Cytological findings in a sample of peritoneal aspirate from a case of bile peritonitis

Bile peritonitis (BP) is a rare and serious condition warranting urgent surgical intervention to prevent the high incidence of mortality. BP is ascribed to the leakage of bile into the peritoneal cavity usually due to a perforation of the gallbladder or common bile duct caused by stones or a trauma. The radiological studies are useful in suggesting the diagnosis. The cytological findings of BP have been reported rarely in the literature characterised by the presence of lakes of stringy bile material admixed with variable numbers of histiocytes, mesothelial cells, and some inflammatory cells. Recently, we have examined an aspirate sample of peritoneal fluid (PF) obtained under ultrasound guidance in a case of BP ascribed to the perforation of the gallbladder in a 19-yr-old female patient in which apart from occasional bile pigment-laden macrophages admixed with a few mesothelial cells and inflammatory cells, numerous crystalline structures of varying shapes, sizes, and colour with birefringence along with some microspheroliths were found. At operation, the abdominal cavity showed a large amount of bile and the gallbladder specimen showed two perforations and gangrenous cholecystitis with numerous yellow-brown somewhat friable stones. The foregoing findings in the aspirate appeared to be of interest because to the best of our knowledge, numerous crystalline structures along with the cytological features of BP have not been described in the English literature.     

Adenosquamous carcinoma of the bile duct: Cytologic features of brush specimens from two cases

Cytologic brushing is a safe and specific procedure for diagnosing carcinoma of the distal bile duct and proximal pancreatic duct. The vast majority of these lesions are pure adenocarcinomas. Occasionally, however, other morphologic subtypes may be encountered. We report our experience with two adenosquamous carcinomas of the bile duct diagnosed by cytologic brushing. Both patients presented clinically with jaundice and were found to have mass lesions obstructing the bile duct. The brush specimens were cellular and contained a mixture of glandular and squamous elements. The glandular component was characterized by cohesive aggregates of cells with hyperchromatic, overlapping nuclei. The squamous component contained clusters and individual cells with hyperchromatic oval-to-spindled nuclei and orangeophilic cytoplasm. Focally, the squamous elements appeared to gradually merge into the glandular component, and there were clusters of hybrid cells which were difficult to classify as squamous or glandular. Although uncommon, these 2 cases demonstrate that the cytologic features of adenosquamous carcinoma can be appreciated on cytologic brushing specimens. Diagn Cytopathol 1996;15:322–324. © 1996 Wiley-Liss, Inc.     

Biliary tract cytology in specimens obtained by direct cholangiographic procedures: A study of 74 cases

A retrospective review of bile (BL) and biliary tract brushings (Br) obtained by endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) was undertaken to determine the sensitivity and specificity of cytology in the diagnosis of pancreaticobiliary malignancies. A total of 104 cytologic specimens (PTC-BL 15, PTC-Br 13, ERCP-BL 8, ERCP-Br 68) received between 1990 and mid-1994 from 77 patients who had undergone ERCP and/or PTC primarily for biliary stricture were reviewed. Specimens were unsatisfactory/inadequate in 11 (10.6%), benign in 41 (39.4%), suspicious in 25 (24%), and positive for malignant cells in 27 (26%). Follow-up was available in 74/77 patients; 46 (59.7%) had tissue confirmation while 28 (32.5%) had adequate clinical follow-up based on chart review. Of those with histologic confirmation, there were 32 malignant and 14 benign cases. The overall sensitivity and specificity of PTC- and ERCP-obtained cytologic specimens were 88.9 and 95.7% respectively. There was only one false positive case (ERCP-Br). Overall positive predictive value was 96%, negative predictive value 88%, and accuracy 96%. PTC had a significantly lower sensitivity rate (42.8%) and higher rate for unsatisfactory specimens (21%) compared with ERCP-obtained material (100 and 1.9%). Bile obtained by PTC or ERCP appeared less sensitive in detecting malignancies compared with endoscopic brushing using either technique (BL 50% vs. Br 100%). All three false negative cases were PTC-BL specimens. Of the 17 suspicious cases, eight were confirmed histologically as malignant, four were clinically consistent with malignancy, and five showed marked inflammatory atypia on biopsy. Positive predictive value and accuracy rate of a “suspicious cytology” diagnosis were 69 and 80.5%, respectively. Inadequate specimen, poor cellular preservation, and cells obscured by bile all interfere with proper cytologic evaluation. Experience is necessary to appreciate subtle malignant changes in well differentiated carcinomas. Communication between the cytopathologist and the clinician is critical in the accurate interpretation and proper management of the patients. Diagn Cytopathol 1996;14:334–348. © 1996 Wiley-Liss, Inc.     

