Usefulness of ploidy, AgNOR and immunocytochemistry for differentiating benign and malignant cells in serous effusions

Ber-EP4 staining in effusion cytology: A potential source of false positives

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.

Multiplexed molecular profiling of lung cancer with malignant pleural effusion using next generation sequencing in Chinese patients

Lung cancer is the most common type of cancer and the leading cause of cancer-associated death worldwide. Malignant pleural effusion (MPE), which is observed in ~50% of advanced non-small cell lung cancer (NSCLC) cases, and most frequently in lung adenocarcinoma, is a common complication of stage III-IV NSCLC, and it can be used to predict a poor prognosis. In the present study, multiple oncogene mutations were detected, including 17 genes closely associated with initiation of advanced lung cancer, in 108 MPE samples using next generation sequencing (NGS). The NGS data of the present study had broader coverage, deeper sequencing depth and higher capture efficiency compared with NGS findings of previous studies on MPE. In the present study, using NGS, it was demonstrated that 93 patients (86%) harbored EGFR mutations and 62 patients possessed mutations in EGFR exons 18-21, which are targets of available treatment agents. EGFR L858R and exon 19 indel mutations were the most frequently observed alterations, with frequencies of 31 and 25%, respectively. In 1 patient, an EGFR amplification was identified and 6 patients possessed a T790M mutation. ALK + EML4 gene fusions were identified in 6 patients, a ROS1 + CD74 gene fusion was detected in 1 patient and 10 patients possessed a BIM (also known as BCL2L11) 2,903-bp intron deletion. In 4 patients, significant KRAS mutations (G12D, G12S, G13C and A146T) were observed, which are associated with resistance to afatinib, icotinib, erlotinib and gefitinib. There were 83 patients with ERBB2 mutations, but only two of these mutations were targets of available treatments. The results of the present study indicate that MPE is a reliable specimen for NGS based detection of somatic mutations.

Are we ready to develop a tiered scheme for the effusion cytology? A comprehensive review and analysis of the literature

BACKGROUND

Cytology is widely utilized in the initial evaluation of fluid accumulation in the body cavities. The aim of this study was to determine the accuracy of cytology in distinguishing between benign and malignant (MAL) effusions.

METHODS

A comprehensive and systematic review of the literature was conducted to evaluate the accuracy of serous effusion cytology (SEC) against tissue biopsy/resection histology, imaging, or clinical follow-up as the reference test. Risk of publication bias and level of heterogeneity in the included studies was assessed. Meta-regression was performed to assess the effect of various variables on the accuracy of SEC.

RESULTS

Eighty studies met the inclusion criteria for meta-analysis comprising of 34 941 samples; of which 52 (0.2%), 22 202 (72.7%), 194 (0.6%), 711 (2.3%), and 6507 (21.3%) could be reclassified as nondiagnostic (ND), negative for malignancy (NFM), atypical (atypia of uncertain significance-AUS), suspicious for malignancy (SFM), and malignant (MAL), respectively. On follow-up, the mean risk of malignancy for ND, NFM, AUS, SFM, MAL was 17.4%, 20.7%, 65.9%, 81.8%, and 98.9%, respectively. A total of 73 studies were included in estimating the diagnostic accuracy of SEC. The bivariate mixed-effect model estimated the SEC sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio as 73.1%, 99.9%, 7850.6%, 2112.2%, and 0.27%, respectively.

CONCLUSION

Serous effusion cytology shows high specificity and moderate sensitivity in the evaluation of serous effusions. A tiered classification scheme can improve the consistency of terminology for reporting SEC results, thus improving communication between the pathologists and clinical team, and quality of patient care.

AgNOR Pleomorphic Count as a Tumor Marker in Cervical Carcinogenesis and Feasibility of Its Introduction in Cervical Cancer Screening Programs to Discriminate High-Risk Cases of Squamous Intraepithelial Lesions of the Cervix

BACKGROUND

AgNOR pleomorphism has been widely used for its diagnostic importance in differentiating premalignant and malignant lesions of different human neoplasms. However, an evaluation of its potential for discriminating cases of high-risk squamous intraepithelial lesions of the cervix (SIL) has been rarely attempted.

AIM

The tumor marker potential of AgNOR pleomorphism counts was assessed by correlating high and low mean counts in low-grade SIL (LSIL) cases with persistence or regression of the lesion and HPV positivity.

MATERIALS AND METHODS

The 115 LSIL cases selected for the study were registered from the ongoing cervical cancer screening of the rural population of Lucknow West. Silver nitrate staining for AgNOR counts and HPV DNA testing were done in all 115 cases.

