Diagnostic cytology of cerebrospinal fluid by the cytocentrifuge method

Cyto-3D-print to attach mitotic cells

The Cyto-3D-print is an adapter that adds cytospin capability to a standard centrifuge. Like standard cytospinning, Cyto-3D-print increases the surface attachment of mitotic cells while giving a higher degree of adaptability to other slide chambers than available commercial devices. The use of Cyto-3D-print is cost effective, safe, and applicable to many slide designs. It is durable enough for repeated use and made of biodegradable materials for environment-friendly disposal.

Cytopathology of neoplastic meningitis: A series of 66 cases from a tertiary care center

Background:

Neoplastic meningitis (NM) is a condition characterized by leptomeningeal involvement by metastatic carcinoma. Detection of exfoliated malignant cells in cerebrospinal fluid (CSF) due to meningeal metastasis is frequently associated with diverse neurologic presentations.

Materials and Methods:

In this retrospective study of all cases of NM diagnosed in CSF samples over a 20-year period at a tertiary care referral center, the cytomorphologic features were reviewed.

Results:

Sixty six cases of NM were identified of which 36 already had an established diagnosis of malignancy while in 30 patients, there was no previously known tumor. The most common known primary in the former group was breast followed by ovary. Single cell pattern, cellular cannibalism, moderate cytoplasm and rounded nuclei were seen in breast and lung tumors. Papillary architecture and cytoplasmic vacuolation were seen in the ovarian primaries. Melanin pigment was seen in malignant melanoma.

Conclusion:

CSF cytology is an important tool for diagnosis of NM. Cytomorphologic features helped in diagnosis and for prediction of the primary site. Correct identification of this condition is important as it has therapeutic and prognostic implications.

Meningeal metastases: clinical aspects and diagnosis

The authors review the clinical and diagnostic aspects involved in leptomeningeal disease due to solid tumours, leukaemias and lymphomas. The importance of the combination of clinical findings with cerebral spinal fluid (CSF) examination and imaging studies in making an early diagnosis is underlined. The raising prevalence of this complication of systemic cancer deserves specific attention on the part of neurologists involved in consultation liason with general medicine and oncology.

Detection of herpes simplex virus in clinical specimens by cytospin-enhanced direct immunofluorescence

For 275 samples tested for herpes simplex virus (HSV), cytospin-enhanced direct immunofluorescence using Chemicon HSV monoclonal antibodies identified 80 (95%) and culture identified 77 (92%) of 84 confirmed positive specimens. Cytospin-prepared slides contained a greater number of total cells than standard cell spots, resulting in fewer inadequate cell smears and a higher HSV detection rate.

Hypersegmentation of neutrophils in the cerebrospinal fluid: report of a case with hematologic correlation and review of the literature

Hypersegmented neutrophils can occasionally be seen in the cerebrospinal fluid (CSF) of patients with acute pyogenic meningitis, and rarely as an artifact of cytocentrifugation. We report a case of florid neutrophil hypersegmentation in cytocentrifuged CSF specimens from a patient presenting with anemia and mental status changes. Megaloblastic anemia was excluded by a thorough hematologic evaluation, and the patient was later found to have an epidural abscess. The striking hypersegmentation is attributed to the combined effects of meningeal infection and cytocentrifugation, and a review of the available limited literature on cytomorphologic alterations in CSF cells, specifically neutrophils, is presented.

Diagnostic value of cerebrospinal fluid cytology in comparison with tumor marker activity in central nervous system metastases secondary to breast cancer

BACKGROUND

Central nervous system (CNS) metastases occur in approximately 35% of patients with breast cancer. Parenchymal brain metastases (MET) remain undetected in a large proportion of patients, and only 50% of patients with leptomeningeal carcinomatosis (MC) are diagnosed in vivo.

METHODS

Cytology and activity of the tumor markers tissue polypeptide antigen (TPA) and creatine kinase-BB isoenzyme (CK-BB) were evaluated in the cerebrospinal fluid (CSF) in 71 consecutive patients with breast cancer suspected for CNS metastases.