Optimization of the peritoneal lavage

Review of 275 consecutive peritoneal lavages and concurrent histologic material from gynecologic operations suggested that cytologic evaluation was clinically indicated for only 60.7% of the lavages, representing 46% of the patients in the study. More than one concurrent lavage was received from 21.6% of all patients in the study, comprising 50% of patients with malignant lavages, 18.7% of patients with benign lavages, and 5.3% of patients for whom cytologic evaluation of peritoneal lavage was not clinically indicated. Malignant cells were diagnosed in 15% of the 167 lavages for which cytologic examination was clinically indicated. In this series of patients, identification of malignant cells in peritoneal lavages did not increase the tumor stage beyond that obtained solely from examination of the concurrent histologic material. There were no false-positive cytologic diagnoses and no lavages in which neoplastic cells were misinterpreted as benign. A significant number of lavages, including several from patients with histologically confirmed peritoneal tumor, were sparsely cellular and/or excessively bloody. It is suggested that although peritoneal lavages might be collected during all gynecologic operations, only specimens from selected cases should be submitted for cytologic evaluation, and greater attention should be given to specimen collection to ensure that only well-preserved and representative material from the peritoneum is submitted for cytologic evaluation. Diagn. Cytopathol. 1998;18:265–269. © 1998 Wiley-Liss, Inc.     

Cytodiagnosis of bile microspheroliths: a case report

We recently observed numerous microspheroliths consisting of microscopic organized crystalline structures of varying shapes, sizes, and colors in a bile specimen from a 65-yr-old woman obtained directly from the gallbladder during a surgical procedure for cholecystectomy. Detection of microspheroliths could be very useful in the diagnostic approach to patients with recurrent pain in the biliary region or with acute pancreatitis of unknown origin. To date, we are unaware of any cytologic reports describing microspheroliths in bile.     

The transient appearance of IgM antibodies in the bile of rats injected with Salmonella enteritidis

Following the intravenous injection of 2 × 10⁸ killed Salmonella enteritidis into rats, high levels of specific antibodies were detected in the serum and bile after 4 days. The level in serum persisted while that in bile had virtually disappeared by day 7. On the basis of gel filtration on Ultrogel AcA₂₂ the activity in bile was found to be associated with the IgM fraction. The transient nature of the biliary response was further evidenced by the association of the agglutinating activity with a four-fold increase in the concentration of IgM and the presence of complement-fixing bactericidal antibody. Initial evidence suggests that the source of the biliary IgM is from cells within the liver rather than transport of IgM from blood to bile. It is proposed that immune stimulation by blood-borne microorganisms can lead to a pulse of IgM in the bile, providing rapid augmentation of other local immune processes in the gastrointestinal tract.     

My approach to intraductal bile duct proliferations

Intraductal proliferations of the bile duct usually involve large bile ducts, and can occur in the intrahepatic, perihilar, and extrahepatic sites. Pre-invasive grossly detectable neoplasms are currently termed as intraductal papillary neoplasms of the bile duct (IPN-B). There is cytologic and architectural heterogeneity between and within these tumors. Based on morphologic differences between intrahepatic and extrahepatic IPN-B, the tumors can be subclassified into Type 1 and Type 2. These neoplasms show a spectrum from low-grade to high-grade dysplasia and can be associated with invasive carcinoma. The neoplasms can also be diagnosed in a biliary biopsy. The prognosis of malignancy arising in IPN-B is better than other cholangiocarcinomas. Molecular changes usually involve common genetic alterations in KRAS, CDKN2A, and TP53 genes. Complete surgical resection is curative in a non-metastatic setting.     

