CYTOPATHOLOGIC DIAGNOSIS of SEROUS FLUIDS

CYTOPATHOLOGIC
DIAGNOSIS of
CYTOPATHOLOGIC
SEROUS FLUIDS DIAGNOSIS of
SEROUS FLUIDS
Vinod B Shidham
Barbara F Atkinson
Shidham Atkinson

www.elsevierhealth.com
 Cytopathologic
Diagnosis of
Serous Fluids
Vinod B Shidham MD FIAC FRCPath
Professor
Director of FNAB Service and Cytopathology Fellowship Training Program
Medical College of Wisconsin
Milwaukee, WI
USA

Barbara F Atkinson MD
Executive Vice-Chancellor, Kansas University Medical Center and
Executive Dean, University of Kansas School of Medicine
Kansas City, KS
USA

iii

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 SAUNDERS
An imprint of Elsevier Inc
© 2007, Elsevier Inc. All rights reserved.

First published 2007

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ISBN: 978-1-4160-0145-4

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Notice
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but as new research and clinical experience broaden our knowledge, changes in treatment
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 Contents

Contributors vii
Foreword ix
Preface xi
Acknowledgments xii
Dedication xiii
List of abbreviations xv

1 Introduction 1
Vinod B Shidham
2 The panorama of different faces of mesothelial cells 19
Vinod B Shidham
3 Approach to diagnostic cytopathology of serous effusions 31
Vinod B Shidham and Barbara F Atkinson
4 Diagnostic pitfalls in effusion fluid cytology 43
Vinod B Shidham
5 Immunocytochemistry of effusion fluids: introduction to SCIP approach 55
Vinod B Shidham and Barbara F Atkinson
6 Reactive conditions 79
Nirag C Jhala, Darshana N Jhala and David C Chhieng
7 Diagnostic cytopathology of peritoneal washing 91
Rosemary E Zuna
8 Mesothelioma 107
R Nagarjun Rao
9 Metastatic carcinoma in effusions 115
Vinod B Shidham
10 Metastatic sarcomas, melanoma, and other non-epithelial neoplasms 147
Mamatha Chivukula and Reda Saad
11 Where do they come from? Evaluation of unknown primary site of
origin 157
David C Chhieng and Nirag Jhala
12 Hematolyphoid disorders 171
Steven R Sanchez and Chung-Che (Jeff) Chang
13 Flow cytometry, molecular analysis, and other special techniques 195
Choladda Vejabhuti and Chung-Che (Jeff) Chang
14 Appendix I: Collection and processing of effusion fluids for cytopathologic
evaluation 207
Vinod B Shidham and John Epple
15 Appendix II: Immunocytochemistry of effusions— processing and
commonly used immunomarkers 237
Vinod B Shidham

