WEBVTT 00:00:08.466 --> 00:00:11.678 Welcome to this video lecture entitled microscopy of CSF 00:00:11.678 --> 00:00:14.681 and Body Fluids, presented by Doctor Tracy George. 00:00:15.432 --> 00:00:19.102 Doctor George is the executive director of Clinical Trials and Pharma DX, 00:00:19.269 --> 00:00:22.689 and a medical director of Amateur Pathology at IRP laboratories. 00:00:23.106 --> 00:00:25.191 Additionally, she is a professor of pathology 00:00:25.191 --> 00:00:27.736 at the University of Utah School of Medicine. 00:00:27.736 --> 00:00:31.823 Doctor George completed her MD in residency training and anatomic pathology 00:00:32.073 --> 00:00:35.326 and laboratory medicine at the University of California, San Francisco, 00:00:35.577 --> 00:00:39.998 with fellowships in matter pathology and surgical pathology at Stanford University. 00:00:40.790 --> 00:00:44.127 Doctor George is board certified in anatomic pathology, clinical 00:00:44.127 --> 00:00:47.505 pathology, and hematology by the American Board of Pathology. 00:00:48.006 --> 00:00:52.385 Her research interests include mast cell disease and laboratory hematology. 00:00:53.053 --> 00:00:55.597 She has authored more than 100 publications, 00:00:55.597 --> 00:00:58.058 is the vice president of Scientific Communications 00:00:58.058 --> 00:01:02.103 for the International Society of Laboratory Hematology, and co editor 00:01:02.103 --> 00:01:05.440 in chief of the International Journal of Laboratory Hematology. 00:01:06.191 --> 00:01:08.735 She received the College of American Pathologists 00:01:08.735 --> 00:01:11.738 Lifetime Achievement Award in 2014. 00:01:11.738 --> 00:01:13.990 I'll now turn our lecture over to Doctor George. 00:01:13.990 --> 00:01:18.411 So the objectives of today's lecture are distinguished benign 00:01:18.411 --> 00:01:22.457 from malignant cytology on CSF and body fluids. 00:01:22.916 --> 00:01:27.879 And also to help you recommend appropriate further evaluation when necessary. 00:01:30.173 --> 00:01:31.716 The agenda is I'm 00:01:31.716 --> 00:01:35.470 briefly going to talk about different side of preparatory methods. 00:01:35.929 --> 00:01:39.766 Then I'll spend a lot of time on cerebrospinal fluid. 00:01:40.308 --> 00:01:45.313 And then the final part of the lecture will be on the these three different types 00:01:45.313 --> 00:01:48.399 of serous fluids pleural fluid, peritoneal 00:01:48.399 --> 00:01:51.402 fluid and pericardial fluid. 00:01:52.237 --> 00:01:55.782 So let's talk a little bit about preparatory methods. 00:01:56.116 --> 00:01:59.619 So we centrifuge these with preparations from sediment. 00:02:00.328 --> 00:02:03.957 So we'll often have pseudo centrifugation preps. 00:02:04.332 --> 00:02:07.418 Then there's then there's like proprietary fixative 00:02:08.211 --> 00:02:11.214 and preparations like thin prep for example. 00:02:11.923 --> 00:02:14.592 You can also get membrane filters 00:02:14.592 --> 00:02:18.221 and you can even do cell block preparations, which are necessary 00:02:18.221 --> 00:02:20.682 if you're going to do immunohistochemistry, 00:02:20.682 --> 00:02:23.893 in situ hybridization or really any, molecular 00:02:23.893 --> 00:02:26.896 studies. 00:02:27.397 --> 00:02:28.314 So let's move 00:02:28.314 --> 00:02:31.317 into cerebrospinal fluid or CSF. 00:02:34.362 --> 00:02:36.114 So typically when you're collecting 00:02:36.114 --> 00:02:39.576 CSF from a patient you'll collect three tubes. 00:02:40.076 --> 00:02:42.370 And it may be a little different. 00:02:42.370 --> 00:02:43.955 At your medical center. 00:02:43.955 --> 00:02:49.586 But I'm just giving you an overall, analysis of, of how I've seen it done. 00:02:49.794 --> 00:02:55.425 So tube one is typically collected for chemistry and any, immunology studies. 00:02:55.884 --> 00:02:59.679 Tube two is collected for microbiology studies. 00:03:00.013 --> 00:03:05.143 And tube three is where the cell count inside a logic examination occurs. 00:03:05.476 --> 00:03:08.479 And so for most labs the cell count 00:03:08.479 --> 00:03:13.651 and the sidel preps are performed in a hematology laboratory. 00:03:13.651 --> 00:03:14.944 But not always. 00:03:14.944 --> 00:03:18.406 Now sometimes you may actually collect even more and send it off 00:03:18.406 --> 00:03:21.409 to cytology, or a different lab. 00:03:21.701 --> 00:03:27.040 And the red arrow indicates that if you have a traumatic tap, what happens 00:03:27.040 --> 00:03:30.585 is your tube one is going to have the most amount of red cells. 00:03:30.710 --> 00:03:33.129 But those should clear by tube three. 00:03:34.214 --> 00:03:34.964 And after 00:03:34.964 --> 00:03:38.593 centrifugation, the supernatant fluid will be clear. 00:03:39.010 --> 00:03:42.847 You may or may not have a clot in a traumatic tap tap, 00:03:42.972 --> 00:03:46.935 but by tube three you should have no evidence of chromium. 00:03:47.435 --> 00:03:51.022 The easiest way to tell if you have peripheral blood contamination 00:03:51.022 --> 00:03:54.067 is if you have 1000 red cells for every white cell. 00:03:54.943 --> 00:03:57.946 Just like reflecting the blood. 00:03:59.656 --> 00:04:02.617 So let's talk about some normal values. 00:04:02.617 --> 00:04:06.412 In CSF and I've separated out adult versus neonate. 00:04:06.788 --> 00:04:10.875 So for white cells, an adult will have usually less than five, 00:04:11.542 --> 00:04:15.672 leukocytes per microliter but a neonatal is much higher than that. 00:04:15.672 --> 00:04:18.424 So less than 30 is considered normal. 00:04:18.424 --> 00:04:21.886 For red cell numbers you really should have very few. 00:04:22.136 --> 00:04:26.266 We we talked about the champagne tap in CSF. 00:04:26.266 --> 00:04:31.062 And that's because, generally speaking, your CSF is completely clear 00:04:31.062 --> 00:04:34.440 and does not have any, red cells in the neonate. 00:04:34.482 --> 00:04:37.485 These are really difficult taps to get. 00:04:37.860 --> 00:04:40.863 So you'll often see a variable number of red cells. 00:04:40.989 --> 00:04:45.159 And then if you look at the differential of the cells that you do get in terms 00:04:45.159 --> 00:04:49.455 of the leukocytes, generally it's 40 to 80% lymphocytes. 00:04:49.455 --> 00:04:54.210 And then smaller number of monocytes about 15 to 45%. 00:04:54.585 --> 00:04:58.923 And neutrophils or PMS is 0 to 6%. 00:05:03.803 --> 00:05:07.932 So let's look at lymphocytes and monocytes. 00:05:08.683 --> 00:05:10.059 In the CNS. 00:05:10.059 --> 00:05:13.438 So these are and what I've shown in the upper 00:05:13.438 --> 00:05:16.899 part of the figure is a bunch of lymphocytes. 00:05:17.233 --> 00:05:21.696 And just in that a image you can see they're small and round. 00:05:21.696 --> 00:05:23.323 They've got a nice condensed 00:05:23.323 --> 00:05:26.743 chromatin just like you would see in a peripheral blood smear. 00:05:27.076 --> 00:05:29.287 B is a reactive lymphocyte. 00:05:29.287 --> 00:05:31.205 It's got a little bit more cytoplasm. 