Cytopathological spectrum of unusual malignant pleural effusions at a tertiary care centre in north India

BACKGROUND: Cytological examination of pleural fluid is one of the most informative laboratory procedures in the diagnosis of pleural effusions. Although tuberculosis is the commonest cause of pleural effusions in developing countries, tumours, including grade ones, can present with effusions. OBJECTIVE: The aim of the present study was to evaluate the uncommon causes of malignant pleural effusion. METHODS: A 2-year retrospective analysis of pleural fluid cytological specimens submitted to the Department of Cytopathology, PGIMER, Chandigarh between January 2003 and December 2004 was performed to retrieve unusual metastases. Out of a total of 898 samples reviewed, 710 were negative for malignancy and 24 cases were suspicious for malignancy. The remaining 164 cases were positive for malignancy, out of which 38 cases revealed malignancies other than adenocarcinoma. RESULTS: The 38 unusual malignancies metastasizing to the pleural cavity included 29 haematological malignancies (non-Hodgkin's lymphoma, acute lymphoid leukaemia, multiple myeloma and chronic myeloid leukaemia) and nine non-haematological malignancies (Ewing's sarcoma, neuroblastoma, Wilms' tumour, squamous cell carcinoma, small-cell carcinoma and malignant fibrous histiocytoma). CONCLUSION: Although metastatic adenocarcinoma was the commonest aetiology of malignant pleural effusions, a significant number of unusual causes of malignant pleural effusion were also encountered.     

Comparison of NCL-hTERT antibody reactivity and telomere repeat amplification protocol in situ in effusions

OBJECTIVE: To compare the performances of 2 methods, telomerase repeat amplification protocol (TRAP) in situ and antibodies to the hTERT protein, in assessing telomerase activity. STUDY DESIGN: TRAP in situ and immunohistochemistry with a commercial antibody (NCL-hTERT) was performed on 54 body cavity effusions. The results were compared and correlated to diagnosis. RESULTS: Thirty-four effusions from patients with verified malignant disease contained cytologically malignant cells. Both methods were positive in 33 of the cases, whereas only hTERT was positive in 1 case. Twenty effusions, all containing mesothelial cells, came from patients with benign conditions. In 2 fluids atypical, hyperplastic mesothelial cells were both TRAP in situ and hTERT positive. All remaining 18 fluids were TRAP in situ negative, whereas 12 of 18 were hTERT positive. Thus the results of TRAP in situ and hTERT immunohistochemistry disagreed in 1 of 34 (3%) malignant and 12 of 20 (60%) benign cases. CONCLUSION: The sensitivities for malignancy were similar for TRAP in situ and hTERT immunohistochemistry. The specificity of the applied hTERT antibody was significantly lower, due to hTERT reactivity in mesothelial cells.     

肺癌性胸腔积液中生存素基因检测的诊断意义探讨

目的：生存素基因（survivin）是一种新近发现的抗凋亡基因,在肿瘤组织中呈现表达。本文旨在探讨和比较肺癌性胸腔积液和结核性胸腔积液中生存素基因的表达情况,以及其联合细胞学检查对判断肺癌性胸腔积液的敏感度。方法：应用逆转录酶-聚合酶链反应法（RT-PCR）检测2007年06月～2008年03月42例肺癌患者癌性胸腔积液标本,及同时期28例结核性胸腔积液标本的生存素mRNA表达情况,并联合细胞学检查结果进行对比分析。结果：42例肺癌患者胸腔积液标本中生存素mRNA的阳性率为52138％（22／42）;癌细胞的检出率为30．95％（13／42）;生存素mRNA检测联合细胞学检查诊断肺癌的敏感性为61．90％（26／42）,显著高于单独胸腔积液细胞学检测的敏感性（P〈0．001）。28例结核性胸腔积液标本的生存素mRNA阳性率为7．14％（2／28）,显著低于肺癌患者胸腔积液标本生存素mRNA的阳性率（P〈0．001）。结论：运用RT—PCR方法检测胸腔积液中生存素mRNA的表达在判断肺癌性胸腔积液中具有一定的敏感性和特异性,可能作为肺癌辅助诊断的一个新检测指标。     

An investigation of adequate volume for the diagnosis of malignancy in pleural fluids

S. C. Thomas, L. R. R. Davidson and M. E. McKean An investigation of adequate volume for the diagnosis of malignancy in pleural fluids Objective: The cytological examination of pleural effusions is an important investigation in the diagnosis of malignancy. Maximizing the chances of identifying malignant effusions is therefore desirable. Recent Royal College of Pathologists guidelines, based on the British Society for Clinical Cytology codes of practice, have suggested that a minimum of 20 ml of pleural fluid is required for diagnostic purposes. Methods & Results: We examined 2155 pleural fluids received over a 6‐year period in order to define a minimum required volume for adequacy. By examining the plateau phase of a graph of threshold volumes for initial samples received for each patient (n = 1584) we determine that a minimum fluid volume of 25 ml is required and that more than 50 ml does not improve sensitivity. Conclusion: Between 25 and 50 ml of fluid are required for the adequate assessment of pleural effusions for malignancy.     

