Serosal balls detected immunocytochemically in peritoneal lavage obtained during surgery

Using the immunoperoxidase technique, we studied “serosal balls,” which have features resembling those of cells from primary and metastatic tumors, and may thus complicate cytodiagnosis. Serosal balls were detected in 32 (18%) of 174 peritoneal washings. The balls consisted of oval clusters of cells in solid masses surrounded by flattened cells. The interior of the serosal balls was stained green with Papanicolaou method, showing the presence of homogeneous amorphous material, sometimes stained in a filamentous pattern. Almost all serosal balls were stained immunocytochemically for both keratin and vimentin. The interior was stained with antibodies against collagen types I and III. Therefore, these balls were fragments of serous membrane, and contained fibrous tissue and mesothelial cells. © 1995 Wiley-Liss, Inc.     

Cytology of granulosa cell tumor of the ovary

Granulosa cell tumor of the ovary may create a diagnostic challenge in cytologic preparations. Our experience with needle aspiration material, ascitic fluid, and peritoneal washings indicates that in fluids, despite some similarity between the tumor cells and reactive mesothelial cells, a correct diagnosis can be achieved by careful examination. The paucity of the cytoplasm and an intense indentation of nuclear membrane are the most helpful features in distinguishing the granulosa cells from mesothelial cells. The literature is reviewed, and the controversies regarding needle aspiration of ovarian neoplasms are discussed.     

Cytologic features of atypical mesothelial cells in peritoneal dialysis fluid

From February 1988 through October 1988, 23 samples of peritoneal dialysis fluid from 20 patients with end-stage renal disease were cytologically analyzed in an attempt to determine the effect of the dialysate on the mesothelial cells lining the peritoneal cavity. The patients, five female and 15 male, ranging in age from 26 to 75 yr, had been on continuous ambulatory peritoneal dialysis (CAPD) from 1 mo to 6 yr, 4 mo. The patients had no history of cirrhosis, neoplastic disease, radiation and/or chemotherapy, or current findings of infection. Smears and cytosieve filter preparations were made. Smear analysis included the mesothelial cell pattern, the degree of mesothelial cell atypia, and the presence of atypical multinucleated cells and mitoses. In the majority of the fluid samples, reactive mesothelial cells were arranged singly and in sheets. Moderately and severely atypical mesothelial cells were glandular and papillary in configuration. All samples contained at least a few reactive mesothelial cells; in six, the highest degree of cellular atypia was moderate; in 17, it was severe. The development of severe cellular atypia did not appear to be time dependent (a finding noted in samples from patients on dialysis for 6 mo up to 6 yr). When present, multinucleated mesothelial cells showed moderate to severe atypia. In four cases mitotic figures were present. On the basis of these findings, it is proposed that peritoneal dialysis plays a role in the development of mesothelial cell atypia.     

Flow cytometric immunophenotyping of serous effusions and peritoneal washings: comparison with immunocytochemistry and morphological findings

AIM: To evaluate immunophenotyping by means of flow cytometry as a complementary method for the detection of malignant cells in serous effusions and peritoneal washings. MATERIAL AND METHODS: Frozen samples of 49 fresh serous effusions and peritoneal washings were analysed by flow cytometry, using monoclonal antibodies against CD45, Ber-EP4, and N-cadherin. Results were compared with smear and cell block morphology, as well as immunocytochemistry on paraffin wax embedded cell blocks. RESULTS: Seventeen specimens were cytologically diagnosed as malignant, whereas 25 were interpreted as benign. The remaining seven specimens were diagnosed as indeterminate or suspicious for malignancy. Ber-EP4 positive cells were detected in 16 of the 17 cytologically malignant effusions, as well as in five of seven suspicious cases and five of 25 specimens with benign cytology. In the latter group, three specimens showed atypical or malignant cell groups that were missed in routine morphological evaluation. In two additional samples, obtained from patients with benign and borderline ovarian tumours, Ber-EP4 positive cells showed benign or mildly atypical features, and were interpreted as exfoliated benign or borderline malignant epithelial cells of tubal origin, or as endosalpingiosis. All five Ber-EP4 positive indeterminate specimens showed atypical or malignant cells on re-evaluation, and were Ber-EP4 positive in four of five cases using immunohistochemistry in cell block sections. Large numbers of CD45 positive and relatively few N-cadherin positive cells were detected in most specimens with the use of flow cytometry, when compared with morphological evaluation. CONCLUSIONS: Flow cytometry is a rapid and highly effective method for the evaluation of effusions and peritoneal washings. The detection of Ber-EP4 positive cells using flow cytometry is strongly indicative of the presence of carcinoma cells in effusions and peritoneal washings. Although false positives are relatively infrequent, all specimens should be carefully evaluated morphologically to prevent the diagnosis of benign epithelial clusters as malignant.     