Clear-cell adenocarcinoma of the female genital tract: presence of hyaline stroma and tigroid background in various types of cytologic specimens

Hyaline basement membrane-like stromal material and tigroid background are distinctive cytologic features observed in Diff-Quik (DQ)- or Giemsa-stained smears of clear-cell adenocarcinoma (CCA) of the female genital tract. However, it is uncertain how often these features are present in different types of cytologic specimens, and which type of preparation is optimal for this diagnosis. We therefore reviewed the cytologic features of CCA in three types of specimens, including 15 scrape cytology specimens, 7 fine-needle aspiration (FNA) specimens, and 15 peritoneal cytology specimens, with emphasis on the features observed in DQ-stained smears. The cell morphology in scrape cytology specimens and FNA specimens was comparable, whereas in peritoneal cytology specimens, the cytoplasm was better preserved. Most tumor cells had fragile cytoplasm containing variable amounts of fine vacuoles, and round nuclei with distinct or prominent nucleoli. Hyaline stroma was present in 93% of scrape cytology specimens, 71% of FNA specimens, and 80% of peritoneal cytology specimens. Tigroid background was observed in 47% of scrape cytology specimens, 43% of FNA specimens, but in none of the peritoneal cytology specimens. Formation of a tigroid background may be prevented by the abundant fluid content in peritoneal cytology specimens. Hyaline stroma and tigroid background were uncommonly seen in scrape smears from other types of primary ovarian tumors, mainly juvenile granulosa cell tumor and yolk sac tumor. However, the additional presence of papillary structures allows CCA to be readily distinguished from these other tumors. We propose that scrape cytology offers the best approach for the intraoperative cytologic diagnosis of CCA.     

Peritoneal interleukin-10 increases with decrease in activated CD4+ T lymphocytes in women with endometriosis

This study was performed to determine whether peritoneal T cells are suppressed in the CD4+ or CD8+ T cell subpopulation and whether they are Th1 or Th2 predominant in women with endometriosis. Immune cells in the peritoneal fluid (PF) were obtained from women undergoing laparoscopy for endometriosis or tubal ligation. Three-colour flow cytometry was utilized for immunophenotyping of peritoneal fluid mononuclear cells (PFMC). Concentrations of interleukin (IL)-4, IL-5 and interferon-gamma (IFN-gamma) produced by PFMC with and without mitogen stimulation and concentrations of IL-10 and IL-12 were measured in PF. The peritoneal T lymphocytes were predominantly of the Th1 type that produced much more IFN-gamma but less IL-4 or IL-5 in women with or without endometriosis. The decrease in peritoneal lymphocytes was significant in the HLA-DR+ CD4+ CD3+ subpopulation and the concentrations of peritoneal IL-10 and IL-12 were significantly elevated in women with early stage endometriosis. There was impaired IL- 5 production by PFMC after phytohaemagglutinin stimulation in women with advanced stage endometriosis. We concluded that the activated peritoneal CD4+ Th1 cells from the women with endometriosis were decreased in number. The suppression of these T cells may be due to the elevation of IL-10 and IL-12 in the peritoneal fluid.      

Bile duct epithelia as target cells in primary biliary cirrhosis and primary sclerosing cholangitis

 Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are chronic autoimmune-mediated diseases of the biliary tree, resulting in a loss of bile ducts. There are morphological features that clearly distinguish them from each other: in PBC, there is overt destruction of the bile ducts with disruption of the basement membrane; in PSC there is abundant periductular fibrosis with shrinkage and subsequent loss of the bile ducts. In order to see if the disparate histopathology is paralleled by different immunohistology we looked at a panel of epitopes on bile duct epithelia especially to see if biliary epithelial cells may present as targets for cell mediated immune respone. In PBC bile duct epithelial cells mostly expressed CD58 (lymphocyte function-associated antigen 3), CD80 (B7 BB1), and CD95 (Fas). In PSC, however, these epitopes were only expressed in a few examples to a lower degree. The respective effector T lymphocytes were positive for CD2 and CD28. Subtyping of the lymphocytes in the liver tissue further showed a predominance of CD4 positive T cells over CD8 cells up to 2-to-1 in both diseases. Determination of lymphocytes by cytokines to Th1 or Th2 subtype showed a majority of Th1 lymphocytes in PBC and PSC. We conclude that in PBC bile duct epithelial cells may display features of target cells of a T cell-mediated immune reaction with the Th1 cells predominating. In PSC other mechanisms of bile duct loss may play a role, since in this disease the majority of cells lack essential epitopes that constitute targets of cell mediated immunity. Received: 19 November 1996 / Accepted: 26 February 1997     

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.     

