Diagnostic Accuracy of Ber-EP4 for Metastatic Adenocarcinoma in Serous Effusions: A Meta-Analysis

Numerous studies have investigated the utility of Ber-EP4 in differentiating metastatic adenocarcinoma (MAC) from malignant epithelial mesothelioma (MM) and/or reactive mesothelial cells (RM) in serous effusions. However, the results remain controversial. The aim of this study is to determine the overall accuracy of Ber-EP4 in serous effusions for MAC through a meta-analysis of published studies. Publications addressing the accuracy of Ber-EP4 in the diagnosis of MAC were selected from the Pubmed, Embase and Cochrane Library. Data from selected studies were pooled to yield summary sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), and receiver operating characteristic (SROC) curve. Statistical analysis was performed by Meta-Disc 1.4 and STATA 12.0 softwares. 29 studies, based on 2646 patients, met the inclusion criteria and the summary estimating for Ber-EP4 in the diagnosis of MAC were: sensitivity 0.8 (95% CI: 0.78–0.82), specificity 0.94 (95% CI: 0.93–0.96), positive likelihood ratio (PLR) 12.72 (95% CI: 8.66–18.7), negative likelihood ratio (NLR) 0.18 (95% CI: 0.12–0.26) and diagnostic odds ratio 95.05 (95% CI: 57.26–157.77). The SROC curve indicated that the maximum joint sensitivity and specificity (Q-value) was 0.91; the area under the curve was 0.96. Our findings suggest that BER-EP4 may be a useful diagnostic adjunctive tool for confirming MAC in serous effusions.     

Manual and automated AgNOR count in differentiating reactive mesothelial from metastatic malignant cells in serous effusions

OBJECTIVE: To distinguish reactive mesothelial cells from malignant cells in serous effusions using manual and automated methods of enumeration of argyrophilic nucleolar organizer regions (AgNORs). STUDY DESIGN: In this prospective study, 38 samples of benign (19 cases) and malignant (19 cases) serous effusions were included. AgNOR stain was used in each case along with routine Papanicolaou stain. The smears were examined under an oil immersion objective, and AgNOR dots were counted by direct observation independently by 2 observers. Automated AgNOR counting and morphometry were performed with a Quantimet 600 image cytometer (Leica, Cambridge, England). At least 100 cells were counted in each case. The number of AgNOR dots in individual cells, AgNOR area, nuclear area, AgNOR vs. nuclear area and nuclear perimeter were measured. Data on benign and malignant cells were compared. RESULTS: The AgNOR dots were discrete and smaller in benign effusion cases as compared to coarse and aggregated in malignant effusion cases. In benign reactive effusion cases the mean number of AgNOR dots per nucleus was 2.33 +/- 0.71 and 2.83 +/- 1.15 by the manual and automated method, respectively, whereas that for malignant effusion cases was 7.48 +/- 2.51 and 8.09 +/- 1.69 by the manual and automated method, respectively. Mean total AgNOR areas in benign and malignant groups were 4.77 +/- 2.66 microns 2 and 38.22 +/- 13.71 microns 2, respectively. Mean nuclear area, nuclear perimeter and ratio of AgNORs vs. nuclear area were 48.72 +/- 19.30 microns 2, 24.68 +/- 10.25 microns and .098 in benign effusion cases as compared to 174.25 +/- 82.36 microns 2, 69.03 +/- 27.23 microns and 0.22 in malignant effusion samples. All these values were significantly higher (P < .001, Student's t test) in malignant cells as compared to benign reactive cells. CONCLUSION: AgNOR dot enumeration, AgNOR area and ratio of AgNORs to nuclear area are valuable adjuncts to cytomorphology in differentiating reactive mesothelial cells from malignant cells in serous effusions. Automated AgNOR counting is rapid and less cumbersome.     