00:05:31.205 --> 00:05:35.960 And although there's controversy about reactive lumps in the, CSF, 00:05:35.960 --> 00:05:41.174 I have seen them and see you've got more of a spectrum of lymphocytes 00:05:41.174 --> 00:05:44.052 and there's even a plasma cell up at the top. 00:05:44.052 --> 00:05:47.055 Okay. And obviously, 00:05:47.055 --> 00:05:50.016 this is probably some reactive condition here. 00:05:50.141 --> 00:05:54.395 And then indeed you've got a few more, funny looking lymphocytes here. 00:05:54.896 --> 00:05:57.482 And then, for monocytes, 00:05:57.482 --> 00:06:03.279 you can see these cells really have folded and C shaped and S shaped nuclei, which, 00:06:03.529 --> 00:06:06.532 have more delicate chromatin than lymphocytes 00:06:06.616 --> 00:06:10.411 and this abundant kind of pale gray cytoplasm. 00:06:10.411 --> 00:06:11.871 And you can get vacuoles. 00:06:14.165 --> 00:06:16.793 I'm going to move right into the features 00:06:16.793 --> 00:06:19.796 that distinguish benign from malignant 00:06:20.797 --> 00:06:23.049 cytology and CSF. 00:06:23.049 --> 00:06:26.636 The first thing to think about is your nucleated cytoplasmic ratio 00:06:26.636 --> 00:06:30.765 in the cells that you're examining for benign conditions. 00:06:31.015 --> 00:06:34.227 The N to NC ratio is low to moderate, 00:06:34.644 --> 00:06:39.607 whereas malignant cells tend to have higher nuclear to cytoplasmic ratios. 00:06:40.149 --> 00:06:43.319 The next feature that we look at in cells are nuclear 00:06:43.319 --> 00:06:46.322 contours and or nuclear membrane. 00:06:46.906 --> 00:06:49.367 And again, in benign 00:06:49.367 --> 00:06:52.703 conditions you'll have around to oval nucleus 00:06:52.703 --> 00:06:55.706 in your cell with a regular nuclear contour. 00:06:56.082 --> 00:06:59.502 You often will have a prominent and distinct nuclear membrane. 00:06:59.710 --> 00:07:02.672 And this really differs from malignant features 00:07:02.672 --> 00:07:07.093 where you get irregular nuclear shapes, indistinct nuclear membranes, 00:07:07.093 --> 00:07:10.388 and you can even have blobs of your membrane at the periphery. 00:07:12.557 --> 00:07:16.561 So let's take a, a vote here. 00:07:16.978 --> 00:07:18.646 Even though I can't hear you vote. 00:07:18.646 --> 00:07:20.857 I know you're thinking about this. 00:07:20.857 --> 00:07:23.860 So we're again, we're you're still in the CSF. 00:07:24.026 --> 00:07:27.530 So I want you to take a look at these cells and ask yourself, 00:07:27.822 --> 00:07:30.825 are these benign or malignant? 00:07:31.117 --> 00:07:33.411 We've got a cell cluster here. 00:07:33.411 --> 00:07:38.916 You've got pretty, round to slightly oval nuclei and abundant cytoplasm. 00:07:38.916 --> 00:07:42.253 So using those few features that we just went over, 00:07:43.421 --> 00:07:45.131 let's 00:07:45.131 --> 00:07:46.507 tell me what you think. 00:07:46.507 --> 00:07:47.091 Okay. 00:07:47.091 --> 00:07:50.094 Has everyone made a decision? Good. 00:07:50.678 --> 00:07:53.598 So these are benign cells. 00:07:53.598 --> 00:07:58.019 These are benign lining cells that you can see, from the meninges. 00:07:58.019 --> 00:08:01.022 And these are called choroid plexus cells. 00:08:01.147 --> 00:08:04.567 And the key feature here is when you look at that nuclear 00:08:04.567 --> 00:08:07.904 to cytoplasmic ratio it's really low right. 00:08:08.237 --> 00:08:11.657 Because these cells have abundant amount of cytoplasm. 00:08:11.949 --> 00:08:16.537 And when you look at the nuclear contours they're round and regular. 00:08:16.537 --> 00:08:20.082 And we don't see any irregularities or nuclear bleb. 00:08:20.124 --> 00:08:24.837 So these are all features of benign cells in the CSF. 00:08:27.006 --> 00:08:28.007 The next features 00:08:28.007 --> 00:08:31.385 we're going to talk about are nuclear texture and nuclear lie. 00:08:31.802 --> 00:08:36.432 So nuclear texture and benign cells are fine 00:08:36.432 --> 00:08:41.020 uncon dense nuclear chrome chromatin with uniform smooth texture. 00:08:41.354 --> 00:08:44.315 But malignant cells are uneven. 00:08:44.815 --> 00:08:47.652 With prominent chromatin spaces. 00:08:47.652 --> 00:08:50.071 And I'll be showing you some examples of this. 00:08:50.071 --> 00:08:55.368 Now in nuclear lie it's often hard to see them in benign cells. 00:08:55.826 --> 00:08:58.829 And if you do they're small to medium size. 00:08:59.121 --> 00:09:02.625 But malignant cells will have large and often angulation 00:09:02.625 --> 00:09:05.628 nuclei lie in them. 00:09:06.128 --> 00:09:10.132 So here's something again found in the CSF. 00:09:11.092 --> 00:09:14.470 And you can see we have it looks like three cell clusters. 00:09:15.763 --> 00:09:18.766 Kind of hard to see the nuclear membranes. 00:09:19.725 --> 00:09:20.685 So take a look. 00:09:20.685 --> 00:09:23.688 Do you think this is benign or malignant. 00:09:25.773 --> 00:09:28.359 Actually these are also benign. 00:09:28.359 --> 00:09:30.152 These are appendage muscle cells. 00:09:30.152 --> 00:09:33.614 And again these are cells that line the meninges. 00:09:33.990 --> 00:09:37.368 And even though I know that cell cluster at the far right 00:09:37.368 --> 00:09:40.871 looks a little bit scary when when you look at it 00:09:40.871 --> 00:09:45.376 you realize that the the nuclear chromatin is fairly smooth. 00:09:45.585 --> 00:09:47.670 We don't see large nuclei. 00:09:47.670 --> 00:09:50.006 I don't see any nuclei at all. 00:09:50.006 --> 00:09:53.009 And the cells all actually kind of resemble each other. 00:09:53.050 --> 00:09:57.054 And the nuclear to cytoplasmic ratios in the smaller 00:09:57.054 --> 00:10:01.225 cell clusters, where you can really see the cells better is quite low. 00:10:04.770 --> 00:10:07.773 So we are still in the CSF 00:10:08.608 --> 00:10:11.235 and you see these cells. 00:10:11.235 --> 00:10:15.698 So the question here is are these benign or are these malignant. 00:10:15.698 --> 00:10:19.744 And these are more trying triangular shaped cells. 00:10:20.536 --> 00:10:23.497 And it looks like they even have some nuclei alive. 00:10:24.665 --> 00:10:25.750 So take a guess. 00:10:25.750 --> 00:10:28.711 Benign or malignant. 00:10:28.711 --> 00:10:32.048 These are actually CNS ganglion cells. 00:10:32.048 --> 00:10:33.341 So from the brain. 00:10:33.341 --> 00:10:36.552 And you can sometimes see these especially in patients 00:10:36.552 --> 00:10:41.766 who have shunts in place or who have had brain surgery recently. 00:10:41.766 --> 00:10:44.268 They'll have often still have the shunt in place. 00:10:44.268 --> 00:10:48.731 And so again, these are actually benign cells from the brain. 00:10:48.731 --> 00:10:51.734 But they were happened to be found in the CSF. 00:10:54.820 --> 00:10:57.823 So again we are still in the CSF. 00:10:57.907 --> 00:11:00.910 This is a case I saw a number of years ago. 00:11:00.993 --> 00:11:02.828 Actually from a neonatal. 00:11:05.915 --> 00:11:07.625 So first 00:11:07.625 --> 00:11:10.878 question you have to ask yourself is this benign or malignant. 