State-of-the-art cytology of pleural fluid,focusing on the diagnosis of mesothelioma

Mesothelioma has always been a challenging diagnosis to render in body cavity cytology samples. This review is a timely update on pleural fluid cytology and ancillary studies that should be considered in the diagnosis of mesothelial proliferations, specifically mesotheliomas. Information about new diagnostic approaches and ancillary studies in mesothelioma was obtained from the peer-reviewed literature and the authors' experiences. Although the morphological diagnosis of mesothelioma is fraught with numerous challenges given the overlap with other diagnostic entities, there are a variety of immunohistochemical and fluorescence in situ hybridization studies available to help in determining mesothelial origin and in distinguishing malignant proliferations from the more common benign or reactive mesothelial proliferations. Although ancillary studies can be helpful, there are important pitfalls to be aware of when interpreting these cases, and this review highlights some of the challenges that require caution.     

Diagnostic imaging of small amounts of pleural fluid: pleural effusion vs. physiologic pleural fluid

The aim of this article is to present an overview of our 10 years clinical research work and early clinical experience with small pleural effusions. Small amounts of pleural fluid are severely difficult to identify with imaging methods (chest x-rays and ultrasound). Nevertheless, it may be an important finding, sometimes leading to a definitive diagnosis of pleural carcinomatosis, infection or other pathologic condition. Chest x-rays were used for many years for the diagnosis of small pleural effusions. Lateral decubitus chest radiographs represented a gold standard for imaging of small amounts of plural fluid for more than 80 years. In the last two decades, ultrasonography of pleural space became a leading real-time method for demonstrating small pleural effusions. Furthermore, the advent of sonographic technology actually enables detection of physiologic pleural fluid in some otherwise healthy individuals. In conclusion, new definitions of the key terms in the field of diagnostic imaging of small amounts of pleural fluid seem to be justified. We suggest that the term pleural fluid should determine physiologic pleural space condition while the term pleural effusion should only be used in the cases of pleural involvement or pleural illness.     

Computerized interactive morphometry as an aid in the diagnosis of pleural effusions

A morphometric study of cytologic preparations from patients with benign and malignant (mesothelioma and carcinoma) pleural effusions is reported. The routine cytologic smears from these specimens were studied with a new system of video-based computerized interactive morphometry (CIM) that allows the measurements of real-time images of cell profiles by the simple procedure of touching the two extreme points of a diameter of interest on a touch-sensitive screen. For each cell, the nuclear profile diameter (NPD) and the cytoplasmic profile diameter (CPD) are measured and categorized into classes with 2-microns intervals; the NPD/CPD ratio is also calculated. The mean NPD is calculated for the specimen after measurement of 100 cells. The data were interpreted by two independent methods: a statistical method of discriminant analysis that classifies the lesions as benign, carcinoma or mesothelioma and provides a probability statement of membership in a particular diagnostic class and an ad-hoc algorithm that categorizes the effusions as benign or malignant based on hierarchic analysis. A data base derived from study of the first 24 cases was constructed and utilized for the test classification of the second 24 cases, which were treated as specimens of unknown diagnosis. The discriminant analysis correctly classified 21 of the 24 test cases into their proper diagnostic groups. The algorithm for a computer-generated pathologic diagnosis correctly identified 47 of the 48 cases as benign or malignant. The technical advantages of video-based CIM over the existing morphometric methods are discussed.     

Multilobated B-cell lymphoma. Report of a case with immunocytologic diagnosis in pleural fluid

The cytologic, histologic and immunocytochemical findings in an aggressive case of multilobated lymphoma in an 89-year-old man are described. This unusual variant of non-Hodgkin's lymphoma is morphologically distinct but may be of either T-cell or B-cell origin. A battery of immunocytologic stains on pleural fluid specimens allowed determination of a B-cell (follicular center cell) origin to be made. Previous literature on this neoplasm is briefly reviewed, and the unreliability of morphologic findings in predicting a T-cell or B-cell origin is discussed.     

