Diagnostic Value of Interferon-γ Release Assays on Pericardial Effusion for Diagnosis of Tuberculous Pericarditis

Diagnosis of tuberculous pericarditis remains a challenge. We aimed in this study to evaluate the diagnostic value of T-SPOT.TB on pericardial effusion for diagnosis of tuberculous pericarditis. Patients with suspected tuberculous pericarditis were enrolled consecutively between August 2011 and December 2015. T-SPOT.TB was performed on both pericardial effusion mononuclear cells (PEMCs)and peripheral blood mononuclear cells (PBMCs). Sensitivity, specificity, predictive value (PV), and likelihood ratio (LR) of T-SPOT.TB on PEMCs and PBMCs were analyzed. Among the 75 patients enrolled, 24 patients (32%) were diagnosed with tuberculous pericarditis, 38 patients (51%) with nontuberculous pericarditis, and 13 patients (17%) were clinically indeterminate and were excluded from the final analysis. The sensitivity, specificity, positive PV (PPV), negative PV (NPV), positive LR (LR+), and negative LR (LR-) of T-SPOT.TB on PEMCs was 92%,92%,88%,95%,11.61, and 0.09, respectively, compared to 83%, 95%, 91%, 90%,15.83, and 0.18, respectively of T-SPOT.TB on PBMCs. In patients with tuberculous pericarditis, the median frequencies of spot-forming cells (SFCs) of T-SPOT.TB on PEMCs and PBMCs was 172SFCs/106MCs (IQR 39~486), and 66 SFCs/106MCs (IQR 24~526), respectively, but the difference was not statistically significant (P = 0.183). T-SPOT.TB on PEMCs appeared to be a valuable and rapid diagnostic method for diagnosis of tuberculous pericarditis with high sensitivity and specificity.

Abnormal cytology predicts poor prognosis in cancer patients with pericardial effusion

PURPOSE

Pericardial tamponade is a life-threatening disorder caused by varying medical conditions. Malignancy and complications of its treatment are a common cause of pericardial effusion. The natural history of pericardial effusion remains largely unknown. We investigated the association of malignancy with adverse outcomes after pericardiocentesis.

PATIENTS AND METHODS

Consecutive patients undergoing pericardiocentesis at a single institution between January 1, 1999, and January 31, 2003, were included. Death was confirmed with the Social Security Death Index. Survival estimates were obtained by the Kaplan-Meier method. Cox regression was performed to determine the clinical characteristics associated with death.

RESULTS

Two hundred nineteen patients underwent pericardiocentesis during the study period. The effusion was cancer-related in 43.8% of cases. Median survival was 59.6 weeks (95% CI, 24.3 to 94.8 weeks). During the follow-up period, 47.9% of patients died. Cancer-related pericardial effusion was associated with decreased survival (median, 15.1 weeks). Abnormal fluid cytology was further associated with poor prognosis among patients with malignancy (median survival, 7.3 v 29.7 weeks; P = .022). Patients with cancer-related pericardial effusion were more likely to require repeat pericardiocentesis (OR = 6.0; P = .001) and pericardial surgery (odds ratio [OR] OR = 5.7; P < .001). Cancer-related effusion and abnormal cytology were independent predictors of death in a multivariate model.

CONCLUSION

Malignancy is the most common cause of pericardial effusion in a tertiary care center. Cancer-related pericardial effusion is associated with adverse outcomes, and abnormal cytology further worsens prognosis. The poor survival among cancer patients with pericardial effusion and abnormal fluid cytology may have important implications for management.

The composition of normal pericardial fluid and its implications for diagnosing pericardial effusions

BACKGROUND

Pericardial fluid obtained at pericardiocentesis is often subjected to biochemical and hematological analysis, and interpreted using criteria borrowed from pleural effusions. However, the validity and diagnostic yield of this approach is uncertain. Moreover, there is little data regarding the normal composition of the physiological pericardial fluid, which could serve as a reference for pathological effusions.

METHODS

Pericardial fluid from 30 patients undergoing elective open heart surgery was collected. Patients were excluded if they had known pericardial disease, had systemic disorders known to be associated with pericardial disease, or if the fluid samples were hemolytic. The biochemical and hematological parameters of the fluid were determined using standard laboratory techniques, and compared with the results obtained for concurrently drawn venous blood.

RESULTS

The median age of the study population was 64.5 +/- 10.6 years. Chemistry results of soluble molecules were consistent with the plasma ultrafiltrate nature of the fluid. However, fluid lactate dehydrogenase (LDH) level was unexpectedly high, averaging 2.4 times the serum level, and the mean protein level was 0.6 of the serum level. No correlation was found between comorbidities of patients and fluid characteristics. Fluids contained an average of 1430 leukocytes/muL, with a differential count that was predominated by lymphocytes (53.2 +/- 14%) and monocytes (11.6 +/- 6%).