Diagnostic value of clot examination for malignant cells in serous effusions

Objective:  To assess the diagnostic value of clot examination for satisfactory processing and confirmation of malignancy in serous effusions in routine cytological evaluation and compare the results with those of conventional smear and cell block preparations.
Methodology:  Body cavity fluids ( n  = 600) received in our laboratory were processed according to a pre-designed protocol for the study as follows: Day1: on receipt of the specimen, smears were made and a cell block was prepared from the sediment. Day2: after overnight sample storage of the remaining specimen at 2–8 °C all fluids were examined for the presence of a clot at the bottom of the container. Fluids in which clot had formed were fixed in formalin. The clot was then placed on a lens paper, wrapped and processed routinely. Diagnostic yields were compared.
Results:  In this study, we included 600 cases of serous fluids from pleural, pericardial and peritoneal effusions. In 73% ( n  = 437) of samples, clot formation was seen, while in 27%, ( n  = 163) no clot had formed. Routine smear and cell block preparations showed malignant cells in 9.6% ( n  = 42). However, with the addition of the clot preparation, the number of cases in which atypical/malignant cells were seen increased from 42 to 85 (19.4%), with a P  < 0.001. Special stains and immunohistochemistry (IHC) were also performed on clot preparations in 10 difficult cases.
Conclusion:  Clot preparation from body cavity fluids on the second day can be used as an adjunct to smear and routine cell block preparation to improve the accuracy and yield of the cytological diagnosis and may also be of great help for special studies such as IHC staining.     

Diagnostic accuracy of cytology and immunocytology in carcinomatous effusions

Background: Immunocytology substantially improves the diagnostic accuracy of conventional cytology in the diagnosis of carcinomatous effusions. Due to the unequivocal characterization of the various cell populations, a sensitivity of 92% and specificity of 100% was achieved by immunocytology, examining samples of 1234 serous effusions. Objective: Cytology plays a central role in the aetiological clarification of serous effusions. The sensitivity of this method for the diagnosis of carcinomatous effusions varies between 40% and 80%. The aim of the present study was to investigate whether immunocytology substantially improves the diagnostic quality of the cytological examination in the diagnosis of carcinomatous effusions. Method: Consecutive serous effusions were examined by conventional cytology and by immunocytology. The immunocytological examination was performed on smears, using a standard panel of three antibodies against pancytokeratin, human epithelial antigen 125 and calretinin. Results: Altogether, 1234 effusion samples were examined. A total of 603 effusions were caused by carcinomas, five by malignant mesotheliomas, 11 by malignant lymphomas and 615 by non‐malignant disorders. In conventional cytology, carcinomatous effusions were correctly diagnosed in 314 samples, corresponding to a sensitivity of 52%. In 31 specimens (5%) tumour cells without further specification were described and in 161 samples (27%) the presence of tumour cells was suspected (84% overall sensitivity). A total of 97 carcinomatous effusions (16%) were diagnosed false‐negatively and 50 (8%) of the 615 non‐malignant effusions false‐positively (92% specificity). In immunocytology, 561 carcinomatous samples were correctly diagnosed, representing a sensitivity of 93%. In six cases (1%) the presence of tumour cells was suspected. A total of 36 carcinomatous effusions (6%) were diagnosed false‐negatively (94% over‐all sensitivity). Out of the 615 non‐malignant specimens, there were no false‐positive diagnoses (100% specificity). Conclusion: Immunocytology is a simple, cost‐effective, routinely practicable method which substantially improves the diagnostic accuracy of conventional cytology in the diagnosis of carcinomatous effusions. Therefore, we recommend the use of immunocytology in all those cases where cytology on its own is not completely unequivocal.     

Posttransplantation lymphoproliferative disorder mimicking a nonspecific lymphocytic pleural effusion in a bone marrow transplant recipient. A case report

BACKGROUND: Serous effusions are rare complications of bone marrow transplantation (BMT) and result mainly from infections or tumor relapse. CASE: We report a case of posttransplantation lympho-proliferative disorder (PTLD) revealed by cytodiagnostic examination of serous effusions in a BMT recipient. The effusion was initially considered reactive, but morphologic, immunocytologic and molecular studies subsequently revealed PTLD. CONCLUSION: This case demonstrates the importance of cytologic examination of effusions in BMT or organ recipients. Since most PTLDs are Epstein-Barr virus (EBV)-associated B-cell lymphoproliferative disorders and T cells predominate in reactive effusions, appropriate initial immunostaining, including CD3, CD79a and EBV latent membrane protein, should aid in their early detection.     