Nodular histiocytic/mesothelial hyperplasia: a potential pitfall

We present five cases of nodular histiocytic/mesothelial hyperplasia (two peritoneal, two pulmonary, and one pericardial) with identical microscopic features. All the lesions were biphasic and composed of cohesive monotonous epithelioid clusters of polygonal or oval cells with round or deeply grooved nuclei in association with darker cuboidal cells. Because of the increased cellularity and monotonous histologic pattern with some degree of cytologic atypia, neoplastic processes were seriously considered in the differential diagnoses. The majority of the cells marked as histiocytes by immunostain. A few scattered individual cells or small epithelial cell clusters were confirmed by calretinin stain to be mesothelial cells. The histologic patterns of the current lesions, irrespective of the location, were identical to nodular histiocytic/mesothelial hyperplasia. Histiocytic proliferations can be erroneously confused with primary mesothelial lesions or neoplasms such as granulosa cell tumor, eosinophilic granuloma, chronic myelogenous leukemia, and carcinoma. The purpose of this article is to describe the clinicopathologic features of nodular histiocytic/mesothelial hyperplasia and help familiarize pathologists with this lesion to prevent an erroneous diagnosis, particularly when it occurs in locations where mesothelial cells are not normally present.     

Multiple peritoneal cytologies collected during laparotomy for gynecologic malignancy

Review of an 18-mo experience with peritoneal cytology specimens showed that 760 peritoneal washings and 177 diaphragmatic smears were collected during 300 laparotomies on patients known to have or suspected of having gynecologic malignancy. One hundred three patients were eventually shown to have benign gynecologic disease. The remaining 197 procedures were done on patients undergoing primary operations for gynecologic malignancy or laparotomies for previously treated gynecologic malignancy. Of the 197 laparotomies for gynecologic malignancies, 168 had washings separately collected from multiple intra-abdominal sites, and these fluids were interpreted as either all positive or all negative in all but seven (4%) patients. The location and extent of the gross or microscopic disease did not correlate with the site of positive washings. Only three of the 177 diaphragmatic smears were positive for malignant cells; these were collected from three patients undergoing primary treatment of ovarian carcinoma, two of whom had extensive peritoneal involvement by carcinoma. Only 35 of the 197 patients with gynecologic malignancy had positive peritoneal cytologies; 32 of these patients had gross or microscopic peritoneal involvement by malignancy, and one additional patient had metastatic carcinoma in pelvic lymph nodes. The analysis of multiple peritoneal washings separately collected from various intra-abdominal sites and the analysis of diaphragmatic smears collected in the absence of gross diaphragmatic disease appear to be of benefit in few cases.     