CONCLUSIONS

The composition of the physiologic pericardial fluid is remarkable for high LDH and protein content, and for predominance of lymphocytes. Thus, the biochemical criteria useful for diagnosing pleural effusions are probably not applicable for differentiating transudative from exudative pericardial effusions, and lymphocytosis should be interpreted cautiously.

Flow cytometric analysis of effusions in dogs and cats with the automated haematologyanalyser ADVIA 120

Samples were aspirated from 12 thoracic effusions, 10 abdominal effusions and four pericardial effusions in 17 dogs and nine cats. They were analysed cytometrically with the ADVIA 120 flow cytometer and the results were compared with the results of cytological examinations of May-Grünwald-Giemsa-stained smears. The conventional cytology revealed a purulent or pyogranulomatous inflammation in 12 of the animals, lymphoma in six, malignant histiocytosis in two, and an unspecified carcinoma in two; two animals had a chylous effusion, two had a modified transudate, and one dog had an idiopathic pericardial haemorrhage. The flow cytometric analysis was based on cellular volume, peroxidase staining intensity and the determination of nuclear lobularity, and made it possible to identify predominant cell lineages and cell debris, which were shown in characteristic cytograms. Inflammatory effusions, monocytic proliferation and lymphoma were easily detected, but carcinoma cells and mesothelial cells were classified as 'mononuclear blasts'.

The use of CDKN2A deletion as a diagnostic marker for malignant mesothelioma in body cavity effusions

BACKGROUND

The distinction between benign reactive mesothelial cells and malignant mesothelial cells in serous effusions is difficult and has an unusually high false negative rate. Unfortunately, there are no generally accepted markers to distinguish between benign reactive and malignant mesothelial cells. Homozygous deletion of CDKN2A is frequent in mesothelioma (present in > 70% of tumors). Therefore, detection of CDKN2A deletion by fluorescence in situ hybridization (FISH) was evaluated as an ancillary test in the cytologic diagnosis of malignant mesothelioma.

METHODS

Dual-color FISH for CDKN2A and chromosome 9 centromere was performed on cytolyt-fixed Thinprep slides from 6 cytologically suspicious and 7 cytologically positive effusions (all with histologically confirmed mesothelioma) and in 19 cytologically benign effusions (14 pleural effusions, 3 pericardial effusions, and 2 abdominal fluid specimens). Specimens containing > or = 15 nuclei that lacked signals for CDKN2A but showed at least 1 signal for chromosome 9 centromere were considered positive. In samples with negative cytology, the nuclei of at least 100 mesothelial cells were evaluated; whereas, in specimens with positive or suspicious cytology, counting nuclei was done only if < 15% of nuclei showed homozygous loss of CDKN2A.

RESULTS

Homozygous deletion was detected in mesothelial cells in six of seven specimens with positive cytology and in six of six specimens with suspicious cytology. Cytologically, there were numerous tumor cells in a single positive specimen without homozygous deletion. All 19 cytologically negative specimens were negative for CDKN2A deletion.

CONCLUSIONS

The detection of homozygous CDKN2A deletion by FISH would have been helpful in confirming a diagnosis of mesothelioma over reactive mesothelial cells in 12 of 13 samples with positive or suspicious cytology. Further studies on larger series of patients with suspicious cytology are needed to evaluate the validity and efficiency of this approach for improving the diagnostic accuracy of effusion cytology.

Abdominal, thoracic, and pericardial effusions

The laboratory evaluation of abdominal, thoracic, and pericardial effusions is a useful diagnostic tool for the assessment of disease states that result in fluid accumulation. Although the numeric values pertaining to cell count and protein content are important, the microscopic evaluation is a critical aspect of the diagnostic procedure; not only does it allow complete classification of the fluid but it allows identification of specific cell types or microorganisms that might be responsible for the fluid accumulation. These findings should always be interpreted in conjunction with the history, signalment, physical findings, and other diagnostic aids in making a definitive diagnosis.