Tuberculin purified protein derivative up-regulates the telomerase activity of peripheral blood mononuclear cells from patients with pulmonary tuberculosis.

Telomerase activity was detectable in cells of tuberculous pleural effusions at high percentage. To investigate the possible role of telomerase in the immune function, we examined the proliferating state and the expression of telomerase activity in peripheral blood mononuclear cells (PBMC) from 13 patients with pulmonary tuberculosis (TB) and 13 healthy volunteers in response to tuberculin purified protein derivative (PPD) challenge. Exposure of cells to phytohemagglutinin (PHA) significantly promoted PBMC proliferation during a 6 day-period in both TB patient and healthy volunteer groups. PPD treatment also significantly promoted PBMC proliferation during a 6 day-period in TB patient group, but had no significant effect in healthy volunteer group. During the same period, telomerase activity was detected in every PHA- and PPD-treated samples of the TB patient group. However, the telomerase activity was not detected in PPD-treated samples from healthy donors and all the untreated samples. Our results indicate that the telomerase activity in PBMC could be induced by PPD stimulation in TB patients. Telomerase activity may thus play a permissive role in cell division and clonal expansion of the immune cells in response to TB.     

Cytodiagnosis of malignant non-Hodgkin's lymphomas in effusions (author's transl)

Body cavity effusions in malignant non-Hodgkin's lymphomas, particularly in the early stages of those neoplasms, are rare in comparison to the far more common effusions in other malignant diseases and in inflammatory processes. Therefore, the cytological differential diagnosis is of great importance. Of 7,000 pleural and 1,700 ascitic effusions, only 42 cases were malignant non-Hodgkin's lymphoma and in 30 lymphoma was suspected. When lymphoma is suspected, particularly low-grade lymphoma, there are great difficulties in making a differential diagnosis. Using the more or less typical cellular and nuclear criteria of the various lymphoma types, an attempt was made to classify the unequivocal lymphomas according to the Kiel classification of malignant non-Hodgkin's lymphomas. In principle these criteria are the same in cytological and histological examinations. In 31 cases the lymphoma subtype could be specified and confirmed in part by subsequent histological examination. Apart from the suspect lymphoma cases (40%), cases of a low grade of malignancy were predominantly observed (28%). Lymphomas with a high grade of malignancy were less frequently encountered (15%), a proportion similar to that of unclassifiable lymphomas (16%). Apparently the cytological and karyological criteria are not yet adequate to classify lymphomas from conventionally prepared cytological specimens with a higher degree of accuracy.     

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.     

A quantitative method to measure telomerase activity by bioluminescence connected with telomeric repeat amplification protocol.

Telomerase is expected to be a new biomarker for cancer diagnosis. The telomeric repeat amplification protocol (TRAP) is a sensitive method to detect telomerase activity. However, TRAP and its modified protocols are not always suitable for measuring telomerase activity of a large number of clinical samples to diagnosis cancer because these methods generally require a time-consuming detection step such as gel electrophoresis. To improve the procedure for mass diagnosis, we applied bioluminescence to replace the detection step. Telomerase activity is measured by evaluating the amount of inorganic pyrophosphate generated in PCR amplification of telomerase elongation product, with use of the sensitive enzymatic luminometric inorganic pyrophosphate detection assay (ELIDA). TRAP connected with ELIDA (TRAP-ELIDA) can quantitatively detect telomerase activity within linearity from 2 to 1000 cell equivalents. The ELIDA signals accorded with results of TRAP-SYBR green staining, and the results of ELIDA were significantly correlated to those of TRAP connected with an enzyme-linked immunosorbent assay (TRAP-ELISA) (r(2) = 0.992, P < 0.001). TRAP-ELIDA is a simple and sensitive method to quantify telomerase activity without time-consuming gel electrophoresis. Because TRAP-ELIDA measures telomerase activity with a luminometer, it could be applied to a large number of clinical samples at the same time.     

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.     

Additional techniques in serous effusions.

Cytological examination is a valuable diagnostic tool in case of a serous effusion. The first manifestation of malignancy may be an effusion of the pleural, pericardial, or peritoneal cavity, especially in carcinoma of the ovary, or lung, and malignant mesothelioma. In other malignancies effusions may occur in the course of the disease. The contribution by Mother by et al. in this issue of ACP focuses on the contribution of image and flow cytometry to establish the presence or absence of malignancy in serous effusions. They point out that the sensitivity of DNA image cytometry in equivocal effusions may be as high as 87.5%, and that for the detection of malignancy, DNA image cytometry is superior to flow cytometry.     

