Curschmann's spirals in pleural and peritoneal effusions

Curschmann's spirals were found in smears and cell block preparations of five spontaneously occurring pleural and peritoneal fluids. The spirals were similar to those seen in the respiratory tract, although generally much smaller. In three of the five cases, the fluids also contained mucus-secreting adenocarcinoma cells; it is postulated that the spirals formed from mucus secreted by these cells. In the other two cases, there was evidence of serosal inflammation; it is suggested that the spirals in these cases developed from submesothelial connective tissue mucosubstances that entered the serosal cavity through a mesothelium of increased permeability due to the inflammation. No simple explanation can be accepted as to the exact mode of spiral formation, which is presumed to be a complex physical and biochemical phenomenon.     

Curschmann's spirals in cyst fluid associated with a teratoma of the ovary. A case report

BACKGROUND: Curschmann's spirals, first described more than 100 years ago, are common in cytologic specimens from the respiratory tract and have also been observed in cervical smears, urine, and peritoneal and pleural effusions. No simple theory can explain the exact mode of spiral formation, which is presumed to be a complex physical and biochemical phenomenon. CASE: A 29-year-old woman, gravida 2, para 2, underwent right ovarian cyst excision after an abdominal ultrasound examination revealed a cystic mass of the right ovary. Histologically, the cyst was an immature cystic teratoma containing respiratory epithelium with mucous glands in the submucosa. Cytologic examination of the cyst fluid showed the presence of Curschmann's spirals. CONCLUSION: To the best of our knowledge, the formation of Curschmann's spirals associated with an immature cystic teratoma has not been previously reported. In this situation, the presence of spirals could be explained by formation from mucus normally found in that environment.     

Curschmann's spirals and actinomycosis in a fine needle aspirate of the parotid

Fine needle aspiration (FNA) of bilaterally enlarged submandibular salivary glands yielded both Curschmann's spirals and actinomycetes filaments in the FNA smears. Histologic study of specimens from the bilateral submandibulectomy confirmed the actinomycosis but failed to demonstrate the presence of spirals. The presence of Curschmann's spirals in FNA material is a finding not previously described in the English literature. Actinomycosis, although well documented in exfoliative cytology, has been rarely reported in fine needle aspirates. This unique case afforded the opportunity of illustrating the characteristic features of Curschmann's spirals and actinomycetes colonies, as well as reviewing the etiology and pathogenesis of Curschmann's spirals, in FNA material.     

Peritoneal washing cytology in cervical carcinoma. Analysis of 109 patients

The peritoneal washing cytologies of 109 patients (112 procedures) undergoing laparotomy for cervical carcinoma were evaluated retrospectively and compared with the clinical and pathologic findings. Nine patients (8.3%) had malignant peritoneal washings (including three of four with washings initially termed "inconclusive"). Four (4.9%) of the 82 patients with squamous carcinoma and 3 (16.7%) of 18 with adenocarcinoma had positive washings. Five (5.6%) of 90 washings obtained at initial explorations were positive, as compared with 4 (18.2%) of 22 washings obtained as follow-up operations in recurrent cases. The 111 peritoneal washing cytologies with a corresponding histologic evaluation of the peritoneal cavity showed a good correlation; peritoneal washing cytology had an efficiency of 91.0%, a sensitivity of 52.9% and a specificity of 100%. Two cases in which the cytologies were considered positive only after review had negative peritoneal histologies; both patients died of progressive disease within 11 months. Peritoneal washing cytology was positive in 5 (5.9%) of 84 cases with FIGO stage 1 cancers, 2 (18.2%) of 11 cases with stage 2 cancers, 1 (33.3%) of 3 cases with stage 3 cancers, and 1 (10%) of 10 cases with recurrent tumors. Eight (88.9%) of nine patients with malignant peritoneal washings died of disease from 3 to 15 months following surgery; one showed no evidence of disease at 9 months. These results suggest that: (1) cervical carcinomas are infrequently associated with a positive peritoneal washing; (2) peritoneal washing cytology is more likely to be positive in cases of adenocarcinoma than in cases of squamous carcinoma; (3) peritoneal washings obtained at the time of surgery for recurrence are more likely to contain malignant cells than are washings obtained during initial exploration; (4) nonkeratinizing malignant squamous cells may be confused with reactive mesothelial cells; and (5) peritoneal washing cytology is a relatively insensitive technique for detecting advanced cervical disease, but correlates with a poor prognosis when positive.     