00:11:10.878 --> 00:11:14.006 And then you have to ask yourselves what kind of cells are these. 00:11:15.007 --> 00:11:18.010 I don't want to bias anybody. 00:11:18.844 --> 00:11:20.179 So this is actually 00:11:20.179 --> 00:11:23.182 an example of bone marrow contamination. 00:11:23.766 --> 00:11:26.894 In a CSF sample in a neonate. 00:11:27.186 --> 00:11:31.649 So unfortunately, when they were doing the, lumbar puncture 00:11:31.649 --> 00:11:34.902 in this child, they actually passed through the bone 00:11:34.902 --> 00:11:37.822 marrow and collected some of the bone marrow. 00:11:37.822 --> 00:11:40.825 So these cells here 00:11:40.950 --> 00:11:45.996 that I'm circulating at in the right, those are actually erythrocyte precursors. 00:11:45.996 --> 00:11:50.668 And these larger cells are all granule acidic precursors. 00:11:51.085 --> 00:11:54.046 And so this is a clue that you might be dealing with bone 00:11:54.046 --> 00:11:57.049 marrow contamination in a CSF sample. 00:11:58.592 --> 00:12:01.595 And again this is completely benign. 00:12:03.556 --> 00:12:04.557 And then of course 00:12:04.557 --> 00:12:08.102 I also want to show you, you know we worry about things 00:12:08.102 --> 00:12:11.564 in the CSF and other body fluids that are going to kill you quick. 00:12:12.064 --> 00:12:14.108 That's kind of how I think about it. 00:12:14.108 --> 00:12:18.779 And so you worry about the tumors and then you also worry about infection. 00:12:18.821 --> 00:12:22.116 So this is from a patient with bacterial meningitis. 00:12:22.366 --> 00:12:24.618 And I know these cells look a little bit up. 00:12:24.618 --> 00:12:27.163 And they are these are all neutrophils here. 00:12:27.163 --> 00:12:29.999 And they're beat up because they're fighting off an infection. 00:12:29.999 --> 00:12:34.003 And so you'll often see some degenerative changes or evacuations 00:12:34.420 --> 00:12:38.382 in neutrophils where you have such intense bacterial meningitis. 00:12:38.841 --> 00:12:42.136 And of course the organ intracellular organisms here 00:12:42.136 --> 00:12:45.139 stain a deep purple on this right. 00:12:45.139 --> 00:12:46.974 Gives a stain. Right. 00:12:46.974 --> 00:12:48.726 So this is not a gram stain. 00:12:48.726 --> 00:12:51.729 It's always important not to give a gram stain 00:12:51.729 --> 00:12:54.732 result unless unless you're looking at a gram stain. 00:12:54.940 --> 00:12:58.611 Now we always worry about bacterial contamination. 00:12:59.069 --> 00:13:04.742 But you're pretty safe if you identify these organisms within the cells. 00:13:04.742 --> 00:13:06.076 So that's the clue. 00:13:06.076 --> 00:13:08.954 If I see them outside the cells 00:13:10.289 --> 00:13:11.665 I then may look at 00:13:11.665 --> 00:13:15.669 may want to look at my stains to make sure there's no bacterial contamination. 00:13:15.669 --> 00:13:19.089 But if I see them inside the cells in a fresh specimen, 00:13:19.340 --> 00:13:22.927 I know that I'm dealing with bacterial meningitis in this case. 00:13:22.927 --> 00:13:26.138 And then I'd want to follow this up, obviously, with a gram 00:13:26.138 --> 00:13:29.141 stain and culture. 00:13:30.226 --> 00:13:34.104 Here's, another, organism 00:13:34.104 --> 00:13:37.107 that we found within a CSF specimen. 00:13:38.192 --> 00:13:41.195 I'm sure many of you have seen this. 00:13:41.362 --> 00:13:44.990 This is an example of Cryptococcus neo formance. 00:13:45.449 --> 00:13:49.995 And so again, this is a er dried right games stain. 00:13:49.995 --> 00:13:54.708 So from the hematology lab where we did this, in my lab years ago, 00:13:54.959 --> 00:14:00.464 and you can see the very thick, capsule here surrounding these organisms, 00:14:00.464 --> 00:14:05.761 which, and you could see the, kind of a purple, pink color to it. 00:14:06.178 --> 00:14:09.598 So obviously, if you were to see something like this, 00:14:11.225 --> 00:14:12.184 you would want to 00:14:12.184 --> 00:14:16.480 do, you would want to make sure that you had, fungal cultures. 00:14:16.480 --> 00:14:19.567 And whenever I think about fungal cultures, I'm also 00:14:19.567 --> 00:14:22.611 thinking about, mycobacterial cultures. 00:14:22.611 --> 00:14:27.074 So I always recommend that the clinicians get them and, tandem. 00:14:27.366 --> 00:14:30.995 You could also do a silver stain like a geomar stain, 00:14:31.662 --> 00:14:34.456 on a preparation in order to prove what they are. 00:14:34.456 --> 00:14:38.210 And we used to do remember India Inc, a long time ago. 00:14:39.003 --> 00:14:41.755 Nowadays most people will be doing serology 00:14:41.755 --> 00:14:44.758 or Crypto.com for Cryptococcus, antigen. 00:14:47.052 --> 00:14:50.306 So now I'm moving on to other features 00:14:50.306 --> 00:14:54.518 of benign versus malignant cytology in lymphoid cells. 00:14:54.518 --> 00:14:57.813 So lymphoid cells are a little bit different because 00:14:58.355 --> 00:15:02.443 if it's benign you'll see a spectrum of forms. 00:15:02.484 --> 00:15:05.946 So they're heterogeneous with different morphologic forms. 00:15:06.280 --> 00:15:10.951 And the lymphocytes are round to being shaped nuclei with regular contours. 00:15:10.951 --> 00:15:13.579 And you'll often have a clear Golgi zone present. 00:15:13.579 --> 00:15:17.166 But malignant lymphocytes are homogenous. 00:15:17.166 --> 00:15:18.918 So they all look alike. 00:15:18.918 --> 00:15:22.212 And you'll get a homogenous infiltrate of malignant cells. 00:15:22.212 --> 00:15:23.255 They look clonal. 00:15:23.255 --> 00:15:26.842 The nuclear often will have uneven contours, and the Golgi 00:15:26.842 --> 00:15:29.929 region is often absent in lymphoma cells. 00:15:31.847 --> 00:15:34.850 So what about this case? 00:15:34.934 --> 00:15:36.644 This is a patient that presented 00:15:36.644 --> 00:15:40.064 with an elevated white blood cell count in their CSF. 00:15:40.564 --> 00:15:43.567 And they had a headache. 00:15:43.651 --> 00:15:46.654 And I know that you're looking at this right now saying 00:15:46.987 --> 00:15:49.865 there is a spectrum of cells lymphocytes. 00:15:49.865 --> 00:15:54.119 And you would be correct because this is an example of herpes 00:15:54.536 --> 00:15:57.331 meningitis or viral meningitis 00:15:57.331 --> 00:16:00.209 where you've got some smaller lymphocytes. 00:16:00.209 --> 00:16:01.251 Not so scary. 00:16:01.251 --> 00:16:04.838 And there's some really larger almost plasma site void forms. 00:16:05.130 --> 00:16:07.925 But this is very typical for what you can see 00:16:07.925 --> 00:16:10.928 in a viral process. 00:16:13.180 --> 00:16:16.767 Also other features to think about for lymphoid cells. 00:16:17.101 --> 00:16:21.188 Benign lymphoid lymphocytes have nuclear chromatin that varies 00:16:21.188 --> 00:16:25.275 from condense to blast stick, for example in the immune oblast. 00:16:25.651 --> 00:16:31.073 And you can get some small nuclear ly but malignant lymphoid cells or lymphoma 00:16:31.365 --> 00:16:36.120 you'll or leukemia, you'll get blasted nuclear chromatin in all cells. 00:16:36.120 --> 00:16:37.913 And the nuclei can be large. 