Flow Cytometry and Effusions in Lymphoproliferative Processes and Other Hematologic Neoplasias

Lymphocyte immunophenotyping and concentration of MMP-9 in transudates and exudates in horses

This study is the first to provide information on the lymphocyte subpopulations in peritoneal effusions in horses. Peritoneal transudates (n = 12), peritoneal exudates (n = 6) and a pleural exudate (n = 1) were analyzed. The total nucleated cell count (TNCC), total protein (TP) and matrix metalloproteinase-9 (MMP-9) concentration determined by ELISA were measured and routine cytological evaluation was performed. CD3, CD4, CD8 and CD21 positive cells were detected by flow cytometry. A higher percentage of neutrophils (P < 0.05) and higher MMP-9 (P < 0.01) levels were found in exudates. A higher percentage of macrophages (P < 0.05) and lymphocytes (P < 0.01) were found in transudates. CD4 + lymphocytes were the most common lymphocyte subpopulation in all samples. CD21 + lymphocytes were the least common in all samples. A large variability in the percentage of CD21 + lymphocytes was found in exudates. The percentage of CD21 + lymphocytes positively correlated with the level of total protein (r = 0.5704, P < 0.05). The correlation was even stronger in the group of exudates. The percentages of lymphocyte subpopulations did not correlate with the level of MMP-9 or with cytological findings. The level of MMP-9 positively correlated with the percentage of neutrophils (r = 0.4980, P < 0.05), the level of TP (r = 0.7855, P < 0.01) and TNCC (r = 0.6129, P < 0.01). A significantly higher level of MMP-9 was detected in euthanized horses than in horses that survived (P < 0.05). However, it was shown that the level of MMP-9 in the peritoneal fluid can change significantly in a short time. More studies on repeated abdominocentesis could contribute to elucidating the role of MMP-9 as a prognostic indicator.

Deep Learning-Based Computational Cytopathologic Diagnosis of Metastatic Breast Carcinoma in Pleural Fluid

A Pleural effusion cytology is vital for treating metastatic breast cancer; however, concerns have arisen regarding the low accuracy and inter-observer variability in cytologic diagnosis. Although artificial intelligence-based image analysis has shown promise in cytopathology research, its application in diagnosing breast cancer in pleural fluid remains unexplored. To overcome these limitations, we evaluate the diagnostic accuracy of an artificial intelligence-based model using a large collection of cytopathological slides, to detect the malignant pleural effusion cytology associated with breast cancer. This study includes a total of 569 cytological slides of malignant pleural effusion of metastatic breast cancer from various institutions. We extracted 34,221 augmented image patches from whole-slide images and trained and validated a deep convolutional neural network model (DCNN) (Inception-ResNet-V2) with the images. Using this model, we classified 845 randomly selected patches, which were reviewed by three pathologists to compare their accuracy. The DCNN model outperforms the pathologists by demonstrating higher accuracy, sensitivity, and specificity compared to the pathologists (81.1% vs. 68.7%, 95.0% vs. 72.5%, and 98.6% vs. 88.9%, respectively). The pathologists reviewed the discordant cases of DCNN. After re-examination, the average accuracy, sensitivity, and specificity of the pathologists improved to 87.9, 80.2, and 95.7%, respectively. This study shows that DCNN can accurately diagnose malignant pleural effusion cytology in breast cancer and has the potential to support pathologists.

Malignant Pleural Effusions: Updates in Diagnosis and Management

Malignant pleural effusions remain a significant clinical problem resulting in greater than 125,000 hospitalizations per year and leading to over 5 billion dollars in healthcare utilization costs. Not only are health care expenditures related to malignant pleural effusion significant, but malignant pleural effusions also often result in significant patient discomfort and distress, largely at the end of life. Advances in management over the past several years have provided patients with greater autonomy as they are able to provide self-aid at home either alone or with family assistance. Additionally, practice changes have allowed for fewer interventions allowing patients to spend more time out of the clinic or inpatient wards.