Cadherin expression in ovarian carcinoma and malignant mesothelioma cell effusions

OBJECTIVE: To analyze potential differences in cadherin expression between ovarian carcinoma/primary peritoneal carcinoma (OC/PPC) and malignant mesothelioma (MM) at this anatomic site. STUDY DESIGN: MM (N=24) and OC/PPC (N= 53) effusions were analyzed for E-cadherin, N-cadherin and P-cadherin protein expression using immunocytochemistry. RESULTS: Both MM and OC/PPC cells showed frequent expression of all 3 cadherins. OC/PPC specimens expressed E-cadherin and N-cadherin in 52 of 53 cases and P-cadherin in 51 of 53 cases. MM effusions expressed E-cadherin, N-cadherin and P-cadherin in 22 of 24, 21 of24 and 23 of24 cases, respectively. The differences in the percentage of cadherin-positive cells was weakly significant for P-cadherin (higher expression in MM, p = 0.04), but E-cadherin and N-cadherin expression was comparable (p > 0.05). CONCLUSION: MM and OC/PPC coexpress different cadherin family members. P-cadherin, E-cadherin and N-cadherin are not useful for differentiation between OC/PPC and MM in effusions.     

Diagnostic accuracy of toluidine blue-stained wet films in effusion cytology

OBJECTIVE: To evaluate the usefulness of toluidine blue-stained wet films in the preliminary cytologic evaluation of serous effusions by means of specificity, sensitivity, and positive and negative predictive value. STUDY DESIGN: One hundred seventy-six samples consisting of 122 pleural and pericardial effusions and 54 peritoneal effusions from 160 patients were included in the study. A toluidine blue-stained wet film of each sample was evaluated, and diagnoses were compared with the diagnoses by conventional smears and cell blocks on the same sample. RESULTS: The sensitivity of wet films was 69%, 68% in pleural and pericardial effusions and peritoneal effusions, respectively, and the specificity of wet films was 93%, 92% in pleural and pericardial effusions and peritoneal effusions, respectively. Positive predictive values of smears alone were 78% and 75%; negative predictive values of smears alone were 96% and 95% in pleural and pericardial effusions and peritoneal effusions, respectively. CONCLUSION: Preliminary cytologic evaluation of serous effusions with toluidine blue-stained wet films is simple and economical. It provides the opportunity to plan additional procedures for the samples.     

Therapeutic effects of maximal strength training on walking efficiency in patients with schizophrenia - a pilot study

ABSTRACT: BACKGROUND: Patients with schizophrenia frequently have disabling gait deficits. The net mechanical efficiency of walking (epsilonnet) is an accurate measure often used to evaluate walking performance. Patients with gait deficits have a reduced epsilonnet with excessive energy expenditure during sub-maximal walking. Maximal strength training (MST) improves epsilonnet in healthy individuals and is associated with reduced risk of mortality. The aim of this study was to investigate whether MST improves epsilonnet in patients with schizophrenia. METHODS: Patients (ICD-10 schizophrenia, schizotypal or delusional disorders (F20-F29)) were included in a non-randomized trial. Patients were assigned to one of two groups: 1) MST consisting of 4x4 repetitions at 85-90% one repetition maximum (1RM) performed in a leg press apparatus or 2) playing computer games (CG). Both groups carried out their activity three days per week for eight weeks. 1RM, epsilonnet at 60 watt walking, peak oxygen uptake (VO2peak), the Positive and Negative Syndrome Scale (PANSS) and the 36-items short form (SF-36) were measured pre and post intervention. RESULTS: The baseline epsilonnet was 17.3 +/- 1.2% and 19.4 +/- 3.0% in the MST (n = 6) and CG groups (n = 7), respectively, which is categorized as mechanical inefficiency. The MST group improved 1RM by 79 kg (p = 0.006) and epsilonnet by 3.4% (p = 0.046) more than the CG group. The MST group improved 1RM and epsilonnet, by a mean of 83 kg (p = 0.028) and 3.4% (p = 0.028), respectively. VO2peak at baseline was 34.2 +/- 10.2 and 38.3 +/- 9.8 ml * kg-1 * min-1 in the MST and CG groups, respectively, and did not change (p > 0.05). No change was observed in PANSS or SF-36 (p > 0.05). CONCLUSIONS: MST improves 1RM and epsilonnet in patients with schizophrenia. MST could be used as a therapeutic intervention for patients with schizophrenia to normalize their reduced epsilonnet.     

