Body fluid Cytology

Mr. Lin Wai Fung

MSc, MPH, CMIAC
31/1/2012
 Major Body Cavities
• Pleural cavity (left and
right)
• Pericardial cavity
• Peritoneal cavity

From: Shidham V & Atkinson BF (2007)

 Histology of serous cavity lining

• Cavity lined by parietal and visceral layer formed

by a monolayer of mesothelial cells
• A thin layer of fibrous tissue under the
mesothelium
• Mesothelium can undergo hypertrophy /
hyperplasia secondary to stimuli (reactive
changes)
 Transudate and Exudate

• Normally only thin layer of fluid, effusion is pathologic

Transudate
Caused by changes in osmotic
pressue
Implies systemic problem
Clear appearance
Low specific gravity <1.015
Low protein content <30 g/L
Low cellularity
Common cause: Congestive heart
disease, hypoproteinemia (cirrhosis,
renal failure)
Exudate
Damage to capillary blood vessel
Implies local problem
Turbid / bloody
High specific gravity >1.015
High protein content >30g/L
High cellularity
Common causes: malignancy,
inflammation, pulmonary infarction,
chemotherapy and radiotherapy
 Effusions: a culture medium

• Newly developed effusions: solitary cells and

small aggregates

• long standing effusions (e.g. 3 weeks): large

spherical balls, papillary structures..etc
 Cytology of serous cavity

• Normally lined by thin layer fluid containing low cellularity of :

– Mesothelial cells
– Lymphocytes
– Macrophages
– Neutrophils
– etc...
 Cytomorphology of Benign mesothelial cells

• Uniform cell population

• Monotonous, oval, round, 15-20 um and centrally placed nuclei
• Evenly distributed fine chromatin
• Inconspicuous nucleoli
• Two zone cytoplasm
• Fuzzy cell border (due to long microvilli)
• Windows between cells
• Papillary group, cytoplasmic vacuolation (signet ring) in long
standing effusions
• Peritoneal washing: mesothelial cells typically stripped from
underlying connective tissue: flat sheets
 Benign Mesothelial cells
Uniform, round centrally placed nuclei, fine chromatin, inconspicous
nucleoli, fuzzy border, background are lymphocytes
Benign Mesothelial cells
Clusters of benign mesothelial cells
3-D structures and strips of benign mesothelial cells
Papillary group of benign mesothelial cells
Look like adenocarcinoma, note: uniformity of nuclei and
inconspicious nucleoli, lymphocyte in background
 Vacuolated benign mesothelial cells
Renal failure patient, vacuolation properly due to degeneration
especially in chronic effusion, or drug induced. Mild nuclear
enlargement, look like signet ring CA but nuclear is fine, no mucin
in vacuole
Benign mesothelial cells in peritoneal washing
Note flat sheet of mesothelial cells with regular nuclei
 Reactive mesothelial cells

• Common in chronic or long-standing serous effusion

• Secondary to cirrhosis, chronic inflammatory lung
diseases, collagen vascular disease or trauma
• May form large 3-D ball clusters
• If nuclei atypia mimick malignant cells (enlarged,
hyperchromatic, irregular nuclei, presence of nucleoli):
atypical mesothelial cells
 Reactive mesothelial cells
Note nuclei irregularity, enlargement, and conspicious nucleoli but
fine chromatin, size of nucleoli not alarming, uniformity of the cells
Reactive mesothelial cells
Note: the multinucleated mesothelial cells
Atypical mesothelial cells in a SLE patient
Note nuclei hyperchromasia and enlargement
Benign conditions
 Neutrophils predominate in effusions

– Empyema (a collection of pus within a naturally existing anatomical cavity)

– puenmonia,
– infarction,
– rupture of organ
– malignancies
– etc
Neutrophils predominate in pleural effusion
Patient has pneumonia
 Lymphocytes predominate in effusion

• Chronic pleurisy (an inflammation of the pleura)

• TB
• Viral pneumonia
• Congestive heart failure (common)
• Lymphoma
• Other malignancies
• etc…..
Lymphocytes predominate in pleural effusion
TB case
Lymphocytes predominate, a cluster of
epitheloid cells in pleural effusion
M/77, right pleural fluid. TB case
 Eosinophilic pleural effusion
• Definition: pleural effusion: >10% eosinophil
• Causes
– Air in pleural cavity (pneumothorax)]
– blood in pleural cavity
– Post surgery or repeated thoracentensis
– Infections / infestations
– Pulmonary infarcts
– Hypersensitivity
– Drug induced pleural effusion
– etc……
• Uncommon in TB and malignancies
• No etiology causes in 1/3 of patients
 Systemic lupus erythematosus (SLE)