Lymphoproliferative disorder involving body fluid: diagnostic approaches and roles of ancillary studies

Lymphocyte-rich effusions represent benign reactive process or neoplastic condition. Involvement of lymphoproliferative disease in body cavity is not uncommon, and it often causes diagnostic challenge. In this review, we suggest a practical diagnostic approach toward lymphocyte-rich effusions, share representative cases, and discuss the utility of ancillary tests. Cytomorphologic features favoring neoplastic condition include high cellularity, cellular atypia/pleomorphism, monomorphic cell population, and frequent apoptosis, whereas lack of atypia, polymorphic cell population, and predominance of small T cells usually represent benign reactive process. Involvement of non-hematolymphoid malignant cells in body fluid should be ruled out first, followed by categorization of the samples into either small/medium-sized cell dominant or large-sized cell dominant fluid. Small/medium-sized cell dominant effusions require ancillary tests when either cellular atypia or history/clinical suspicion of lymphoproliferative disease is present. Large-sized cell dominant effusions usually suggest neoplastic condition, however, in the settings of initial presentation or low overall cellularity, ancillary studies are helpful for more clarification. Ancillary tests including immunocytochemistry, in situ hybridization, clonality test, and next-generation sequencing can be performed using cytologic preparations. Throughout the diagnostic process, proper review of clinical history, cytomorphologic examination, and application of adequate ancillary tests are key elements for successful diagnosis.

[Cytology of body cavity fluids - established methods and new developments]

BACKGROUND

Body cavity fluids are among the most frequently examined samples in cytology. Cytomorphology is supplemented by additive testing. An international system of terminology and classification has been recently presented.

OBJECTIVES

Cytopreparation and staining techniques as well as some exemplary morphological patterns are presented. "The International System for Serous Fluid Cytopathology" (TIS) is briefly presented.

MATERIALS AND METHODS

Pleural effusion, pericardial effusion, and ascites: special technical issues, immunocytochemistry, molecular diagnostics, and reporting system issues are discussed.

RESULTS

Body cavity fluids are important samples that provide significant information. Additive testing is established for routine use. The form and structure of reports is widely divergent in practical use.

DISCUSSION

A reporting system for serous fluid cytopathology that is easily applied and recognized internationally is highly desirable. TIS is a valuable approach to this goal.

Preliminary cytomorphologic diagnosis of hematolymphoid malignancies in effusions: A cyto-histo correlation with lessons on restraint

Background:

Effusions as part of hematologic neoplasms are rare and as a primary presentation, rarer. In standalone laboratories of developing countries, resorting to techniques such as flow cytometry or immunohisto/cytochemistry may not be possible. A near definitive diagnosis on cytomorphology would, therefore, be an ideal beginning. To that end, we compiled our cases of primary hematolymphoid effusions, devising reproducible reporting categories and looked at their concordance with the final histopathology.

Subjects and Methods:

Fifty-four cases of primary hematolymphoid effusions over 10 years with cytology-histopathology correlation were chosen. Post morphology assessment, the cases were organized into six categories: suspicious of hematolymphoid malignancy, non-Hodgkin lymphoma-high-grade (NHL-HG), low-grade NHL (NHL-LG), Burkitt lymphoma, acute leukemias, and plasma cell dyscrasias. Discordance with histology was assigned as major and minor based mainly on therapeutic implications.

Results:

Concordance was seen in a good number (81.5%) of cases. The NHL-HG and NHL-LG categories contributed to 33.3% each of major discordance. Tuberculosis and epithelial malignancies comprised the bulk of the major discordance. Overdiagnosis of a high-grade lymphoma for a histologically proven low-grade follicular lymphoma was the only case with minor discordance.

Conclusion:

The cytologic categories used are not foolproof for hematologic neoplasms but have a fairly good concordance. A scanty abnormal population should always be viewed with suspicion and definitive labels should be avoided. While morphologic examination is fraught with danger, a good assessment directs the judicious selection of ancillary methods, and hence cannot be supplanted.

Hematolymphoid Neoplasms in Serous Effusions: Morphological Spectrum, Distribution, and Role of Ancillary Techniques—A Retrospective Analysis of 75 cases

Introduction Involvement of body fluids can occur at the time of diagnosis or during the disease course of hematolymphoid neoplasms. Cytodiagnosis of malignant effusion is important in effective clinical management.