Müllerian inclusions in peritoneal washings. Potential source of error in cytologic diagnosis

Müllerian inclusions in peritoneal washings from female patients may be mistaken for adenocarcinoma. Such findings were studied in the peritoneal washing cytology specimens from eight cases. The inclusions usually presented as tubular or papillary structures, often forming a single layer of epithelium surrounding psammoma bodies. The cells forming these structures often displayed some degree of atypia. Recognition of this entity in peritoneal fluids is important to avoid a misdiagnosis of disseminated cancer. A general outline is proposed for interpreting such findings in peritoneal washings, based on the cytomorphology of these structures as well as the microscopic features of the primary neoplasms.     

"Collagen balls" in peritoneal washings. Prevalence, morphology, origin and significance.

Peritoneal washings obtained at laparotomy from women undergoing surgery for neoplasms of the genital tract may contain "collagen balls," consisting of tissue fragments composed of collagen covered with mesothelial cells. Collagen balls were found in 19 (4.5%) of 418 peritoneal washings and were more prevalent in specimens labeled pelvic washings (17 of 294, or 5.8%) than in those labeled peritoneal washings (2 of 124, or 1.6%). In 15 of the 19 cases in which we found collagen balls, at least one ovary was available for microscopic examination. In 14 of the 15 cases minute nodular papillary stromal projections covered with mesothelium were found on the surface of the ovaries. We conclude that collagen balls, a nonspecific entity, most probably originate on the surface of the ovaries. Their significance lies in their being mistaken for mucin-distended cells exfoliated from a neoplasm or from detached fragments of a papillary ovarian neoplasm.     

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.     

Curschmann's spirals in cervicovaginal smears. Prevalence, morphology, significance and origin

A retrospective examination of 172,119 cervical and vaginal smears was undertaken to study the prevalence, morphology, significance and origin of Curschmann's spirals in such specimens. Spirals morphologically identical to those seen in sputum were found in 101 specimens from 100 patients, for a prevalence of 1 in 1,704 smears. Spirals were found only in patients who had not had their cervices removed. The presence of the spirals could not be correlated with any particular gynecologic or nongynecologic abnormality. Most of the patients had no gynecologic abnormality. The literature contains suggestions that Curschmann's spirals in cervicovaginal smears are a manifestation of orogenital sexual contact or are formed in endocervical mucus, particularly in cigarette smokers. To investigate whether such spirals have an extraneous origin, we examined the smears for dust-containing histiocytes, vegetable cells, skeletal muscle fibers and other extraneous material, none of which was found. We found no correlation between the presence of spirals and cigarette smoking. Moreover, histologic sections of the uterine cervices from some of the patients who had spirals in their smears showed evidence of spiral formation in endocervical mucus. We conclude that Curschmann's spirals in cervicovaginal smears are an uncommon finding with no clinical significance, that they are formed from endocervical mucus and that their presence has nothing to do with orogenital sexual contact or cigarette smoking.     

