, but inconclusive. The 82 positive cases were confirmed to be malignant. Among the 51 negative cytology cases, videothoracoscopy-guided pleural biopsy revealed malignancy in three; aneuploid cells were detected by FISH in all cases. In 43 of the 67 cases with inconclusive cytology, malignancy was confirmed based on histology and fluorescence in situ hybridization. One case of parapneumonic effusion with no evidence of cancer during clinical follow-up had a suspicious cytology and positive fluorescence in situ hybridization result. The remaining 23 cases had no histological, radiological, clinical, or genetic evidence of malignancy. This study demonstrated that cytogenetic analysis of fresh pleural fluid samples using only two FISH probes is a valuable ancillary method for the identification of malignant pleural effusion, particularly in cases in which oncotic cytology is inconclusive.
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Affiliation(s)
- Débora C B Rosolen
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil
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Uchino J, Takayama K, Nakagaki N, Shuo W, Hisasue J, Nakatom K, Ohta K, Hirano R, Tashiro N, Miiru I, Fujita M, Watanabe K, Nakanishi Y. A new cancer cell detection method using an infectivity-enhanced adenoviral vector. Asian Pac J Cancer Prev 2013; 13:5551-6. [PMID: 23317216 DOI: 10.7314/apjcp.2012.13.11.5551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Cytological examination is widely used as a diagnostic tool because of the ease of collecting cells from the involved area. However, the diagnostic yield of cytological examination is unsatisfactory; the reasons include sampling error, poorly prepared samples, small numbers of malignant cells, and low grades of cellular atypia. In this study, we focused on the high infectivity of adenovirus towards epithelial cells and applied the luciferase- expressing adenoviral vector to a new cancer cell detection tool. In addition, adenoviral infectivity was enhanced by modifying viral fiber proteins. The sensitivity of the diagnostic tool was tested using the NCI-H1299 lung cancer cell line, and validated in body fluid samples from cancer patients with a variety of etiology. Results showed that the adenovirus efficiently transfected NCI-H1299 with high sensitivity. Only 10 cancer cells were sufficient for detection of luciferase signals. In body fluid samples, the adenovirus confirmed the diagnosis for malignant and benign cancer, but not in non-epithelial cell derived samples. This study provides proof-of-concept for a more reliable and sensitive diagnostic tool for epithelium-derived cancer.
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Affiliation(s)
- Junji Uchino
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Japan
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Chowdhuri SR, Fetsch P, Squires J, Kohn E, Filie AC. Adenocarcinoma cells in effusion cytology as a diagnostic pitfall with potential impact on clinical management: a case report with brief review of immunomarkers. Diagn Cytopathol 2012; 42:253-8. [PMID: 23161830 DOI: 10.1002/dc.22915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 05/31/2012] [Accepted: 07/20/2012] [Indexed: 11/05/2022]
Abstract
Distinguishing metastatic carcinoma cells from reactive mesothelial cells in effusion samples is often challenging based on morphology alone. Metastatic carcinoma cells in fluid samples may mimic reactive mesothelial cells due to overlapping cytological features. We report a case of a pleural effusion in a 51-year-old female patient with a medical history significant for bilateral ovarian tumors and peritoneal implants diagnosed as serous tumor of borderline malignant potential. The effusion was composed almost entirely of adenocarcinoma cells that morphologically mimicked reactive mesothelial cells. The diagnosis of metastatic adenocarcinoma was made after a wide immunostaining panel of antibodies. Recognizing metastatic adenocarcinoma cells in effusion samples can be challenging and an accurate diagnosis may have significant impact on clinical management as demonstrated by this case.
