Malignant Mesothelioma in
Effusions and Fine Needle
Aspirates
Armando C. Filie, M.D.
National Cancer Institute
No relationship exists that represents a possible
conflict of interest with respect to the content of this
presentation
CYTOTELECONFERENCE 2007 - 2008
2
OBJECTIVES
Objectives
• Recognize the cytological features of malignant
mesothelioma (mesothelioma) in effusion samples
• Recognize the cytological features of fine needle
aspirates of mesothelioma
• Recognize the cytological features of major
lesions in the differential diagnosis of
mesothelioma
• Familiarize with current ancillary studies in the
diagnosis of mesothelioma
CYTOTELECONFERENCE 2007 - 2008
3
MesotheliomaBLANK SLIDE
• Malignant neoplasm of pleura, peritoneal cavity and
pericardium
• Incidence of 2,500 cases/year (pleural)
• Clinical Findings
• age and presentation: males, 6th-8th decade,
unilateral
• pathogenesis: asbestos exposure (latency of 2050 years), ?simian vacuolating virus (SV40)
• imaging findings: CT scan [pleural masse(s)],
invasion by magnetic resonance imaging (MRI)
• Diagnosis: clinical history + imaging findings +
cytology(?)/biopsy
CYTOTELECONFERENCE 2007 - 2008
4
Mesothelioma
• Prognosis and Treatment
• poor prognosis
• treatment: surgery (most effective), chemotherapy,
radiotherapy (localized recurrences), combine
therapy
• Histologic Types
• epithelioid (epithelial): up to 17 subtypes
(deciduoid, clear cell, small cell, signet ring)
• sarcomatoid: 8 subtypes (fibrosarcomatous,
lymphohistiocytoid, MFH-like)
• biphasic (mixed)
• desmoplastic
CYTOTELECONFERENCE 2007 - 2008
5
Mesothelioma
• Cytological Features in Effusions
• sample preparation: smear, cytocentrifugation, thin
layer, cell block (immunostains)
• stains: Diff-Quik, Papanicolaou
CYTOTELECONFERENCE 2007 - 2008
6
Mesothelioma
• Cytological Features in Effusions
• patterns: epithelioid (malignant epithelial),
sarcomatous (sarcomatoid), anaplastic, biphasic
• sarcomatoid mesothelioma differential diagnosis:
spindle cell sarcomas
• biphasic mesothelioma differential diagnosis:
carcinomas (renal cell carcinoma)
• anaplastic mesothelioma differential diagnosis:
pleomorphic sarcomas
• epithelioid mesothelioma: most frequent pattern,
associated with effusion more frequently than other
patterns.
CYTOTELECONFERENCE 2007 - 2008
7
Mesothelioma in Effusions
Cytological Features of Epithelioid Mesothelioma
• cellular sample
• one cell population
• clusters (scalloped border)
• cell-in-cell formations
• intercellular spaces
(“windows”)
• two-tone cytoplasm
• surface blebs
• variable N/C ratio
• multinucleation
• macronucleoli
CYTOTELECONFERENCE 2007 - 2008
8
Mesothelioma in Effusions
Cytological Features of Epithelioid Mesothelioma
CYTOTELECONFERENCE 2007 - 2008
9
Mesothelioma in Effusions
Cytological Features of Epithelioid Mesothelioma
CYTOTELECONFERENCE 2007 - 2008
10
Mesothelioma in Effusions
Differential Diagnosis
• Metastatic carcinoma: adenocarcinomas (lung,
breast, gynecologic tract, gastrointestinal tract), may be
the first manifestation of an occult primary
• Hematologic neoplasms: B-cell lymphomas (diffuse
large B-cell), T-cell lymphomas (anaplastic large cell),
plasma cell neoplasms, primary effusion lymphoma
(PEL)
• Melanoma: may be the first manifestation of disease
• Others: squamous cell carcinoma, mesothelial cell
lesions
CYTOTELECONFERENCE 2007 - 2008
11
Mesothelioma in Effusions
Cytological Features of Metastatic Adenocarcinoma
• cellular sample
• two cell population
• clusters (smooth border)
• cell-in-cell formations
• high N/C ratio
• multinucleation
• macronucleoli
• irregular nuclear contours
• delicate/dense cytoplasm
• vacuole(s) displacing the
nucleus
CYTOTELECONFERENCE 2007 - 2008
12
Mesothelioma in Effusions
Cytological Features of Metastatic Adenocarcinoma
CYTOTELECONFERENCE 2007 - 2008
13
Mesothelioma in Effusions
Cytological Features of Metastatic Melanoma
• cellular sample
• two cell population (?)
