Presence of simian virus 40 sequences in malignant mesotheliomas and mesothelial cell proliferations

Malignant mesotheliomas (MMs) are pleural‐, pericardial‐, or peritoneal‐based neoplasms usually associated with asbestos exposure. Mesothelial cells are biphasic and may give rise to epithelial and sarcomatous MMs. In addition, benign or atypical proliferations of mesothelial cells may occur in response to many stimuli. There have been recent reports of simian virus 40 (SV40) DNA large T antigen (Tag) sequences in pleural MMs. To further understand the relationship between SV40, MMs, and mesothelial proliferations, we studied 118 MMs from multiple sites in Germany and North America, including 93 epithelial pleural, 14 sarcomatous or mixed pleural MMs, and 11 peritoneal MMs. In 12 pleural MMs, adjacent noninvasive tumor foci were identified and studied separately. Information about asbestos exposure (detailed history and/or microscopic examination for asbestos bodies) was available from 43 German patients. In addition, 13 examples of reactive mesothelium and 20 lung cancers from the United States were tested. DNA was extracted from frozen tumor and adjacent nontumorous tissues or after microdissection of archival formalin‐fixed, paraffin‐embedded microslides. Two rounds of PCR were performed with primers SVFor 3 and SVRev, which amplify a 105 bp region specific for SV40 Tag. The specificity of the PCR product was confirmed in some cases by sequencing. Our major findings were: 1) Specific SV40 viral sequences were present in 57% of epithelial invasive MMs, of both pleural and peritoneal origin. No significant geographic differences were found, and frozen and paraffin‐embedded tissues were equally suitable for analysis. 2) There was no apparent relationship between the presence of SV40 sequences and asbestos exposure. 3) SV40 sequences were present in the surface (noninvasive) components of epithelial MMs. 4) SV40 sequences were not detected in MMs of sarcomatous or mixed histologies. 5) Viral sequences were present in two of 13 samples (15%) of reactive mesothelium. 6) Lung cancers lacked SV40 sequences, as did non‐malignant tissues adjacent to MMs. Our findings demonstrate the presence of SV40 sequences in epithelial MMs of pleural and peritoneal origin and their absence in tumors with a sarcomatous component. Viral sequences may be present in reactive and malignant mesothelial cells, but they are absent in adjacent tissues and lung cancers. J. Cell. Biochem. 76:181–188, 1999. © 1999 Wiley‐Liss, Inc.     

Ascitic fluid cytology in a case of metastatic malignant mixed mesodermal tumor of the ovary

The cytologic features of the abdominal fluid from a patient with a malignant mixed mesodermal tumor (MMMT) of the ovary are presented. Both malignant epithelial and stromal elements were cytologically appreciated and confirmed by histologic examination. Other ovarian neoplasms that can present with malignant sarcomatous elements or mixed epithelial and sarcomatous elements are discussed; this case documents the importance of recognizing these features when staging patients with unusual ovarian neoplasms. To our knowledge, this is the first complete report of the ascitic fluid cytology of an MMMT of either ovarian or uterine origin.     

Cytology of vaginal and uterine sarcomas

OBJECTIVE: To retrospectively review, based on cytologic and histopathologic findings, the diagnoses of 13 patients with uterine sarcoma and 1 with vaginal sarcoma. STUDY DESIGN: There were 8 cases of uterine carcinosarcoma (CS), 2 of leiomyosarcoma, 2 of endometrial stromal sarcoma (ESS), 1 of endocervical stromal sarcoma (ECSS) and 1 of malignant fibrous histiocytoma (MFH) of the vagina. The presence of sarcomatous components was retrospectively investigated by microscopic observation of preoperative specimens from the endocervical canal and endometrial cells. Characteristic features of sarcomatous cells were then investigated by cytodiagnostic micrometry of malignant cells. RESULTS: Of the 14 patients, 1 with low grade ESS and 1 with homologous CS were diagnosed as negative for sarcomatous components. One case of high grade ESS had been overlooked, as were 4 cases of CS. Thus, 7 cases (50%) were diagnosed as positive for sarcomatous cells by preoperative cytologic observation. Based on these findings, 12 of the 14 cases (85.7%) were positive for sarcomatous elements on retrospective reexamination of the specimens. CONCLUSION: Careful attention should be paid to small sarcomatous cells since cases of ESS or ECSS with such cells show morphologic characteristics similar to those of stromatous cells. Furthermore, careful microscopic observation of an entire specimen is required to avoid misdiagnosis as carcinoma since it is easy to overlook sarcomatous elements in smears with carcinosarcoma if there are only a few sarcomatous cells.     