The study of telomerase activity in gastric cancer

Telomerase activity was examined in tissue specimens from patients with gastric adenocarcinomas and gastric lymphoma using a modified TRAP (telomeric repeat amplification protocol) assay. Telomerase activity was found in 16 of 18 (89%) patients with gastric adenocarcinomas and gastric lymphoma, whereas it was not detected in a patient with noncancerous gastric mucosa. Almost all analyzed specimens had “high” and “very high” levels of telomerase activity. Telomerase is almost certainly associated with the process of malignant transformation and it can be an important marker for diagnostics of gastric cancer.     

Autoantibodies against p53 are not increased in human ascites and pleural effusions

 Mutated human p53 may give rise to the formation of autoantibodies and may be a marker for a worse prognosis. We speculated that ascites or pleural effusions may enhance the formation of such autoantibodies in cancer patients and, therefore, we measured the presence of autoantibodies in the ascites or pleural effusion of 40 patients with advanced malignancies. As controls, p53 autoantibodies were measured in 15 patients with effusions who did not have a malignancy. Using a specific enzyme-linked immunosorbent assay, p53 autoantibodies could only be detected in the effusions of 5/40 patients (12.5%) with known malignancies. The formation of autoantibodies did not correlate with the presence or absence of tumor cells in the effusion. The effusions of the patients without tumor were all negative for p53 autoantibodies. Our study shows that malignant or reactive effusions do not stimulate the local or systemic production of autoantibodies against p53. Received: 14 November 1995 / Accepted: 8 February 1996     

荧光定量PCR 法检测肿瘤细胞端粒酶活性的变化

目的：利用荧光定量PCR法检测端粒酶抑制剂作用于人肝癌细胞SMMC-7721后端粒酶活性的变化,探讨其抑制端粒酶活性的可能机制,为端粒酶抑制剂的临床应用提供理论依据。方法：利用荧光染料SYBR—Green I建立一种新的端粒酶活性检测方法：FQ—TRAP法。利用FQ—TRAP法检测端粒酶抑制剂作用后肿瘤细胞端粒酶活性变化。结果：端粒酶抑制剂作用后,肝癌细胞端粒酶活性都有变化,其中以ASODN,EGCG,AZT抑制效果较明显。结论：端粒酶FQ—TRAP法是一种特异性、灵敏度、重复性都较好,可快速、简便及定量检测人端粒酶活性的方法,端粒酶抑制剂作用后癌细胞端粒酶活性的变化,为端粒酶抑制剂的临床应用提供理论依据。     

Molecular basis of artifacts in the detection of telomerase activity and a modified primer for a more robust 'TRAP' assay.

Human somatic cells have essentially no telomerase activity. Telomerase is linked to tumor genesis and is a valuable marker for malignant growth. Extreme paucity of the enzyme neccessitated development of a PCR-based assay, 'telomeric repeat amplification protocol' (TRAP). Unfortunately, this method is not without difficulties.Amplification products are not related to the size of the amplified telomerase products. Furthermore, false positive results can occur, and careful control of reaction conditions is crucial. We analyzed in detail the molecular basis of artifacts. Based on these data, reverse PCR primer was changed and both problems in the TRAP assay were eliminated.     

Development of a novel telomerase assay using the PPDK–luciferin–luciferase detection system

Telomerase participates in malignant transformation or immortalization of cells, and has attracted attention as an anticancer drug screening and diagnostic tumor marker. We developed a novel telomerase assay called the PPDK–luciferin–luciferase system bioluminescence assay (PLLBA) using pyruvate phosphate dikinase (PPDK). In this assay, pyrophosphate produced by the telomerase reaction and polymerase chain reaction (PCR) is converted to ATP by PPDK, and ATP is detected by the firefly luciferin–luciferase reaction. In this work, telomerase substrate was obtained in accordance with the telomeric repeat amplification protocol (TRAP). Telomerase‐positive (500 cells/assay), ‐inactive (heated for 10 min at 85 °C) and ‐negative (only Chaps lysis buffer) samples were used. As a result, the findings clearly showed that the signal‐to‐noise (S/N) ratio of the positive cells was 39.5. After the telomerase reaction and PCR, PLLBA was completed ~ 120 s later. A high level of reproducibility was obtained with ‐ coefficient of variation (CV) of 4.1% (positive cells). The detection limit for cells using telomerase was one cell per assay. This assay for telomerase activity was also shown to be adaptable to human cancer‐derived cell lines. Copyright © 2013 John Wiley & Sons, Ltd.     