Cytohistologic correlation of peritoneal washing cytology in gynecologic disease

The peritoneal washings and cul de sac aspirates from 204 patients undergoing 217 procedures for the evaluation of gynecologic disease were examined retrospectively and correlated with the histologic diagnoses. Of the 73 washings from patients with histologically benign genital disease, cytology diagnosed 64 (87.7%) as negative, 6 (8.2%) as inconclusive and 3 as malignant. One malignant washing was a true positive from a nongenital primary. False positives thus occurred in 2.7% of the benign cases on blind review. Of 144 cytologic examinations of washings from patients with histologically confirmed malignant disease of the female genital tract, 38 (26.4%) were considered positive after cytohistologic correlation. Four malignant cases (2.1%) were undercalled on blind review while 3 (2.0%) were considered overcalls. Eleven of 47 cases (23.4%) with biopsy-proven peritoneal disease had negative cytology after histologic correlation. Recurring problems in interpreting peritoneal washings included: (1) the differential diagnosis of the spectrum encompassed by reactive mesothelium, endosalpingiosis, borderline serous tumors and well-differentiated serous cystadenocarcinoma; (2) morphologic similarities between some tumor cells and mesothelial cells associated with treatment effects; and (3) a paucity of malignant cells in some washings, resulting in false-negative interpretations. Ineffective cytopreparation, particularly of bloody specimens, hampered interpretation of some specimens. Correlation with previous histology and cytology enhanced the accuracy of peritoneal washing cytology in this study.     

Detached ciliary tufts in female peritoneal washings. A common finding

Detached ciliary tufts (DCTs) have been observed in sputum, in cervicovaginal smears and, rarely, in fluid from the pouch of Douglas. DCTs occur frequently in peritoneal washings from female patients. Twenty-five consecutive peritoneal washings were studied for DCTs. Fourteen specimens were from women in the reproductive age group (21 to 47 years); all contained DCTs. All of these 14 patients, except for one in the 14th week of pregnancy, were in the secretory phase of the menstrual cycle. The 11 patients without DCTs in their peritoneal washing had an age range of 23 to 88 years. Three were postmenopausal, seven were in the proliferative phase of the menstrual cycle, and one had had a previous hysterectomy and bilateral salpingo-oophorectomy. DCTs most likely represent a physiologic process of cyclic shedding of cilia from the cells of the fallopian tubes during the luteal phase of the menstrual cycle.     

Prospective comparative cytologic study of direct peritoneal smears and lavage fluids in patients with epithelial ovarian cancer and benign gynecologic disease

Direct peritoneal samples obtained by scraping or brushing (with a Cytobrush) were compared to peritoneal lavages (washings) for the cytologic evaluation of patients with gynecologic disease. The direct samples were obtained during laparotomy or laparoscopy, following saline lavage if that was performed, and were immediately smeared on glass slides and fixed in 95% alcohol. Only 9 of the direct peritoneal samples taken from 64 patients with benign gynecologic disease were unsatisfactory for cytologic interpretation while 19 of the 33 lavage specimens simultaneously collected from these patients were considered unsuitable for analysis (P less than .001). Two direct smears from cases with benign histology were reported as suspicious. Nineteen patients with epithelial ovarian cancer also had cytologic specimens collected by direct sampling and by washing. The direct smears were positive for malignancy in 12 cases, suspicious in 4 cases and negative in 3 cases while the lavage samples were positive in 9 cases, suspicious in 4 cases, negative in 4 cases and unsatisfactory in 2 cases. These results indicate that direct peritoneal sampling is a simple and reliable alternative to peritoneal lavage and produces a significantly lower incidence of unsatisfactory specimens.     

Peritoneal washing cytology. Uses and diagnostic criteria in gynecologic neoplasms

Review of a 20-month experience with 241 peritoneal washes performed on 191 patients showed that the use of these specimens has expanded greatly. Of the 19 patients with neoplastic cells in their peritoneal washing cytology specimens, 12 had primary ovarian neoplasms, 4 had primary uterine cervical neoplasms, 2 had primary endometrial neoplasms, and 1 had mammary carcinoma metastatic to the ovary. Gynecologic oncologists at this institution are now routinely obtaining peritoneal washing cytology specimens whenever there is intraabdominal surgery on patients known to have or suspected of having a pelvic neoplasm. The following criteria were found to be essential to the accurate evaluation of these specimens: (1) cells considered to be malignant should be present both singly and in groups and should be malignant by the usual cytologic criteria, (2) the patients must have or be known to have had a neoplasm whose cells are similar to those in the washing specimen, and (3) the cells considered to be neoplastic must be different from and not confused with reactive mesothelial cells. The last criterion is important because the peritoneal lavage traumatically removes mesothelium, which can appear atypical. These criteria make the cytologic interpretation of most peritoneal washing specimens straightforward; interesting diagnostic problems occur, however, including the evaluation of neoplasms of borderline malignancy, those "spilled" during surgery and second neoplasms found by peritoneal washing cytology.     