RESULTS

Forty-three patients had no CNS metastases, 12 patients had MET, 5 patients had both MET and MC, and 11 patients had MC alone. Seven of the patients with MC had an intracerebroventricular (ICV) reservoir inserted, and an additional 70 ICV CSF samples from these patients were obtained. In CSF obtained by lumbar puncture, 11% of the samples were classified as "suspicious for malignancy," but a very limited interobserver variability was demonstrated (Kappa test value, 0.81; 95% confidence limits, 0.67-0.95%). Fifty-one percent of the ICV CSF samples were classified as "suspicious for malignancy" (Kappa test value, 0.58; 95% confidence limits, 0.34-0.82%). TPA and CK-BB were both measured in 101 CSF specimens (61 from lumbar puncture and 40 ICV samples). The differences between patients with and without CNS metastases were significantly different according to TPA (P < 0.00001) and CK-BB (P < 0.00003; Mann-Whitney test). The sensitivity and predictive value of a negative test for having any CNS metastases (in case of elevated values of either TPA or CK-BB or both) were 85% (95% confidence limits, 65-96%) and 90% (95% confidence limits, 76-97%), respectively. In addition, a significant correlation between TPA and CK-BB was demonstrated in CSF from lumbar puncture (Spearmans-Rho, 0.49; P < 0.0001) and ICV (Spearmans-Rho, 0.37; P < 0.02).

CONCLUSIONS

Cytologic evaluation of CSF obtained by lumbar punctures is a reliable procedure. In CSF from ICV reservoirs, cytologic evaluation is of limited use, but CK-BB and TPA is of potential value.

Evaluation of cytocentrifuge apparatus with special reference to the cellular recovery rate

Two types of commercially available cytocentrifuge apparatus (type A and type B apparatus) using disposable funnels were compared for percentage of cell recovery and degree of cell preservation. The cellularity of each cell suspension was determined using a Sysmex micro cell counter for blood analysis, and the cell recovery was obtained by counting cells in the total smeared area on the May-Grünwald Giemsa (MGG)-stained slide. Overall recovery rate by the type A apparatus was between 54.3% and 74.9% with a mean of 63.0%, whereas, the recovery rate for type B apparatus was between 30.6% and 51.8%, with a mean of 42.5%, indicating that the type A apparatus was significantly better. In the type A apparatus, a higher yield of all cells was obtained (69.7-74.9%) in the group of low cell counts (350 cells/0.5 ml), which was run for 10 minutes at 2,000 rpm. On the other hand, in the type B apparatus a higher yield of all cells was obtained (38.6-42.6%) in the group of low cell counts which was run for 10 minutes at 2,000 rpm. Cellular structure was better preserved on the slides in the type A apparatus. However, the percentage of ghost cells was somewhat higher in the type B apparatus. The cytocentrifugation of the type A apparatus consistently recovered a higher percentage of cells than with the type B apparatus. Using the type A apparatus, a high rate of cellular recovery, which is extremely important, such as for accurate morphological evaluation of cerebrospinal fluid, can be consistently obtained.

Creatine kinase-BB in the cerebrospinal fluid as a marker of CNS metastases and leptomeningeal carcinomatosis in patients with breast cancer

To determine whether creatine kinase-BB isoenzyme would be useful in detecting central nervous system metastases secondary to breast cancer, we measured the cerebrospinal fluid (CSF) activity of creatine kinase (CK) and its BB isoenzyme (CK-BB) in 65 consecutive patients suspected of having CNS involvement. All patients underwent neurological evaluation, computer tomography (CT) scan and/or radionuclide scintigraphy and lumbar puncture with CSF examination. Thirty patients had CNS metastases, of whom 18 had parenchymal brain metastases (MET). Twelve had leptomeningeal carcinomatosis (MC), of whom four also had parenchymal brain metastases. Thirty-four patients were concluded not to have CNS involvement, whereas one was considered equivocal. CK-BB activity was significantly higher in patients with CNS metastases than in those without (P less than 0.05). This difference was primarily related to the fact that patients with MC had a significantly higher CK-BB activity than patients without CNS metastases or patients with parenchymal brain metastases only (P less than 0.01 and P less than 0.05, respectively). Taking 0.20 U/l as a tentative cut-off value (the upper limit range of patients without CNS metastases being 0.19 U/l), 10 out of 12 patients with MC had activities above this level. The sensitivity and specificity for having MC were 83% and 87%, and the positive and negative predictive values 60% and 96%, respectively. The sensitivity and negative predictive value for having any CNS metastases were 57% and 72%. Specificity and positive predictive value: 100%. The CSF activity of CK-BB appears to be a contribution in the diagnosis of MC secondary to breast cancer and seems superior to protein and LDH.

Leptomeningeal cancer in leukemia and solid tumors

Although some patients with overt leptomeningeal cancer can now be cured, the proportion of patients who survive is very small, and the cost of cure, in terms of neuropsychological and educational morbidity, is substantial. Yet the incidence of central nervous system infiltration of systemic cancer is generally increasing, in most instances because control of systemic cancer has sufficiently prolonged survival to permit leptomeningeal metastases to develop and become symptomatic or detectable. The best chance for prolongation of life and possible cure is early detection and aggressive therapy in those forms of cancer that are amenable to therapy. We review the incidence of the various forms of leptomeningeal metastases, current concepts of pathogenesis and pathophysiology, clinical and laboratory features of leptomeningeal cancer, the available therapies, and the associated toxicities. The various methods that have been used to prevent and treat leptomeningeal cancer are described with an emphasis on childhood acute lymphoblastic leukemia (ALL) because it plays a predominant role in our understanding of meningeal neoplasms in general.