Transforming growth factor-beta increases the expression of aminopeptidase N/CD13 mRNA and protein in monocytes and monocytic cell lines

Aminopeptidase N (APN)/CD13 is a membrane-bound surface ectopeptidase with a ubiquitous distribution. In hematopoiesis, APN/CD13 is expressed on stem cells and during most developmental stages of myeloid cells. Because APN/CD13 has been implicated in the trimming on the cell surface of peptides that protrude out of MHC class II molecules, we wanted to study the regulation of this membrane peptidase in antigen presenting cells by TGF-beta. TGF-beta is a potent inducer of the maturation of monocyte precursors towards a macrophage phenotype. Using competitive RT-PCR and cytofluorimetric analyses, we quantified the modulation of the APN/CD13 mRNA as well as protein expression by TGF-beta 1 and -2 and found a stimulation of the APN/CD13 expression in a time- and dose-dependent manner in monocytic cells. In U937 cells, the time course showed a maximum for APN/CD13 mRNA at 24 hours incubation with TGF-beta. In experiments with actinomycin D- treated cells was found a stabilization of APN/CD13 mRNA by TGF-beta 1. Contrary to the IL-4-induced expression of APN/CD13 as well as of MHC class II in monocytic cells, we could show that TGF-beta is able to augment the APN/CD13 expression but decreases the MHC class II expression.

Immunohistochemical detection of cytotoxic lymphocytes in malignant serous effusions

The use of ancillary techniques to aid in the diagnosis of metastatic carcinoma in serous effusions has been the subject of numerous studies. In this article, we study 35 cases of malignant effusions (metastatic adenocarcinoma) and 20 benign effusions using a panel of immunohistochemical markers to determine whether changes in the subpopulations of accompanying lymphoid cells can be detected with this technique and whether such changes are associated with the presence of malignancy. We noted a significant increase in cytotoxic lymphocytes, defined as the percentage of all lymphoid cells staining with an antibody to TIA-1 (an antigen localized to the cytotoxic granule membranes of cytotoxic T cells and natural killer cells) in malignant compared with benign effusions (23% vs. 12%; P < 0.05). In addition, nearly all cases in which cytotoxic lymphocytes composed > 20% of the lymphoid cell population contained metastatic tumor. Thus, immunohistochemical staining for TIA-1 can reliably detect cytotoxic lymphocytes in cell blocks of serous effusions; in addition, a relative increase in their number is associated with the presence of malignancy.

Differential diagnostic significance of the paucity of HLA-I antigens on metastatic breast carcinoma cells in effusions

Distinction between benign reactive mesothelial cells and metastatic breast adenocarcinoma cells in effusions from patients with a known prior history of breast cancer is not the easiest task in diagnostic pathology. Here, we report the usefulness of testing the expression of class I HLA antigens (HLA A, B, C) in this respect. Cytospins were prepared from effusions of patients without the history of breast cancer (5 cases) and from effusions of patients with infiltrating ductal carcinoma (11 cases). Three effusions from cancerous patients were not malignant cytologically. The expression of HLA-A, B, C, HLA-DR and beta2-microglobulin as well as the macrophage antigen, CD14, was evaluated by immunocytochemistry. In 10 of 11 effusions the cytologically malignant cells expressed very weak or undetectable HLA-A,B,C as compared to the mesothelial cells and macrophages. The paucity of expression of HLA-A, B, C was detectable in those 3 cases where a definitive cytological diagnosis of malignancy could not be established. In contrast, mesothelial cells and macrophages from all samples were uniformly and strongly positive for both HLA-A, B, C and beta2-microglobulin. We conclude that the paucity of HLA-I antigens provides a marker helpful in distinguishing metastatic breast carcinoma cells from reactive mesothelial cells in effusions.

Cytological diagnosis and telomerase activity of cells in effusions of body cavities

Telomerase is a ribonucleoprotein that synthesizes telometric DNA on chromosome ends, and may be related to the aging and immortality of cells. Recently, a telometric repeat amplification protocol (TRAP) assay for telomerase activity, using the polymerase chain reaction, was developed. We examined the limitations of TRAP assay by applying it to a cultured colon cancer cell line (COLO320) and 58 human cytological materials from body cavity effusions, and obtained the following results; i) The limits of the TRAP assay were 20-50 cells for the COLO320 cell line; ii) One COLO320 cell per 100 normal blood white cells was detectable; iii) Seventeen of 58 samples were positive for telomerase activity in this study. The sensitivity was 69% (9/13) and the specificity was 87.5% (28/32) between cytological diagnosis and telomerase activity; iv) Among 29 malignant cases, 15 were positive for telomerase activity, while there were 11 cytologically positive cases. The positive cases detected by the combination of cytology and telomerase activity accounted for 21 of the total 29 cases (72.4%). These results suggest that the measurement of telomerase activity in body cavity effusions may be useful as an adjunctive tool for cytological and clinicopathological diagnosis and that this technique is potentially applicable to remnant cytological materials.