Diagnostic value of hair shafts and squamous cells in peritoneal washing cytology

OBJECTIVE: Little attention has been given to hair shafts and squamous cells in peritoneal fluid. To investigate their diagnostic value in peritoneal washing specimens, we reviewed peritoneal washing cytology preparations from 83 cases of ovarian tumors. STUDY DESIGN: We reviewed peritoneal washing specimens and histologic sections of 86 cases of ovarian tumors and tumorous conditions, including 22 teratomas, 16 serous adenocarcinomas, 10 clear cell adenocarcinomas, 9 endometrioid adenocarcinomas, 5 cases of endometriosis, 4 mucinous adenomas, 3 serous cystadenocarcinomas and 17 other tumors. RESULTS: We observed both squamous cells and hair shafts surrounded by inflammatory cells in 5 of the 22 cases of ovarian teratoma. Rupture of an ovarian teratoma was clinically and histologically found in one of the five cases. Hair shafts were not observed in the other tumors or in nonneoplastic conditions. The diameter of hair shafts in peritoneal washing specimens ranged from 10 to 28.8 microns (average, 16.6), and such hair shafts were present within an ovarian teratoma examined histologically. The diameter of hair shafts from six normal adults who were examined as controls ranged from 61.5 to 118.6 microns (average, 89.4). CONCLUSION: Hair shafts and squamous cells surrounded by inflammatory cells in peritoneal washing specimens are a diagnostic clue to ovarian teratoma and can be observed even when rupture of the tumor is not detected clinically or microscopically.     

P-3THE VALUE OF PERITONEAL WASHING CYTOLOGY IN THE STAGING OF GYNAECOLOGICAL MALIGNANCY

Introduction:  Current protocols for staging gynaecological cancers include cytopathological examination of peritoneal washings taken at the time of definitive surgery. We investigated the clinical usefulness of this procedure.
Methods:  During 2004 and 2005, 140 peritoneal washings were submitted for cytopathological examination in our institutions for staging of 36 ovarian, 101 endometrial and 3 synchronous ovarian/endometrial cancers.
Results:  The washings contained malignant cells in 39 cases (28%). 35 of these cases had high stage disease – not confined to the organ of origin (i.e. stage 2 or more for ovary and stage 3 or more for endometrial). The other 4 were stage 1C ovarian cancers where there was either rupture or tumour involvement of the capsule. In only 2 of the 39 positive cases the cancer was marginally upstaged by the positive washings – these were ovarian cancers upstaged from 2A /B to 2C.
Discussion:  These findings suggest that peritoneal washing cytology as a routine procedure for staging ovarian and endometrial cancer is of limited clinical value. A larger study is needed to determine whether this procedure should continue to be included in staging protocols for gynaecological cancer.     

Increase in the incidence of peritoneal collagen balls over a 10-year period

OBJECTIVE: To describe the detection of collagen balls in peritoneal washings over a 10-year period, revealing an unexpected and unexplained higher incidence than in the past. STUDY DESIGN: Reports of routinely processed, Papanicolaou-stained smears and cytospins and hematoxylineosin-stained cell blocks from peritoneal washes and ascitic fluids seen over an 8-year period (1995-2002) were reviewed, and the percentage of specimens in which collagen balls were noted was determined. To rule out a learning curve phenomenon, the first 100 consecutive peritoneal washings and ascitic specimens from years 1993-2001 plus 2002 were rescreened, and the percentage of specimens containing collagen balls was determined. RESULTS: The percentages of cases with collagen balls increased steadily beginning with 8 of 467 cases (3.2%) in 1995 to 185 of 650 (28.5%) in 2002, as reported in the case records. Rescreened cases also showed a similar increase, 4.0% in 1993 to 29% in 2002. No procedural modifications were made in specimen processing during this interval, nor are we aware of any procedural change in obtaining cytologic samples. CONCLUSION: An unexplained 7-fold increase in the percentage of peritoneal samples with collagen balls occurred over a 10-year period. This increase cannot be attributed to changes in specimen handling or to a learning curve phenomenon. This finding is of unknown significance and may warrant further investigation.     

