Metastatic Pleural Effusion: An Unusual Presentation of Urothelial Bladder Carcinoma

Metastatic upper tract urothelial carcinoma with nest-like features presenting as malignant pleural effusion

Metastatic urothelial carcinoma is a rare cause of pleural effusions. We report a case of urothelial carcinoma of the upper urinary tract in an oldest-old male patient, a smoker, with situs inversus totalis, that presented uniquely with malignant pleural effusion at presentation without evidence of a primary tumor on imaging. Cytological smears of the massive left pleural effusion revealed epithelioid neoplastic cells arranged in short cords, small-to-large clusters, and raspberry-like morules, mimicking mesothelioma; cell block preparations highlighted the presence of tubules and nest-like structures. The tumor cells showed a high nuclear-to-cytoplasmic ratio, nuclear grooves, and mitotic figures. Cytomorphologic features coupled with the immunophenotype of neoplastic cells (p63, GATA3, and uroplakin II positive) allowed the diagnosis of metastatic urothelial carcinoma and a possible nested subtype. These findings were supported by a total body computed tomography (CT) showing no evidence of a mass in the bladder or elsewhere in the urinary tract but a concentric parietal thickening of the proximal left ureter, suggesting malignancy. To our knowledge, a malignant effusion as a primary manifestation of urothelial carcinoma with nest-like features originating in the upper urinary tract has never been described previously. Our case focuses on the value of cell block in the working-up of neoplastic effusions by revealing the architectural pattern of an uncommon malignancy and the correlation between cytopathology and imaging gross findings to reach an accurate diagnosis.

Malignant effusions secondary to metastatic thyroid carcinomas: A review of 15 cases

BACKGROUND

Malignant effusions secondary to thyroid carcinomas are rare, and publications on this topic are limited. This study presents a large cohort of thyroid carcinomas involving effusion cytology.

METHODS

A 20-year computerized search for fluid cytology diagnosed with thyroid malignancy was performed. The following data were collected: patients' demographics, clinical findings, and histologic diagnoses. The cytology slides and ancillary tests were reviewed.

RESULTS

Among 47,593 specimens, 15 thyroid carcinomas involving the pleural fluid from 11 patients were found. There were six males and five females with a mean age of 72 years. Ten patients with available follow-up died of their disease. Papillary thyroid carcinoma (PTC) was the only histologic type. Ten cytology cases were available for review. The cytologic findings common to all cases were nonspecific (clusters/three-dimensional architecture, enlarged irregular nuclei, and scant to abundant to vacuolated cytoplasm). The classic PTC features were not present in all cases (fine/powdery chromatin [80%], micronucleoli [70%], nuclear grooves [50%], papillary-like architecture [40%], psammoma bodies [40%], and pseudo-nuclear inclusions [20%; present on the cell block only]). In 11 of the 15 cases, the diagnosis was rendered with immunohistochemical stains performed on the cell block (paired box 8, thyroid transcription factor 1, and thyroglobulin). In four of the 15 cases, the cytologic diagnosis was made after a comparison with prior surgical pathology or fluid cytology.

CONCLUSIONS

PTC is the most common histologic type of thyroid malignancy involving pleural effusion. Because the cytologic findings are nonspecific and classic PTC features are not always present, the clinical history in conjunction with immunohistochemical stains is helpful in arriving at the correct diagnosis.

Case study-based systematic review of literature on lymphoma-associated cardiac tamponade

This study aimed to compile all the relevant studies of patients presenting with pericardial tamponade before or after diagnosis of lymphoma, describe the clinical presentations of patients with lymphoma and cardiac tamponade, and assess the difference in overall survival based on the timing of cardiac tamponade diagnosis.

A comprehensive search strategy was conducted in the following databases: PubMed and Cochrane Library, using the following keywords: Lymphoma AND Cardiac Tamponade. The criteria for eligibility included cases with a confirmed diagnosis of lymphoma and cardiac tamponade, human studies, and publications in English language. The statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS) version 20. We included 48 research articles (n = 52 cases) with adequate reporting of measured outcomes. The median age of the patients was 52 (9–94) years. Only 6 patients were noted to have primary cardiac lymphoma, while the majority of cases were considered to have secondary cardiac lymphoma (88.5%). According to the data on the type of lymphoma reported through cytology and immunohistochemistry, 49 patients were diagnosed with non-Hodgkin lymphoma, and of these cases the most common subtype was large B-cell lymphoma (42.9%). Overall, the average duration of illness was 14 ± 23 days. A total of 13 patients had distant heart sounds, 12 cases were noted to be hypotensive, and 13 subjects were found to have increased jugular venous pressure.

Our retrospective study demonstrated that most patients presented with pericardial tamponade after lymphoma diagnosis, and those were mostly secondary cardiac lymphoma of the non-Hodgkin type with large B-cell as the most common subtype. Dyspnoea, oedema, and constitutional symptoms were the most common presenting signs. The median overall survival of patients with lymphoma and cardiac tamponade is 4 months, with no significant difference in mortality in the presentation timing before and after the diagnosis of lymphoma.