• Exudate
• Neutrophils predominate
• Presence of LE cells (a neutrophil / a marcophage
containing homogenous haematoxylin body)
 LE cells
From: Chou KT et.al.(2007), Lupus erythematosus (LE) cells in ascites:
initial diagnosis of systemic lupus erythematosus by cytological
examination: a case report, Clinical Rheumatology, Volume 26, Number
11, 1931-1933
 Neoplastic diseases
• Primary tumor: Malignant mesothelioma
• Lung Carcinoma
• Breast Carcinoma
• GI tract Carcinoma
• Ovarian tumor
• lymphoma

(Recognition of 2nd population approach)

 Prevalence of metastatic cancers in pleural effusion

• Men
– Lung
– Lymphoma
– Gastrointestinal

• Women
– Breast
– Lung
– Ovarian
– Gastrointestinal caner

In USA, only 1% mesothelioma

 Prevalence of metastatic cancers in peritoneal fluid

• Men
– Gastrointestinal
– Lung
– Lymphoma

• Women
– Ovarian
– Breast
– Gastrointestinal
 Identifying metastatic cancers in effusions

• Cytomorphology can divide cancers to epithelial, lymphomatous, melanocytic and

sarcomatous

Cytomorphology Most likely primary sites

Single cell pattern Lymphomas

Cannonball pattern Ductal CA of breast and ovary

Paillary formation and psammoma Carcinoma of ovary

bodies
Single file pattern Lobular ca of breast

Pseudomyxoma peritonei Mucinous neoplasm of ovary and

appendix
Signet ring cells CA of stomach and breast (lobular)

Pigmented cells melanoma

Small cells Small cell carcinoma of lung

Lobular carcinoma
Squamous cells Squamous cell carcinoma

Spindle cells Sarcoma

 Mesothelioma
• Rare primary disease
• Commonly related to occupational asbestos
exposures
• Other potential causes: chronic inflammation,
organic chemicals, irradiation etic
• Mainly in pleural cavity
• 75% patients: 50 to 70 age
 Cytology of mesothelioma (EM)
• In 50% of cases: Tumor cells in singly, small groups or
clusters (>50 cells)
• In 25% cases: predominantly in 3-D clusters
• In 25% cases: predominantly singly
• Resemble normal mesothelial cells except larger,
prominent nucleoli
• Spectrum of nuclear changes ranging from benign to
atypical to malignant
• “window between cells”
• Fuzzy border
• Adenomatoid mesothelioma with extensive
cytoplasmic vacuolization (look like signet ring cell)
 Malignant mesothelioma
Singly, larger cluster of malignant cells
 Malignant mesothelioma
Note: cytoplasmic blebbing (irregular bulge in the plasma membrane,
formed by coalescence of microvilli)
 Lung carcinoma
• 30% of all pleural malignant effusions

• Adenocarcinoma (most common), Bronchioalveolar carcinoma,

large cell carcinoma, squamous cell carcinoma, small cell carcinoma

• Express CK7, CEA, and TTF-1 (except SCC)

– TTF-1: Thyroid transcription factor-1, found in pneumocytes of lung and
follicular cells of thyroid
– CEA : Carcinoembryonic antigen, tumor markers for colon, breast, lung
etc….
 Lung carcinoma (adenocarcinoma)
Pericardial fluid: F/53: Large to medium sized nuclei, irregular
cluster, prominent nucleoli, cytoplasmic vacuolization in some
group, irregular nuclei, psammoma bodies noted in cell block
 Lung carcinoma (adenocarcinoma)
Pleural fluid: F/85: Mainly singly or loose cluster, prominent
nucleoli, irregular nuclei. IM: TTF-1 +ve, AE1/AE3 +ve; Calretinin -
ve
Lung carcinoma in pleural fluid
Uncommon, well differentiated Keratinizing SCC
 Small cell carcinoma of lung
• Small, cuboidal cells, scant cytoplasm
• Small round nuclei
• Stippled chromatin
• Inconspicious nucleoli
• Chains or clusters with nuclear molding
• Express neuroendocrine markers (neuron-specific
enolase, chromogranin, synaptophysin) and TTF-1
 Small cell carcinoma of lung
Pleural fluid: M/76: Small tumor cells with scant cytoplasm,
hyperchromatic nuclei and nuclear molding
 Small cell carcinoma of lung, intermediate type
Pleural fluid: F/70: tumor cells of medium size with scant
cytoplasm, hyperchromatic nuclei and nuclear molding
 Breast carcinoma
• 25% all malignant pleural effusion

