Journal of Pathology and Translational Medicine

Review

Lymphoproliferative disorder involving body fluid: diagnostic approaches and roles of ancillary studies: Jiwon Koh, Sun Ah Shin, Ji Ae Lee, Yoon Kyung Jeon; J Pathol Transl Med. 2022;56(4):173-186. Published online July 4, 2022; DOI: https://doi.org/10.4132/jptm.2022.05.16

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Lymphocyte-rich effusions represent benign reactive process or neoplastic condition. Involvement of lymphoproliferative disease in body cavity is not uncommon, and it often causes diagnostic challenge. In this review, we suggest a practical diagnostic approach toward lymphocyte-rich effusions, share representative cases, and discuss the utility of ancillary tests. Cytomorphologic features favoring neoplastic condition include high cellularity, cellular atypia/pleomorphism, monomorphic cell population, and frequent apoptosis, whereas lack of atypia, polymorphic cell population, and predominance of small T cells usually represent benign reactive process. Involvement of non-hematolymphoid malignant cells in body fluid should be ruled out first, followed by categorization of the samples into either small/medium-sized cell dominant or large-sized cell dominant fluid. Small/medium-sized cell dominant effusions require ancillary tests when either cellular atypia or history/clinical suspicion of lymphoproliferative disease is present. Large-sized cell dominant effusions usually suggest neoplastic condition, however, in the settings of initial presentation or low overall cellularity, ancillary studies are helpful for more clarification. Ancillary tests including immunocytochemistry, in situ hybridization, clonality test, and next-generation sequencing can be performed using cytologic preparations. Throughout the diagnostic process, proper review of clinical history, cytomorphologic examination, and application of adequate ancillary tests are key elements for successful diagnosis.

Citations

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Original Articles

A Study of Bcl-2 Oncoprotein Expression in Endometrial Carcinoma Correlated with Hormone Receptor Status.: Young Im Han, Hye Jin Lee, Ji Yeon Lee, Sun Kyung Lee; Korean J Pathol. 1996;30(5):408-416.

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Abstract PDF: Bcl-2 is a proto-oncogene initially described in follicular lymphoma, associated with chromosomal translocation(14;18). Recent studies have shown the presence of Bcl-2 in nonhematolymphoid tissue, especially in hormonally responsive tissue. The endometrium is an attractive model for studying the hormone dependent regulation of Bcl-2 expression. We have studied the immunoreactivity of Bcl-2 oncoprotein in relation to the immunoreactivity of estrogen receptors(ER) and progesterone receptors(PR) by immunohistochemistry in 52 human endometrial carcinomas, according to nuclear grade. The results obtained are summarized as followings, 1) Immunohistochemical grade of Bcl-2 showed a significant inverse correlation with nuclear grade. 2) Immunohistochemical grades of ER and PR also showed a significant inverse correlation with nuclear grade, and were well correlated with each other. 3) Immunohistochemical grades of Bcl-2 and hormone receptors showed a strongly significant correlation. On the basis of the above results, we suggest that Bcl-2 expression may be under hormone dependent control and that it can be used in prognosis and choice of hormonal therapy in the presence of hormone receptor.

p 53 Protein Expression in Imprint Cytology of Breast Carcinoma.: Dong Sug Kim, Eun Hi Lee, Ki Kwon Kim, Mi Jin Kim, Soo Jung Lee; Korean J Cytopathol. 1995;6(1):1-9.

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Abstract PDF: This study was carried out to determine the usefulness of imprint cytology for detecting p 53 protein in breast carcinoma. NCL-DO7(Novocastra, U.K.) was used to detect p53 protein immunocytochemically. A total of 33 cases was studied. Immunostaining of imprint cytology with NCL-DO7 was positive in 64%(21\33) and showed relatively high coincident rate (80 %) with immunostaining of formalin-fixed, paraffin - embedded specimen. p 53 protein was related to negative estrogen receptor status, but not to the nuclear grade, lymph node metastasis, or tumor size. The fact that p53 protein expression was not related to nuclear grade might be due to predominance of nuclear grade 3. It was easier to determine the nuclear grade is one of the most important prognostic factors, in imprint cytology than in tissue specimen. p53 protein tended to be stained more strongly in imprint cytology than in tissue.