Fine needle aspiration cytology of malignant mesothelioma

The results of fine needle aspiration (FNA) cytology in 19 cases of malignant mesothelioma are presented. Adequate material for a diagnosis of malignancy was obtained in 17 cases, and in 8 cases a specific diagnosis of mesothelioma could be made. In four other cases, the findings were either consistent with or suggestive of mesothelioma; in four, accurate distinction from other neoplasms was not possible, and in two cases, adenocarcinoma was suggested. The spectrum of cytologic findings ranged from neoplasms of purely epithelial appearance through more pleomorphic biphasic neoplasms to anaplastic tumors. A combination of epithelial-like cell clusters, pavement-like sheets of epithelial cells with well-defined cell borders and prominent cell separation, dispersed angular cells with dense cytoplasm and some spindle-cell forms was the most specific cytologic pattern for mesothelioma. In four neoplasms, ultrastructural examination of aspirated material provided the additional evidence for a definitive diagnosis. The identification of hyaluronic acid within intracytoplasmic vacuoles, either in smears or in cell blocks, confirmed the diagnosis in three tumors. Only in one case, with a strong clinical background suggesting mesothelioma, was the cytologic preparation sufficient for diagnosis without ancillary diagnostic methods. FNA is of particular value in the diagnosis of pleural mesothelioma in patients who do not present with a pleural effusion. Obtaining material for cell block preparations, cytochemistry or ultrastructural study is generally necessary for definitive tumor typing.     

Positive effusion cytology as the initial presentation of malignancy

During a period of four years (1981 to 1984), 641 ascitic, 860 pleural and 47 pericardial fluid specimens were examined cytologically. Of these, 154 ascitic samples, 174 pleural specimens and 10 pericardial effusions, obtained, respectively, from 108, 133 and 7 patients, were found to contain malignant cells. In 7 patients, ascites, and in 18 cases, pleural effusions were the first indication of cancer. None of the positive pericardial fluids was the initial presentation of malignancy. The cytologic findings and follow-up data on these 25 patients are the subject of this study. The most common type of neoplasm in these effusions was adenocarcinoma (86% of the ascitic and 78% of the pleural fluids). Most of the malignant neoplasms in ascitic fluids were derived from ovarian tumors (5 of 7) while those in pleural effusions came mainly from lung tumors (12 of 18). Mammary carcinoma, which was the most common malignant tumor found in cases of pleural effusions, did not present initially with an effusion in any of our cases. The cytologic diagnosis was confirmed in all cases by either biopsy or strong clinical evidence. The prognosis in patients who initially presented with an effusion was poor. All of the patients with an adequate follow-up died within 29 months in cases of ascites and within 19 months in cases of pleural effusions.     

Malignant phyllodes tumor with pleomorphic liposarcomatous stroma diagnosed by fine needle aspiration cytology: a case report

BACKGROUND: Liposarcomatous differentiation within a phyllodes tumor is extremely rare. Cytologic and histologic findings of a case of malignant phyllodes tumor with liposarcomatous stroma of the breast are presented. CASE: A 45-year-old female had a malignant phyllodes tumor with pleomorphic liposarcomatous stroma diagnosed by fine needle aspiration (FNA) cytology. The cytologic findings were representative of the histologic features. CONCLUSION: Malignant phyllodes tumor of the breast can be diagnosed by FNA. It is very important to acknowledge the morphologic variants of sarcomatous stroma and to recognize the cytologic features of such rare tumors to prevent misdiagnosis as primary sarcomas of the breast. Preoperative diagnosis is important in planning the most appropriate type of treatment. It is also important to follow patients for long periods for recurrence and metastasis after surgery for this tumor.     