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Affiliation(s)
- Sinchita Roy Chowdhuri
- Cytopathology Section, Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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Knoepp SM, Placido J, Fields KL, Thomas D, Roh MH. The application of immunocytochemistry to direct smears in the diagnosis of effusions. Diagn Cytopathol 2012; 41:425-30. [DOI: 10.1002/dc.22852] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 02/11/2012] [Indexed: 01/04/2023]
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Wilkosz S, Edwards LA, Bielsa S, Hyams C, Taylor A, Davies RJO, Laurent GJ, Chambers RC, Brown JS, Lee YCG. Characterization of a new mouse model of empyema and the mechanisms of pleural invasion by Streptococcus pneumoniae. Am J Respir Cell Mol Biol 2011; 46:180-7. [PMID: 21885676 DOI: 10.1165/rcmb.2011-0182oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Although empyema affects more than 65,000 people each year in the United States and in the United Kingdom, there are limited data on the pathogenesis of pleural infection. We investigated the pathogenesis of empyema using animal and cell culture models of Streptococcus pneumoniae infection. The pathological processes during the development of empyema associated with murine pneumonia due to S. pneumoniae (strain D39) were investigated. Lungs were examined using histology, and pleural fluid and blood bacterial colony-forming units, cytokine levels, and cellular infiltrate were determined over time. Bacterial migration across mesothelial monolayers was investigated using cell culture techniques, flow cytometry, and confocal microscopy. After intranasal inoculation with 10(7) S. pneumoniae D39 strain, mice developed pneumonia associated with rapid bacterial invasion of the pleural space; raised intrapleural IL-8, VEGF, MCP-1, and TNF-α levels; and caused significant intrapleural neutrophilia followed by the development of fibrinous pleural adhesions. Bacterial clearance from the pleural space was poor, and in vitro assays demonstrated that S. pneumoniae crossed mesothelial layers by translocation through cells rather than by a paracellular route. This study describes key events during the development of S. pneumoniae empyema using a novel murine model of pneumonia-associated empyema that closely mimics human disease. The model allows for future assessment of molecular mechanisms involved in the development of empyema and evaluation of potential new therapies. The data suggest that transmigration of bacteria through mesothelial cells could be important in empyema development. Furthermore, upon entry the pleural cavity offers a protected compartment for the bacteria.
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Affiliation(s)
- Sylwia Wilkosz
- Centre for Respiratory Research, Department of Medicine, Royal Free and University College Medical School, Rayne Institute, 5 University Street, London, UK.
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Arora R, Agarwal S, Mathur SR, Verma K, Iyer VK, Aron M. Utility of a limited panel of calretinin and Ber-EP4 immunocytochemistry on cytospin preparation of serous effusions: A cost-effective measure in resource-limited settings. Cytojournal 2011; 8:14. [PMID: 21829416 PMCID: PMC3151400 DOI: 10.4103/1742-6413.83233] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 06/05/2011] [Indexed: 11/21/2022] Open
Abstract
Background: Differentiation between reactive, but morphologically atypical, mesothelial cells and adenocarcinoma in effusions can be problematic. Elaborate immunohistochemical panels have been devised. Techniques like DNA analysis, flow/image cytometry, and K-ras mutation analysis are research oriented and difficult to perform in routine, especially in resource-poor centers. We evaluated the efficacy of a limited two-antibody panel comprising calretinin and Ber-EP4 on cytospin and cell block preparations, in 100 effusion samples. Materials and Methods: Fifty cases of reactive mesothelial hyperplasia and 50 cases of adenocarcinoma diagnosed by cytomorphology in ascitic/pleural fluid specimens over a 2-year period were assessed. The diagnoses were confirmed by clinical/histopathologic correlation. Cytospin smears were made in all. Cell blocks were prepared, wherever adequate fluid was available. Immunocytochemistry (ICC) for calretinin and Ber-EP4 was performed. Results: Forty-five of the reactive effusion cases (90%) were calretinin reactive and Ber-EP4 negative. Among the adenocarcinoma cases, 49 (98%) were calretinin negative but Ber-EP4 positive. Thus, both calretinin and Ber-EP4 had a high sensitivity (90% and 98%, respectively), as well as a high specificity (100% and 86%, respectively). In the 21 reactive mesothelial cases, whose cell blocks were made, results were comparable to those on cytospin. However, of the 19 adenocarcinoma cases in which cell blocks were prepared, all were Ber-EP4 immunopositive except for three, which were positive on cytospin, implying false-negative results on cell blocks. Conclusions: A limited panel of two monoclonal antibodies, calretinin and Ber-EP4, may be useful in cytology, as a “primary antibody panel”, for accurate diagnosis and patient management. Additionally, ICC can be performed easily on cytospin preparations, which gave results comparable to cell blocks in our study.
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Affiliation(s)
- Raman Arora
- Address: Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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