p53 immunostaining is a highly specific and moderately sensitive marker of malignancy in serous fluid cytology

Several studies have suggested that p53 immunostaining does not occur in benign mesothelium but is common in malignancies involving the serous surfaces, including malignant mesothelioma. As a result, p53 has been advocated as a marker of malignancy in serous fluid cytology. However, the specificity of p53 in this context has been brought into question by some studies that claim to have found immunostaining in benign mesothelium. The aim of our study was to examine p53 immunostaining in a large series of serous fluids to try to resolve the uncertainty. Monoclonal Do‐7 antibody was used to immunostain ethanol‐fixed cytospin preparations employing an alkaline phosphatase method. Positivity was found in 17 of 35 malignant effusions, including two probable mesotheliomas, but was not found in any of 115 benign effusions. Our study suggests that p53 immunostaining is a highly specific and moderately sensitive marker of malignancy in serous fluids.     

Characterizing subpopulations of neoplastic cells in serous effusions. The role of immunocytochemistry

OBJECTIVE: To analyze the role of immunochemistry in serous effusions. STUDY DESIGN: We analyzed cell blocks of 18 pleural and 18 peritoneal effusions diagnosed as malignant (18), benign (14) and suspicious (4). They were immunostained by the avidin-biotin complex method with a panel of four monoclonal antibodies--CEA, Ber-EP4, LeuM1 (CD15) and p53--and, for lectins (Ulex europaeus) UEA-l, ConA and ConBr. RESULTS: Seventeen of the 18 cases of adenocarcinoma were positive for CEA (95%), 12 (66.6%) for Ber-EP4, 11 (61%) for CD15 and 11 (61%) for p53. Twelve of the 18 (66.6%) were positive for UEA-1, CEA, Ber-EP4 and CD15. UEA-1 did not react with mesothelial cells. p53 Gave a positive reaction in only one case, reactive mesothelial cells. ConA and ConBr reacted indiscriminately with benign and malignant cells; thus, it was not useful in distinguishing between these cells. CONCLUSION: In this context no antibody used alone is reliable for corroborating a diagnosis, but the selective use of a small panel of three markers (CEA, Ber-EP4 and LeuM1) can be very useful in solving diagnostic difficulties in the cytodiagnosis of serous effusions.     

Utility of HBME-1 immunostaining in serous effusions

Utility of HBME-1 immunostaining in serous effusions
HBME-1 is an anti-mesothelial cell monoclonal antibody derived from human mesothelioma cells. We investigated 227 body cavity effusions to test its utility in differentiating mesothelioma from adenocarcinoma. HBME-1 outlined cell membranes in non-neoplastic mesothelial cells. Thick surface staining was observed on all mesotheliomas. HBME-1 reactivity was also detected in 24% of metastatic carcinomatous effusions. Most ovarian carcinomas (83%) reacted with this antibody, showing surface staining. Cytoplasmic HBME-1 immunoreactivity was observed in a small proportion of non-ovarian adenocarcinomas (14%). Despite its limited specificity, HBME-1 might be added to the battery of other markers of epithelial and/or mesothelial differentiation to be used in cases of suspected mesothelioma. Evaluation of suspicious cells should include careful study of the pattern of immunostaining.     

Pleural effusions and sera from patients with benign or malignant diseases

In pleural effusions and sera from 66 patients copper and zinc were quantified by inductively coupled argon plasma-mass spectrometry after mineralizations in a closed-pressurized microwave unit with a mixture of concentrated nitric acid and 30% hydrogen peroxide. Total protein, pH, leukocyte count, lactate dehydrogenase, glucose, C-reactive protein, ceruloplasmin, and alpha1-antitrypsin were determined in many of the effusions. All but four effusions had concentrations of copper (range 58-1720 microg/kg) and zinc (range 27-1001 microg/kg) that were lower than the concentrations in the corresponding sera. Very high concentrations of zinc (1930-6470 microg/kg) were characteristic for thoracic empyemata. In the scatterplots of serum copper versus effusion copper, serum zinc versus effusion zinc, and serum copper/effusion copper versus serum zinc/effusion zinc no clearly delineated regions were noticeably useful for identifying malignant effusions. Similar plots of the concentrations of copper or zinc versus the eight clinical laboratory parameters or plots of clinical parameter versus clinical parameter failed to be of diagnostic value. Statistically highly significant correlations (p < or = 0.05, n > 45, r2 > 0.25) were observed for 9 of 28 pairs of the clinical parameters, for total protein and copper in the effusions and zinc in the effusions and for ceruloplasmin and copper in the effusions. Among the patients suffering from benign or malignant effusions, 52% had zinc concentrations in the sera below the low limit of the normal range (600 microg/kg). Supplementation of such patients with zinc should be considered.     