Cytology of angiosarcoma in effusions

The cytologic and immunocytochemical findings in pleural effusions from three cases of angiosarcoma are presented. In two of the cases, the primary lesion was on the scalp; in the third case, an angiosarcoma of the small intestine developed after radiotherapy for Hodgkin's disease. Single malignant cells and small clusters of cells were seen in cytologic preparations from two cases while only single cells were seen in preparations from one case. The malignant cells had delicate, finely vacuolated cytoplasm with distinct borders. No specific morphologic features were noted. Immunoperoxidase studies revealed binding of Ulex europaeus and reactivity for vimentin in all three cases and expression of Factor VIII-related protein in two of the cases but no expression of epithelial markers. The clinical history and immunoperoxidase studies are necessary to distinguish angiosarcoma from metastatic adenocarcinoma and other malignancies in effusions.     

Preoperative cytologic diagnosis of primary gastrointestinal malignant lymphoma

This report is based on the review and study of primary gastrointestinal malignant lymphomas as seen in cytologic brushing and washing specimens. During a period of 12 years (1970 to 1981), a total of 2,675 patients with malignant lymphoma involving the gastrointestinal tract were seen at Memorial Sloan-Kettering Cancer Center. Of these patients, 73 were diagnosed as having primary malignant lymphoma of the gastrointestinal tract. A total of 49 preoperative cytologic specimens obtained from 29 patients with histologically confirmed primary gastrointestinal malignant lymphoma were examined and are the basis for this study. Twenty-four patients had gastric primaries; three tumors were in the colon and two were small intestinal lymphomas. Thirty-three cytologic specimens taken from 25 patients were considered diagnostic for malignant lymphoma. A positive cytologic brushing was the only diagnostic preoperative specimen for 9 of the 29 patients. Combined cytologic and biopsy specimens provided a diagnosis of malignant lymphoma for 16 patients. Cytologic washings did not add to the diagnostic accuracy. The 29 cases of malignant lymphoma reviewed here were histologically subclassified as 23 large-cell, poorly differentiated and six small-cell, well-differentiated lesions. The cytomorphologic features of malignant lymphoma as observed in gastrointestinal specimens are outlined, and differential diagnoses are discussed. Clinicopathologic implications of the cytologic findings are considered.     

Exfoliative cytology of nonlymphoreticular neoplasms in children

During the last 11 years, 144 nonlymphoreticular neoplasms were diagnosed in exfoliative cytology specimens obtained from patients younger than 17 years of age. Neuroblastoma was the single most common neoplasm (30 cases). Other categories of malignant neoplasms were primary bone tumors (30 cases), soft-tissue sarcomas (25 cases), brain tumors (25 cases) and epithelial neoplasms (7 cases). Of the 780 cytologic specimens, 335 were positive for malignant cells. Serous effusions provided most of the positive specimens from patients with neuroblastoma, germ-cell tumors and bone sarcomas. Exfoliated cells of metastatic embryonal rhabdomyosarcoma and primary brain tumors were detected most often in cerebrospinal fluid specimens. A most unusual presentation of an immature teratoma of the ovary is described in some detail. Despite the rarity of pediatric neoplasms, certain specific or suggestive cytologic features were recognized, including rosette formation of neuroblasts, nuclear notching of myoblasts, pleomorphism of osteoblasts and fibrillar processes of glial elements.     

Potential use of loss of heterozygosity in pleural effusions of breast cancer metastases using the microsatellite marker of the 16q22.1 region of the CDH1 gene

OBJECTIVE: To evaluate the presence of allelic loss in 16q22.1, including the locus of E-cadherin, in pleural effusions in breast cancer patients. STUDY DESIGN: Molecular analysis of DNA was performed using a DNA extraction kit (NucleoSpin, Macherey-Nagel, Germany). Loss of heterozygosity (LOH) in primary tumors and pleural effusions was analyzed using a microsatellite marker of the CDH1 gene, D16S265, described in previous studies. LOH was evaluated by radioactive polymerase chain reaction assay in 17 samples of pleural effusions and breast tissues (primary tumors and nonneoplastic adjacent tissue) from breast cancer patients: 7 positive for neoplastic cells, 6 suspected and 4 cases without evidence of neoplastic cells in the effusions. RESULTS: Thirteen cases (76%) were informative. LOH was detected in 5 cases (38.5%). In 3 of them LOH was detected only in the cytologic sample, and in 2 of them LOH was detected in the primary tumor and cytologic sample. CONCLUSION: Results show that LOH in the CDH1 gene can identify tumor cells in pleural effusions when morphologic analysis is difficult.     