00:16:37.913 --> 00:16:39.915 And these cells can be quite polymorphic. 00:16:42.001 --> 00:16:45.004 So what about your diagnosis here? 00:16:45.337 --> 00:16:49.258 This is a patient that had a history of acute leukemia 00:16:49.508 --> 00:16:53.762 in the blood and bone marrow and had been treated and was in remission, 00:16:54.138 --> 00:16:57.141 but then presented with a headache. 00:16:58.058 --> 00:16:59.143 And indeed, 00:16:59.143 --> 00:17:02.688 this is an example of cute leukemia in the CSF. 00:17:02.688 --> 00:17:05.691 And the thing about this is look at all of these blasts. 00:17:05.733 --> 00:17:07.109 They all look alike. 00:17:07.109 --> 00:17:09.778 It's like their brothers and sisters here. 00:17:09.778 --> 00:17:12.865 Because they're leukemic blast, they have smooth chromatin, 00:17:12.865 --> 00:17:15.868 but you can see that there are multiple nuclei 00:17:16.243 --> 00:17:19.246 in these cells. 00:17:22.958 --> 00:17:27.421 Now moving on to non hematologic conditions. 00:17:27.546 --> 00:17:31.091 Let's talk about what separates benign from malignant 00:17:31.592 --> 00:17:35.846 and cell clusters is a very important characteristic of malignancy. 00:17:36.180 --> 00:17:39.641 Now benign cells can have thin spaces between them. 00:17:39.641 --> 00:17:42.644 Windows like mesothelioma windows 00:17:43.270 --> 00:17:46.899 and the outer border of the cell cluster is discontinuous. 00:17:47.107 --> 00:17:51.528 But when you get three dimensional large clusters, we often say with the more 00:17:51.528 --> 00:17:56.366 you like a grape like appearance, that's a feature of malignancy. 00:17:56.700 --> 00:18:01.121 And the outer border of the cell cluster is often smooth and continuous, 00:18:01.121 --> 00:18:04.958 and it can be darkly stained because the cells tend to overlap. 00:18:05.834 --> 00:18:07.503 So here's a case. 00:18:07.503 --> 00:18:10.964 This was also in a child benign or malignant. 00:18:10.964 --> 00:18:12.883 So you can see their cell clusters. 00:18:12.883 --> 00:18:14.468 Do they have windows. 00:18:15.677 --> 00:18:18.305 Are they three dimensional. 00:18:18.305 --> 00:18:21.308 What about these cell borders. 00:18:23.018 --> 00:18:26.146 So if you thought this was malignant you are correct. 00:18:26.271 --> 00:18:30.192 This is an example of of medulloblastoma. 00:18:30.943 --> 00:18:36.156 And you can see here this is a malignancy that children can get in their brain. 00:18:36.156 --> 00:18:37.908 So it's a brain tumor. 00:18:37.908 --> 00:18:41.120 And when we looked at a number of malignant 00:18:41.495 --> 00:18:45.290 CSF samples in children, we found that the most common one 00:18:45.290 --> 00:18:49.837 that we found involving the CSF was medulloblastoma. 00:18:50.587 --> 00:18:55.926 And again these cells have high nuclei or cytoplasmic ratios. 00:18:55.926 --> 00:18:59.888 You've got a Morelia like grape like three dimensional appearance 00:18:59.888 --> 00:19:04.059 over here and very irregular nuclear contours. 00:19:04.059 --> 00:19:05.769 And you might say what about that. 00:19:05.769 --> 00:19:08.564 Is that a window? I'm going to show you a better window. 00:19:08.564 --> 00:19:12.734 So, you know, none of these features can be used alone, 00:19:12.734 --> 00:19:16.238 but you use them together to predict benign from malignant. 00:19:18.157 --> 00:19:21.160 So now I want to show you the differences, 00:19:21.952 --> 00:19:26.331 just in a few slides of what you can see between different types of preparation. 00:19:26.707 --> 00:19:29.376 So you might ask, well, hey, cytology 00:19:29.376 --> 00:19:32.379 is getting a sample of this CSF specimen. 00:19:32.671 --> 00:19:37.509 You know, do we really need to be looking at the same sample in the hematology lab? 00:19:37.801 --> 00:19:42.014 And the answer is absolutely yes because this is a patient 00:19:42.014 --> 00:19:44.850 with large cell lymphoma in their CSF. 00:19:44.850 --> 00:19:48.312 And it left this is a thin Prep specimen. 00:19:48.312 --> 00:19:51.356 And this is the papa papa Nicolau stain. 00:19:51.815 --> 00:19:57.279 And in the inset box is shown a normal small lymphocyte from this patient. 00:19:57.946 --> 00:20:01.116 This is what large cell lymphoma looks like on a pap stain. 00:20:01.116 --> 00:20:03.493 I think this is incredibly subtle. 00:20:03.493 --> 00:20:06.079 And this was missed in the lab. 00:20:06.079 --> 00:20:10.417 Now I want to show you the situs spin prep from the CSF. 00:20:10.417 --> 00:20:12.044 This is an air dried right? 00:20:12.044 --> 00:20:13.420 Seems a stain. Right? 00:20:13.420 --> 00:20:15.756 This looks totally atypical. Right. 00:20:15.756 --> 00:20:18.759 And here's a small lymphocyte in the inset. 00:20:18.842 --> 00:20:23.013 So I find for hematologic malignancies in particular 00:20:23.388 --> 00:20:26.266 the air dried right gives us stains. 00:20:26.266 --> 00:20:30.312 The situs pins are much more helpful in making that diagnosis. 00:20:32.105 --> 00:20:33.190 This is 00:20:33.190 --> 00:20:37.361 another case of a patient with acute lymphoblastic leukemia. 00:20:37.945 --> 00:20:43.533 At the right you can see an obvious blast, much larger than the red cells next 00:20:43.533 --> 00:20:48.372 to it, with an irregular nuclear contour, smooth chromatin, and a big, nucleolus. 00:20:48.664 --> 00:20:53.335 And at left, this was the best I could find from the thin prep specimen. 00:20:53.377 --> 00:20:57.381 This is the exact same CSF from the same patient, 00:20:57.381 --> 00:20:59.466 but just stained different ways. 00:20:59.466 --> 00:21:01.635 And you can see these cells. 00:21:01.635 --> 00:21:04.721 I would be very hard pressed to call these blasts. 00:21:05.138 --> 00:21:09.309 So that's why your examination of CSF 00:21:09.309 --> 00:21:13.272 and other body fluids in the clinical lab, is very important. 00:21:15.274 --> 00:21:18.277 Now, I want to move on to the serous fluids. 00:21:18.277 --> 00:21:21.863 And by that that includes pericardial, pleural 00:21:21.863 --> 00:21:24.866 and peritoneal fluids. 00:21:25.784 --> 00:21:26.910 So first of all, let's 00:21:26.910 --> 00:21:29.913 talk about transit dates versus actually dates. 00:21:30.038 --> 00:21:34.501 So transit dates of course is much more common 00:21:34.501 --> 00:21:39.339 in benign conditions and reflects systemic disease most typically. 00:21:39.798 --> 00:21:42.676 But when you have a next you date, you're much more likely 00:21:42.676 --> 00:21:45.846 to have a patient with infection or malignancy. 00:21:46.305 --> 00:21:49.182 So there's a couple of things that we measure in the lab. 00:21:49.182 --> 00:21:52.811 We measure fluid protein, serum protein, fluid. 00:21:53.145 --> 00:21:55.897 LDH and serum LDH. 00:21:55.897 --> 00:22:00.277 And you can put together ratios such that the fluid protein over the serum 00:22:00.277 --> 00:22:06.158 protein, if it's less than or equal 2.5, that's more typical of a trans you date. 00:22:06.158 --> 00:22:09.161 And if it's more than 0.5, that's an exudate. 