Objectives (1) The aims of the study were to determine the frequency of distribution of various hematolymphoid neoplasms involving body fluids, (2) to study the morphology of hematolymphoid neoplasms in fluids, and (3) to assess the role of ancillary techniques in the diagnosis.

Materials and Methods In this retrospective study, all cases of hematolymphoid neoplasms involving body fluids diagnosed from January 2016 to December 2018 were evaluated.

Results During the 3-year period, there were 75 cases of hematological malignancies involving body fluids. These included 48 male patients and 27 female patients. Pleural fluid was involved in majority of cases (56 cases; 74.67%), followed by ascitic fluid (17 cases; 22.67%), and pericardial fluid (2 cases; 2.67%). High cellularity, monotonous population of cells, high nuclear-cytoplasmic (N/C) ratio, indentation/irregularity of nuclear membrane, immature chromatin/irregular clumping of chromatin, increased mitosis, and karyorrhexis were the key features which helped to differentiate between reactive and neoplastic processes. There were 35 cases of B-cell neoplasms, 33 cases of T-cell neoplasms, and seven cases of myeloid neoplasms involving body cavity fluids. T-lymphoblastic lymphoma was the most common subtype (29 cases; 38.7%), followed by diffuse large B-cell lymphoma (DLBCL) (12 cases; 16%). In 53 cases, effusion was present in the initial presentation itself. Initial diagnosis was made in effusion cytology in 25 cases (33.33% of the total), with the help of flow cytometry in 20 cases, and immunohistochemistry (IHC) in cell blocks in five cases.

Conclusion Diagnosis of hematolymphoid neoplasms in body fluids based on correlation with clinical details, critical evaluation of cytology findings, and comparison with previous diagnosis along with the judicious use of ancillary techniques helps in deciding an early treatment plan.

An unusual case of paediatric plasmablastic lymphoma presenting with malignant effusion and the challenges in its diagnosis

Plasmablastic lymphoma (PBL) is an aggressive non-Hodgkin lymphoma occurring commonly in the oral mucosa and jaw of human immunodeficiency virus (HIV) positive adult males. PBL is not a common occurrence in children and a presentation with malignant effusion is rarely reported. Herein, we share our experience in the challenges confronted in the diagnosis of PBL in a 6-year-old, HIV positive boy presenting with malignant pleural and peritoneal effusions along with gum hypertrophy, lymphadenopathy and paranasal sinus mass. Amenability of pleural effusion to exfoliative cytology led to an initial cytological examination demonstrating large atypical lymphoid cells with plasmacytoid morphology and a plasmablastic variant of Burkitt lymphoma was initially considered. However immunophenotyping by flowcytometry (FCM) and a cell block immunohistochemical evaluation of the serous effusion suggested a plasma cell immunophenotype and a diagnosis of PBL was favored. A subsequent biopsy from the paranasal sinus mass confirmed the diagnosis of PBL but showed tumour cell angiocentricity on morphology and CD45 expression on immunohistochemistry (IHC), both unusual features in PBL. A CD20 negative/MUM-1 positive immunoprofile and presence of a solid tumour mass in a typical location in addition to malignant effusion substantiated the diagnosis of PBL. The patient was offered HAART (highly active antiretroviral therapy) and chemotherapy and is on follow-up. Paediatric PBL with malignant effusion is rarely reported and this case stresses the importance of use of a multimodality diagnostic approach for an accurate diagnosis.

Cytomorphology, Immunophenotype, and cytogenetic profile of leukemic serous effusions

BACKGROUND

Serous effusions (SE) in leukemic patients can be due to infections, therapy, volume overload, lymphatic obstruction or malignancy having implications on treatment and mortality. The objective of the present study is to highlight the spectrum of cytomorphology, immunophenotype, and cytogenetics in leukemic serous effusions (LSE).

MATERIALS

Present study is retrospective and descriptive. We reviewed all the SE, which were reported as suspicious or positive of leukemic infiltration from 2016 to 2019 for cytomorphological features. CSF and effusions involved by lymphomas were excluded. Cyto-diagnosis was compared with primary proven diagnosis (by ancillary techniques) and disconcordant cases were analyzed.