RESULTS

The AgNOR counts in the 115 LSIL cases revealed low counts in 92 and high counts in 23 cases. Follow-up, available in 107 cases, revealed persistence of the lesion in 21 of the 23 cases with high counts and in 4 of the 84 cases with low counts. HPV positivity showed a strong correlation with high counts. Persistence of LSIL was also more frequent with high AgNOR counts and in HPV-positive cases.

CONCLUSIONS

The study showed a correlation of high mean AgNOR counts with HPV positivity and persistence of LSIL.

Use of Sialic Acid as a Complementary Method in the Cytological Diagnosis: Preliminary Study

INTRODUCTION

Cellular morphology does not allow, in many cases, to safely establish a diagnosis of malignancy or benignity. Sialic acid is found in the membranes of well-differentiated mature cells, normally located in the alpha-2,3 position. During tumor progression, changes occur in glycosylation of proteins and lipids, including alterations in the sialylation patterns of tumor cells.

OBJECTIVE

To confirm the overexpression of alpha-2,6 sialinization in exfoliated cells of body fluids and bronchoalveolar lavage (BAL) as a malignant indicator mechanism, using glycan-binding lectins.

MATERIALS AND METHODS

Thirty samples (20 effusion liquids and 10 BAL) diagnosed by Giemsa and Papanicolaou staining as negative and positive for malignancy, were studied. They were then stained with fluorescein-labeled Sambucus nigra lectin (Sigma Chemicals, USA), which specifically recognizes sialic acid in alpha-2,6 position. The fluorescence obtained at 515 nm evidenced the presence of sialic acid in the 2,6 position.

RESULTS

Negative body fluids for malignancy showed a fine and homogeneous fluorescence pattern for reactive mesothelial cells. Neoplastic cells revealed a thick, heterogeneous pattern. In BAL, benign hyperplastic cells showed a homogeneous fine pattern while neoplastic cells showed a thick and heterogeneous fluorescence pattern. The pattern described was observed in all cases in the cell membrane.

CONCLUSION

It was observed that the change in sialic acid conformation detected through Sambucus nigra Lectin could be used as a complementary method for the diagnosis of malignancy in different cytological samples.

The role of VEGF in the diagnosis and treatment of malignant pleural effusion in patients with non‑small cell lung cancer (Review)

Malignant pleural effusion (MPE) is a severe medical condition, which can result in breathlessness, pain, cachexia and reduced physical activity. It can occur in almost all types of malignant tumors; however, lung cancer is the most common cause of MPE, accounting for ~1/3 of clinical cases. Although there are numerous therapeutic approaches currently available for the treatment of MPE, none are fully effective and the majority can only alleviate the symptoms of the patients. Vascular endothelial growth factor (VEGF) has now been recognized as one of the most important regulatory factors in tumor angiogenesis, which participates in the entire process of tumor growth through its function to stimulate tumor angiogenesis, activate host vascular endothelial cells and promote malignant proliferation. Novel drugs targeting VEGF, including endostar and bevacizumab, have been developed and approved for the treatment of various tumors. Data from recent clinical studies have demonstrated that drugs targeting VEGF are effective and safe for the clinical management of MPE. Therefore, VEGF‑targeting represents a promising novel strategy for the diagnosis and treatment of MPE. The present review summarized recent advances in the role of VEGF in the pathogenesis, diagnosis and clinical management of MPE in patients with non‑small cell lung cancer.

Diagnostic accuracy of epithelial membrane antigen for malignant effusions: a meta-analysis

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.

Diagnostic accuracy of Ber-EP4 for metastatic adenocarcinoma in serous effusions: a meta-analysis

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.

Role of argyrophilic nucleolar organizer region staining in identification of malignant cells in effusion

Background:

Cytological examination of effusions helps to differentiate between benign and malignant effusions, but fails a definitive diagnosis in a number of cases. The main problem here is to distinguish reactive mesothelial cells from neoplastic cells.

Aim:

In the present study, we used argyrophilic nucleolar organizer region (AgNOR) staining for diagnosis of benign and malignant effusions.

Materials and Methods:

In this study, 100 cases of effusion samples were taken and centrifuged. Four smears were prepared from sediment, one each for Leishman, hematoxylin and eosin (H and E) staining and two for AgNOR staining. AgNORs were counted as black dots in the nuclei of all abnormal cells using ×100 oil immersion objective. Their dispersion and shape was compared in benign, malignant and atypical cases.

