Cytology Cytology of of Pleural Pleural Fluid Fluid as a as a Diagnostic Diagnostic Challenge Challenge Paavo Paavo Pääkkö Pääkkö , MD, , MD, PhD PhD Chief Chief Physician Physician and and Head Head of the of the Department Department Department Department of of Pathology Pathology, Oulu Oulu University University Hospital Hospital , Finland , Finland
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Cytology of Pleural Fluid as a Diagnostic Challenge · pleural effusions! Exfoliative cytological examination of pleural effusions common method for determining whether effusion is
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CytologyCytology of of PleuralPleural FluidFluid as a as a
DiagnosticDiagnostic ChallengeChallenge
Paavo Paavo PääkköPääkkö, MD, , MD, PhDPhD
ChiefChief PhysicianPhysician and and HeadHead of the of the DepartmentDepartment
DepartmentDepartment of of PathologyPathology,,
Oulu Oulu UniversityUniversity HospitalHospital, Finland, Finland
Oulu University Hospital
General General overviewoverview of of cytologycytology of of
pleuralpleural effusionseffusions
!! ExfoliativeExfoliative cytologicalcytological examinationexamination of of pleuralpleural effusionseffusionscommon common methodmethod for for determiningdetermining whetherwhether effusioneffusion is isbenignbenign oror malignantmalignant
!! EffusionsEffusions subdividedsubdivided into into transudatestransudates and and exudatesexudatesdependingdepending on the on the proteinprotein contentcontent
!! TransudatesTransudates resultresult fromfrom alterationsalterations in in hydrostatichydrostatic ororoncoticoncotic pressurepressure, , oftenoften duedue to to systemicsystemic factorsfactors, , e.ge.g..congestivecongestive heartheart failurefailure
!! ExudatesExudates resultresult fromfrom pathologicalpathological processesprocesses localizedlocalizedto the to the serosalserosal membranesmembranes => => higherhigher proteinprotein contentcontentand and cellularitycellularity increasedincreased comparedcompared to to transudatestransudates, , e.ge.g..infectionsinfections
UtilityUtility and and limitationslimitations of of cytologycytology of of
pleuralpleural effusionseffusions
!! CellsCells exfoliatedexfoliated into into effusioneffusion fluidfluid cancan bebe examinedexamined as as
!! MostMost of the of the exudatesexudates benignbenign
!! The The absenceabsence of of malignantmalignant cellscells doesdoes notnot rulerule out out
malignancymalignancy
!! OnlyOnly 30-40 % of 30-40 % of malignantmalignant mesotheliomasmesotheliomas, and 60-70, and 60-70
% of % of cancerscancers metastaticmetastatic to the to the pleurapleura diagnoseddiagnosed byby
exfoliativeexfoliative cytologycytology
CytologyCytology vs. vs. histologyhistology
!! ExfoliativeExfoliative cytologycytology hashas of of limitedlimited usefulnessusefulness in indiagnosingdiagnosing malignantmalignant mesotheliomamesothelioma
!! BenignBenign reactivereactive mesothelialmesothelial cellscells maymay havehave featuresfeatures thatthatmimicmimic malignancymalignancy, and , and malignantmalignant mesotheliomasmesotheliomas maymaybebe cytologicallycytologically blandbland
!! WithoutWithout evidenceevidence of of invasioninvasion of of underlyingunderlying tissuestissues,,diagnosisdiagnosis of of mesotheliomamesothelioma on on cytologiccytologic groundsgrounds maybemaybedifficultdifficult
!! SarcomatousSarcomatous mesotheliomasmesotheliomas typicallytypically dodo notnot shedshed cellscellsinto into effusioneffusion
CytologicalCytological featuresfeatures of of malignancymalignancy
!! CancerCancer cellscells as as individualindividual cellscells, , sheetssheets of of cohesivecohesive cellscells,,
and and three-dimensionalthree-dimensional sphericalspherical clustersclusters, , calledcalled morulaemorulae
!! MalignantMalignant mesotheliomamesothelioma cellscells lacklack the the significantsignificant
degreedegree of of cytologicalcytological pleomorphismpleomorphism
!! CellsCells arrangedarranged in in sheetssheets, , clustersclusters, , morulaemorulae oror
papillarypapillary structuresstructures
HintsHints for for correctcorrect interpretationinterpretation
!! AtypicalAtypical reactivereactive mesothelialmesothelial cellscells blendblend withwith cellscells withwith lesserlesserdegreesdegrees of of reactivereactive atypiaatypia withinwithin a a benignbenign effusioneffusion, , givinggiving the theimpression of impression of oneone populationpopulation of of cellscells
!! In In casescases of of malignancymalignancy, , reactivereactive mesothelialmesothelial cellscells and and malignantmalignantcellscells oftenoften appearappear as as twotwo separateseparate and and distinctdistinct populationpopulation of of cellscells
!! ItIt is is necessarynecessary to to firstfirst determinedetermine ifif cellscells in a in a fluidfluid areare trulytrulymalignantmalignant beforebefore secondarilysecondarily determiningdetermining the the typetype of of malignancymalignancy
!! ImmunohistochemicalImmunohistochemical confirmationconfirmation thatthat atypicalatypical cellscells arearemesothelialmesothelial in in originorigin doesdoes notnot help to help to distinguishdistinguish betweenbetweenreactivereactive mesothelialmesothelial cellcell proliferationproliferation and and mesotheliomamesothelioma
Case 1Case 1
!! 60-year 60-year oldold manman
!! ExposedExposed to to asbestosasbestos
!! HydrothoraxHydrothorax and and pleuralpleural plaquesplaques
!! MostMost of the of the exudatesexudates benignbenign
!! The The absenceabsence of of malignantmalignant cellscells doesdoes notnot rulerule out outmalignancymalignancy
!! MalignantMalignant mesotheliomasmesotheliomas causecause <1 % of <1 % of malignantmalignantpleuralpleural effusionseffusions, and , and onlyonly epithelialepithelial malignantmalignantmesotheliomasmesotheliomas likelylikely exfoliateexfoliate cellscells into into effusioneffusion fluidsfluids
!! ItIt is is necessarynecessary to to firstfirst determinedetermine ifif cellscells in a in a fluidfluid arearetrulytruly malignantmalignant beforebefore secondarilysecondarily determiningdetermining the the typetypeof of malignancymalignancy
!! ImmunohistochemistryImmunohistochemistry of of histologicalhistological sectionssections fromfrom a acellcell blockblock maymay help to help to determinedetermine the the typetype of of malignancymalignancy