RESULTS

Out of total 9723 effusions, only 0.4% (n = 40) showed leukemic involvement and included nine cases of AML, three of B-ALL, 13 T-ALL, 2 MPAL, 6 CML, 5CLL, one each of chronic myelomonocytic leukemia and AML with myelodysplasia. The most common site of involvement was the pleural cavity (n = 30), followed by the peritoneal cavity (n = 7) and the pericardial cavity (n = 3). T -ALL (41.9%) was the most common leukemia involving pleural fluid followed by AML (23.3%). CML (42.8%) was the most common leukemia involving the ascitic fluid followed by B-ALL (28.6%). Accurate diagnosis was given on cytomorphology in 72.5% (29/40) cases and 15.0% (6/40) were reported as non-Hodgkin lymphoma.

CONCLUSION

Cytology is an effective tool available to make a diagnosis of LSE. Nuclear indentations in large atypical cells and cells with eosinophilic granular cytoplasm with sparse or abundant eosinophils in the background are an important clue in favor of leukemia over lymphoma.

A Simple and Practical Guide for Triaging Lymphocyte-rich Effusions for Ancillary Studies

Lymphocyte-rich effusions of the body cavities may represent a reactive/benign condition, primary effusion lymphoma, or systemic lymphoma with secondary malignant effusion, either as initial presentation or as a late complication. Cytomorphologic examination is essential and fundamental for diagnosis and may provide important clues to the nature of diseases. However, based on morphology alone, cytologic diagnosis of lymphocyte-rich effusions could be very challenging, particularly when the lymphocytes are small. Cytologists/cytopathologists might be uncertain when a lymphocyte-rich effusion specimen warrants a comprehensive hematopathologic workup. Herein we present a simple and practical algorithmic approach. On the basis of the cytomorphology of lymphocytes (small vs. large cells), presence or absence of cellular atypia, and clinical information (an earlier history or current lymphoma), the lymphocyte-rich effusion samples could be triaged for ancillary studies including immunophenotyping and molecular assays if indicated. Incorporation of cytomorphology, correlation with clinical information, and appropriate application of various ancillary techniques is mandatory for a correct diagnosis of lymphocyte-rich effusion specimens.

Not Always (and Only) Heart Failure-A Case Report of Primary Pleural Lymphoma in an Elderly Patient

Pleural involvement in Non-Hodgkin Lymphoma (NHL) is well documented, but primary pleural lymphomas are extremely rare, occurring mostly in immunosuppressed patients or associated with chronic pleural inflammation. Nevertheless, the pathogenesis and therapeutic approaches to counteract primary pleural lymphomas are still matter of debate. The authors present the clinical case of an 81-year-old female with respiratory and constitutional symptoms. A valvular heart disease and bilateral pleural effusion were known. The study carried out showed a large right pleural effusion; the fluid analysis was compatible with Diffuse Large B-cell Lymphoma (DLBCL), and two lymphomatous masses with pleural origin were found at the ipsilateral hemithorax. Primary pleural lymphoma was considered and chemotherapy was initiated with a good response and evolution. The authors report this remarkable clinical case because of its rarity, its excellent clinical evolution and the absence of an immunodeficiency context.

Diagnosis of Hodgkin Lymphoma from Cell Block: A Reliable and Helpful Tool in "Selected" Diagnostic Practice

Background: The diagnosis of lymphoma requires surgical specimens to perform morphological evaluation, immunohistochemical and molecular analyses. Ultrasound-guided fine needle aspiration may represent an appropriate first approach to obtain cytological samples in impalpable lesions and/or in patients unsuitable for surgical procedures. Although cytology has intrinsic limitations, the cell block method may increase the possibility of achieving an accurate diagnosis. Methods: We retrospectively selected a total of 47 ultrasound-guided fine needle aspiration and drainage samples taken from patients with effusion and deep-seated lesions which are clinically suspicious in terms of malignancy. Results: In 27 cases, both cell block and conventional cytology were performed: 21/27 cell blocks were adequate for the diagnosis of lymphoma and suitable for immunocytochemistry and molecular analyses vs. 12/20 samples to which only conventional cytology was applied. Moreover, in five patients we were able to make a diagnosis of Hodgkin lymphoma with the cell block (CB) technique. Conclusions: Contrary to conventional cytology, the cell block method may allow immunocytochemistry and molecular studies providing useful information for the diagnosis and subtypization of lymphoma in patients unsuitable for surgical procedure or with deep-seated lesions or extra-nodal diseases; additionally, it is a daily, simple and helpful approach. Moreover, we describe the usefulness of cell blocks in the diagnosis of Hodgkin lymphoma.