Bronchial cytology in pleural mesothelioma. A report of 3 positive cases, including 1 diagnosed initially on bronchial brushings

OBJECTIVE: To evaluate retrospectively the value of bronchial aspiration cytology in patients with histologically proven pleural mesothelioma, reappraising positive smears in light of conventional microscopic features and, when feasible, immunocytochemical investigations. STUDY DESIGN: In 3 cases of mesothelioma with bronchial brushings positive for malignant cells, the cytologic features were correlated with the histologic findings. RESULTS: Salient microscopic features included scant to moderate cellularity arranged in micropapillary clusters, morular aggregates with scalloped borders and isolated malignant cells. Intercellular clear spaces or windows suggesting a brush border on cell membranes were also noted. In cases with available material, immunocytochemistry was positive for keratins, epithelial membrane antigen and calretinin and negative for carcinoembryonic antigen. All the cases were histologically confirmed epithelial mesotheliomas. CONCLUSION: In rare cases, pleural mesothelioma cells are shed within the airway lumina and can be detected in bronchoscopic cytology specimens. Cytologic features seem comparable to their analogues in pleural effusions. Although no single criterion appears diagnostic, their combined documentation could ensure correct interpretation, especially if supported by a limited immunocytochemical panel.     

Fine needle aspiration of borderline ovarian lesions. Is It useful?

Borderline ovarian tumors are a low grade form of epithelial ovarian carcinoma with a low rate of growth and a low potential to invade or metastasize. According to the new World Health Organization classification, these tumors are placed between clearly benign and obviously malignant tumors because they exhibit some, but not all, of the morphologic features of malignancy. For a distinction between borderline lesions and cystadenomas or carcinomas, 2 criteria are of the utmost importance: presence of nuclear atypia and absence of stromal invasion. The pathologic subtype ofperitoneal implants is probably one of the main prognosticfactors in patients with serous tumors of low malignant potential, while the prognostic value of micropapillary serous carcinoma in patients with noninvasive implants remains debatable. Although fine needle aspiration (FNA) is the most accurate diagnostic method in cytopathology, its value in the diagnosis of borderline lesions is limited, mainly because of its inability to establish the absence of stromal invasion. The diagnostic accuracy of RNA can be improved by supplementing cytologic examination with such diagnostic techniques as immunocytochemistry and cytometry.     

Logistic regression analysis of low grade spindle cell lesions. A cytologic study

OBJECTIVE: To identify key diagnostic cytologic criteria for various low grade spindle cell lesions. STUDY DESIGN: We reviewed 20 synovial sarcomas, 18 benign neural tumors, 10 reparative lesions, 24 other benign and 27 additional malignant low grade spindle cell lesions. All specimens were coded as to the presence or absence of the following variables: high cellularity, tissue fragments, tissue culture appearance, epithelial fragments, vessel fragments, vascular arcades, fibrillar ground substance, myxoid background, microcystic areas, parallel arrangement of nuclei, naked nuclei, single cells, binucleate cells, multinucleate cells, long filamentous cells, short spindle cells, stellate cells, lipoblasts, nuclear pleomorphism, nuclei with pointed ends, comma/fishhook nuclei, cigar-shaped nuclei, ovoid/round nuclei, small nucleoli, large nucleoli, mitotic figures, intranuclear vacuoles and background histiocytes. A logistic regression analysis was performed to identify the variables predictive of malignant lesions, specifically synovial sarcomas, benign neural tumors and reparative lesions. RESULTS: Statistical analysis selected high cellularity, short spindle cells, small nucleoli and absence of tissue culture appearance as the main criteria for malignant neoplasms. Tissue fragments and high cellularity were selected as the primary criteria and absence of long filamentous cells and of myxoid background as the secondary criteria for synovial sarcomas. It selected fibrillar ground substance and absence of ovoid/round nuclei as the key criteria for benign neural tumors. The presence of a tissue culture appearance was the major criterion for reparative lesions. CONCLUSION: There are many previously described cytologic criteria, but we found that when subjected to statistical analysis, only a few features were significant in the evaluation of low grade spindle cell lesions.     