• Ductal carcinoma: monomorphic, irregular nuclei, multiple nucleoli,

3-D clusters / papillary, or singly, resemble atypical or reactive
mesothelial cells

• IM Positive: CK7, ER, PR, Gross cystic disease fluid proteins

(GCDFP-15, highly specific and sensitive breast CA marker)

• CK20: negative
 Ductal carcinoma of breast
Pleural fluid: F/66: Note cannoball appearance in low power. Tumor
cells show medium sized nuclei with multiple nucleoli with
occasional vacuolated cytoplasm
 Lobular carcinoma of breast

• Small cell singly or loose cluster

• Hyperchromatic irregular nuclei
• Signet ring / Small chains ( indian file)
• IM Similar to ductal CA
 lobular carcinoma of breast
Pleural fluid, F/72: Note signet ring appearance, eccentric nuclei
and mild nuclear pleormorphism
 Gastrointestinal carcinoma
• Poorly differentiated: May be mainly singly

• Well differentiated: Cohesive clusters of atypical glandular cells

• Diffuse gastric carcinoma: Intracytoplasmic vacuoles (signet ring

CA) (signet ring CA cells: also in colon, breast..etc.)

• Malignant effusions caused by carcinomas of small intestine:

relatively uncommon (stomach and colorectal: common)

• Adenocarcinoma of appendix: common cause of mucinous ascitis

(pseudomyxoma peritonei)
 Adenocarcinoma
of colorectal origin in peritoneal fluid
Peritoneal fluid: M/66: poorly differentiated, mainly solitary tumor
cells
Colonic adenocarcinoma, non-secretory type
Pleural fluid: F/64: Note: elongated, oval, medium sized nuclei
 Colonic adenocarcinoma, secretory type
Peritoneal fluid: M/65: Note: clear or vacuolated cytoplasm
 Poorly differentiated adenocarcinoma c/w
gastric primary
Pleural fluid: F/30: high celluarity, solitary medium size tumor cells
with hyperchromatic nuclei and high N/C ratio
Adenocarcinoma (signet ring) c/w stomach primary

Note : Peritoneal fluid: F/58, cytoplasmic vacuole (signet ring

appearance)
 Adenocarcinoma, gastric primary (intestine type)

Note : Peritoneal washing: M/68, 3D cell balls, hyperchormatic

medium size nuclei, conspicuous nucleoli, vacuolated cytoplasm
 Pseudomyxoma peritonei
Note: atypical cells in a background of mucin. Patient has mucinous
adenocarcinoma of appendix
 Ovarian carcinoma

• Serous carcinoma of ovary:

– papillary clusters and /or psammoma bodies
– express WT-1, CA125 (cancer antigen 125) and CK7;
– CK20: negative

• Mucinous carcinoma:
– vacuolated cytoplasm in a background of mucin
– Express CK7 and CK20;
– WT-1 and CA125: negative
Serous carcinoma of ovary in peritoneal
fluid
Peritoneal fluid: F/50: Note papillary group with no cytoplasmic
vacuole
 Endometrioid adenocarcinoma
of uterus in peritoneal fluid
Peritoneal fluid, F/48; Patient has grade 1 endometrioid
adenocarcinoma of uterus
 Malignant lymphoma

• Koss (2006): 4 groups in effusions (for purpose of

recognition)

– Large cell lymphoma

– Small cell lymphoma
– Hodgkin lymphoma
– Miscellaneous lymphoproliferative and haematologic
disorders such as myeloma.
 Cytology of malignant lymphoma in effusions

• Single, isolated cancer cells, never form clusters

• Monomorphic population
• Scant cytoplasm
• Nuclei: spherical, oval, irregular
• Nuclear protusion, cleft, indentation (characteristic of
lymphoma)
• Hodgkin lymphoma: Presence of Reed-Sternberg (RE)
cells
 Large-Cell lymphoma
Pericardial fluid: M/24: large lymphoid cells, round to oval nuclei,
some with nuclear protusion and cleft, enlarged and multiple
nucleoli, apotosis noted
 Burkitt lymphoma
• Monomorphic, non-cohesive, non-cleaved, medium sized cell with regular
nuclei.
• Prominent cytoplasmic vacuoles (readily seen in DQ)
• Multiple prominent nucleoli
 Small-cell lymphoma
Peritoneal fluid: M/36: monotonous small lymphoid cells,
hyperchromatic nuclei, some show cleaved nuclei (cleft,
protusion, indentation)
The End

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