Membranous lamellar cytoplasmic inclusions in histiocytes and mesothelial cells of serous fluids. Their relationship to phagocytosis of red blood cells

OBJECTIVE

To define the composition of cytoplasmic inclusions forming stacks and concentric whorls in histiocytes and mesothelial cells of serous fluids, imparting to them a resemblance to Gaucher cells, and to draw conclusions on the mechanism of their formation.

STUDY DESIGN

Three serous fluids (one pleural and two pericardial) containing a fair number of the cells referred to were progressively subjected to the following studies: (1) cytochemistry for mucopolysaccharides, proteins, phospholipids and hemoglobin; (2) immunocytochemistry for immunoglobulins IgA, IgG, IgM and lysozyme; (3) transmission electron microscopy (TEM), and (4) scanning electron microscopy-based energy dispersive X-ray microanalysis (SEM-EDAX).

RESULTS

All three specimens were blood stained and contained large numbers of histiocytes and mesothelial cells, arranged singly and in groups, with abundant cytoplasmic inclusions. The inclusions stained strongly positive for phospholipids, weakly positive for hemoglobin and negative for all other substances examined by cytochemistry and immunocytochemistry. By TEM the inclusions had a concentric lamellar membranous structure, reminiscent of myelinosomes or lamellar bodies of lipid-forming or -storing cells. There was also phagocytosis by histiocytes and mesothelial cells of red blood cells, which were mostly in a degenerated state. SEM-EDAX of inclusion-bearing cells showed a modest peak for phosphorus and a variable but small peak for iron, which corroborated the cytochemical and TEM findings.

CONCLUSION

Since there was not metabolic or other systemic disease in the patients to account for these cells, we posit that phospholipids derived from cell membranes of phagocytized cells, especially red blood cells, provide the building blocks for the formation of such inclusions as they enter the metabolic pathway of phagocytic cells (mesothelial cells and histiocytes) and appear in their lysosomal structures. It is advantageous for cytologists to be familiar with significance of such changes and not to mistake them for metabolic or other systemic disease.

Diagnosis of systemic lupus erythematosus in an elderly male by pericardial fluid cytology: a case report

Although pleural and pericardial effusions are common and may rarely be the initial manifestation of disease, there are few reports of SLE diagnosed in a cytopathology laboratory. We describe an unusual case of SLE in a 75-year-old man who presented with cardiac tamponade. Cytologic examination of the pericardial fluid revealed numerous LE cells and led to the diagnosis of SLE. This case illustrates the importance of careful evaluation of a serous effusion for LE cells in patients of either gender and of any age.

Cytologic features of sarcomas in fluids

BACKGROUND

Sarcomas account for < 6% of malignant effusions and their diagnosis usually is made in the setting of a known primary tumor. However, these tumors often exhibit a variety of features that can differ from those of the original neoplasm and may preclude the correct diagnosis. This article evaluates the cytomorphology of sarcomas in fluids and determines characteristic features for identification and classification.

METHODS

The study included 24 Papanicolaou-stained fluid samples (15 pleural, 8 peritoneal, and 1 pericardial) from patients with a diagnosis of sarcoma. The following features were evaluated: cellular arrangement, cellularity, nuclear/cytoplasmic ratio, background, quality and quantity of cytoplasm, cell borders, and nuclear details.

RESULTS

All cytology specimens were diagnosed accurately as malignant. The histopathologic diagnoses were eight malignant fibrous histiocytomas, five leiomyosarcomas, three rhabdomyosarcomas, three liposarcomas, two high grade sarcomas, one osteogenic sarcoma, one synovial sarcoma, and one chondrosarcoma. Cytomorphologic features shared by sarcomas in metastatic sites included single cell arrangement (23 of 24; 95.8%), indistinct cell borders (18 of 24; 75.0%), nuclear pleomorphism (18 of 24; 75.0%) multinucleation (13 of 24; 54.2%), and proteinaceous background with lysed blood (17 of 24; 70.8%).

CONCLUSIONS

Sarcomas in effusions share morphologic features that allow their correct diagnosis. Further subclassification can be attempted in the proper clinical setting and by comparison with the primary lesion.

A comparison of the effectiveness of malignancy detection in body fluid examination by the cytopathology and hematology laboratories

BACKGROUND

Body fluid specimens in many institutions are submitted for cytologic examination as well as for examination in a clinical microscopy or hematology laboratory. The cytology laboratory is generally seen as the standard for detection of malignancy, whereas the clinical microscopy laboratory is often depended on predominantly for cell counting and categorization.