• aggregates
• cell-in-cell formations
• low N/C ratio
• multinucleation
• macronucleoli
• intranuclear cytoplasmic
inclusions
• melanin pigment
• vacuoles
CYTOTELECONFERENCE 2007 - 2008
14
Mesothelioma in Effusions
Cytological Features of Metastatic Melanoma
CYTOTELECONFERENCE 2007 - 2008
15
Mesothelioma in Effusions
Cytological Features of PEL
• cellular sample
• two cell population
• variable N/C ratio
• multinucleation
• macronucleoli
• dense basophilic
cytoplasm
CYTOTELECONFERENCE 2007 - 2008
16
Mesothelioma in Effusions
Cytological Features of PEL
CYTOTELECONFERENCE 2007 - 2008
17
Mesothelioma in Fine Needle Aspirates
• Image-guided fine needle aspiration (FNA) may be used
for the initial diagnosis of mesothelioma
• 4% needle tract seeding for core-needle biopsy with
sensitivity of 86% (pleural)
• FNA of metastatic mesothelioma (rare): scalp, thyroid,
cervical lymph node, axillary lymph node, subcutaneous
nodules, breast, liver
• metastasis may be the first indication of mesothelioma
• inclusions of benign mesothelial cells in lymph nodes
• Mesothelial cell lesions of pleura: solitary fibrous tumor
(most benign, rare malignant), nodular pleural plaque,
adenomatoid tumor, simple mesothelial cyst, multicystic
mesothelioma, well-differentiated papillary mesothelioma,
localized malignant mesothelioma
CYTOTELECONFERENCE 2007 - 2008
18
Mesothelioma in Fine Needle Aspirates
Cytological Features of Mesothelioma in FNAs
• cellular aspirate
• clusters and flat sheets
• papillary groups (core)
• acinar/tubular groups
• single cells
• intercellular spaces
• round/polygonal shape
• spindle cells (sarcomatoid,
biphasic)
• small cytoplasmic vacuoles
• multinucleation
CYTOTELECONFERENCE 2007 - 2008
19
Mesothelioma in Fine Needle Aspirates
Cytological Features of Mesothelioma in FNAs
CYTOTELECONFERENCE 2007 - 2008
20
Mesothelioma in Fine Needle Aspirates
Differential Diagnosis
• Epithelioid: carcinoma - lung (adenocarcinoma and
bronchoalveolar carcinoma [BAC]), ovary and
peritoneal serous carcinoma; mesothelial cell lesions;
thymoma; epithelioid sarcomas, reactive mesothelial
proliferations
• Sarcomatoid: mesothelial cell lesions, desmoid tumor,
schwannoma, spindle cell sarcomas
• Biphasic: thymoma, synovial sarcoma, desmoplastic
small round cell tumor, pleuropulmonary blastoma
• Anaplastic: pleomorphic sarcomas
CYTOTELECONFERENCE 2007 - 2008
21
Mesothelioma in Fine Needle Aspirates
Cytological Features of Lung BAC in FNAs
• monolayer sheets
• papillae
• single cells
• round nuclei
• nuclear grooves and
pseudoinclusions
• nuclear crowding/overlapping
• pleomorphic cells
• mucin (mucinous)
CYTOTELECONFERENCE 2007 - 2008
22
Mesothelioma in Fine Needle Aspirates
Cytological Features of Lung BAC in FNAs
CYTOTELECONFERENCE 2007 - 2008
23
Mesothelioma (Ancillary Studies)
• Histochemical stains: mucin (Alcian blue, mucicarmin)
• Electron microscopy: long microvilli (meso), short (adeno)
• FISH: detection of chromosomal alterations
• Hyaluronic acid levels in effusion samples