Index 259

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 Contributors

Barbara F Atkinson MD R Nagarjun Rao MD, FRCPath

Executive Vice-Chancellor, Kansas University Medical Center and Assistant Professor of Pathology
Executive Dean, University of Kansas School of Medicine Department of Pathology
Kansas City, KS Medical College of Wisconsin
USA Milwaukee, WI
USA
Chung-Che (Jeff) Chang MD
Associate Professor of Pathology Reda S Saad MD, PhD
Director of Hematopathology Associate Professor of Pathology
The Methodist Hospital Department of Pathology and Laboratory Medicine
Houston, TX Drexel University College of Medicine
USA Allegheny General Hospital
Pittsburgh PA
David C Chhieng MD, MBA, MSHI
USA
Professor of Pathology
Director, Immunohistochemistry Lab Vinod B Shidham MD, FIAC, FRCPath
Department of Pathology Professor
University of Alabama at Birmingham Director of FNAB Service and Cytopathology Fellowship Training
Birmingham, AL Program
USA Medical College of Wisconsin
Milwaukee, WI
Mamatha Chivukula MD
USA
Assistant Professor
Department of Pathology Steven R Sanchez MD
Magee Womens Hospital of UPMC Associate Pathologist
Pittsburgh, PA Pathology Associates of Tyler
USA Tyler, TX
USA
John Epple SCT(ASCP)
Cytology Supervisor Choladda Vejabhuti MD
Dynacare Laboratory—Cytology Hematopathology/Cytopathology Fellow
Milwaukee, WI Department of Pathology
USA Baylor College of Medicine
Houston, TX
Darshana N Jhala MD, BMus
USA
Associate Professor, Anatomic Pathology
Division of Anatomic Pathology Rosemary E Zuna MD
University of Alabama at Birmingham Associate Professor of Pathology
Birmingham, AL Department of Pathology
Medical Director, Cytotechnology Program University of Oklahoma Health Sciences Center
Auburn University Montgomery Oklahoma City, OK
Montgomery, AL USA
USA
Nirag C Jhala MD, MIAC
Associate Professor of Pathology
Division of Anatomic Pathology
University of Alabama at Birmingham
Birmingham, AL
USA
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 Foreword
This book is a most comprehensive account of the cytopa-
thology of serous effusions and peritoneal washings. It
opens with an introductory chapter on the histology of the
serous cavities and the blood-derived constituents that may
be found in them, the complementary roles of the Papanico-
laou and Romanowsky stains, the types of serous effusions
and a list of the human and non-human entities that may
be found in them, and an analysis of the morphology of the
mesothelial cell. This is followed by a ‘panorama of different
faces’ of mesothelial cells, which illustrates just about every
variant of the cell that is likely to be encountered, both in its
solitary form and in clusters. Since it is hard to imagine that
there is any seasoned cytopathologist who has not stumbled
into making a false-positive report initiated by the sight of
‘reactive’ mesothelial cells, this is a worthy choice of subject,
one that would be especially important for the newcomer to
the cytology of serous effusions.
The chapter on the approach to diagnostic cytopathology
is systematically and logically presented. A helpful feature
in this section consists of two algorithms clearly intended to
lead the way to correct diagnoses. This chapter, as do many of
the chapters, contains a helpful listing of various features and
techniques relevant to the subject. Diagnostic pitfalls in effu-
sion cytology, a subject of paramount importance, are fully
dealt with and serve as a warning to those about to undertake
this important aspect of cytopathology.
The section on the immunocytochemical approach to
cytologic diagnosis in serous effusions introduces the term
‘subtractive coordinate immunoreactivity pattern’ to high-
light what are and what are not neoplastic cells by using a
variety of immunomarkers to provide a contrast between dif-
ferent types of cells, neoplastic and non-neoplastic. The sec-
tion on ‘reactive conditions’ deals with conditions that have
characteristic cellular features that could mimic carcinoma.
Although most of the conditions are a manifestation of the
ever-present reactive mesothelial cell, included amongst
them are systemic lupus erythematosus and rheumatoid effu-
sions. The section on peritoneal washings includes a large
variety of non-neoplastic and neoplastic entities. The chap-
ter on the cytopathology of diffuse malignant mesothelioma
of epithelial type is dealt with in a conventional manner by
identifying its cells in effusions as being of mesothelial lin-
eage and observing their excessive number and tendency to
form numerous cellular clusters, thereafter corroborating the
diagnosis by immunocytochemistry.
A large chapter is devoted to the cytopathology of neoplasms
of various organs, predominantly lung, breast, ovary, and gas-