Case Report

Extrarenal Malignant Rhabdoid tumor: A Case Report.: Sang Yong Lee, Dae Cheol Kim, Seo Hee Rha, Sook Hee Hong, Tae Hun Kang, Young Ho Lee, Kyoung Jin Nam, Jin Sook Jeong; Korean J Cytopathol. 1996;7(1):69-74.

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Abstract PDF: Malignant rhabdoid tumor is a distinct renal tumor in the pediatric age group. It was originally described as a rhabdomyosarcomatoid variant of Wilms tumor. However, subsequent studies failed to confirm myogenous differentiation, so it is now considered to be a distinct and unique type of highly malignant tumor, histogenetically unrelated. Although extrarenal forms of this tumor are rare, several examples have been described in other sites, especially the liver, prostate, paravertebral area, urinary bladder and soft tissue. We experienced a case of malignant rhabdiod tumor located in the intraabdominal cavity in a 10 month-old boy. Smear of peritoneal fluid showed round, polygonal and irregular shaped cells with large nuclei, ample cytoplasm containing Jight pink "to purple cytoplasmic inclusions, and one or a few prominent nucleoli. Immunocytochemistry revealed positivity to cytokeratin, epithelial membrane antigen and vimentin, and negativity to desmin and neuron-specific enolase. These distinct cytologic appearance and immunophenotypes were most consistent with a diagnosis of extrarenal malignant rhabdoid tumor. The cytoplasmic inclusions were correlated with eosinophilic inclusions seen in histologic section and electron microscopy confirmed this interpretation, showing filamentous aggregations in the cytoplasms of the tumor cells.

Original Articles

Distinction between Reactive Mesothelial and Carcinoma Cells in Serous Effusions by Mucin- and Immuno-cytochemical Panel .: Byung Heon Kim; Korean J Cytopathol. 1998;9(1):1-14.

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Abstract PDF: The cytologic distinction of carcinoma cells from reactive mesothelial cells can be difficult, especially in specimens containing abundant reactive mesothelial cells and inflammatory cells with scant carcinoma cells. This study evaluates the usefulness of mucin and immunocytochemistry for discrimination between reactive mesothelial cells and carcinoma cells, and sensitivity and specificity of these stains for the detection of metastatic carcinoma in serous effusions. Immunocytochemical panel including mucin cytochemistry with the periodic acid-Schiff(PAS) reaction after or without diastase digestion was undertaken on 127 serous effusion specimens with histologically confirmed diagnoses. The specimens including cell smears and cell blocks were stained with PAS and antibodies to carcinoembryonic antigen(CEA), epithelial membrane antigen(EMA), cytokeratin(CK), and vimentin. The sensitivities of these stains for metastatic carcinoma(127 cases) were 49%(46/94) in PAS, 48%(60/124) in CEA, 89%(97/109) in EMA, 88%(93/106) in CK, and 25%(20/81) in vimentin. The sensitivities of stains for reactive mesothelial cells(36 cases) were 19%(7/36) in EMA, 78%(28/36) in CK, and 75%(27/36) in vimentin. The PAS and CEA stains were not reacted with all cases of benign reactive serous effusions containing abundant reactive mesothelial cells. The specificities of stains for metastatic carcinoma(127 cases) were 100% in PAS, 100% in CEA, 81% in EMA, 22% in CK, and 25% in vimentin. The optimal combination of stains for use in a panel was PAS and CEA. Combined results from these two stains yielded an advanced sensitivity of 8% in PAS and 4% in CEA for metastatic carcinoma. EMA wasalso cosiderably useful for identification of carcinoma cells. CK and vimentin were not suitable for distinguishing between reactive mesothelial cells and carcinoma cells.

Usefulness of E-Cadherin Expression in Malignant Effusion .: Sung Jig Lim, Gou Young Kim, Youn Wha Kim, Yong Koo Park, Juhie Lee, Moon Ho Yang, Nam Hee Won; Korean J Cytopathol. 1999;10(2):121-126.

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Abstract PDF: The usefulness of E-cadherin immunostaining as a marker of malignancy in the body fluids was investigated in the present study. Thirty-three histologically proven cases of cell blocks from the pleural, peritoneal, and pericardial fluids were studied by immunocytochemistry for E-cadherin antibody using LSAB method. These cases were cytologically diagnosed as adenocarcinoma (25 cases) and atypical cells (8 cases). Tumor cells showed strong positive membranous staining for E-cadherin antibody in 21 out of 25 cases (84%) of adenocarcinoma. E-cadherin staining was not found in 6 of 8 cases of suspicious maligancy. The sensitivity and specificity were 84% and 75%, respectively. Reactive mesothelial cells and inflammatory cells scattered were all negative. In conclusion, E-cadherin is an useful adjunctive marker to distinguish reactive mesothelial cells from the carcinoma cells in the body fluids.