Morphologic features of endometriosis in various types of cytologic specimens

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. This study evaluates the cytomorphologic features of endometriosis in various cytologic specimen types [fine‐needle aspiration (FNA), effusion cytology (EF), touch imprint (ToP), and cervical smear (PAP)], and assesses the key elements helpful in recognizing this lesion. A total of 18 cases (8 FNA, 4 EF, 5 ToP, and 1 PAP) of cytologically diagnosed and histologically/clinically confirmed endometriosis diagnosed between 1988 and 2006 comprises the material for this study. The morphologic features evaluated of the three components included: cellularity, presence of sheets of glandular cells, three‐dimensional (3D) glandular clusters, tubular structures, single cells, syncytial groups of stromal cells, stromal cells entrapped within basement membrane (BM)‐like material, cytologic atypia, presence of mitotic figures, and hemosiderin‐laden histiocytes. Endometrial glands, stroma, and hemosiderin‐laden histiocytes were all identified in 14/18 (77.8%) cases. FNA specimens were more cellular than that of both EF and ToP specimens. Tubular structures, 3D glandular clusters, stromal cells entrapped in BM and syncytial stromal groups were more common in FNAs, and ToPs compared with the EFs. The ratio of the endometrial glandular and stromal cells was similar in all specimen types. Atypia and mitotic figures were rarely encountered. Diagnosis of endometriosis could be made independently on either smears/ThinPrep^? slides or on cell blocks in all cases where these preparations were available. On follow up, none of the patients developed malignancy. Endometriosis can be reliably and safely diagnosed in various cytologic materials. Cytologic atypia is uncommon. Components of endometriosis could show minor morphologic alterations in different specimen types. Diagn. Cytopathol. 2013;41:936–942. © 2013 Wiley Periodicals, Inc.     

Cytology and DNA flow cytometry of peritoneal washings in gynecologic patients.

Peritoneal washing cytology, widely used in the management of gynecologic malignancy, entails several difficulties in interpretation. Quantitative DNA analysis by flow cytometry (FCM) holds promise as a more objective method fo diagnosis of malignancy. We performed traditional cytologic examination and single-parameter FCM DNA analysis on peritoneal washings from 136 gynecologic laparotomies, compared these results with the final pathologic findings, and analyzed sources of error. A total of 50 laparotomies were performed for benign disease. Another 86 were performed for cervical, endometrial, and ovarian carcinomas and various other cancers. In the benign group, cytology had one false suspicious but no false positive results, and FCM showed only diploid cells. In the cancer cases, cytology had five suspicious and 13 positive results and one false negative from laboratory error. On review, 16 washings contained confirmed cancer cells. FCM, performed in 13 of these cases, was diploid in 10 and aneuploid in only 3. In six of the diploid cases, visual cell counts showed that tumor cells were present in concentrations of 2.5% or less of total cells. In the remaining four diploid cases, a second DNA determination was obtained by FCM of nuclei retrieved from paraffin blocks of the tumors. These nuclei were diploid by FCM in three of the tumors and aneuploid in only one. Single-parameter DNA FCM was too insensitive to be helpful in our material.     

Cytologic diagnosis of pseudomyxoma peritonei: Common and uncommon causes

Pseudomyxoma peritonei (PP) refers to accumulation of mucus in the peritoneal cavity, regardless of cause or pathogenesis. We have reviewed 8 cases of PP diagnosed in our institution over the past 5 years. Pertinent cytologic features include a mucinous background with mesothelial cells and histiocytes. Two cases contained rare clusters of neoplastic epithelial cells, with low-grade nuclear features of malignancy. The origin and nature of the parent neoplasms were variable, with no reflection of the cytologic features of PP. Diagn Cytopathol 1996;14:10–13. © 1996 Wiley-Liss, Inc.     