Fine needle aspiration cytology of extraskeletal chondrosarcoma

The cytologic presentation of a case of extraskeletal chondrosarcoma diagnosed by fine needle aspiration in a 57-year-old asymptomatic female is described. A mass detected on routine chest X ray and defined by CAT scan was subjected to a preoperative percutaneous fine needle aspiration under fluoroscopic guidance; a core biopsy was also obtained. Cytologic findings included pleomorphic malignant cells, with occasional spindle-shaped forms and binucleated and multinucleated cells having various degrees of nuclear atypia. The sarcomatous nature of this neoplasm was readily recognized in the cytologic material, although histologic and ultrastructural studies, which are also illustrated, were necessary to establish its specific histologic type. The biopsy was interpreted as a probable chondrosarcoma, and an exploratory laparotomy revealed a soft tissue tumor arising in the retroperitoneum. A diagnosis of soft tissue chondrosarcoma was rendered. In retrospect, the distinctive cytologic findings in the aspirated material suggest that extraskeletal chondrosarcoma should be considered in the differential diagnosis of soft tissue tumors.     

Spindle cell malignant melanoma metastatic to the breast from a pigmented lesion on the back. A case report

BACKGROUND: Tumors metastatic to the breast are quite unusual (1.2% of all tumors). Malignant melanoma is an exception and is one of the principal metastasizing tumors, described mainly as a primary tumor. There are 5 different cytologic patterns; the spindled pattern is very uncommon, more difficult to diagnose and can be confused with a wide range of sarcomatous lesions. Nevertheless, there are some cytologic features that allow differentiation from similar tumors. CASE: A 30-year-old woman presented with a firm, deep, nontender mass in the upper outer quadrant of the right breast. Fine needle aspiration cytology was performed, and the aspiration smears showed spindle-shaped neoplastic cells arranged singly or in clusters with marked nuclear atypia. Melanin pigment was sometimes seen in the cytoplasm of some cells. Pathologic study of the breast tumor corroborated the diagnosis, and later study revealed lymph node metastases and relapse in the breast area and on a scar on the back. Two years earlier, biopsy of a pigmented lesion on the back was diagnosed as a cellular blue nevus. CONCLUSION: The cytologic features of spindle cell melanoma are distinctive. The presence of atypical fusiform cells with elongated cytoplasm; enlarged nuclei, some of them binucleated or multinucleated; prominent nucleoli; intranuclear cytoplasmic inclusions; and melanin pigment can help to diagnose these unusual metastases to the breast. This case was the first of malignant metastatic melanoma with the spindled pattern in which the diagnosis was made by fine needle aspiration cytology.     

The interval between the diagnosis of malignancy and the development of effusions, with reference to the role of cytologic diagnosis

An analysis was made of the time lapse between the diagnosis of malignancy and the development of an effusion in relation to the sex and age of the patients and the site of the primary malignancy. The total number of patients studied was 254; of these, 171 patients had a pleural and 83 patients a peritoneal effusion. In the total group, sex distribution was two men to three women: about equal in the pleural effusion group and about two men to nine women in the ascites group, with the latter ratio reflecting the large number of primary malignant processes in the breast and ovaries. The average age at the time of the effusion, whether it was located in the pleural or in the peritoneal cavity, was about 55 years. This figure was roughly 60 years for men and 51 years for women. The nine-year average age difference between sexes can be explained by the size of the four largest groups of different primary malignant localizations and their sex distribution. The interval between the discovery of the primary malignancy and the first fluid sample was longer for patients with a pleural effusion (average of 77.0 weeks) than for patients with ascites (average of 54.5 weeks). The longest interval was seen in the breast carcinoma group, with the shortest interval in lung carcinoma patients. The interval was significantly longer for women, being 111.9 weeks for pleural effusions and 57.9 weeks for ascites (average for both sites of 88.7 weeks). In 30.7% of the patients, the primary malignancy was discovered at the same time or later than the effusion; in patients with lung cancer, a strikingly higher percentage of 53.0% was found. In this respect, the cytologic diagnosis of effusions is of great importance not only for the detection and proper identification of a malignant process but also as an indicator of the life expectancy of a patient.     