Telomerase repeat amplification protocol (TRAP): A new molecular marker for parathyroid carcinoma.

Telomerase results to be active in human germ, stem cells, several malignant cell tumors and in immortalized cell lines. In order to investigate if molecular mechanisms other than Rb gene inactivation can be helpful to diagnose malignancy of parathyroid tumors, we decided to investigate the presence of active telomerase in homogenates from different pathological parathyroid tissues (hyperplastic, adenomatous, carcinomatous, and normal) and primary cell cultures. The TRAP assay was performed to detect this activity in histologically characterized normal, hyperplastic, adenomatous, and carcinomatous human parathyroid tissues, primary cell lines, and one metastatic tissue from parathyroid carcinoma. Only malignant parathyroid glands and the metastatic tissue were TRAP positive. Our findings suggest that telomerase expression could represent an important molecular mechanism underlying the acquisition and progression of an aggressive phenotype of epithelial parathyroid cells and it may help to predict their malignant potential. The TRAP assay is easy to perform and it could become an additional tool to be included in the harmamentarium for the molecular diagnosis of parathyroid carcinoma.     

Diagnostic interest of the monoclonal antibody CA1 in malignant pleural effusion

The Ca1 antibody was used in an immunohistochemical procedure on smears of cells from 40 patients with malignant pleural effusion. The control group consisted of 25 benign pleural effusions with a high percentage of reactive mesothelial cells. The Ca1 Mc Ab was positive in 19 (79%) of the 24 pleural effusions with positive malignant cytology. In all the benign cases the Ca1 Mc Ab was negative (100% specificity). The Ca1 Mc Ab detected malignant mesothelial cells in two cases and was negative with reactive mesothelial cells and other nucleated cells present in the pleural effusion. We conclude that the Ca1 antibody offers a useful diagnostic method for malignant pleural effusions, when the morphological interpretation is doubtful.     

Telomerase activity in Kaposi's sarcoma, squamous cell carcinoma, and basal cell carcinoma

Patients with acquired immune deficiency syndrome (AIDS) often develop Kaposi's sarcoma (KS), an unusual skin tumor. The malignant nature of KS has long been disputed. Telomerase activity that maintains telomere length and ensures chromosomal stability, a frequently appearing marker in human malignancies, has been proposed to play a critical role in supporting continued cell growth, hence formation of tumors. We examined telomerase activity in tissue extracts from 22 KS, 10 squamous cell carcinoma (SCC), and 22 basal cell carcinoma (BCC) using the telomeric repeat amplification protocol (TRAP). All of the tumor tissues were previously cryopreserved at -80 degrees C. In this study, all tumor samples tested were positive for telomerase activity. Consistent with the presence of the enzyme activity, the skin tumors had relatively long telomeres. Inhibitors in the tissue extracts of some samples needed to be diluted or extracted by phenol before the enzyme activity was detected in the TRAP assay. All KS as well as two other skin carcinoma samples revealed positive telomerase activity. Our finding supports telomerase's role in tumor cell immortality and suggests the true neoplastic nature of KS.     

Development patterns of telomerase activity in barley and maize

Eukaryotic chromosomes terminate with specialized structures called telomeres. Maintenance of chromosomal ends in most eukaryotes studied to date requires a specialized enzyme, telomerase. Telomerase has been shown to be developmentally regulated in man and a few other multicellular organisms, while it is constitutively expressed in unicellular eukaryotes. Recently, we demonstrated telomerase activity in plant extracts using the PCR-based TRAP (Telomeric Repeat Amplification Protocol) assay developed for human cells. Here we report telomerase activities in two grass species, barley and maize, using a modified, semi-quantitative TRAP assay. Telomerase was highly active in very young immature embryos and gradually declined during embryo development. The endosperm telomerase activity was detectable, but significantly lower than in the embryo and declined during kernel development with no detectable activity in later stages. Telomerase activity in dissected maize embryo axis was several orders of magnitude higher than in the scutellum. Telomerase activity was not detected in a range of differentiated tissues including those with active meristems such as root tips as well as the internode and leaf base. The role of telomerase repression during differentiation and the relationship between chromosome healing and telomerase activity is discussed.     

Increased sensitivity and reproducibility of TRAP assay by avoiding direct primers interaction.

Telomeric Repeat Amplification Protocol (TRAP) is a sensitive procedure to measure telomerase activity in small samples of cell or tissue extracts. Due to the strict correlation between high levels of telomerase activity and neoplastic transformation, TRAP assay could provide an important diagnostic marker of malignancy. Although the original TRAP assay is very sensitive and some improvements have been described, occasional artifacts still persist in the modified procedures. Here we describe how changes in the sequence of the primer used for the amplification step enhance the reproducibility and sensitivity in the TRAP assay.