2 juin 2011 4 02 /06 /juin /2011 18:57

Malignant serous effusion in the pleura, peritoneum and (less frequently) pericardium is a frequent complication of primary adenocarcinomas, particularly in female patients with breast or ovarian cancer, and in both sexes with lung carcinoma. In female patients, about 2/3 of ovarian carcinoma cases have intraperitoneal free cancer cells (IFCCs) in the peritoneum at the stage of diagnosis. Patients may develop malignant effusions years or, particularly in breast cancer cases, tens of years after the initial diagnosis.

 

Frequency of primary tumour sites in case of metastatic effusion:


PLEURAL EFFUSIONS

About 50% of carcinomatous effusions are metastatic adenocarcinomas, followed by pulmonary large cell carcinomas and lymphomas/leukemias (about 15% each)

 

Male patients: lung (50%), lymphoma/leukemia (21%), gastrointestinal tract (7%), genitourinary tract (6%) and malignant melanoma (1.5%)

Female patients: breast (38%), genital tract (ovary: 20%), lung (15%), lymphoma/leukemia (8%) and gastrointestinal tract (4%)


 


PERITONEAL EFFUSIONS

Malignant ascitis accounts for about 10% of all ascites and occurs as complication of a variety of primary cancers, particularly from the breast, bronchus, ovary, stomach, pancreas and colon sites. Up to 20% of patients with malignant ascitis have primary tumours of unknown origin at time of the diagnosis.

 

Male patients: colon, rectum, stomach, pancreas

Female patients: ovary (30-54%), endometrium, uterine cervix, pancreas, stomach, uterus + extra-abdominal sites (breast, lung, lymphomas)

 

Pathophysiology of malignant ascitis is incompletely understood. Accumulation of fluid may result from obstruction of lymphatic vessels by tumour cells. Many patients with malignant ascites having exsudates with high protein content, alteration of vascular permeability has also been implicated. As a consequence of obstructed lymphatics the circulating bloodvolume is reduced and this activates the renin-angiotensin-aldosterone system, leading to sodium retention. Reduced sodium intake together with diuretics is therefore used to treat malignant ascites, although there is no consensus on effectiveness. In contrast to the treatment of underlying cancer, there is no accepted evidence-based guideline for the management of malignant ascites.  

 


 


PERICARDIAL EFFUSIONS

Primary malignancy of the pericardium is rare, whereas secondary involvement is more common. About 40% of patients with malignancy and pericardial disease have benign alteration of the pericardium. Restrictive pericardial disease with effusion is most commonly associated with radiation therapy (radiation pericarditis), whereas idiopathic pericarditis is usually associated with chest pain, dyspnea, and fever.

 

Male patients: lung, lymphoma/leukemia, melanoma

Female patients: breast, lung, lymphoma/leukemia, melanoma


 

Malignant mesothelioma (MM) which also affects the serous cavities as primary malignancy often present as recurrent unilateral haemorragic effusion, with rapid clinical evolution.

 

Considering the prognostic implications the presence of malignant cells have in effusions, accurate morphological diagnosis is of paramount importance. Therefore, recognition of malignancy needs that reproducible morphological criteria are known and widely diffused. Reactive mesothelial cells may mimic malignant cells, particularly after radio- or chemotherapy, and malignant cells may be as regular as the more benign-appearing cells. In the peritoneum, caution is advised to avoid misinterpretation of endometriosis or endosalpingiosis with adenocarcinoma (Lin, 2009). Malignant cells may be rare and surrounded by many inflammatory and reactive cells, thus rendering their detection harmful.

 

For both reasons, sensitivity of cytology for the detection of malignant cells varies between 40% and 80%. Such values not only depend on the manner the fluid has been collected, fixed and transported, but also on the quality of preparatory methods. Standardization of  concentration and staining procedures has been achieved in most laboratories with cytocentrifugation, liquid-based procedures and staining automatons. The use of cell blocks also has gained wide acceptance, thus allowing immunochemical techniques to be applied more confidently. But even experienced cytopathologists are not always capable to distinguish between reactive, degenerative and malignant cells, particularly in suboptimal conditions.