The cytopathological spectrum of lymphomas in effusions in a tertiary center in Taiwan

Lymphomas presenting in effusions could either be primary or secondary, with very limited data from Taiwan.

METHODS

We retrospectively reviewed effusion lymphomas from our archives in a tertiary center from July 2011 to June 2019.

RESULTS

We identified 59 specimens from 43 patients, including 7 cases with primary effusion lymphoma (PEL) and 36, secondary effusion involvement. Half of the secondary cases presented concurrently with effusion lymphoma, while the remaining half-experienced effusion lymphoma during disease progression. All patients with PELs were males with a median age of 77 and presented with massive pleural effusion. None was HIV-related. Two (29%) PEL cases were positive for human herpes virus 8 (HHV8). The only case with plasmablastic phenotype in the PEL group was positive for both HHV8 and EBV. Four patients died shortly after diagnosis; while the remaining three were alive at the last follow-up (two at 13 months and one at 99 months). Of the secondary cases, diffuse large B-cell lymphoma/high grade B-cell lymphoma was the most common (n = 16, 44%), followed by mantle cell lymphoma (n = 5, 14%). Only 8 cases (22%) were T-cell neoplasms. Prognosis for patients with secondary effusion involvement was dismal, with 1- and 2-year overall survival rates at 17% and 8%, respectively.

CONCLUSION

We found a wide cytopathological spectrum of effusion lymphoma in Taiwan. Most of our PEL cases were distinct from that defined in the World Health Organization scheme by a B-cell phenotype, HHV8-negativity, and absence of immunodeficiency. As compared to PEL cases, the prognosis of those with secondary involvement was extremely poor.

Triaging of pleural effusion cytology specimens for ancillary flow cytometric analysis

INTRODUCTION

There are no established criteria in selecting pleural effusion (PE) specimens for flow cytometric analysis (FCA). FCA on effusion specimens may be ordered by a clinician or a cytopathologist. In an effort to improve lab test utilization, this retrospective study aims to identify characteristics of PE specimens on which the addition of FCA has high diagnostic yield.

MATERIALS AND METHODS

We identified consecutive cases of PE cytology specimens on which FCA was performed over a 5-year period (2014-2019). Patient demographic data and history, FCA diagnosis, cytologic diagnosis, cellular quantity and composition, and peripheral blood cell counts were collected. Chi-square, Mann-Whitney U, and t tests were used when appropriate with a significance level of P < 0.05.

RESULTS

We identified 164 FCA cases corresponding to 142 patients (age: 19-90 years; male:female 2:1). The majority of cases had no abnormality by cytologic examination, whereas others were obviously malignant due to non-hematologic malignancy. Most (119 of 164, 73%) had negative immunophenotypic studies by FCA. Forty-five of 164 (27%) FCA cases were positive for a monoclonal myeloid or lymphoid population. Clinicopathologic features associated with positive FCA results included a history of hematologic malignancy, peripheral blood lymphocytes of ≥20%, the presence of a monomorphic lymphoid population, large atypical cells, and mitoses.

CONCLUSIONS

This study identifies features that are associated with positive FCA in PE cytology specimens. Using these features by cytopathologists to order FCA on PE specimens as a reflex test would significantly reduce unnecessary testing and improve FCA utilization.