00:22:09.494 --> 00:22:14.624 Similarly, you can do the same thing for LDH if it's 0.6 or less 00:22:15.125 --> 00:22:20.047 trans, you date more than 0.6 exudate and then low LDH. 00:22:20.839 --> 00:22:24.426 Trans you date high LDH exudates. 00:22:24.760 --> 00:22:27.637 Probably the easiest thing is just look at the at the fluid 00:22:27.637 --> 00:22:32.434 is that typically trans you date of fluids are clear and pale yellow 00:22:32.768 --> 00:22:38.440 whereas cloudy, turbid, purulent or bloody fluids are examples of exudates. 00:22:40.776 --> 00:22:43.779 So let's talk about pericardial fluids. 00:22:44.071 --> 00:22:48.575 These are constitute approximately 1% of all serous effusions. 00:22:48.575 --> 00:22:51.578 And the vast majority of these are exudates. 00:22:51.703 --> 00:22:55.040 And generally, you know, you shouldn't have any pericardial fluid. 00:22:55.040 --> 00:22:57.000 And when you do, it's 00:22:57.000 --> 00:23:00.670 it's often patients are at a high risk for malignancy and infection. 00:23:01.213 --> 00:23:06.259 It can also be seen with trauma, myocardial infarction, a leaking aneurysm, 00:23:07.010 --> 00:23:11.306 rheumatoid arthritis, lupus, anticoagulation therapy. 00:23:11.681 --> 00:23:15.727 You can see trans you dates and patients with congestive heart failure, 00:23:16.311 --> 00:23:19.773 rheumatoid arthritis, sarcoidosis or hypothyroidism. 00:23:19.773 --> 00:23:22.776 So you can see there's a little bit of overlap. 00:23:22.859 --> 00:23:26.738 Now if you see a lymphocyte ptosis in a pericardial fluid, 00:23:27.489 --> 00:23:31.326 that's more often found in adults with tuberculosis, 00:23:31.701 --> 00:23:36.248 and children with viral infections, rarely you can see lymphomas. 00:23:36.248 --> 00:23:39.251 But I've seen that. 00:23:39.709 --> 00:23:40.669 So what about 00:23:40.669 --> 00:23:43.880 what are the sources of malignancy in pericardial fluids? 00:23:44.131 --> 00:23:49.678 Turns out 27% of all pericardial fluids are malignant. 00:23:49.678 --> 00:23:54.266 This is an old paper from the 70s, but it's an oldie but a goodie. 00:23:54.474 --> 00:23:55.475 Okay. 00:23:55.475 --> 00:24:00.480 And when they looked at a very large number of pericardial fluids, 00:24:00.480 --> 00:24:03.775 of the malignant ones, they found that 33% 00:24:03.775 --> 00:24:06.820 were from breast cancer, 20% from colon, 00:24:07.154 --> 00:24:11.324 20% lung, 7% lymphoma or leukemia, 00:24:11.616 --> 00:24:15.203 and 20% were Miscellaneous and unknown. 00:24:17.414 --> 00:24:20.417 Now I want to move on to plural effusions. 00:24:20.792 --> 00:24:23.920 So in pleural effusions, approximately 00:24:23.920 --> 00:24:27.132 25 to 45% are malignant. 00:24:27.966 --> 00:24:31.178 Congestive heart failure is found in about 12% 00:24:31.178 --> 00:24:35.682 infection, which can be a variety of different infections from tuberculosis. 00:24:35.682 --> 00:24:41.062 Bacterial, viral, fungal is about 22% 10% in this study. 00:24:41.229 --> 00:24:43.064 They was indeterminate. 00:24:43.064 --> 00:24:46.193 3% was due to pulmonary embolism or infarct, 00:24:46.485 --> 00:24:50.197 2% cirrhosis and 2% college and disease. 00:24:50.739 --> 00:24:53.742 College and vascular disease. 00:24:53.867 --> 00:24:58.288 And pleural effusion is again the same thing you're trying to assess. 00:24:58.288 --> 00:25:01.291 Is this a trans you date or is it an exudate. 00:25:01.708 --> 00:25:02.918 Now trans due dates. 00:25:02.918 --> 00:25:06.129 There's many causes for pleural fusions including. 00:25:06.129 --> 00:25:10.175 The primary one is congestive heart failure cirrhosis hypo 00:25:10.258 --> 00:25:13.261 protein immune nephrotic syndrome and so on. 00:25:13.720 --> 00:25:16.973 Exudates are two big ones are malignancy and infection. 00:25:17.349 --> 00:25:20.936 But again, just like in the pericardium we talked the you can see 00:25:20.936 --> 00:25:26.024 trauma PS pulmonary infarction autoimmune disease and so on. 00:25:28.860 --> 00:25:29.319 And then 00:25:29.319 --> 00:25:34.366 moving on to peritoneal infections again transient versus exudate 00:25:34.658 --> 00:25:38.495 congestive heart failure cirrhosis nephrotic syndrome. 00:25:38.745 --> 00:25:43.458 These are examples of trans U dates and exudates are malignancy 00:25:43.458 --> 00:25:46.461 infection trauma and so on. 00:25:48.880 --> 00:25:51.383 So what about malignant societies fluids. 00:25:51.383 --> 00:25:54.386 Because we often see a lot of these fluid in the lab. 00:25:54.553 --> 00:25:59.849 So in men the miscellaneous it's often 00:25:59.849 --> 00:26:03.520 not we're often not aware of where they're coming from. 00:26:03.520 --> 00:26:05.730 It counts for malignant societies. 00:26:05.730 --> 00:26:10.485 Fluid 38 to 46% gastrointestinal tract 00:26:10.485 --> 00:26:15.282 malignancies is can be ranges from, you know, 23 to 42. 00:26:16.366 --> 00:26:21.538 Unknown where we're really not sure malignancy of uncertain origin 00:26:21.538 --> 00:26:26.084 and then lung in women is generally from the general tract. 00:26:26.084 --> 00:26:30.755 And that includes ovaries as a very common cause of malignant societies. 00:26:30.755 --> 00:26:33.800 Fluid followed by miscellaneous breast 00:26:33.800 --> 00:26:37.178 is smaller GI tract unknown and then lung. 00:26:39.347 --> 00:26:40.140 So now I 00:26:40.140 --> 00:26:44.144 want to move on to showing you macrophages and mesothelioma cells, 00:26:44.144 --> 00:26:47.981 because I find that these cell types cause the most problems. 00:26:49.357 --> 00:26:52.360 In, in the lab and amongst pathologists. 00:26:52.736 --> 00:26:56.489 So here's an example on the right of a macrophage 00:26:56.489 --> 00:26:59.951 with abundant cytoplasm containing small vacuoles. 00:26:59.951 --> 00:27:03.580 And it's got a nice round nucleus with smooth chromatin. 00:27:03.997 --> 00:27:06.249 And next to it are a bunch of lymphocytes. 00:27:06.249 --> 00:27:09.252 And then a few red cells. 00:27:10.337 --> 00:27:14.257 So what's important to realize is that you can get Signet 00:27:14.257 --> 00:27:17.510 ring macrophages as shown here with the arrows. 00:27:18.553 --> 00:27:23.433 And that's important because we often think of signet ring carcinoma. 00:27:23.892 --> 00:27:25.685 But if you look at these cells 00:27:25.685 --> 00:27:29.564 and you look at the nucleus the nucleus is round to oval. 00:27:29.564 --> 00:27:30.440 It's regular. 00:27:30.440 --> 00:27:33.693 It doesn't look like the nucleus of a malignant cell. 00:27:33.693 --> 00:27:37.155 So even though it's got it's this big round vacuole in it, 00:27:38.490 --> 00:27:40.659 it's not a malignant cell. 00:27:40.659 --> 00:27:43.870 And if you're not sure it's especially in 00:27:43.870 --> 00:27:46.956 these sorts of samples, it's important to look around 00:27:46.956 --> 00:27:49.959 and you see other macrophages 00:27:50.043 --> 00:27:53.046 and they look completely normal. 00:27:53.213 --> 00:27:54.547 So always look at these cells. 