METHODS

To analyze the effectiveness of the hematology laboratory at detecting malignant fluids, this study retrospectively analyzed reports on 397 body fluid specimens (cerebrospinal, pericardial, peritoneal, and pleural) that were concurrently submitted over a 12-month period to both the cytopathology laboratory and the hematology laboratory.

RESULTS

Thirty-seven (9.3%) of the cases were diagnosed as malignant by at least one of the two examinations. The cytopathology examination reported 27 (73%) of the 37 malignant cases as malignant and 30 (81.1%) as at least atypical (27 malignant and 3 inconclusive), and the hematology examination reported 34 (91.9%) as malignant and 36 (97.3%) as at least atypical. A concordant malignant diagnosis was given by both laboratories in 24 (64.9%) of the 37 cases.

CONCLUSIONS

These results show that examination of specimens by the hematology laboratory can provide a highly sensitive diagnostic evaluation in addition to its more customary role of providing timely cell counts.

[Clinical clues and echocardiographic diagnosis of cardiac metastases in lung cancer]

We analysed the clinical manifestations and echocardiographic findings of cardiac metastases in 18 lung cancer cases treated in our hospital in fifteen years. All cases were chest x-ray and bronchoscopy proved lung cancer patient with cardiac metastases diagnosed by pericardial effusion cytology and echocardiographic examinations. The echocardiographic findings were as follows: 1 case with a large round-like mass constricting heart exteriorly, 2 cases with intracardiac metastases, 2 cases with both effusion and mass within the pericardial space, 13 cases with various amount of pericardial effusion characterized by quick fluid re-accumulation after pericardiocentesis. Finally, we integrate with the documents and probe into the main clinical clues and echocardiographic findings of cardiac involvements in lung cancer patients with cardiac metastases. We warn the clinical practitioners that if the diagnosed lung cancer or other malignant tumor patients exibit cardiac arrhythmia, heart failure, enlargement of heart or development of new heart murmur etc. with unknown causes in clinical practice, the possibility of cardiac metastases should be suspected and echocardiography should be done to help diagnose the sites of cardiac involvements and the degree of severity.

The value of multiple fluid specimens in the cytological diagnosis of malignancy

Multiple fluid specimens of a patient are often received in the cytology laboratory. Both clinicians and pathologists question the optimal number of specimens required to detect a malignancy. We reviewed the computerized cytology files at Boston's Beth Israel Hospital from 1988 to 1991 to identify patients with two or more specimens from the same anatomic site. Two hundred and fifteen patients with a total of 570 specimens were identified. Before December 19, 1990, two direct smears were examined per fluid sample. After December 19, 1990, two direct smears and two cytospin preparations were examined. Medical records of patients without a positive diagnosis of cytology were reviewed. Overall, a cytological diagnosis of malignancy was made on at least one specimen for 55 patients (26%). The first positive diagnosis was made on the initial specimen in 36 patients (65%), on the second in 15 patients (27%), the third in three patients (5%), and the fifth in one patient (2%). For those specimens prepared with the two techniques described above (two direct and two concentrated smears), the first positive diagnosis was made on the initial specimen in 89% of the cases. Medical record review uncovered 55 additional patients who had clinical evidence of malignancy. Of these, 22 (40%) had at least one suspicious diagnosis of their fluid specimens. The first suspicious diagnosis was made with three or fewer specimens in all 22 patients. The majority of malignant effusions are detected with two specimens. Examination of more than three specimens is of little value. Multiple preparatory, especially concentration, techniques may increase the probability of detecting malignancy in one specimen.

Immunophenotyping of cytologic specimens by flow cytometry

Immunophenotyping by flow cytometry is well established as an ancillary technique in the diagnosis of hematopoietic neoplasms. However, flow cytometry is rarely performed on cytologic specimens because most cytologist are more comfortable with direct microscopy and believe that there is inadequate cellularity for analysis. Paradoxically, cytologic material is usually cell suspensions making it ideal for flow cytometry. In order to evaluate the usefulness of immunophenotyping cytologic specimens by flow cytometry, we retrospectively reviewed all cytologic specimens submitted to our flow cytometry unit from 1988 to 1991. Thirty-one cerebrospinal fluid specimens were analyzed. There were inadequate cells for analysis in 15 cases. Five showed a monoclonal proliferation; 11 were nondiagnostic. A range (r) of one to six cell surface markers were performed. Thirty-two body cavity fluids were analyzed: 7 peritoneal, 19 pleural, 2 pericardial, and 4 bronchoalveolar lavage. There were cells to analyze in all cases. Seven had a monoclonal proliferation; 25 were nondiagnostic (r = 4-21 markers performed). One hundred eighteen fine needle aspirates (FNA) were reviewed; 58 FNA were radiologically guided, 60 were superficial lesions. There were inadequate cells for analysis in two cases. Sixty-one demonstrated a monoclonal proliferation; 55 were nondiagnostic (r = 1-22 markers performed). We conclude that immunophenotyping by flow cytometry is of limited value for cerebrospinal fluid analysis and that knowledge of previous immunophenotyping studies is essential for correct analysis; analysis of body cavity fluids is easily performed but less often demonstrates a monoclonal proliferation. Immunophenotyping by flow cytometry is a valuable adjunctive technique for FNA and yields adequate cells for analysis.