Uterine Müllerian adenosarcoma with psammoma bodies: cytologic, histologic and ultrastructural studies of a case

Epithelial cells associated with psammoma bodies and undifferentiated sarcomatous tumor cells were found in peritoneal washings obtained during laparotomy for removal of metastatic lesions from a uterine stromal sarcoma. Histologic studies of the primary and recurrent tumors showed characteristics of Müllerian adenosarcoma. The cytologic, histologic and ultrastructural features are described.     

Cystosarcoma phyllodes. Diagnosis by fine needle aspiration cytology.

The cytologic features of 10 benign, 2 borderline and 5 malignant phyllodes tumors were studied, and an attempt was made to correlate the cytologic findings with corresponding histologic categories. Seventy-five percent of the benign and borderline tumors were interpreted as benign cystosarcoma phyllodes on fine needle aspiration cytology. Eighty percent of the malignant phyllodes tumors were identified as malignant lesions cytologically. The cytologic features assessed were the epithelial:stromal ratio and morphology of the stromal component, including the degree of atypia, mitotic activity, capillary vessels traversing the stromal fragments, presence of foamy macrophages, histiocytic giant cells and bipolar naked nuclei. A diagnosis of phyllodes tumor was suggested cytologically by the presence of both epithelial and stromal elements; the stroma was present as cellular "phyllodes fragments" and isolated mesenchymal cells. The parameters suggesting malignancy were extreme paucity or absence of epithelial elements and stromal cells in diffuse sheets and clusters less cohesive than normal, with marked stromal atypia and mitotic activity.     

Cytologic features on needle aspiration of Wilms' tumor in an adult. A case report

A needle aspiration specimen from a left kidney mass in a 28-year-old woman was submitted for cytologic evaluation. Malignant cells were found, and the cytologic appearance was suggestive of a poorly differentiated sarcoma, with the possibility that it was a nephroblastoma. Important cytologic features of the needle aspiration specimen included round or oval blastomatous cells mixed with spindle or elongated sarcomatous cells, rare tubulelike formations of cells that appeared epithelial and a pronounced tumor diathesis. Histologic study of the nephrectomy specimen showed a Wilms' tumor, with anaplastic blastomatous and undifferentiated sarcomatous elements.     

The value of epithelial membrane antigen in the diagnosis of ovarian tumors.

The value of epithelial membrane antigen (EMA) in the diagnosis of ovarian tumors was investigated using an indirect immunoperoxidase staining technique on 91 histologic sections (88 tumors and 3 normal tissues) and 39 ascitic fluid smears (28 from patients with epithelial ovarian tumors and 11 from cases of myoma uteri). The rate of positive EMA staining was highest in malignant tumors (89.2%), second highest in tumors of low malignant potential (33.3%) and lowest in benign tumors (25.0%); normal ovarian tissues were negative for EMA. Of the malignant tumors, all 48 serous cystadenocarcinomas (100%) and 18 of 26 mucinous cystadenocarcinomas (69.2%) stained positively for EMA. In serous cystadenocarcinomas, the EMA staining was mainly localized on the luminal membrane of cells in well-differentiated tumors, but appeared on the entire cell surface and cytoplasm of cells in poorly differentiated tumors. The results of EMA staining on ascitic fluid smears were almost the same as the results for the histologic sections. The intensity and the localization of EMA staining were related to the grade of malignancy in these ovarian tumors. In comparison with staining for other antigens (carcinoembryonic antigen, CA-125 and human keratin protein), EMA was found to be one of the most sensitive markers for the diagnosis of ovarian cancer.