Flow Cytometry Analysis Versus E-Cadherin Immunohistochemistry for the Diagnosis of Pure Erythroid Leukemia: A Case Report

Pure erythroid leukemia (PEL) is a rare form of acute myeloid leukemia characterized by the neoplastic proliferation of erythroblasts. PEL is associated with inferior survival outcomes, particularly among patients harboring complex karyotype abnormalities. In this case, we present a 21-year-old Sudanese man who presented to our ER with a two-week history of fever, shortness of breath, fatigue, and exercise intolerance. He had no significant personal medical history or family history of malignancy. A bone marrow biopsy revealed hypercellularity and infiltration by cells with an immature appearance. A flow cytometry (FC) analysis of the bone marrow aspirate revealed that approximately 21% of the total nucleated cells were negative for CD45 and positive for CD71, glycophorin A, and CD36 but negative for myeloperoxidase (MPO), CD33, CD13, CD61, CD41, and other lymphoid and myeloid markers. Consistent with the microscopic analysis, <1% of the total cells were identified as CD34/CD13/CD117-positive myeloblasts. Notably, all stains (CD45, MPO, CD34, CD163, CD61, glycophorin A) were negative except E-cadherin, which positively stained >80% of the cells. Our findings suggested a differential diagnosis that included erythroid leukemia and myelodysplastic syndrome (MDS). The morphological, FC, immunohistochemistry, and cytogenetic findings strongly supported a diagnosis of PEL.

Application of flow cytometry in the analysis of lymphoid disease in the lung and pleural space

Various types of lymphoid neoplasms can occur in the lung. Lung parenchyma, the pleura or the pleural cavity can be the primary site of a lymphoid neoplasm or can be involved secondarily as a result of systemic dissemination from a separate primary site. Recognition of pulmonary lymphoid neoplasms (PLN) has increased secondary to technological advances in the medical field. Multiparameter flow cytometry (FC) is a one of the diagnostic tools that serves an essential role in the detecting and categorizing PLNs. FC allows for rapid identification and immunophenotypic characterization of PLN. In this article, we discuss the role of FC in the diagnosis of the most commonly encountered PLNs as well as their basic clinicopathologic features. We briefly discuss the role of FC in identifying non-hematolymphoid neoplasms in lung specimens as well.

A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System

BACKGROUND

The evaluation of lymph nodes (LN) by fine-needle aspiration cytology (FNAC) is routinely used in many institutions but it is not uniformly accepted mainly because of the lack of guidelines and a cytopathological diagnostic classification. A committee of cytopathologists has developed a system of performance, classification, and reporting for LN-FNAC.

METHODS

The committee members prepared a document that has circulated among them five times; the final text has been approved by all the participants. It is based on a review of the international literature and on the expertise of the members. The system integrates clinical and imaging data with cytopathological features and ancillary techniques. The project has received the endorsement and patronage of the International Academy of Cytology and the European Federation of the Cytology Societies.

RESULTS

Clinical, imaging, and serological data of lymphadenopathies, indications for LN-FNAC, technical procedures, and ancillary techniques are evaluated with specific recommendations. The reporting system includes two diagnostic levels. The first should provide basic diagnostic information and includes five categories: inadequate/insufficient, benign, atypical lymphoid cells of undetermined/uncertain significance, suspicious, and malignant. For each category, specific recommendations are provided. The second diagnostic level, when achievable, should produce the identification of specific benign or malignant entities and additional information by utilizing ancillary testing.

CONCLUSION

The authors believe that the introduction of this system for performing and reporting LN-FNAC may improve the quality of the procedure, the report, and the communication between cytopathologists and the clinicians. This system may lead to a greater acceptance and utilization of LN-FNAC and to a better interdisciplinary understanding of the results of this procedure.

Current applications of molecular testing on body cavity fluids

INTRODUCTION

Effusion cytology has a high sensitivity for the diagnosis of malignancy and provides abundant material for molecular testing. Effusion draining is a minimally invasive procedure with few complications.

MATERIALS AND METHODS

We performed a review of publications regarding the use of molecular testing in serous effusions.