Metrizamide myelography in patients with small cell carcinoma of the lung suspected of meningeal carcinomatosis

Twenty patients suspected of meningeal carcinomatosis (MC) secondary to small cell carcinoma of the lung were evaluated by myelography and by cytologic examination of cerebrospinal fluid (CSF). In 4 patients both investigations demonstrated MC. Four had positive cytology but a negative myelogram. Five patients had a positive myelogram but negative cytology. Thus 13 of the 20 patients had MC diagnosed by one or both of these investigations. Two additional patients suspected of MC were studied; both had positive myelography, but cytologic examination of CSF was not performed in either case. Six patients underwent autopsy with microscopic examination of the spinal cord; in all cases post-mortem findings supported myelographic findings. In conclusion, myelography is useful in the evaluation of patients suspected of MC secondary to small carcinoma of the lung and complements the diagnostic role of CSF examination.

Significance of neutrophils in cerebrospinal fluid samples processed by cytocentrifugation

We reviewed medical records of 155 pediatric patients whose cerebrospinal fluid (CSF) samples contained an increased proportion of neutrophils when processed by cytocentrifugation, despite normal CSF total white blood cell count. It was determined that these CSF findings occurred more commonly in patients with bacteremia, peripheral leukocytosis, and increased numbers of red blood cells in the CSF. Pulmonary infiltrates in infants and otitis media in children were also significantly associated. Cytocentrifugation allows the identification of neutrophils in the CSF, even in the absence of central nervous system infection. Infants and children with more than 10 per cent neutrophils in CSF require evaluations for focal and bacteremic infections.

Concentrated gram stain smears prepared with a cytospin centrifuge

A Cytospin slide centrifuge was used to concentrate 0.05- to 0.5-ml samples of cerebrospinal and other body fluids for Gram stain. Trials with cerebrospinal fluid containing known numbers of microorganisms indicated that the Cytospin increased the sensitivity of cerebrospinal fluid Gram stains by up to 2 logs compared with unconcentrated and conventional centrifuge smears. Cytospin-concentrated smears were prospectively compared with unconcentrated Gram-stained smears and bacteriological culture results for 80 clinical body fluid specimens. Bacteria were seen in unconcentrated smears of 9 of the 16 (56%) fluids which were infected, whereas Cytospin smears of 12 of the 16 (75%) showed bacteria. Cytospin smears revealed more bacteria and demonstrated better leukocyte morphology than did unconcentrated or conventionally centrifuged samples of small volumes of infected body fluids, allowing early diagnosis of infection.

Diagnosis and treatment of leptomeningeal metastases from solid tumors: experience with 90 patients

The clinical findings and response to treatment of leptomeningeal metastases from solid tumors are analyzed in 90 patients treated at Memorial Sloan-Kettering Cancer Center during the period from January 1975 to February 1980. Patients included those who had either typical clinical findings of leptomeningeal tumor or conclusive laboratory evidence supporting the diagnosis. Carcinoma of the breast (46 patients), lung (23 patients) and melanoma (11 patients) were the common primary tumors. Symptoms of leptomeningeal metastasis occurred as the presenting sign in five patients and as late as ten years after the primary tumor was diagnosed in four other patients. Most patients had active systemic disease outside the nervous system. Signs and symptoms could be classified as involving either the brain, cranial nerves, or spinal nerves. Most patients had either symptoms or signs in more than one area at the time the diagnosis was established. The initial spinal fluid examination was abnormal in all but three patients, but only 49 had cytologic evidence of leptomeningeal metastases. Repeated spinal fluid assay yielded a positive cytology in 82 patients. Measurement of biochemical markers, including beta-glucuronidase, carcinoembryonic antigen and lactic dehydrogenase, assisted in the diagnosis. Approximately half of the patients treated by intraventricular methotrexate experienced improvement or stabilization of neurological symptoms for more than a month; median survival was 5.8 months after diagnosis, with a range of 1--29 months. In 18 patients disease was limited to the nervous system, and median survival was eight months, with four patients surviving one year and two patients for two years. Side effects of therapy were, for the most part, minor. We conclude that vigorous treatment of leptomeningeal metastases with intrathecal chemotherapeutic agents improves symptomatology in some patients, and at times prolongs survival.