The value of calretinin and cytokeratin 5/6 as markers for mesothelioma in cell block preparations of serous effusions

Objective: To determine the value of calretinin and cytokeratin (CK) 5/6 in discriminating mesothelioma from adenocarcinoma in serous effusion specimens. Methods: A total of 101 recent, histologically or clinically confirmed malignant effusions with immunostained cell block preparations were reviewed. The cases consisted of 34 mesotheliomas and 67 adenocarcinomas. This included 17 ascitic fluid and 84 pleural fluid samples. The adenocarcinomas included metastatic carcinomas from the breast (12), lung (19), stomach (3), colon (1), pancreas (2), ovary (6) endometrium (1) and 23 histologically confirmed metastases from unknown primary sites. The cases were assessed as negative or positive (>5% of cells stained). The staining pattern was recorded as cytoplasmic, cell membrane, nuclear or cytoplasmic and nuclear staining. Results: Calretinin staining was present in 97% (33/34) of the mesothelioma cases with a majority of them showing both cytoplasmic and nuclear staining (29/33). Only 3% (2/67) of adenocarcinomas were positive for calretinin, one being a lung adenocarcinoma and the other an adenocarcinoma of unknown primary site in an ascitic fluid. Cytokeratin 5/6 staining was also present in 33/34 (97%) of mesothelioma cases. Six (9%) adenocarcinomas were positive, including metastases from the lung (1), breast (1), ovary (2) and unknown primary site (2). Four of the six adenocarcinoma cases positive for CK5/6 were in ascitic fluids. No cases of mesothelioma were negative for both calretinin and CK5/6. Only one adenocarcinoma case, (which was from unknown primary site in an ascitic fluid sample), was positive for both markers. Conclusions: The results confirm that calretinin and CK 5/6 are useful markers for mesothelioma in effusion specimens. CK5/6 staining may be less useful for peritoneal fluid specimens where metastatic adenocarcinomas may be more likely to express the antigen. Further study of ascitic/peritoneal specimens is warranted. However, positive staining, particularly for both antigens, is highly indicative of a mesothelial origin for cells. The two markers make a useful addition to EMA and the panel of adenocarcinoma markers routinely applied to effusion specimens.     

Cytology of benign multicystic peritoneal mesothelioma in peritoneal washings

Objective:  To describe the cytological aspect of peritoneal washings in benign multicystic peritoneal mesothelioma (BMPM).
Methods:  Three peritoneal washing specimens stained by standard cytological and histological procedures and analysed by light microscopy.
Results:  The specimens showed an abundance of monomorphous mesothelial cells devoid of atypia or mitoses. The mesothelial cells were calretinin positive. They also showed numerous squamous metaplastic cells arranged in flat sheets or isolated cells. The background contained some inflammatory cells.
Conclusion:  The combination of cytology of the peritoneal washing, histology (cell block and surgical specimen) and clinical history allow differentiation of BMPM from other cystic lesions (cystic lymphangioma and malignant mesothelioma).     

Lavage fluid from continuous ambulatory peritoneal dialysis. A model for mesothelial cell changes

Continuous ambulatory peritoneal dialysis (CAPD) lavage can be interpreted as an artificial short-term ascites. The cellular content of 362 CAPD specimens from 32 patients was investigated. Irregular inflammatory reactions were seen in 85.3% of the specimens and eosinophilia in 27.6%. Mesothelial aggregates of great variability were registered in 59.4% of the specimens and mainly atypical mitoses in 7.5%. The cytologic changes seen in those patients from whom lavage fluids were examined over 10 to 12 months did not correlate with the changes in blood chemistry (BUN and creatinine) in those cases.