RESULTS

In diagnostics, BAP-1 IHC and CDKN2A FISH are powerful tools for the diagnosis of malignant mesothelioma. FISH, PCR, and EBER-ISH work well in lymphomas. RT-PCR may enhance the diagnosis of secondary epithelial malignancies. In theranostics, molecular testing on serous effusions is widely reported for the detection of alterations in genes related to lung carcinomas, such as EGFR, ALK, ROS1, and BRAF. PD-L1 expression testing by immunohistochemistry (IHC) also seems to be viable in this type of sample. HER2 FISH and IHC provide actionable results in the context of breast malignancies. Results in serous effusions seem to be equivalent to tissue biopsies for most applications and across different molecular techniques. The most interesting technology is next-generation sequencing (NGS), given its ability to sequence multiple genes on a single sample and the decreasing costs that have closely followed increasing throughputs. Cell-free DNA from effusion supernatants might be the most promising area for future research, showing superiority to serum and even to cell-block samples in limited studies.

CONCLUSIONS

Molecular tests are viable in serous effusion specimens when sufficient material is available. Given the rising importance of molecular testing we expect this to be an active field of research in the near future.

Differential diagnosis between lymphoma-associated malignant pleural effusion and tuberculous pleural effusion

Background

Lymphoma-associated malignant pleural effusions (L-MPE) can mimic tuberculous pleural effusion (TPE) characterized by lymphocytic exudate with high adenosine deaminase (ADA) levels. Furthermore, the low cytological yield of L-MPE makes differentiation between L-MPE and TPE more challenging. However, there are few data regarding differential diagnosis of L-MPE and TPE.

Methods

All consecutive patients diagnosed with L-MPE or TPE between January 2011 and December 2016 were retrospectively recruited using the Electronic Medical Record database. Clinical symptoms and laboratory and pleural fluid data [including serum lactate dehydrogenase (LDH), C-reactive protein, and pleural fluid ADA levels] were compared between L-MPE and TPE. Useful variables in the differential diagnosis of L-MPE and TPE were evaluated by multivariate logistic regression analysis.

Results

Seventeen patients with L-MPE and 216 patients with TPE were included in this study. In the multivariate analysis, fever was negatively associated with L-MPE [odds ratio (OR): 0.175, 95% confidence interval (CI): 0.033-0.941, P=0.042], while serum LDH levels were positively associated with L-MPE (OR: 1.005, 95% CI: 1.003-1.007, P<0.001). Serum LDH >460 U/L provided a sensitivity of 76% and a specificity of 81% to distinguish L-MPE and TPE. In contrast, serum C-reactive protein and pleural fluid ADA levels were not significantly different between the groups.

Conclusions

Patients with L-MPE and TPE present very similar clinical, laboratory, and pleural fluid characteristics. Fever and serum LDH levels may be helpful in guiding the differential diagnosis of L-MPE and TPE. Lymphoma should be kept in mind in the differential diagnosis in patients with lymphocytic pleural effusion and high ADA levels.

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

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

Diagnostic role of cytology in serous effusions of patients with hematologic malignancies

BACKGROUND

We investigated serous effusions occurring during the course of an already known hematologic neoplasia or as a first manifestation of it. We correlated cytology results with flow cytometry results, when available. In the absence of flow cytometry, our correlation was based on clinical follow up information obtained retrospectively. We evaluated our results in relation to the data of the literature and we considered some new suggestions for the improvement of cytology service.

METHODS

Serous effusions in hematologic patients were retrieved from the files of the Department of Cytology, Laiko Hospital, for a period of 2 years. All patients had enrolled either a previous hematologic history, or a suspicious clinical and imaging status. Seventy-three serous effusions were included. Cytology reports consisting of morphology and immunocytochemistry assessment were correlated to flow cytometry results and, occasionally, to clinical follow-up.

RESULTS

In the group of patients with previous history, sensitivity was 82.76%, positive predictive value was 100%, specificity 100%, and negative predictive value was 58.33%. In the group of patients without previous history, sensitivity and positive predictive value were both 91%, whereas specificity and negative predictive value could not be estimated.

CONCLUSION

We provide evidence that the diagnostic accuracy of cytology with the adjunct of immunocytochemistry is high compared to flow cytometry for detecting hematologic malignancies. In order to improve clinical performance, it is suggested that a cytology triage of serous effusions in all patients with hematologic malignancy must be implemented.