 

Panels of immunochemical markers are now used in most cases, and not only in the more difficult ones. For years, authors have attempted to define the best combination of antibodies for diagnostic purpose, particularly for the differentiation between MM and metastatic adenocarcinoma. Advances in immunochemical methods and in molecular biology now allow to study diagnostic, therapeutic and prognostic issues in malignant effusions.

 

References

  • Beckera G, Galandib D, Bluma HE. Malignant ascites: systematic review and guideline for treatment. Eur J Cancer 2006; 42: 589-597
  • Fenton KN, Richardson JD. Diagnosis and management of malignant pleural effusions. Am J Surg 1995; 170: 69-74 
  • Johnston WW. The malignant pleural effusion. A review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients. Cancer 1985; 56:905-909
  • Kralstein J, Frishman W. Malignant pericardial diseases: diagnosis and treatment. Am Heart J 1987; 113: 785-790
  • Lewis JP. Malignant pericardial effusion. West J Med 1989; 150: 202-203
  • Lin O. Challenges in the interpretation of peritoneal cytologic specimens. Arch Pathol Lab Med 2009; 133: 739-742
  • Parsons SL, Watson SA, Steele RJC. Malignant ascites. Brit J Surg 1996; 83: 6-14
  • Parsons SL, Lang MW, Steele RJC. Malignant ascites: a 2-year review from a teaching hospital. Eur J Surg Oncol 1996; 22: 237-239
  • Thivolet-Béjui F. Cytopathologie du péricarde. Ann Pathol 2006; 26: 333-339

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31 mai 2011 2 31 /05 /mai /2011 10:57

The diagnostic and molecular characteristics of malignant mesothelioma and ovarian/peritoneal serous carcinoma

Ben Davidson (Division of Pathology, Norwegian Radium Hospital, Oslo University Hospital, Norway) recently published in Cytopathology 2011 Feb;22(1):5-21

 

Malignant mesothelioma and ovarian/peritoneal serous carcinoma are two of the most common tumours affecting the serosal cavities. Unlike other malignant tumours diagnosed at this anatomical site, such as lung and breast carcinoma, malignant mesothelioma and serous carcinoma share a common histogenesis, may be difficult to differentiate morphologically, and co-express many of the diagnostic markers used by cytopathologists in effusion diagnosis.

 

Selected markers have nevertheless shown sufficient sensitivity and specificity to differentiate serous carcinoma from malignant mesothelioma effectively. Recently, our group applied high throughput technology to the identification of new markers that may aid in differentiating these two cancer types and validated several of these markers in follow-up studies. This review will present current data regarding the diagnostic and biological aspects of malignant mesothelioma and ovarian/peritoneal serous carcinoma.

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7 juillet 2009 2 07 /07 /juillet /2009 09:54

Virganeyce Lyons-Boudreaux and colleagues, from the Department of Pathology of Houston (Texas), recently published a paper** about "Cytologic malignancy versus benignancy: how useful are the newer markers in body fluid cytology?" in the January 2008 issue of Archives of Pathology and Laboratory Medicine (2008 Jan; 132(1): 23-8).

 

MOC-31 positige ADC, membraneous pattern

MOC-31 positive adenocarcinoma, membranous staining

 

Key message: MOC-31 and D2-40 were very sensitive and specific markers of epithelial and mesothelial cells, respectively. Compared with calretinin, D2-40 was a more sensitive marker of mesothelial cells. In the study reported, WT1 proved to be nonspecific.