00:27:54.547 --> 00:27:57.550 Look at the company that they keep. 00:27:58.635 --> 00:28:01.596 You can get multi nucleated giant cells 00:28:01.596 --> 00:28:06.226 sometimes I have two different preparations shown here. 00:28:08.269 --> 00:28:11.648 But again the nuclei look very regular. 00:28:12.565 --> 00:28:15.568 It doesn't look like a malignant cell. 00:28:17.070 --> 00:28:21.157 Macrophages can also carry pigment in them. 00:28:22.867 --> 00:28:26.871 So here's some Hema citron pigment in this macrophage here. 00:28:26.871 --> 00:28:28.873 Here's the nucleus there. 00:28:28.873 --> 00:28:31.167 And here's some hematite in crystals. 00:28:31.167 --> 00:28:33.461 Here's the macrophage here. 00:28:33.461 --> 00:28:36.756 And it looks like there's one little hematite in crystal there. 00:28:37.132 --> 00:28:40.510 That's because macrophages are breaking down other cell types. 00:28:40.510 --> 00:28:44.139 They engulf them through phagocytosis and then break them down. 00:28:45.014 --> 00:28:50.228 So if I see a macrophage with Hema citrate it as in here 00:28:50.520 --> 00:28:55.066 I know this patient has had bleeding into that body fluid space. 00:28:55.275 --> 00:29:00.238 And that's because the macrophage is breaking down the red cells into Hema citron. 00:29:03.074 --> 00:29:06.035 Now let's move on to discussing the mesothelioma. 00:29:06.369 --> 00:29:09.372 So it's important to realize that these, 00:29:09.789 --> 00:29:12.667 your peritoneum or your pericardium and, 00:29:12.667 --> 00:29:16.629 and pleura are lined by mesothelioma cells. 00:29:16.796 --> 00:29:20.842 So, and they have almost a it's like pavement, 00:29:20.842 --> 00:29:24.262 like little cobblestones that line the surface here. 00:29:24.554 --> 00:29:28.641 And these are very easily shed into body fluids. 00:29:28.933 --> 00:29:33.271 And so you can get sheets of these, being shed into, like the, 00:29:33.855 --> 00:29:38.193 into the peritoneal cavity or pericardial cavity 00:29:38.318 --> 00:29:41.321 or plural fluid. 00:29:42.697 --> 00:29:46.117 So here's an example of two mesothelioma cells. 00:29:46.534 --> 00:29:52.040 And you can see very nice, round two oval nuclei with smooth chromatin. 00:29:52.332 --> 00:29:55.335 And they have kind of this fluffy, 00:29:55.460 --> 00:29:58.296 cytoplasm with a few vacuoles here. 00:29:58.296 --> 00:30:01.424 But we often talk about them having a two tone look. 00:30:01.424 --> 00:30:05.678 And that's because you can see there's a little bit of peripheral base of philia 00:30:05.678 --> 00:30:09.724 at the edge and a little bit lighter near the nucleus. 00:30:13.353 --> 00:30:15.396 Activated mesothelioma cells 00:30:15.396 --> 00:30:20.276 can take more of a bluish blush or base of like look to it. 00:30:20.819 --> 00:30:24.823 And here's two nice little activated mesothelioma cells. 00:30:25.990 --> 00:30:26.741 But again, 00:30:26.741 --> 00:30:30.537 if you look close to the nucleus, it looks a little bit lighter here. 00:30:30.537 --> 00:30:30.995 Right. 00:30:30.995 --> 00:30:34.415 And then it's a little deeper, blue away from the nucleus. 00:30:34.415 --> 00:30:37.418 So again, that two tone look to it, 00:30:38.086 --> 00:30:41.714 you know, mesothelioma cells have all sorts of little villi, 00:30:42.340 --> 00:30:44.843 in their cytoplasm, but we actually can't see that 00:30:44.843 --> 00:30:47.846 with our typical stains. 00:30:48.847 --> 00:30:51.850 There's a lot of variability within mesothelioma cells. 00:30:51.850 --> 00:30:54.102 So here's some scattered mesothelioma cells. 00:30:54.102 --> 00:30:58.273 And here's a real activated one where you can really get that two tone look. 00:30:58.606 --> 00:31:02.110 And the cytoplasm is, rather blobby here 00:31:03.486 --> 00:31:06.698 we often will talk about like the ruffles on a skirt. 00:31:10.493 --> 00:31:12.620 And then just like you can get signet ring 00:31:12.620 --> 00:31:16.875 macrophages, you can also get signet ring mesothelioma cells. 00:31:16.875 --> 00:31:20.712 And if you asked me to try and distinguish this from a signet ring macrophage, I'm 00:31:20.712 --> 00:31:22.338 not sure I really could. 00:31:22.338 --> 00:31:25.425 But the point is these are both benign 00:31:25.425 --> 00:31:28.386 cell types. 00:31:30.471 --> 00:31:33.725 Now here's where I promised you to just talk about windows 00:31:33.725 --> 00:31:38.396 between cells as a feature of of of benign cells. 00:31:38.688 --> 00:31:40.189 And mesothelioma cells. 00:31:40.189 --> 00:31:44.694 Remember they they line that, body cavity and they come off in sheets 00:31:44.694 --> 00:31:48.823 and this is what they come off and they're like little pavement stones 00:31:49.157 --> 00:31:50.742 like in the garden. 00:31:50.742 --> 00:31:55.455 And you can see the clear windows or spaces that surround them 00:31:55.455 --> 00:31:56.456 and set them apart. 00:31:56.456 --> 00:31:58.875 And this is what we mean by mesothelioma cells. 00:31:58.875 --> 00:32:04.380 So here's a bunch of totally benign mesothelioma cells separated from each other. 00:32:07.175 --> 00:32:08.217 Now let's talk about 00:32:08.217 --> 00:32:11.220 mesothelioma hyperplasia. 00:32:12.472 --> 00:32:14.557 So body 00:32:14.557 --> 00:32:18.728 cavities can be irritated for a variety of reasons. 00:32:19.103 --> 00:32:22.357 And so the mesothelioma cells that line 00:32:22.357 --> 00:32:25.360 the body cavity can proliferate 00:32:25.485 --> 00:32:28.488 so that they're hyperplastic or there's too many of them. 00:32:28.696 --> 00:32:31.115 And so you can start to get some abnormalities. 00:32:31.115 --> 00:32:34.911 So here we have the embracing mesothelioma cells. 00:32:36.829 --> 00:32:39.374 But again if you look at those two cells 00:32:39.374 --> 00:32:42.335 they look completely benign. 00:32:42.460 --> 00:32:45.463 The low nuclear to cytoplasmic ratio. 00:32:45.755 --> 00:32:47.674 There's no nuclear blubbing. 00:32:47.674 --> 00:32:50.009 We don't have a three dimensional ball. 00:32:50.009 --> 00:32:54.305 All of those features instead favor a, benign process. 00:32:56.307 --> 00:32:59.143 You can also get clumps of mesothelioma cells 00:32:59.143 --> 00:33:02.939 because, remember, if they're being shed from the, 00:33:03.523 --> 00:33:07.402 the body cavity, they can ball up like a little cluster. 00:33:07.402 --> 00:33:11.280 And that can be rather scary because remember we talked about 3D cell coat, 00:33:11.948 --> 00:33:14.951 cell clusters being a sign of malignancy. 00:33:15.076 --> 00:33:20.081 But here, even though you might be a little bit scared looking at them, 00:33:21.082 --> 00:33:24.085 remember we talked about how the outer cell membrane 00:33:24.252 --> 00:33:28.131 was, not continuous and benign processes. 00:33:28.131 --> 00:33:29.716 And that's what we have here. 00:33:29.716 --> 00:33:32.510 The outer cell membrane is not continuous. 00:33:32.510 --> 00:33:35.555 You have windows between many of the cells. 