Prelims-X0145.indd ix
trointestinal tract. This section is profusely illustrated by pho-
tographs of cells from these organs. It is usually possible with
a fair degree of accuracy to predict the primary site of neoplas-
tic cells found in a serous effusion if the clinical circumstances
are known. However, the prediction of unknown primary sites
of origin of neoplastic cells in serous effusions could be facil-
itated by the two interesting tables on the cytologic features,
differential diagnosis, ultrastructural features, and possible
primary sites of origin that this chapter contains.
Hematolymphoid disorders are thoroughly dealt with.
Each of the disorders is accompanied by an explanatory para-
graph about the entity and often by photographs of relevant
cells. This section contains a large table on immunopheno-
typic comparison of fifteen lymphomas and leukemias. Flow
cytometry, molecular techniques, and other special tech-
niques are now being more used in an adjunctive manner for
the evaluation of serous effusions. The uniqueness of surface
marker flow cytometric studies of hematopoietic neoplasms
in serous effusions is such that the authors conclude that they
may provide a valuable way to confirm the primary diagnosis
of lymphoid cancer. This section also includes tables on the
major molecular genetic abnormalities of lymphomas, acute
leukemias, and soft tissue tumors.
Finally, two appendices are provided that deal with the col-
lection of serous effusions for cytopathologic examination,
including processing and commonly used immunomarkers.
Both of these sections are replete with valuable, practical
information.
In summary, this is an outstanding monograph which
makes full use of the older techniques for the cytologic eval-
uation of serous effusions, but which also demonstrates
how the modern techniques, particularly of flow cytometry,
genetic evaluation, and immunocytochemistry, may be put
to good use.
Bernard Naylor MD
University of Michigan
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 Preface
Because of its complexity, cytopathologic evaluation of effu-
sion fluids can be challenging. However, because effusion
fluids are relatively easy to collect, any pathology laboratory
may be confronted with such specimens, regardless of its level
of expertise. In comparison to other common specimens,
effusion fluids need special and unique approaches for
cytopathologic evaluation.
This book was planned and written with the following
major goals in mind:
• to highlight effusion fluid processing methodology
• to simplify the interpretation approach based on
cytomorphology
• To emphasize a special approach for evaluation of
effusion fluid immunocytochemistry
• to introduce other ancillary tests.
The readership we have in mind includes beginners such
as pathology residents, fellows, and cytotechnology students,
and also those who have experience in cytopathology but are
faced with a difficult diagnostic dilemma.
Each chapter begins with a general outline. We anticipate
that many readers may not read the book from beginning to
end and may prefer to focus on topics of specific concern.
Although the chapters are interrelated, the contributors of
each have attempted to cover their topic as an independent
entity. Due to the overlap of related areas, there will be some
repetition of certain themes.
A picture is worth a thousand words. Emphasis is given
to the inclusion of as many images and sketches as possible,
with a broad range of stains and magnifications highlighting
multiple images of the same phenomenon. The figures and
legends have been designed so that they can stand by them-
selves or be used in addition to the text of a chapter. Thus,
there is some repetition of information in the text and the
figure legends, which reinforces the material, but the pictures
on their own are instructive.
Many readers, especially in their early phase of training,
would benefit from the algorithms presented in some
Prelims-X0145.indd xi
chapters. To summarize the theory with a practical touch,
some of the chapters are concluded with study cases.
The layout of the pages attempts to simplify the process
of finding important points that are periodically highlighted
in italic type, as teaching points. The additional details are
explained as a preamble to the book in Chapter 1. Similarly,
the chapters are color-coded to be identifiable from the side
of the book as different color bars for quick chapter reference
after a reasonable grasp of the general pattern of the book has
been obtained.
A significant proportion of problems associated with cyto-
pathologic evaluation of effusion fluids are related to spec-
imen collection and processing. Chapter 14 is dedicated to
addressing this, along with recommended approaches based