Results:

Out of 50 pleural effusion samples, 29 were benign, 10 were malignant and 11 atypical. Among the 47 peritoneal effusion samples, 27 were benign, 16 were malignant and 4 atypical. Out of three cases of pericardial effusion samples, one was benign and two were malignant. All effusions were subjected to AgNOR staining. The benign group consisted of cells showing 1 to 2 dots of regular size and shape. In malignant group, 3 to 5 dots of variable size, shape and irregular contours were observed per cell. In atypical group, the reactive mesothelial cells showed 1 to 2 dots, malignant cells showed 3 to 4 irregular dots. Thus, a differentiation was noted between activated mesothelial cells and malignant cells, which was not possible in Leishman and H and E-stained smears alone.

Conclusion:

Therefore, AgNOR can be branded as an extremely useful additional diagnostic tool for cytodiagnosis of effusions.

Diagnostic molecular biomarkers for malignant pleural effusions

Malignant pleural effusions (MPEs) are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis using minimally invasive tests is important because the median survival after diagnosis is only 4–9 months. Pleural fluid cytology is pivotal to current MPE diagnostic algorithms but has limited sensitivity (30–60%). Consequently, many patients need to undergo invasive diagnostic tests such as thoracoscopic pleural biopsy. Recent genomic, transcriptomic, methylation and proteomic studies on cells within pleural effusions have identified novel molecular diagnostic biomarkers that demonstrate potential in complementing cytology in the diagnosis of MPEs. Several challenges will need to be addressed prior to the incorporation of these molecular tests into routine clinical diagnosis, including validation of molecular diagnostic markers in well-designed prospective, comparative and cost–effectiveness studies. Ultimately, minimally invasive diagnostic tests that can be performed quickly will enable clinicians to provide the most effective therapies for patients with MPEs in a timely fashion.

Sensitivity and specificity of cytodiagnosis of body fluids in a laboratory of urgencies

The main purpose for studying cytological body fluids is confirmation of a benign or malignant effusion. Our cytology laboratory analyzes body fluids and results are requested urgently. The samples are stained by the Giemsa and Papanicolaou methods to give a preliminary report, then they are examined by other complementary techniques. Three hundred thirty samples of pleural and peritoneal fluids were studied to compare the sensitivity of Papanicolaou and Giemsa stains. AgNOR assay, immunocytochemistry and assessment of ploidy were used to improve the sensitivity of the cytodiagnosis. Two hundred one samples were positive, 84 negative and 45 inconclusive using the Papanicolaou stain, while 135 samples were positive, 72 negative and 123 inconclusive using Giemsa stain. The sensitivity was 79%, 53% and 83% for Papanicolaou, Giemsa, and both techniques together, respectively. Using complementary techniques, the sensitivity reached 95% for AgNOR, 87% for tumor markers (panel), and 92% for Ploidy. There were no false positive in our series; therefore specificity was 100%. The use of both Papanicolaou and Giemsa in conjunction increased the sensitivity of the cytodiagnosis in body fluids. The complementary methods, especially AgNOR assay and assessment of ploidy, diminished the number of inconclusive cases.

Immunocytochemical panel for distinguishing carcinoma cells from reactive mesothelial cells in pleural effusions

OBJECTIVE

The aim of this study was to evaluate the individual and combined diagnostic utility of carcinoembryonic antigen (CEA), cytokeratin 19 fragments (CK19) and HBME-1 in pleural effusions of patients with lung cancer.

STUDY DESIGN

CEA, CK19 and HBME-1 were detected by immunocytochemistry in pleural effusions from patients with lung cancer (86 cases) and without lung cancer (40 cases).

RESULTS

CEA and CK19 expression were significantly higher in the carcinoma cell group and in three subgrouped as adenocarcinoma (AC), squamous cell carcinoma (SCC) and small cell lung cancer than in the mesothelial cell group, whereas HBME-1 expression was lower in the former group (P < 0.01). In the subgrouped tumours, CEA expression was higher in AC than in SCC (P < 0.05), whereas HBME-1 expression was higher in SCC than in AC (P < 0.01). Used alone, CK19 had the highest sensitivity (95.3%) and accuracy (93.7%), whereas CEA had the highest specificity (97.5%). When combinations of antibodies were evaluated together and membrane staining with HBME-1 taken as a negative outcome, CK19 and HBME-1 gave a high diagnostic performance: sensitivity of 100.0% and accuracy of 95.2% respectively.

CONCLUSION

A panel of CEA, CK19 and HBME-1 monoclonal antibodies proved to be suitable for distinguishing carcinoma cells from reactive mesothelial cells in pleural effusions.