Immunocytochemical Assay of Cathepsin D in Fine Needle Aspiration Cytology of Breast Carcinoma and Benign Breast Diseases .: Kyeongmee Park, Illhyang Ko; Korean J Cytopathol. 2000;11(2):75-81.

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Abstract PDF: Cathepsin D is a protease which is known to facilitate invasion and metastasis of breast carcinoma. Overexpression of cathepsin D is associated with poor clinical outcome and biologic aggressiveness of the breast cancer. We underwent immunocytochemical assay(ICA) for cathepsin D in fine needle aspiration cytology(FNAC) specimens from the breast carcinoma and benign breast diseases. In FNAC specimens cathepsin D was expressed in 21(42.9%) out of 49 cases of invasive ductal carcinoma, whereas negative result was observed in all 15 cases of benign breast diseases including 7 fibroadenomas, 6 fibrocystic diseases, and 2 benign ductal hyperplasias. Among the 11 FNAC specimens from ductal carcinoma in situ(DCIS), cathepsin D was expressed in 3 cases(27.3%). In FNAC specimens immunocytochemistry for cathepsin D showed positive result in 24 out of 60 carcinomas(sensitivity, 40%) and negative result in 15 out of all 15 benign breast diseases(specificity, 100%). No significant correlation was noted between cathepsin D expression in FNAC specimen and clinicohistological characteristics of the breast carcinoma, such as hormone receptors and cell differentiation. In conclusion, ICA of cathepsin D in FNAC specimens thought to be a good adjunct to differentiate malignancy from benign breast diseases.

Immunocytochemical Expression of E-cadherin in Cell Blocks of Serous Effusions.: Byung Heon Kim, O Jun Kwon; Korean J Cytopathol. 2001;12(2):81-88.

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Abstract PDF: The differentiation between reactive mesothelial and carcinoma cells in serous effusion cytology can be a diagnostic challenge based on morphology alone. The expression of some cell adhesion molecules may be helpful in the differential diagnosis. This study evaluated the usefulness of E-cadherin immunocytochemistry for discrimination of carcinoma cells from reactive mesothelial cells. Alcohol fixed, paraffin embedded cell blocks taken from 42 reactive and 102 malignant serous effusions with histologically confirmed diagnoses were immunostained with monoclonal antibody to E-cadherin by LSAB method. E-cadherin expression was identified in only 2 benign reactive serous effusions(5%) whereas 91 malignant serous effusions(89%) expressed E-cadherin. The differences in immunostaining for E-cadherin between reactive and malignant serous effusions were statistically significant(p<0.001). The sensitivity and specificity of the E-cadherin immunostaining for carcinoma cells were 89% and 95%, respectively. In conclusion, E-cadherin is a useful diagnostic adjunct for differentiation between reactive mesothelial and carcinoma cells in serous effusions.

Utility of Calretinin in Distinction between Benign Reactive Mesothelial and Carcinoma Cells in Serous Effusions.: Byung Heon Kim; Korean J Cytopathol. 2001;12(2):89-96.

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Abstract PDF: The cytological distinction of carcinoma cells from reactive mesothelial cells in serous effusions may be difficult or impossible based on morphology alone, especially in specimens containing reactive mesothelial cells which form glandular or ball- or papillary-shaped conglomerates or which mimic malignant nuclear features. Calretinin is a newly reported immunocytochemical marker for mesothelial cells, which can potentially be utilized for facilitating this distinction. This study evaluated the usefulness of calretinin for the discrimination between reactive mesothelial and metastatic carcinoma cells in serous effusion. Immunocytochemical staining was undertaken on 33 benign reactive and 87 malignant serous effusion specimens with histologically confirmed diagnoses. The specimens including smears and cell blocks were stained with polyclonal antibody to calretinin by labelled streptavidin-biotin method. The positive expression of calretinin was noted in 32(97.0%) of 33 benign reactive effusions and 9(10.3%) of 87 malignant effusions. The sensitivity and specificity of the calretinin immunostaining for reactive mesothelial cells was 97.0% and 89.7%, respectively. In conclusion, calretinin is a useful marker for distinguishing between reactive mesothelial cells and carcinoma cells in serous effusions.