Updates in Effusion Cytology

Effusion cytology plays multiple roles in the management of benign and malignant disease, from primary diagnosis to tissue allocation for ancillary diagnostic studies and biomarker testing of therapeutic targets. This article summarizes recent advances in pleural effusion cytology, with a focus on the practical application of immunohistochemical markers, cytogenetic techniques, flow cytometry, and molecular techniques for the diagnosis and management of primary and secondary neoplasms of the pleura.

Free-Floating Mesothelial Cells in Pleural Fluid After Lung Surgery

OBJECTIVES

The mesothelium, the surface layer of the heart, lung, bowel, liver, and tunica vaginalis, is a complex tissue implicated in organ-specific diseases and regenerative biology; however, the mechanism of mesothelial repair after surgical injury is unknown. Previous observations indicated seeding of denuded mesothelium by free-floating mesothelial cells may contribute to mesothelial healing. In this study, we investigated the prevalence of mesothelial cells in pleural fluid during the 7 days following pulmonary surgery.

STUDY DESIGN

Flow cytometry was employed to study pleural fluid of 45 patients after lung resection or transplantation. We used histologically validated mesothelial markers (CD71 and WT1) to estimate the prevalence of mesothelial cells.

RESULTS

The viability of pleural fluid cells approached 100%. Leukocytes and mesothelial cells were identified in the pleural fluid within the first week after surgery. The leukocyte concentration was relatively stable at all time points. In contrast, mesothelial cells, identified by CD71 and WT1 peaked on POD3. The broad expression of CD71 molecule in postoperative pleural fluid suggests that many of the free-floating non-leukocyte cells were activated or proliferative mesothelial cells.

CONCLUSION

We demonstrated that pleural fluid post lung surgery is a source of mesothelial cells; most of these cells appear to be viable and, as shown by CD71 staining, activated mesothelial cells. The observed peak of mesothelial cells on POD3 is consistent with a potential reparative role of free-floating mesothelial cells after pulmonary surgery.

Cytology and clinical features of myelomatous pleural effusion: Three case reports and a review of the literature

The purpose of this study was to report the clinical features, laboratory findings, and cytomorphology, and prognosis of three patients with myelomatous pleural effusion (MPE). The literature pertaining to MPE was reviewed. The three cases and literature review suggest that MPE is rare and often associated with a poor prognosis. The correct diagnosis depends on the aggressive clinical characteristics, laboratory findings, and chromosomal abnormalities, but routine pathological examination of the pleural effusion has low sensitivity. Cell blocks stained with hematoxylin & eosin and by immunohistochemistry revealed that abnormal proliferation of plasma cells and light chain restrictive expression in MPE may be helpful for improving the detection rate of MPE.

Cytological diagnostic features of late breast implant seromas: From reactive to anaplastic large cell lymphoma

Late breast implant seroma may be the presentation of a breast implant-associated anaplastic large cell lymphoma (BI-ALCL), which claims for a prompt recognition. However, BI-ALCL diagnosis on fine-needle aspiration (FNA) might be challenging for pathologists lacking experience with peri-implant breast effusions. Sixty-seven late breast implant seromas collected by FNA from 50 patients were evaluated by Papanicolaou smear stain and immunocytochemistry on cell blocks. A diagnostic algorithm based on the cellular composition, cell morphology and percentage of CD30⁺ cells was developed. Histological evaluation of the corresponding peri-prosthetic capsules was also performed. Most of the effusions (91% of the samples) were classified as reactive and 9% as BI-ALCL. In the BI-ALCL cases, medium-to-large atypical cells expressing CD30 represented more than 70% of the cellularity, whereas in in the reactive effusions CD30⁺ elements were extremely rare (<5%) and consisted of non-atypical elements. The reactive effusions were categorized into three patterns: i) acute infiltrate with prominent neutrophilic component (33% of the samples); ii) mixed infiltrate characterized by a variable number of neutrophils, lymphocytes and macrophages (30% of the samples); iii) chronic infiltrate composed predominantly of T lymphocytes or macrophages with only sporadic granulocytes (37% of the samples). The inflammatory cytological patterns were consistent with the histology of the corresponding capsules. Our results indicate that cytological analysis of late breast implant effusions, supported by the knowledge of the heterogeneous cytomorphological spectrum of late seromas, is a valuable approach for the early recognition of BI-ALCL.