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.     

Cytologic effects of photodynamic therapy in body fluids

Photodynamic therapy (PDT) has been used in phase I clinical trials at the National Institutes of Health for the treatment of malignancies disseminated within the peritoneal and pleural cavities. Review of records revealed 18 patients who were treated with PDT between April 1988–June 1993. Sixty-five pleural and peritoneal fluids, 22 pre- and 43 post-PDT, were available for evaluation. Mesothelial cell changes seen post-PDT included: increased nuclear-to-cytoplasmic ratios in 7/18 (39%), cytomegaly in 9/18 (50%), and multinucleation in 12/18 (67%), with Touton-like giant cells in 3/18 (17%). Additional changes noted post-PDT comprised histiocytic aggregates in 9/18 patients (50%), with granuloma-like clusters in 3/18 (17%), acute and chronic inflammation in 13/18 (72%), and eosinophilia in 8/18 (44%). Residual tumor was present in 7/18 (39%) patients post-PDT. In 2 patients with malignant mesothelioma, benign mesothelial cells with cytologic changes post-PDT were difficult to distinguish from malignant cells. Mesothelial cell changes following PDT, specifically increased nuclear-to-cytoplasmic ratios and cytomegaly, should be recognized to avert false-positive diagnoses of tumor. In patients with malignant mesothelioma, and less commonly with adenocarcinoma, benign mesothelial cells with changes secondary to PDT may be difficult to distinguish from tumor cells. Diagn Cytopathol 1996;14:356–361. © 1996 Wiley-Liss, Inc.     

Neuroendocrine carcinoma diagnosis from bile duct cytological specimens: A retrospective single‐center study

Neuroendocrine carcinoma (NEC) in the extrahepatic bile duct is extremely rare and clinically aggressive. Cytological examination of bile and/or bile duct brushing specimens plays an important role in the diagnosis of carcinoma of the extrahepatic bile duct, but only a few articles have described the cytological features of NEC in this area. Thus, we retrospectively analyzed the cytological features of NEC in bile and/or bile duct brushing specimens. Patients with a histopathological diagnosis of NEC who underwent bile and/or bile duct brush cytological examination were enrolled in this study. The cytological features, including the background, arrangement, and shape of the neoplastic cells, and nuclear and cytoplasmic features were reviewed. Six patients with small cell NEC were enrolled, and two of them had pancreatic tumors directly invading the bile duct wall. The cytological specimens showed small and/or large neoplastic cell clusters with occasional single cells in all cases. The neoplastic cells had a high nuclear/cytoplasmic ratio and round‐to‐oval nuclei with powdery chromatin, inconspicuous nucleoli, and scant cytoplasm. Nuclear molding was a characteristic finding in all cases. One case had an adenocarcinoma component, which was also present in the cytological specimen. Cytological examination of bile and/or bile duct brushing specimens can be useful for the diagnosis of small cell NEC. This is an extremely rare but aggressive carcinoma, and its diagnosis by identifying characteristic cytological features may facilitate early detection and treatment.     

Expression of inhibitory-motif killer immunoglobulin-like receptor, KIR2DL1, is increased in natural killer cells from women with pelvic endometriosis

Problem:  We investigated inhibitory and activation motif expression of killer immunoglobulin-like receptor (KIR) by natural killer (NK) cells, which may be pathogenetically involved in endometriosis.
Method of study:  We compared cells from 24 Japanese women laparoscopically diagnosed with endometriosis, to cells from 25 women with other laparoscopic diagnoses. KIR expression by NK cells was assessed in peripheral blood (PB) and peritoneal fluid (PF) by flow cytometry. Intracellular immunoreceptor tyrosine-based (IT) inhibitory and activation motifs (ITIM and ITAM) of KIR in PB was assessed by Western blotting.
Results:  ITIM-KIR expression by PB NK cells was significantly and similarly greater than ITAM-KIR expression in women with and without endometriosis. Percentages of CD56⁺ NK cells in PB and PF did not differ significantly between women with and without endometriosis; however, the percentage of CD158a⁺ cells among CD56⁺ NK cells in PB and PF was significantly higher in women with than without endometriosis.
Conclusions:  ITIM-KIR expressing NK cells might confer tolerance to peritoneal endometriotic implants.     

