Serous fluid cytopathology



The foundation of E-sc@n:

E-sc@n is a network of european pathologists currently in progress. It was initated in June 2008 by Eric Piaton, MD (Lyon, France) and Philippe Vielh, MD (Villejuif, France) with the aid and support of a number of friends and colleagues throughout Europe. All contributors or sympathizers are professionals in cyto- or histopathology and are members or leaders of national cytology societies. EP is currently secretary general of the French Society of Clinical Cytology (SFCC), whereas PV is secretary general of the European Federation of Cytology Societies (EFCS).

Ben Davidson (
Oslo, Norway) and Katharina Glatz (Basel, Switzerland) are early partners of the E-sc@n project. They kindly accepted to share their skill and experience in the molecular biology and telecytology/quiz parts of the site. Gilbert Francz (Basel, Switzerland) kindly allowed us to use the Flexiform software to build surveys and quiz. Véronique Hofman (Nice, France) provided a lot of cyto- and histopathological cases, most of them remaining to be included in the educative part of the blog. We hope that we will be able to keep their confidence, in spite of the slowness and difficulties linked to daily hard work and lack of secretaryship.


The aims of E-sc@n:

The vocation of  E-sc@n is to develop exchanges between practicing pathologists involved in the evaluation of serous effusions in humans. The website, under construction, is designed as a blog. The idea is primarily to create ties between european pathologists and have research projects and publications in common. In this way, E-sc@n could contribute to influence renewing international perspectives on quality assurance in cytopathology. It also aims at building an educative, peer-reviewed and thoroughly illustrated content in the field of serous fluid cytopathology. It will ease content sharing, also by non-expert users such as thesis students.

The architecture of E-sc@n:
The educative content will be divided into four parts:

It aims at explaining the etiology and pathogenesis as well as the background of biochemical disorders affecting the serous cavities. It will particularly investigate the role of the fluid tests when considering malignancy: nucleated cell count and differential, total protein, LDH, glucose, pH, amylase, and cytology.

The section will address the requirements that are needed to agree that a slide is technically adequate for assessment. Because ancillary techniques are treated elsewhere, this part will only concern conventional preparatory methods such as cell fixation and concentration, elimination of RBC, cell block method and LBC. Staining schedules will also be described.

MORPHOLOGICAL CRITERIA: This part aims at identifying the cellular and architectural features that allow accurate diagnosis. Cells in a fluid bear little resemblance with their counterparts in tissue specimens. Therefore, interpretation criteria are somewhat different.

Considerable improvements have been achieved in recent years through the use of molecular biology techniques on cell blocks and LBC material. These advances now allow a significant body of data in the diagnosis, classification, and prediction of biological behaviour of effusions to be obtained.


The cooperative work of E-sc@n:

The first cooperative work of E-sc@n was initiated in 2009 but was not transformed into full-text article or formal presentation. A questionnaire on all aspects of serous fluid cytopathology (from the receipt to the transmission of the results) was built. The survey was then completed by members of the E-sc@n project. The results will be presented as soon as the data will be formatted.


Don't hesitate to give your opinion about the project in progress and to register at the Newsletter, in order to keep informed of all further developments.

Jeudi 2 juin 4 02 /06 /Juin 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:


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%)



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.



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.



  • 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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Mardi 31 mai 2 31 /05 /Mai 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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Mardi 7 juillet 2 07 /07 /Juil 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 (

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Mercredi 1 juillet 3 01 /07 /Juil 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 (

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Mardi 30 juin 2 30 /06 /Juin 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 (

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