Echotomography in the diagnosis of pleural effusion]

USI of the pleural cavities was performed in 119 patients (65 men and 54 women) aged 30 to 90 with different abnormalities. Pleural fluid in 106 patients was the leading symptom of the main pathological process, in 13 patients it was a sign of pleural disease. USI was combined with routine x-ray methods. Minimum amounts of pleural fluid could be clearly visualized by ultrasound scanning. Echo-tomographic symptoms of free and encapsulated fluid as well as ultrasound signs permitted differentiation of pleural thickening and exudate accumulation. A program of diagnostic algorithm was worked out for pleural fluid.     

Differential biosynthesis and accumulation of picrosides in an endangered medicinal herb Picrorhiza kurroa

Picrorhiza kurroa Royle ex Benth (Family: Scrophulariaceae) is a medicinal herb, mainly found in the North-Western Himalayas. Extensive harvesting for pharmaceutical purposes, lack of organized cultivation and unorganized methods of uprooting the plants because of unawareness has brought an endangered status to this important herb in nature. The medicinal property of this plant is attributed to monoterpenoid picrosides. The influence of developmental status of different growth stages on picrosides content is poorly understood in Picrorhiza kurroa. Picroside-I (P-I) content increased from 0.05 % to 0.76 % in different growth stages of shoots. Significant increase in the contents of P-I (0.15–0.50 %) and Picroside-II (P-II) (0.1–0.45 %) was observed in rhizomes of different developmental stages. Highest amounts of P-I (8.7 %) and P-II (5.3 %) was detected in uppermost part of mature dried rhizomes compared to bottom part with 2.9 % and 2.2 % of P-I and P-II, respectively. P. kurroa grown at high altitude (Sairopa, 4,500 amsl) showed 1.75-folds increase in P-I in leaves whereas exponential increase in the P-I content was detected (0.05–1.7 %) in the leaves of different developmental stages (L1-L5) of P. kurroa grown at lower altitude (Jagatsukh, 1,900 m). Variable amounts of P-I and P-II in different growth and developmental stages of P. kurroa imply importance of selection of plant material (rhizomes and roots). The study undertaken explored the status of metabolites accumulation and biosynthesis in the field grown plants of P. kurroa where not only environmental parameters but different morphogenetic stages of its developmental cycles, different age groups and different parts of plantlets were extensively analysed and estimated for medicinally important picrosides.     

Highly accurate diagnosis of pleural tuberculosis by immunological analysis of the pleural effusion

Pleural TB is notoriously difficult to diagnose due to its paucibacillary nature yet it is the most common cause of pleural effusions in TB endemic countries such as The Gambia. We identified both cellular and soluble biomarkers in the pleural fluid that allowed highly accurate diagnosis of pleural TB compared to peripheral blood markers. Multi-plex cytokine analysis on unstimulated pleural fluid showed that IP-10 resulted in a positive likelihood ratio (LR) of 9.6 versus 2.8 for IFN-γ; a combination of IP-10, IL-6 and IL-10 resulted in an AUC of 0.96 and positive LR of 10. A striking finding was the significantly higher proportion of PPD-specific IFN-γ+TNF-α+ cell population (PPD-IGTA) in the pleural fluid compared to peripheral blood of TB subjects. Presence of this pleural PPD-IGTA population resulted in 95% correct classification of pleural TB disease with a sensitivity of 95% and specificity of 100%. These data suggest that analysis of the site of infection provides superior diagnostic accuracy compared to peripheral blood for pleural TB, likely due to the sequestration of effector cells at this acute stage of disease.     

Dynamics of fluid accumulation in intestinal segments

Intestinal obstruction occurring in human diseases or produced surgically in animal studies can produce fluid accumulation and intestinal distention. It was found that a quantitative theory for acute intestinal fluid accumulation could be derived and verified for a variety of experimental model systems. The contribution of intestinal secretagogues and distention-induced secretion may augment fluid accumulation in closed loop fluid accumulation experiments in animals. Criteria for stability and decompression of lumen volume were derived.