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.     

Diagnostic pitfalls of peritoneal washing cytology and the role of cell blocks in their diagnosis

Mesothelial cell hyperplasia, collagen balls, endometriosis, and endosalpingiosis are diagnostic pitfalls on peritoneal washing cytology in women who present with gynecologic lesions. Over an 8-month period, the peritoneal washings from 10 patients undergoing gynecologic surgery for presumed malignancy showed unusual cytologic findings, several of which posed diagnostic difficulties. The washings from four patients with ovarian carcinomas were cellular and contained clusters and strips of cells with cytologic atypia mimicking malignancy. Confirmation of their benign mesothelial origin was confirmed on immunohistochemistry utilizing cell block preparations. In two cases of endometrial endometrioid carcinoma, the washings contained several clusters of cells surrounding and/or admixed with a globular substance. Due to their similarity to endometrial cells, immunohistochemistry was performed on cell block preparations. The cells were positive for cytokeratin and negative for carcinoembryonic antigen and B72.3, confirming their mesothelial origin. In one case, clinically presumed to be a malignant mass, the washings contained tight clusters of cells with mild cytologic atypia admixed with hemosiderin-laden macrophages. In conjunction with the cell block findings, a diagnosis of endometriosis was made. Extensive endometriosis was found on the surgically resected specimen. In two cases, strips of ciliated epithelial cells resembling tubal epithelium were present on the cytologic and cell block preparations, consistent with endosalpingiosis. The peritoneal washings in one case contained several clusters and balls of atypical cells surrounding microcalcifications on cell block preparation. Since calcification within groups of cells in peritoneal washings always raised the possibility of malignancy, a serous carcinoma of the ovary, particularly of borderline malignancy, would have to be excluded. Fortunately, the resected specimen was free of tumor and showed calcified endosalpingiosis on the ovarian surface. Preparation of cell blocks from peritoneal washings is of value in the work-up and management of patients who present with cytologic mimickers of malignancy on fluid cytology.     

Evaluation of myeloid and lymphoid dendritic cells in peritoneal fluid in women with non-malignant ovarian tumors

PROBLEM: Identification of myeloid and lymphoid dendritic cells (DCs) in peritoneal fluid (PF) and peripheral blood (PB) of patients with ovarian pathology. METHOD OF STUDY: PF and PB were collected from 60 patients who underwent laparoscopy because of non-malignant ovarian tumors. Mononuclear cells were separated by gradient centrifugation. The cell surface antigens were determined by flow cytometry using monoclonal antibodies. RESULTS: Both myeloid and lymphoid DCs were detected in PF and PB of women with ovarian tumors. The percentage of myeloid DCs was significantly higher in PF than in PB. The concentration of PF myeloid DCs was the highest (P < 0.05) in patients with dermoid cysts (0.67 x 10(6)/mL PF) in comparison with the other studied groups, excluding patients with normal pelvis. CONCLUSIONS: Domination of myeloid and not lymphoid cells in PF may support the hypothesis that local PF immune disturbances may play a role in some non-malignant ovarian pathology.     

Cytopathology of serous neoplasia of the ovary and the peritoneum: Differential diagnosis from mesothelial proliferations

Serous neoplasia of the ovary ranges from benign adenomas through serous borderline tumors to invasive serous adenocarcinoma. This spectrum of neoplasia is at least partially reflected in the cytomorphologic features of these lesions. The objective of this study is to review the cytopathology of serous neoplasia of the ovary. In addition, cytologic features of serous surface papillary carcinoma and its distinction from peritoneal mesothelial proliferations are discussed. Diagn Cytopathol 1996;15:292–295. © 1996 Wiley-Liss, Inc.