00:33:35.930 --> 00:33:40.393 And if you look at the cells on the edge where you can really see them best, 00:33:40.852 --> 00:33:45.898 they look benign low nuclear cytoplasmic ratios, they all look somewhat the same. 00:33:46.482 --> 00:33:49.485 And we don't see some of the features of malignancy. 00:33:51.029 --> 00:33:52.447 You can even get 00:33:52.447 --> 00:33:55.450 mitosis in mesothelioma cells. 00:33:55.950 --> 00:33:57.618 And that's an example here. 00:33:57.618 --> 00:34:01.748 So just because you see a mitotic figure does not mean 00:34:01.748 --> 00:34:04.751 that it's malignant. 00:34:06.753 --> 00:34:08.337 This is a pap stain 00:34:08.337 --> 00:34:11.424 just to show you that mesothelioma cells can often, 00:34:12.341 --> 00:34:16.179 phagocytosis ties, red cells. 00:34:16.179 --> 00:34:17.680 And that's just an example here. 00:34:17.680 --> 00:34:20.141 But again, these are still benign cells. 00:34:23.144 --> 00:34:26.105 So here's this is also a pap stain. 00:34:26.105 --> 00:34:29.067 And you can see you've got a cluster here. 00:34:29.067 --> 00:34:32.028 And then you've got here's some mesothelioma cells. 00:34:32.028 --> 00:34:33.488 Here's some here's some. 00:34:33.488 --> 00:34:36.491 So there's some multi nucleation going on. 00:34:36.699 --> 00:34:39.118 And so you think is this benign 00:34:39.118 --> 00:34:42.121 or is this malignant. 00:34:42.455 --> 00:34:44.082 So going back to this one 00:34:44.082 --> 00:34:47.502 this is an example of benign mesothelioma cells. 00:34:48.169 --> 00:34:50.797 We don't see three dimensional clusters. 00:34:50.797 --> 00:34:55.802 And even if you look here you do have some spaces between the cells 00:34:56.052 --> 00:34:58.930 and where you can really see the cells better. 00:34:58.930 --> 00:35:01.933 They show features of being benign. 00:35:02.683 --> 00:35:07.563 And instead this is an example from a patient with malignant mesothelioma. 00:35:07.939 --> 00:35:11.859 And just to show you how at low power, you've got lots 00:35:11.859 --> 00:35:14.862 and lots of three dimensional cell clusters. 00:35:17.240 --> 00:35:18.282 And in higher power 00:35:18.282 --> 00:35:22.537 they showed the features of malignancy being, polymorphic and irregular. 00:35:25.414 --> 00:35:28.209 Now when you're if you're in this situation 00:35:28.209 --> 00:35:32.755 where you're trying to distinguish between mesothelioma and adenocarcinoma, 00:35:32.755 --> 00:35:35.716 that's where you're really getting cytology involved, 00:35:35.716 --> 00:35:39.137 you can make, that's where you would want to take your sample, 00:35:39.137 --> 00:35:44.100 take it over to a cytology, make a a cell, a cell clot 00:35:44.100 --> 00:35:48.271 so you can perform immunohistochemical, immunohistochemical staining. 00:35:48.646 --> 00:35:52.525 And these are just some examples of stains where you that you can see 00:35:52.525 --> 00:35:55.778 in mesothelioma versus adenocarcinoma. 00:35:57.822 --> 00:36:00.491 This is a cow written in stain here, 00:36:00.491 --> 00:36:04.662 staining lots of mesothelioma cells that left these is a brown stain. 00:36:04.912 --> 00:36:07.123 But this adenocarcinoma right. 00:36:07.123 --> 00:36:10.668 This glandular structure is is not staining. 00:36:14.881 --> 00:36:17.550 And this is I know you're not getting electron 00:36:17.550 --> 00:36:22.597 microscopy on cells, but this is just to show you the nice villus. 00:36:22.930 --> 00:36:26.267 Cell structure here of a mesothelioma 00:36:26.642 --> 00:36:29.770 versus how different it is from an adenocarcinoma. 00:36:33.524 --> 00:36:35.067 So let's moving 00:36:35.067 --> 00:36:40.072 on to some other features for benign versus, malignant cells. 00:36:40.615 --> 00:36:43.618 And unusual homogenous population. 00:36:44.243 --> 00:36:48.915 So generally for benign cells, unusual cells can't be present. 00:36:48.915 --> 00:36:53.544 I've shown you some but there's a heterogeneity of morphologic features. 00:36:53.711 --> 00:36:57.423 And you've got this gradation of normal to reactive cells. 00:36:58.090 --> 00:37:02.803 But in malignant cells you can get atypical distinct populations 00:37:02.803 --> 00:37:06.599 of bizarre cells that don't resemble any known 00:37:06.599 --> 00:37:09.602 benign variant. 00:37:10.770 --> 00:37:13.022 So here are 00:37:13.022 --> 00:37:17.818 so one side is benign and one side is malignant. 00:37:17.818 --> 00:37:21.697 And these are too many lymphocytes in this, 00:37:22.865 --> 00:37:25.868 body fluid. 00:37:26.285 --> 00:37:27.536 Well, 00:37:27.536 --> 00:37:30.539 so at right this is benign. 00:37:30.915 --> 00:37:34.752 You've got many small cells, you've got some intermediate size 00:37:34.752 --> 00:37:37.755 lymphocytes and then a rare larger one. 00:37:38.047 --> 00:37:40.424 But look at the cells at left. 00:37:40.424 --> 00:37:43.427 You can see these best off to the side here. 00:37:43.427 --> 00:37:47.014 And this is from a patient with a primary effusion lymphoma 00:37:47.348 --> 00:37:51.852 where you have some very large and even giant multi nucleated cells 00:37:52.895 --> 00:37:54.146 multiple nuclei 00:37:54.146 --> 00:37:57.400 alive very irregular nuclear contours. 00:37:57.400 --> 00:37:59.485 So this is an example of lymphoma. 00:37:59.485 --> 00:38:02.488 And here's a reactive condition that right. 00:38:03.656 --> 00:38:06.659 What about the diagnosis here. 00:38:07.243 --> 00:38:07.702 Right. 00:38:07.702 --> 00:38:10.913 These cells look pretty pretty wild. 00:38:13.499 --> 00:38:15.710 Lots of nuclear lie 00:38:15.710 --> 00:38:18.713 irregular nuclear contours. 00:38:21.507 --> 00:38:23.009 And this is from a patient 00:38:23.009 --> 00:38:26.012 with large cell lymphoma. 00:38:29.473 --> 00:38:31.934 How about this. 00:38:31.934 --> 00:38:33.853 You have a population of cells here 00:38:33.853 --> 00:38:36.939 including cells undergoing apoptosis is shown here. 00:38:36.939 --> 00:38:40.693 And then here is your, cell population that's, 00:38:41.110 --> 00:38:46.324 large with lots of cytoplasmic vacuoles, multiple nuclei. 00:38:46.532 --> 00:38:50.077 And I know you all of you out there are saying that is clearly malignant. 00:38:50.077 --> 00:38:51.329 And you would be correct. 00:38:51.329 --> 00:38:54.332 This is from a patient with Burkitt lymphoma. 00:38:55.124 --> 00:38:58.961 So a very high grade lymphoma that needs immediate treatment. 00:38:59.337 --> 00:39:03.257 The doubling time on this lymphoma and the human body is very quick. 00:39:04.342 --> 00:39:07.178 And this is an absolute emergency. 00:39:07.178 --> 00:39:11.140 So for me, you know, malignant cells, 00:39:11.682 --> 00:39:15.186 you often you'll have patients who have known metastatic malignancy. 00:39:15.186 --> 00:39:19.565 And so that that may not, you know, be a critical value, but, 00:39:19.940 --> 00:39:23.736 leukemias, Burkitt lymphoma infection, 00:39:23.736 --> 00:39:26.739 those are criticals. 00:39:27.365 --> 00:39:29.283 How about the diagnosis here. 00:39:29.283 --> 00:39:32.286 Some very large atypical cells 00:39:33.037 --> 00:39:36.040 in this from this body fluid. 