 

**Obtained from the Arch. Pathol. Lab. Med. website found on PubMed (http://www.ncbi.nlm.nih.gov/pubmed/)

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1 juillet 2009 3 01 /07 /juillet /2009 09:02

Oscar Lin, pathologist at the Department of Pathology of the Memorial Sloan-Kettering Cancer Center, New York, recently published a paper** entitled "Challenges in the interpretation of peritoneal cytologic specimens" in the May 2009 issue of Archives of Pathology and Laboratory Medicine.

**Obtained from the Allen Press, Inc. full text link found on PubMed (http://www.ncbi.nlm.nih.gov/pubmed/)

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30 juin 2009 2 30 /06 /juin /2009 22:44

Dilip K. Das, Associate Professor at the Department of Pathology, Faculty of Medicine of Kuwait University, recently published a paper** entitled "Psammoma body: a product of dystrophic calcification or of a biologically active process that aims at limiting the growth and spread of tumor?" in the April 2009 issue of Diagnostic Cytopathology.

**Obtained from the Wiley InterScience full text link found on PubMed (http://www.ncbi.nlm.nih.gov/pubmed/)

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17 juin 2009 3 17 /06 /juin /2009 11:22

A new page about the communication and publication actions we intend to develop now appear in the pages section. The page of the day is promotional aspects - communication and publication. For contributing or for adding personal illustrations, please do not hesitate to send material to the E-sc@n project coordinator.

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14 juin 2009 7 14 /06 /juin /2009 11:22

New pages about the various diagnostic features exhibited by adenocarcinomatous cells now appear in the pages section. The page of the day is serous papillary adenocarcinoma (1). For contributing or adding personal illustrations, please do not hesitate to send material to the E-sc@n project coordinator.

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11 juin 2009 4 11 /06 /juin /2009 13:09

As it is stated in the New England Journal of Medicine  "Images in Clinical Medicine" section, images are an important part of what we can learn in medicine. Images shown are those of a Papanicolaou-stained peritoneal fluid in a 89-year-old woman. The patient had no particular history, except ascitis.

Case 09EC04672, provided by E. Piaton
Cytologically the specimen was highly cellular, revealing numerous malignant cells in papillary clusters, packed in three-dimensional groups with evident nuclear atypias (eccentric nuclei with ncreased N/C ratio, irregular nuclear borders, slight hyperchromatism and nucleoli). The cells shown were not mesothelial in nature. Typical psamomma bodies were located at the center of occasional papillary clusters. The diagnosis retained was that of a papillary adenocarcinoma, most probably of ovarian origin. It is unprobable that we obtain any histological confirmation because of the age of the patient.

 


Figures 1 and 2: Papanicolaou, x1000 (oil)

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10 juin 2009 3 10 /06 /juin /2009 11:32

New pages about the various diagnostic features exhibited by mesothelial cells now appear in the pages section. The page of the day is clusters with collagen cores. For contributing or adding personal illustrations, please do not hesitate to send material to the project coordinator.

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10 juin 2009 3 10 /06 /juin /2009 10:47

 

 

 

 

 

 

 

 

 

New, original images have been received from Ben Davidson (Oslo, Norway) about modern immunocytochemical markers that can be successfully applied to effusions. Some markers are clearly diagnostic (calretinin, MUC-4, HER2/neu...) whereas others may have a prognostic value. For example, the growth factor granulin-epithelin precursor (GEP) is a novel marker which may have predictive value for overall survival in epithelial ovarian cancer (Davidson et al, 2004).

Many thanks to Ben for those high quality images (to be completed at a later date by text and references).


Figures 1 and 2: HER2/neu in breast carcinoma (left), and GEP in ovarian carcinoma (right)

 

Figures 3 and 4: HLA-G in ovarian carcinoma (left), and MUC-4 in ovarian carcinoma (right)

Reference
Davidson B, Alejandro E, Florenes VA, Goderstad JM, Risberg B, Kristensen GB, Trope CG, Kohn EC. Granulin-epithelin precursor (GEP) is a novel prognostic marker in epithelial ovarien cancer. Cancer 2004, 100, 2139-2147

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