Self-selected resistance training intensity in healthy women: the influence of a personal trainer

The purpose of the present investigation was to examine the influence of resistance training with a personal trainer versus unsupervised resistance training on the self-selected intensities used by women during resistance exercise. Forty-six resistance-trained women (age = 26.6 +/- 6.4 years; body mass = 64.2 +/- 10.9 kg) who either trained individually (n = 27; No PT) or with a personal trainer (n = 19; PT) were carefully instructed to select a weight they used in their own resistance training workouts that enabled the completion of 10 repetitions for the chest press (CP), leg press (LP), seated row (SR), and leg extension (LE) exercises. Each participant was subsequently tested for one repetition-maximum (1RM) strength on each exercise, and the self-selected intensity was calculated based on a percent of each 1RM value. For self-selected relative intensity, the PT group selected significantly greater intensities for LP (50% vs. 41%), CP (57.4% vs. 48%), and SR (56% vs. 42%) whereas a trend (p = 0.10) was observed for LE (43% vs. 38%) compared with No PT. Overall, the average self-selected intensity for all exercises was approximately 51.4% in PT group and approximately 42.3% in the No PT group. 1RM values for LP, LE, and SR were greater in the PT than No PT group. Ratings of perceived exertion values were significantly greater in the PT compared with the No PT group for CP, LE, and SR but not LP. These results indicate that resistance training under the supervision of a personal trainer leads to greater initial 1RM strength values, self-selection of greater workout intensities, and greater ratings of perceived exertion values during resistance exercise.     

Immunocytochemical panel for distinguishing carcinoma cells from reactive mesothelial cells in pleural effusions

Objective:  The aim of this study was to evaluate the individual and combined diagnostic utility of carcinoembryonic antigen (CEA), cytokeratin 19 fragments (CK19) and HBME-1 in pleural effusions of patients with lung cancer.
Study design:  CEA, CK19 and HBME-1 were detected by immunocytochemistry in pleural effusions from patients with lung cancer (86 cases) and without lung cancer (40 cases).
Results:  CEA and CK19 expression were significantly higher in the carcinoma cell group and in three subgrouped as adenocarcinoma (AC), squamous cell carcinoma (SCC) and small cell lung cancer than in the mesothelial cell group, whereas HBME-1 expression was lower in the former group ( P <  0.01). In the subgrouped tumours, CEA expression was higher in AC than in SCC ( P <  0.05), whereas HBME-1 expression was higher in SCC than in AC ( P <  0.01). Used alone, CK19 had the highest sensitivity (95.3%) and accuracy (93.7%), whereas CEA had the highest specificity (97.5%). When combinations of antibodies were evaluated together and membrane staining with HBME-1 taken as a negative outcome, CK19 and HBME-1 gave a high diagnostic performance: sensitivity of 100.0% and accuracy of 95.2% respectively.
Conclusion:  A panel of CEA, CK19 and HBME-1 monoclonal antibodies proved to be suitable for distinguishing carcinoma cells from reactive mesothelial cells in pleural effusions.     

Diagnostic DNA-flow- vs. -image-cytometry in effusion cytology.