Multiple myeloma complicated by restrictive cardiomyopathy and cardiac tamponade

Restrictive cardiomyopathy from amyloid deposition within the myocardium is a well-described complication of multiple myeloma; however, myelomatous involvement of pericardium with subsequent cardiac tamponade has rarely been described. Optimal treatment for malignant involvement of the pericardium by myeloma cells has yet to be established. The following description is of a patient with myocardial and pericardial manifestations of multiple myeloma. Treatment of the malignant pericardial effusion was implemented with intrapericardial administration of bleomycin. This therapy resulted in no recurrence of pericardial effusion at nine days follow-up. Despite the absence of detectable recurrent effusion, the patient died suddenly from causes felt unrelated to pericardial disease.

High amylase content of neoplastic pleural and pericardial effusion probably secondary to amylase producing tumor cells: report of 2 cases

We report two cases of malignant pleural and pericardial effusion respectively secondary to bronchogenic carcinomas. In both effusions, a significant elevation of the Salivary-type-amylase fraction was found, while the corresponding values were normal in serum and urine. Electronmicroscopy of the malignant tumor cells from the pleural effusion showed typical electron-dense granules, suggesting zymogen granules. It is concluded that the high amylase content of the effusions was due to secretion of S-type-isoamylase by the tumor cells.

[Clinical values of cytological evaluation of pleural and peritoneal fluids]

We reviewed retrospectively the data obtained from our Department of Clinical Cytology, National Cancer Center in the period of 1964 and 1981, which clearly showed an increasing clinical importance of cytological evaluation of pleural and peritoneal fluids for greater diagnostic efficacy. For example, existence of tumor cells could predict a possibility of local infiltration. Cytological examination could also provide significant information for planning the treatment protocols prior to the initiation of the treatment as well as for predicting efficacy of the treatment using characteristics in particular of lymphocytes, phagocytes and granulocytes. Furthermore, accurate interpretation of cytological examination of pleural and peritoneal fluids seem to be clinically highly suggestive for diagnostic efficacy and also could be a helpful means for evaluation of cancer therapy.

[Morphofunctional study of human pericardial macrophages]

Human pericardial macrophages have been studied with the light and electron microscope. The cells showed high activities of acid phosphatase and of non-specific and acid esterases. The macrophages are able to pinocytosis the extracellular space marker--horseradish peroxidase. The network of intracytoplasmic cavities, continuous with the extracellular space, has been documented by applying two different methods of visualization of the cellular surface. A possible role of these cavities in pinocytosis is discussed.

The role of cytology in neoplastic cardiac tamponade

Over a 16-year period, 47 samples of pericardial fluid from 34 patients at Hines Veterans Administration Hospital were cytologically evaluated, constituting approximately 0.1% of the total work load in our cytology laboratory. Eleven cellular samples from nine of the patients were positively identified as containing malignant cells that were histologically classifiable. Correlation with the surgical pathology and/or postmortem findings proved no false positives. Two false-negative cases probably represented inadequate sampling. In three patients, the diagnosis of cancer was initially established by the cytologic examination. In all instances, the pericardial fluid cytology helped determine the prognosis and mode of therapy.

Pericardial disease in patients with cancer. The differentiation of malignant from idiopathic and radiation-induced pericarditis

Pericardial disease developed in 31 patients with a variety of malignancies. Half of the patients (58 percent) were found to have malignant pericardial involvement, 32 percent idiopathic pericarditis and 10 percent radiation-related pericarditis. Facial swelling, cardiac arrhythmias and pericardial tamponade occurred frequently in the patients with malignant pericardial disease. Fever, pericardial friction rub and improvement with nonsteroidal anti-inflammatory drugs characterized the patients with idiopathic pericarditis. Effusive-constrictive pericarditis requiring pericardiectomy was noted in patients with radiation-induced disease. Pericardiocentesis documented malignant pericardial disease in 85 percent of patients studied, while 15 percent required open biopsy for diagnosis. Specific therapy directed at malignant pericardial disease may contribute to survival up to one year in 25 percent of patients. In 40 percent of patients with idiopathic pericarditis and in the majority of patients with radiation-induced pericarditis, survival was one year with specific therapy. A systematic evaluation of pericardial disease will benefit a subset of cancer patients with idiopathic pericarditis and radiation-induced pericarditis who can be managed conservatively.