The role of peritoneal washings in the diagnosis of endometriosis

Endometriosis, the presence of endometrial tissue outside the uterine corpus, is a common finding in reproductive age women. It is classically diagnosed based on the presence of at least two of the following elements: endometrial glands, endometrial stroma, and hemosiderin‐laden macrophages (HLMs). Although a common finding in surgical pathology specimens at the time of gynecologic surgery, there is little literature on the role of pelvic washings in diagnosing endometriosis. Our study aimed to examine the characteristics of endometriosis in pelvic washings at the time of gynecologic surgery. We report nine cases of endometriosis diagnosed on pelvic washing. Two had a reported history of endometriosis. Four had endometriosis on the concurrent surgical pathology specimen. Liquid‐based cytology was diagnostic of endometriosis in seven patients, including five with glandular cells and HLMs and two with glandular cells, HLMs, and endometrial stromal cells. Cell block was diagnostic of endometriosis in eight patients, including four cases with intact fragments of endometrial glands and stroma. Three cases showed glandular cells and HLMs, while one showed separate fragments of glandular cells and stromal cells. Pelvic washings increased the diagnostic yield for endometriosis at the time of gynecologic surgery, as only four out of nine cases had endometriosis diagnosed on surgical pathology. Cell block in particular aids in the diagnosis, since intact glandular and stromal fragments frequently can be identified.     

Cytologic diagnosis of endosalpingiosis with pregnant women presenting in peritoneal fluid: a case report

The cytologic appearance of endosalpingiosis in peritoneal fluid cytology smears has not been extensively described. We report a case of endosalpingiosis in a 29-year-old pregnant female who presented with peritoneal fluid. Dense papillary epithelial clusters with indistinct ciliated cells were found in the Papanicolaou-stained smears. However, long and delicate cilia were obvious in papillary cluster with scanning electron microscopy. Cell nuclei were oval, with finely dispersed chromatin and uniform nuclear membrane. Peritoneal fluid cytology with these findings may be helpful to suggest the probable preoperative diagnosis of endosalpingiosis or benign glandular inclusions involving the pelvic peritoneum.     

Fine-needle aspiration cytology of multicystic mesothelioma.

This report details the cytologic findings from a case of peritoneal multicystic mesothelioma (MCM). Fine-needle aspiration of a 20 cm abdominal mass in a 31-year-old man yielded a specimen which consisted of a monomorphous population of mesothelial cells lacking cytologic atypia which were arranged in three patterns: monolayered sheets, single cells, and two-cell-thick strands of mesothelial cells with little or no intervening stroma. The background was clean, without necrotic debris or abundant inflammatory cells. The mesothelial cells were not arranged in prominent papillary formations; mitotic figures were not found. The mesothelial cells were cytokeratin positive and vimentin positive, and negative for carcinoembryonic antigen (CEA) and factor VIII. The FNA findings from MCM should be distinguished from those of a variety of other abdominal lesions, including cystic lymphangioma, ovarian and primary peritoneal epithelial tumors, necrotic tumors with cystic degeneration, developmental cysts, and infectious cysts.     

The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects

Although the histologic diagnosis of endometriosis is usually straightforward, many diagnostic problems can arise as a result of alterations or absence of its glandular or stromal components. The diagnostic difficulty in such cases can be compounded by tissue that is limited to a small biopsy specimen. The appearance of the glandular component can be altered by hormonal and metaplastic changes, as well as cytologic atypia and hyperplasia. Although the last 2 findings are often referred to collectively as "atypical endometriosis," they should be separately recognized as their premalignant potential likely differs. In some cases, the endometriotic glands are sparse or even absent (stromal endometriosis). The stromal component can be obscured or effaced by infiltrates of foamy and pigmented histiocytes, fibrosis, elastosis, smooth muscle metaplasia, myxoid change, and decidual change. Occasional findings in endometriosis that may raise concern for a neoplasm include necrotic pseudoxanthomatous nodules, polypoid growth (polypoid endometriosis), bulky disease, and venous, lymphatic, or perineural invasion. Inflammatory and reactive changes within, adjacent to, or at a distance from foci of endometriosis can complicate the histologic findings and include infection within endometriotic cysts, pseudoxanthomatous salpingitis, florid mesothelial hyperplasia, peritoneal inclusion cysts, and Liesegang rings. The histologic diagnosis of endometriosis can also be challenging when it involves an unusual or unexpected site. Five such site-specific problematic areas considered are endometriosis on or near the ovarian surface, superficial cervical endometriosis, vaginal endometriosis, tubal endometriosis, and intestinal endometriosis, including the important distinction of an endometrioid carcinoma arising from colonic endometriosis from a primary colonic adenocarcinoma. Finally, endometriotic foci can occasionally be intimately admixed with another process, such as peritoneal leiomyomatosis or gliomatosis, resulting in a potentially confusing histologic appearance.     