• Immunocytochemistry: most commonly used
• may be applied to cytocentrifuged samples, smears,
thin layer samples, cell blocks (preferred)
• panel of mesothelial cell and adenocarcinoma
markers: 2 meso and 2 adeno markers or 1/2 meso
and 3 adeno markers
• other markers: hematopoietic markers, melanoma
markers, site “specific” markers (TTF-1, PSA, PAP,
CDX-2, GCDFP-15, thyroglobulin)
CYTOTELECONFERENCE 2007 - 2008
24
Mesothelioma (Ancillary Studies)
Mesothelial cell (Mesothelioma) Markers
• calretinin: neuron-specific calcium binding protein (neural
tissues and a few other cell types like mesothelial cells)
• cytokeratin 5/6: intermediate filament (mainly keratinized
and non-keratinized squamous cell carcinoma)
• Others: HBME-1, WT1,Mesothelin, Podoplanin
calretinin
CYTOTELECONFERENCE 2007 - 2008
25
Mesothelioma (Ancillary Studies)
Mesothelial cell (Mesothelioma) Markers
HBME-1
CYTOTELECONFERENCE 2007 - 2008
CK 5/6
26
Mesothelioma (Ancillary Studies)
Adenocarcinoma Markers
• B72.3: antibody detects a tumor associated protein
• Ber-EP4: antibody against epithelial adhesion molecule
• CA19.9: antibody against Lewisa blood group antigen
• Others: mCEA, CD15, MOC-31
B72.3
CYTOTELECONFERENCE 2007 - 2008
27
Mesothelioma (Ancillary Studies)
Adenocarcinoma Markers
B72.3
CYTOTELECONFERENCE 2007 - 2008
Ber-EP4
CA19.9
28
Mesothelioma (Ancillary Studies)
• Melanoma markers: HMB45, Mart-1, KBA62, S100
• Hematopoietic markers: LCA, L26, CD38, HHV8
• Others: TTF-1, PSA and PAP, GCDFP-15, thyroglobulin
HMB45
CYTOTELECONFERENCE 2007 - 2008
Mart-1
29
Mesothelioma (Ancillary Studies)
Hematopoietic and other markers
HHV8
CYTOTELECONFERENCE 2007 - 2008
TTF-1
CK 7
30
Mesothelioma (Ancillary Studies)
Molecular Tests
• Gene expression (quantitative RT-PCR)
• Proteomics: protein complement of the genome (serum early cancer diagnosis), potential in cytopathology
• Surface enhanced laser desorption/ionization time of
flight (SELDI-TOF): protein profile in cytology samples
(Fetsch et al, 2002)
• Initial set: 5 renal cell carcinomas, 9 metastatic
melanomas, 6 reactive effusions
• Unknown set: 4 renal cell carcinomas, 8 metastatic
melanomas, 3 reactive effusions
CYTOTELECONFERENCE 2007 - 2008
31
Mesothelioma (Ancillary Studies)
Molecular Tests
•SELDI-TOF in FNAs and fluid samples of 8 MM, 4 RCC, 3
reactive effusions
9
8
7
6
5
Test ed
4
+Cases
3
2
1
0
RC C
Reac Meso
CYTOTELECONFERENCE 2007 - 2008
Met Mel
32
Mesothelioma in Effusions and FNAs
SUMMARY
•
•
•
•
Cytological features of mesothelioma in effusions and
FNAs overlap with those seen in other benign and
malignant lesions (adenocarcinoma)
Some cytologic features of mesothelioma are not often
present in cytology samples of lesions that should be
considered in the differential diagnosis
Ancillary studies are important in supporting the
diagnosis of mesothelioma (immunocytochemistry,
electron microscopy)
Diagnosis of mesothelioma has prognostic, treatment
and legal implications
CYTOTELECONFERENCE 2007 - 2008
33