AIMS: To determine the sensitivity and specificity of flow- and image-cytometry for the detection of DNA-aneuploidy as a marker for malignant cells in effusions. METHODS: 200 effusions (80 tumor cell-positive, 74 negative and 46 cytologically equivocal) were stained with DAPI-SR for DNA-flow- and with Feulgen-Pararosaniline for -image-cytometry. They were measured using a PAS-flow-cytometer and an AutoCyte-QUIC-DNA-workstation according to the ESACP consensus reports for DNA-flow- and -image-cytometry, respectively [7,23,29,49]. RESULTS: Sensitivity of DNA-aneuploidy for the identification of malignant cells was 32.1% for DNA-flow- and 75.0% for -image-cytometry, specificity of -euploidy in benign cells was 100.0% for both methods. Positive predictive value of DNA-aneuploidy for the identification of malignant cells was 100.0% for both techniques, negative predictive value of DNA-euploidy was 48.6% for DNA-flow- and 72.0% for -image-cytometry. CONCLUSIONS: Searching for DNA-aneuploidy as a diagnostic marker for neoplastic cells in serous effusions image-cytometry revealed superior sensitivity as compared with monoparametric flow cytometry.     

Diagnostic utility of BCA-225 in detecting adenocarcinoma in serous effusions

OBJECTIVE: To determine the diagnostic value of the BCA-225 antibody in discriminating adenocarcinoma from benign mesothelium in body cavity effusions. STUDY DESIGN: One hundred four cases of unequivocally benign (34 cases) and malignant (70 cases) serous effusions with cell block material were immunostained for BCA-225 using the ABC method without antigen retrieval. The percentage of positively staining cells in each case was estimated in a blind fashion. RESULTS: BCA-225 stained at least 10% of morphologically malignant cells in 28 of 32 (88%) breast carcinomas and 58 of 67 (87%) adenocarcinomas overall. Neuroendocrine carcinomas (two cases) and one mesothelioma were positive in < or = 5% of their respective tumor cells. Of 34 benign cases, 6 (18%) exhibited positive staining, albeit in rare, morphologically benign cells. CONCLUSION: BCA-225 is able to discriminate adenocarcinoma from reactive mesothelium in cell block preparations and may prove useful as part of an antibody panel.     

Effects of maternal nutritional status on fetal and placental growth and on fetal urea synthesis in sheep

Fetal and placental growth, and fetal and maternal urea synthesis in late gestation, were studied in 2-year-old Corriedale ewes on a maintenance ration (M) except when subjected to moderate dietary restriction from day 50 to day 100 (RM), day 100 to day 135 (MR) or day 50 to day 135 (RR). In comparison with fetuses of ewes maintained throughout the experiment (MM), RR fetuses were smaller and RM fetuses were larger whereas MR fetuses were unaffected; all restrictions were associated with increased placental size. Fetal urea synthesis at day 133 in the well-nourished ewes (MM) was 21.5 mg N h-1 kg-1 increasing to, respectively, 25.7, 27.3 and 38.8 mg N h-1 kg-1 in groups MR, RM and RR; these values were 1.6, 3.9, 2.2 and 3.8 times the maternal rates of synthesis. On the basis of the observed urea synthesis rates, amino acid oxidation could have accounted for up to, respectively, 32, 38, 40 and 57% of fetal oxygen consumption in groups MM, MR, RM and RR. Amino acids, in addition to their role in tissue accretion, may be key energy substrates for the fetus.     

Bull's eye (target) inclusions in neoplastic cells in malignant serous effusions. A study of 289 cases

OBJECTIVE: To study the prevalence and significance of bull's eye (target) inclusions in neoplastic cells in malignant serous effusions. STUDY DESIGN: We reviewed malignant pleural, peritoneal and pericardial effusions from 289 patients who had proven cancer at known primary sites. The ages of the patients ranged from 5 to 72 years; 166 were male and 123 female. RESULTS: Bull's eye inclusions are an uncommon finding and appeared in only 13 cases of metastatic adenocarcinoma of the breast, stomach, colon, lung, ovary, pancreas and urinary bladder. They were positively stained with periodic acid-Schiff stain with diastase. The inclusions were not seen in cells of nonadenocarcinomatous neoplasms, such as squamous cell carcinoma, oat cell (small cell) carcinoma, neuroblastoma, lymphoma and germ cell tumors. CONCLUSION: Bull's eye inclusions are found in about 5% of malignant serous effusions containing cells of metastatic adenocarcinoma. The primary site of an adenocarcinoma cannot be deduced on the basis of the presence of inclusions.