Surgical management of pericardial tamponade as a presenting manifestation of acute leukemia

Two patients with acute leukemia presented with symptomatic acute pericarditis and rapidly developed cardiac tamponade. Conservative management was not possible in either patient due to mechanical problems with fluid removal. Thoracotomy with pericardial decompression resulted in permanent relief of symptoms in both cases. Management of cardiac tamponade in acute leukemia by surgical decompression even in severely immunocompromised hosts is a feasible alternative and should be considered when more conservative measures fail or are not possible.

Cytopathology of pericardial effusions

During a period of four years, 158 cytologic specimens obtained from pericardial effusions of 120 patients were examined. Malignant neoplastic cells were identified in 90 (57%) specimens from 72 (60%) patients. Eighty percent of the neoplasms were epithelial, and 20% were nonepithelial in origin. The most common epithelial tumors were pulmonary (56%) and mammary (39%) neoplasms, and most were adenocarcinomas. In general, the cytologic smears were moderately cellular, with blood and occasional atypical mesothelial cells in the background. There were few reactive cells, such as histiocytes and lymphocytes, in cytologically positive specimens. Pleomorphic nuclei and prominent nucleoli were dominant features of pulmonary adenocarcinomas. Tumor cells of mammary carcinoma were more uniform and often formed cell balls. Epidermoid carcinomas were characteristically poorly differentiated, having a striking resemblance to adenocarcinoma. In most instances, several months elapsed between initial diagnosis of the primary neoplasm and a positive pericardial cytologic finding. The majority of the patients died within ten months after malignant tumor cells were recovered from pericardial effusion. Because of the serious clinical implications, a cytologic diagnosis of cancer in pericardial effusions must never be based on scanty or equivocal evidence. If necessary, any doubt should be resolved by examination of additional material.

Procainamide-induced lupus erythematosus pericarditis encountered during coronary bypass sugery

Procainamide is probably the most common offending drug responsible for the drug-induced lupus erythematosus syndrome today. Pericarditis has been reported to occur in from 14 to 18 per cent of the cases of procainamide-induced lupus erythematosus, and occasional reports of massive pericardial effusion, pericardial tamponade and constrictive pericarditis have appeared in the literature. We describe a patient who presented with features of procainamide-induced lupus erythematosus without any clinical evidence of pericarditis. He underwent coronary bypass surgery 12 days after administration of the drug was stopped and was found to have a significant pericardial effusion at the time of surgery; histologic examination of pericardial tissue and pericardial fluid confirmed that the pericardial effusion was related to the procainamide-induced lupus syndrome. The incidence of pericarditis in procainamide-induced lupus erythematosus may be higher than presently accepted figures would indicate. Symptoms and signs related to procainamide-induced lupus pericarditis may cause diagnostic confusion with common postoperative bypass complications; the full implications of this disease entity to the patient undergoing coronary bypass are unknown.

Granulocytic sarcoma preceding acute leukemia: a report of six cases

An unusual case of granulocytic sarcoma presenting in a pericardial effusion following trauma and preceding acute myelogenous leukemia (AML) by 8 months is presented. Five additional cases of granulocytic sarcoma preceding leukemia collected by the author are also tabulated. Granulocytic sarcoma in a nonautopsy population of myelogenous leukemic patients was found to be 2.9%. When presenting in an extramedullary site, especially preceding peripheral blood and bone marrow manifestations of leukemia, a misdiagnosis of histiocytic lymphoma may result. In questionable cases, other techniques including the naphthol-ASD-chloroacetate stain, touch imprints, immunoperoxidase stain for lysozyme, and electron microscopy should be utilized. Although only a small series, the most recent cases have shown induction/remission and survival characteristics of AML patients without granulocytic sarcoma.

Granulocytic sarcoma preceding acute leukemia: a report of six cases

An unusual case of granulocytic sarcoma presenting in a pericardial effusion following trauma and preceding acute myelogenous leukemia (AML) by 8 months is presented. Five additional cases of granulocytic sarcoma preceding leukemia collected by the author are also tabulated. Granulocytic sarcoma in a nonautopsy population of myelogenous leukemic patients was found to be 2.9%. When presenting in an extramedullary site, especially preceding peripheral blood and bone marrow manifestations of leukemia, a misdiagnosis of histiocytic lymphoma may result. In questionable cases, other techniques including the naphthol-ASD-chloroacetate stain, touch imprints, immunoperoxidase stain for lysozyme, and electron microscopy should be utilized. Although only a small series, the most recent cases have shown induction/remission and survival characteristics of AML patients without granulocytic sarcoma.