00:39:36.374 --> 00:39:40.503 And this is another example of that of primary fusion 00:39:40.503 --> 00:39:43.506 lymphoma in an HIV positive patient. 00:39:46.842 --> 00:39:49.845 So now features of adenocarcinoma 00:39:49.845 --> 00:39:54.350 because many patients with solid tumors are being evaluated at your institutions. 00:39:54.975 --> 00:40:00.523 So, cell groups, solid cell walls, papillary forms, 00:40:00.523 --> 00:40:05.069 free floating arsenic columnar cell from single cell rows. 00:40:05.069 --> 00:40:06.487 These are all things that you can see. 00:40:06.487 --> 00:40:09.698 And I know carcinoma, but you can also see, 00:40:10.616 --> 00:40:14.495 features in individual cells, including signet ring forms, 00:40:14.954 --> 00:40:18.582 interest, cytoplasmic lumens, clear cell change, inter 00:40:18.582 --> 00:40:22.253 cytoplasmic dots and multi nucleated giant cells. 00:40:24.213 --> 00:40:27.216 So this is from a patient with breast cancer. 00:40:27.550 --> 00:40:32.513 And I think you can see all lots of three dimensional cell cell clusters. 00:40:33.013 --> 00:40:37.685 The membrane around the cell balls is continuous. 00:40:37.893 --> 00:40:42.731 And then you even have interest cytoplasmic vacuoles very large vacuoles. 00:40:42.731 --> 00:40:46.360 And then look there's cannibal cells, the cells eating this other cell. 00:40:46.819 --> 00:40:49.238 And that's often a feature of malignancy. 00:40:49.238 --> 00:40:50.948 It's not any one feature though. 00:40:50.948 --> 00:40:53.951 It's the combination which allows you to call it 00:40:53.951 --> 00:40:56.954 malignant. 00:40:56.996 --> 00:40:59.999 So benign versus malignant. 00:41:01.750 --> 00:41:04.753 I know you're all thinking this. 00:41:04.795 --> 00:41:08.632 Well this is another example from a patient with breast carcinoma. 00:41:09.258 --> 00:41:12.720 Breast cancer in particular can look like a lot of other cells. 00:41:13.012 --> 00:41:16.474 Here's a clearly malignant cell here, this large one. 00:41:16.891 --> 00:41:20.603 And you might be asking yourself, well, I don't know, maybe these are mesothelioma 00:41:20.603 --> 00:41:21.896 cells here. 00:41:21.896 --> 00:41:24.148 This is actually all breast cancer. 00:41:27.610 --> 00:41:29.111 And this is an example of 00:41:29.111 --> 00:41:32.656 that intra cytoplasmic dot that you can see. 00:41:33.407 --> 00:41:36.076 It's a it's a mutant here. 00:41:36.076 --> 00:41:39.038 And from this patient with breast cancer. 00:41:40.706 --> 00:41:42.041 But when I start seeing 00:41:42.041 --> 00:41:45.044 interest cytoplasmic material 00:41:45.252 --> 00:41:49.131 in body fluid cells that look atypical like this, I'm very worried. 00:41:49.131 --> 00:41:52.426 I'm dealing with an adenocarcinoma, not just breast cancer. 00:41:54.178 --> 00:41:56.138 This is a kind of a 00:41:56.138 --> 00:42:00.559 more of a papillary, little frond like structure. 00:42:00.559 --> 00:42:03.562 And this is from a patient with ovarian carcinoma. 00:42:04.480 --> 00:42:06.524 Again, you've got a very large 00:42:06.524 --> 00:42:09.652 interest cytoplasmic vacuole here. 00:42:10.402 --> 00:42:13.405 And this looks more three dimensional like 00:42:15.157 --> 00:42:18.410 this is a patient with papillary serous carcinoma. 00:42:18.827 --> 00:42:21.830 And this is a small body here. 00:42:26.168 --> 00:42:27.503 This was a plural fluid 00:42:27.503 --> 00:42:30.756 that I saw from a patient with lung cancer. 00:42:32.174 --> 00:42:36.637 And I saw small numbers of these very large, atypical cells. 00:42:37.972 --> 00:42:40.975 And this is a patient with lung adenocarcinoma. 00:42:41.058 --> 00:42:44.562 And so again I'm not seeing cell clusters here 00:42:44.562 --> 00:42:47.398 but very large I mean these cells are huge. 00:42:47.398 --> 00:42:50.401 There's no way this can be anything but malignant. 00:42:50.401 --> 00:42:53.320 And then look at the irregular nuclear contours 00:42:53.320 --> 00:42:56.323 here. 00:42:58.784 --> 00:43:01.787 Diagnosis here. 00:43:02.329 --> 00:43:04.832 That's actually single cell 00:43:04.832 --> 00:43:07.668 molding from patients with lobular breast 00:43:07.668 --> 00:43:10.671 carcinoma. 00:43:11.505 --> 00:43:15.843 So I mentioned briefly a little bit about cytoplasmic vacuoles. 00:43:15.843 --> 00:43:18.846 These are tiny and poorly defined. 00:43:19.513 --> 00:43:21.015 In benign cells. 00:43:21.015 --> 00:43:23.559 But you can sometimes get phagocytic vacuoles 00:43:23.559 --> 00:43:26.562 or a little bit of vacuoles and mesothelioma cells. 00:43:26.562 --> 00:43:29.106 But larger vacuoles. 00:43:29.106 --> 00:43:32.109 Well defined borders, clear interiors 00:43:32.318 --> 00:43:35.654 or containing material like mucin. 00:43:35.654 --> 00:43:38.616 That's more a feature of malignancy. 00:43:40.451 --> 00:43:41.744 Here's a patient 00:43:41.744 --> 00:43:45.247 with pancreatic adenocarcinoma from an acidic fluid. 00:43:45.623 --> 00:43:48.459 These are it's again a three dimensional cell block. 00:43:48.459 --> 00:43:48.876 Blau. 00:43:48.876 --> 00:43:50.502 There's large vacuoles. 00:43:50.502 --> 00:43:51.795 And then look at the nuclei. 00:43:51.795 --> 00:43:56.884 They're very irregular and that look at those nuclear contours as well. 00:43:58.636 --> 00:44:01.639 Again here's a patient with breast carcinoma. 00:44:01.680 --> 00:44:04.099 Again look at the irregular nuclei. 00:44:04.099 --> 00:44:07.811 And you can see the intra cytoplasmic material 00:44:07.811 --> 00:44:10.814 inside this large well-defined vacuole. 00:44:11.815 --> 00:44:15.486 This is a patient with gastric adenocarcinoma. 00:44:15.486 --> 00:44:16.987 And this is a signet ring. 00:44:16.987 --> 00:44:21.950 Cancer cell looks very different than the other signet ring cells I showed you. 00:44:21.950 --> 00:44:25.371 Right this the nuclei here are very typical. 00:44:25.371 --> 00:44:28.374 And this is also cancer over here. 00:44:30.793 --> 00:44:36.048 So in conclusions I've shown you a number of features that help you 00:44:36.048 --> 00:44:41.261 distinguish between one from benign from malignant cells in body fluids. 00:44:41.679 --> 00:44:44.765 And this included nuclear contours 00:44:45.099 --> 00:44:48.102 nuclear textures, nuclear lie 00:44:48.310 --> 00:44:51.021 nuclear to cytoplasmic ratio, 00:44:51.021 --> 00:44:54.024 mitosis, nuclear molding, 00:44:54.066 --> 00:44:57.486 cytoplasmic vacuoles and granules, Signet ring 00:44:57.486 --> 00:45:01.490 cells, cell clusters, unusual populations. 00:45:01.782 --> 00:45:04.535 And then we specifically, discussed 00:45:04.535 --> 00:45:08.247 reactive versus malignant lymphoid cells. 00:45:10.749 --> 00:45:11.875 For the two 00:45:11.875 --> 00:45:14.920 textbooks I really like are the c, AP, 00:45:15.129 --> 00:45:18.132 call color atlas of Body Fluids. 00:45:18.882 --> 00:45:22.511 And there's actually the same list of malignant features. 00:45:22.511 --> 00:45:26.765 And, and one of the chapters that I wrote and then the shelves for body 00:45:26.765 --> 00:45:30.352 fluids, book is also excellent. Thank you.