on our experience.
For pathology laboratories possessing optimal immunohis-
tochemistry support, the immunocytochemical evaluation of
cell block sections of effusion fluids is invaluable as an objec-
tive ancillary tool. However, the lack of a proper approach
to immunocytochemical evaluation may lead to equivocal
results. A special chapter is devoted to explain the SCIP (sub-
tractive coordinate immunoreactivity pattern) approach to
facilitate easy immunocytochemical interpretation.
Although washing the serous cavity with saline or balanced
salt solution may be expected to yield a cell sample similar
to effusion fluid, there are differences that must be taken into
account. To highlight and address some of the differences
between cytopathologic evaluation of washings and effusion
fluids, periodic references are made to this variation and a
separate chapter is included to discuss peritoneal washing.
We believe that Cytopathologic Diagnosis of Serous Fluids
provides a comprehensive source that will help students learn
about the cytopathologic interpretation of these challeng-
ing specimens as well as providing a practical reference for
busy practicing pathologists and cytotechnologists to evalu-
ate their difficult cases.
Vinod B Shidham MD
Barbara F Atkinson MD
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 Acknowledgments
A project such as this cannot be embarked upon without
help. Although this acknowledgment may not be sufficient in
expressing the depths of our appreciation, it is an attempt to
address this important component of book writing. Specific
acknowledgments at the end of some of the chapters should
also be noted.
Many excellent, hard-working cytopathologists, patholo-
gists, and cytotechnologists have contributed to this project.
Their patience, consideration, and enthusiasm have fueled
the progress leading to its completion. Their high level of
expertise and dedication has been integral to the production
of this book. As editors, we sincerely appreciate the insight,
help, and expertise of all of our contributing authors and
their supporters.
Many faculty members, staff members, residents, and fel-
lows at the Medical College of Wisconsin, Milwaukee, WI,
have put forth significant efforts at various levels. We thank
Dr Richard Komorowski, Dr Anthony Cafaro, Dr Natalia
Markelova, Dr Behnaz Behmaram, Dr Zainab Basir, Dr James
Keating, Dr Steven Kroft, Dr Petio Kotov, Dr Vincent Graffeo,
Dr Jordi Rowe, Dr Krista D'Amore, and Dr Louis Novoa-Takara
for their critical review and input. We are grateful for the coor-
dination and secretarial help of Ms Patsy Gill and Ms Barbara
Petersen. We also acknowledge the periodic copyediting
support of Ms Jeanette Bjerke and Mr Glen Dawson. The
xii
Prelims-X0145.indd xii
encouragement and help from the Chair of Pathology at
the Medical College of Wisconsin, Dr Carl Becker, has been
invaluable. In addition, the timely supply of material and
critical reviews of various chapters by Dr Bernard Naylor and
Dr David Dabbs is highly appreciated.
The contributions and encouragement from our family
members was also invaluable. Anjani Shidham, Anushree
Shidham, Sushrut Shidham, and Abhijeet Kolpekwar have
helped with various aspects of the books production, includ-
ing typing, copyediting, and searching. We are deeply grate-
ful to Mrs Paz B. Naylor, PhD for coordinating many steps
involved with forwarding and reviewing various chapters by
Dr Naylor. We would like to recognize the efforts of Michael
Houston, Elizabeth MacSween, Alan Nicholson, Louise Cook,
Claire Bonnett, Natasha Andjelkovic, and Belinda Kuhn at
Elsevier during various stages of this project.
We would especially like to thank all the people who have
worked with us over the years as our teachers, colleagues,
cytotechnologists, fellows, residents, students, friends, and
mentors. Their contributions may not be obvious, but they
have played critical roles, and each has been an inspiration
in their own way.
Vinod B Shidham MD
Barbara F Atkinson MD
7/19/07 2:16:04 PM
 D EDICATION
Vinod B. Shidham
In fond memory of:
My father-in-law (late Bhaskar Paranjape) and
my mother-in-law (late Pratibha Paranjape)

To:
My dad (Baburao Shidham MD) and my mom (Sunanda Shidham MA);
brothers (Pramod Siddham MD and Ganesh Shidham MD);
sisters (Chhaya Raghoji MD MS and Maya Pathikonda MD);
son—Sushrut;
daughter—Anushree;
loving wife—Anjani;
and
friends, students, residents, fellows, readers, and all well wishers;
whose affection keeps projects such as this book happening.

Barbara F Atkinson
To:
G. William Atkinson MD
Rhoda and Walter Frajola
Julie McCollum and George Atkinson
Will, Sydney, and Raven Nancy and Charles Perkins

xiii

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