Cytodiagnosis of viral infections in body cavity fluids

Pleural and pericardial fluid specimens have been studied in seven patients with diagnosis of viral infection. Intranuclear inclusions, multinucleated giant cells with gelatinous nuclear changes and atypical mesothelial cells were observed. These observations suggest that viral involvement of the mesothelium produces cellular changes which can be detected cytologically in routine Papanicolaou-stained body cavity fluid specimens.

The use of cytology to evaluate pericardial effusions

Pericardial effusions from 27 patients were examined cytologically during the five-year period of 1973-1977. Malignant cells were found in eight cases (30 percent). In three of these patients malignancy was unsuspected clinically, and this was the first time the cancer was diagnosed. In addition, cytology often suggested the specific histological types and possible primary sites to be determined. Special stains were also found helpful. There were no false positive reports. Although the pericardial effusions from the remaining 19 patients were negative for tumor cells, metastatic carcinoma to the pericardium was discovered at autopsy in two of these cases. Thus, cytologic examination of pericardial fluid is an important tool in the diagnosis of malignancy, but false negative results may occur.

Long-term human breast carcinoma cell lines of metastatic origin: preliminary characterization

Nineteen human breast carcinoma cell lines have been established as continuous cultures during the past 6 years in our laboratory. This preliminary report is designed to list the lines by their designated code numbers (MDA-MB) and present a brief summary of their morphological, cytogenetic and biochemical characteristics. Sixteen of our lines were obtained from pleural effusions, two from brain metastases, and one from pericardial fluid. All lines have been shown to be distinct entities and are uncontaminated by HeLa cells or each other. A lq marker chromosome is present in all but one of the lines examined.

Tissue culture of cells in serous effusions. Evaluation as an adjunct to cytology

Cell pellets from peritoneal, pleural and pericardial effusions from thirty-six patients were incubated in tissue culture medium. Both the culture supernatants and the cell monolayers in the flasks were examined for malignant cells. Of the ten cases diagnosed as positive for malignant cells by the conventional cytologic smears, eight were positive on examination of the tissue culture supernatants and only six were positive by analysis of the monolayers. All the cases diagnosed as positive from the culture supernatants and from the monolayers were also positive by the conventional smear method. Hence, tissue culture of cells in serous effusions is not helpful as an adjunct to routine diagnostic cytology techniques.

False-positive Sternberg-Reed cells present in pericardial effusion. Report of a case

Recent reviews have emphasized the value of cytodiagnosis in the evaluation of malignant effusions from patients with lymphoproliferative disorders. We present a case in which the presence of Sternberg-Reed-like cells in pericardial fluid was related to prior radiotherapy and not to recurrent Hodgkin's disease.

Cytologic detection of malignant mesothelioma of the pericardium

We have reported a very rare case, malignant mesothelioma of the pericardium, with the initial diagnosis made by cytology from the smears of the pericardial fluid. There were numerous large clusters in the smears, in which two types of cells were mixed: adenocarcinoma-like round cells and fibrosarcoma-like spindly cells. Some round cells very much resembled benign mesothelial cells. Central collagenous stalks and brush borders with long microvilli in the round cell aggregates were specific for carcinomatous mesothelioma and differentiated the round cells from adenocarcinoma cells. On the other hand, the spindly and pleomorphic tumor cells, present both singly and in clusters, implied malignancy. Therefore, a preliminary cytologic diagnosis of probable mixed malignant mesothelioma was made. Histopathologic and electron microscopic examinations confirmed the cytologic description that this tumor was a malignant mesothelioma.

Recurrent cardiac tamponade and large pericardial effusions: management with an indwelling pericardial catheter

A new technique, using an atraumatic indwelling catheter, has been developed for short-term management of large or rapidly reaccumulating pericardial effusions. This technique (1) permits continuous pericardial fluid drainage, obviating repeated aspirations; (2) provides a convenient route for intrapericardial instillation of chemotherapeutic agents; and (3) enables one to await the results of diagnostic studies without subjecting a patient to thoracotomy. Experience in three patients suggests that in some cases the use of this catheter may eliminate the need for surgery; in others, it may serve as a valuable temporary measure to achieve stabilization of the patient's condition.