Fine-needle aspiration cytodiagnosis of endometriosis in cesarean section scar and rectus sheath mass lesions -- a study of seven cases

The diagnosis of endometriosis is usually established by a biopsy. Since endometriotic lesions can present as a mass lesion, it seems feasible to investigate them by the noninvasive method of fine-needle aspiration cytology (FNAC). In this study, seven cases (5 from a cesarean scar and 2 from rectus sheath) are presented in which FNAC was indicative of endometriosis. The aspirate was obtained using a disposable 10 ml syringe and 22 gauge needle. The material was collected as syringe and needle washings in a cytology container in which 30% ethyl alcohol was present. From half of this material, filter preparations were made on size 3 mum filters and stained by Papanicolaou method, while the remaining aspirate was spun and a cell block was made from the sediment and sections cut and stained with hematoxylin-eosin stain. In all cases the cytologic preparations showed tubular structures indicative of endometrial tissue and stromal cells indicative of endometriosis. This was further confirmed on examination of cell blocks, which showed histologic features of endometriosis characterized by endometrial glands separated by endometrial stroma and rare siderophages. The seven cases described are interesting, since the cytohistological finding in FNAC sample and cell block not only were indicative of the diagnosis of endometriosis, but also obviated the need for an invasive surgical procedure.     

Ovarian and omental ependymomas in peritoneal washings: cytologic and immunocytochemical features

The cytologic findings in peritoneal washings of two women, one of whom had an ovarian ependymoma and the other a primary omental ependymoma, are reported. The ependymomas were characterized by the presence of numerous, isolated, spindle and stellate cells as well as groups of cells forming true rosettes. The tumor cells displayed slightly pleomorphic, round-to-oval eccentric nuclei and abundant fibrillary cytoplasm with tapering cytoplasmic processes. In addition, one of the patients had numerous papillae and cell clusters with associated psammoma bodies indistinguishable from those found in low-grade serous carcinoma. The demonstration of glial fibrillary acidic protein (GFAP) in both cases by immunocytochemical procedures indicates the usefulness of this method in cytologic preparations to confirm the diagnosis of these uncommon neoplasms.     

Sensitivity enhancement of the cytologic detection of cancer cells in effusions by monoclonal antibodies

Cells from 229 pleural and peritoneal spontaneous fluids and 51 peritoneal lavage fluids from patients with neoplastic and nonneoplastic diseases were studied by indirect immunofluorescence with two monoclonal antibodies; MBr1, prepared against breast carcinoma, and MOv2, prepared against ovarian carcinoma. The results were correlated with those obtained by conventional cytologic methods. A cytologic diagnosis of metastatic carcinoma was established in about 50% of the fluids examined. Sixty percent of the cytologically malignant fluids contained tumor cells reactive with at least one of the two monoclonal antibodies tested. The specificity of the labeling was confirmed by immunoelectron microscopy. In addition, 16 fluids with a negative cytologic diagnosis contained cells strongly immunopositive with MBr1 and/or MOv2. Reactive mesothelial cells were consistently negative. These results suggest that antibodies MBr1 and MOv2 are able to identify cancer cells that do not fully meet conventional morphologic criteria for malignancy. The two reagents, when used in support of cytologic analysis, may substantially reduce the number of false negative cytologic diagnoses of fluids from patients with breast and ovarian carcinomas.     