Case Report

Composite Epithelioid Hemangioendothelioma in Pleural Effusion Mimicking Metastatic Adenocarcinoma: Cytologic and Immunocytochemical Findings.: Ki Seok Jang, Hong Xiu Han, Moon Hyang Park; Korean J Cytopathol. 2003;14(1):36-41.

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Abstract PDF: Epithelioid hemangioendothelioma is a rare vascular tumor of borderline malignancy which is characterized by the presence of "epithelioid" or "histiocytoid" endothelial cells. Superficial and deep tumors have been recognized in the extremities, head, neck, chest, and mediastinum of adult patients. It may also occur as a primary tumor of liver, bone, and other visceral organs. Few effusion cytologic findings of epithelioid hemangioendothelioma have been reported. We report a case of composite epithelioid hemangioendothelioma with focal epithelioid angiosarcomatous areas of the iliac bone and adjacent soft tissue in a 38-year-old female, which, during its metastatic course, was presented as a pleural effusion. The effusion was cellular with epithelioid cells presenting both singly and in clusters. The tumor cells were round to ovoid showing cytoplasmic vacuolization, variability in cell size, and prominent nucleoli. The effusion smears and cell block sections revealed strong positive staining for CD31 and vimentin, weak positive for CD34 and Factor VIII-related antigen, and negative for cytokeratin, CEA, and calretinin. The cytologic findings in this case were similar to that of metastatic adenocarcinoma or malignant mesothelioma. Therefore, immunocytochemical staining in smear and cell block is a helpful tool to differentiate malignant "epithelioid" cells in effusion.

Original Articles

Immunocytochemical Staining for p16 of Atypical Squamous Cells in Cervicovaginal Smear.: Hwal Woong Kim, Jong Sil Lee, Jeong Hee Lee, Gyung Hyuck Ko; Korean J Cytopathol. 2004;15(1):28-32.

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Abstract PDF: It was reported that the main cause of intraepithelial neoplasm and squamous cell carcinoma of the uterine cervix is human papilloma virus infection, and that the expression of p16 is increased in cells infected by human papilloma virus. We performed an immunocytochemical staining for protein p16 in 17 cases of cervocovaginal smears initially diagnosed as atypical squamous cells of undetermined significance, to know whether the staining could help the differentiation of neoplastic cells from reactive atypical cells. Of 17 smears, 6 were diagnosed finally as high grade intraepithelial neoplasm or invasive squamous cell carcinoma by follow-up biopsy and smear, and 5 of the 6 were positive for p16. Three were diagnosed as koilocytosis, and one of them was weakly positive for p16. Eight were diagnosed as reactive atypical cells, and all of them were negative for p16. We thought that immunocytochemical staining of p16 in cervocovaginal smears could help the differentiation of neoplastic cells from reactive atypical cells.

A Pathological Review of Pleural Effusion by Immunocytochemical Methods.: Dong Hwan Shin, Hee Jeong Ahn, Woo Ick Yang, In Joon Choi; Korean J Pathol. 1990;24(4):476-481.

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Abstract PDF: An unequivocal diagnosis of mesothelioma during life, on the basis of limited biopsy tissue or cytological specimens, is frequently difficult and requires distinction from inflammatory mesothelial hyperplasia on the one hand and secondary neoplasms, especially adenocarcinoma on the other. Although some studies have produced conflicting results, it is generally believed that immunohistochemical methods can aid in this distinction. To obtain comparable and reproducible results, 23 metastatic carcinoma of the pleura and 2 unequivocal malignant epiehtlial mesotheliomas were studied by the peroxidase-antiperoxedase method on paraffin-embedded cell blocks, and commercially available antibodies to carcinoembryonic antigen (CEA), keratin and epithelial membrane antigen (EMA) were used. Nineteen metastaic adenocarcinoma (73%) and two mesotheliomas (100%) reacted with keratin and EMA antibodies. Nineteen matastatic adenocarcinomas (73%) reacted with EMA antibodies. Nineteen metastatic adenocarcinoma (73%) reacted with CEA antibody; no mesotheliomas stained for CEA. Two cases of reactive mesothlial hyperplasia showed positive for keratin, but negative reaction for EMA and CEA. Noen of the antibodies used in this study was specific for mesothelioma, but CEA was found to be the most useful marker for differentiating between mesothelioma and metastatic carcinoma.

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