Fine-needle aspiration cytology of benign and malignant adenomyoepithelioma: report of two cases.

Cytological features of a malignant spindle-cell variant and a benign tubular variant of adenomyoepithelioma were examined to improve diagnosis of this tumor. Fine-needle aspiration cytology, of both a malignant and a benign case, characterized cellular and cohesive cell clusters composed of epithelial and myoepithelial cells. The smears of the malignant case were rich in spindle-shaped myoepithelial cells, admixed with a few epithelial cells. In about a fourth of the clusters, atypical cells with enlarged hyperchromatic nuclei and prominent nucleoli comprised more than 20% of cells. The smears of the benign case were composed of tubular epithelial cells surrounding one to several layers of myoepithelial cells with clear cytoplasm. Mild atypia was occasionally noticed. A review of the literature showed that a cytological diagnosis of malignancy is not warranted, if nuclear atypia is not generally severe. Focal severe atypia is not definitively indicative of benignity or malignancy.     

经内镜逆行胰胆管造影胰胆管刷检的细胞病理学诊断

目的 探讨经内镜逆行胰胆管造影(ERCP)胰胆管刷检的细胞形态学诊断的敏感性和准确性,及其在诊断胆道和胰腺肿瘤中的作用.方法 回顾性分析长海医院2004年1月至2006年12月行ERCP胰胆管刷片细胞学检查的病例212例,对照术后病理诊断及临床最终诊断,分析胆道及胰腺肿瘤的细胞学特点及意义.结果 212例中样本满意率99%(2例无上皮细胞),细胞学报告阴性者137例,其中临床最终诊断恶性45例(阴性预告值60.2%).细胞学报告低级别异型增生者11例,临床最终诊断恶性6例(阳性预告值54.5%).细胞学报告高级别异型增生和恶性者可信性较高,高级别异型增生23例,1例失随访,临床最终诊断恶性19例(阳性预告值86.4%).细胞学报告恶性41例,临床最终诊断均为恶性(阳性预告值100%).细胞重叠、核大小不等、染色质增粗、黏附性差、坏死背景、核仁、病理性核分裂等特征具有诊断意义.结论 提高诊断效率依赖于从取材、制片、固定到阅片诊断各个环节的质量控制;区分"低级别异型增生"和"高级别异型增生",对临床实际工作的指导意义更大.     

Keratin and carcinoembryonic antigen in exfoliated mesothelial and malignant cells: an immunoperoxidase study

Immunoperoxidase technics were used to identify keratin and carcinoembryonic antigen (CEA) in exfoliated cells of fine-needle aspirates and body cavity fluids. Staining was evaluated in cytocentrifuge preparations from 27 malignant and 30 benign cytologic specimens. Most reactive mesothelial cell preparations were strongly positive for keratin and negative or only weakly positive for CEA. Diffuse, peripheral, and perinuclear concentration of staining for keratin was noted in exfoliated reactive mesothelial cells. Positive staining for keratin, predominantly diffuse, was noted in exfoliated cells from 56% of the adenocarcinomas. Sixty-nine per cent of adenocarcinoma preparations were strongly positive for CEA. These findings suggest that keratin proteins are not restricted to squamous cells and that keratin staining does not permit distinction between adenocarcinoma and mesothelial cells in cytologic specimens. Staining for CEA and keratin was compared in cytocentrifuge preparations and histologic sections of 12 adenocarcinomas and 7 lymphomas. In some adenocarcinomas, staining was detected only in cytologic preparations. Possible explanations for these differences are discussed. Variable staining for keratin was observed among exfoliated reactive mesothelial cells, possibly identifying different mesothelial cell populations. All reactive and neoplastic lymphoid cells were negative for keratin and CEA in cytologic and histologic preparations. Immunoperoxidase technics can be applied to rehydrated Papanicolaou-fixed and Papanicolaou-stained cytologic preparations with excellent preservation of cytologic detail.