Pleural Fluid Cytology Research Articles

Unusual presentation of lepidic adenocarcinoma in a healthy female

BackgroundLepidic adenocarcinoma represents a histologic pattern of non-small cell lung cancer that characteristically arises in the lung periphery with tracking alongside pre-existing alveolar walls. Noninvasive and invasive variants of lepidic adenocarcinoma are dependent on parenchymal destruction, vascular, or pleural invasion. The lepidic-predominant lung malignancies are collectively recognized as slow growing with rare metastasis and excellent prognosis. The World Health Organization classification of lung malignancies depends on molecular and histopathological findings. CT findings most commonly include ground-glass characteristics, commonly mistaken for inflammatory or infectious etiology. These tumors are generally surgically resectable and associated with better survival given infrequent nodal and extrathoracic involvement. Rarely these tumors present with diffuse pneumonic-type involvement associated with worse outcomes despite lack of nodal and distant metastases.Case presentationA 63-year-old Caucasian athletic immunocompetent female presented with 2 months of progressive shortness of breath, fatigue, loss of appetite and 15 pound weight loss. History was only notable for well controlled essential hypertension and hypothyroidism. Contrast computed tomography angiogram and positron emission tomography revealed diffuse hypermetabolic interstitial and airspace abnormalities of the lungs without lymphadenopathy (or distant involvement) in addition to right hydropneumothorax and left pleural effusion. Baseline laboratory testing was unremarkable, and extensive bacterial and fungal testing returned negative. Bronchoscopy and video-assisted thoracoscopic surgery was subsequently performed with pleural fluid cytology, lung and pleural biopsies returning positive for lepidic adenocarcinoma with 2% programmed death ligand 1 expression and genomic testing positive for PTEN gene deletion. Prior to treatment, the patient perished on day 15 of admission.ConclusionWe present a rare case of lepidic predominant adenocarcinoma with extensive bilateral aerogenous spread in the context of no lymphovascular invasion in a healthy, low risk patient. This case presentation may add to the body of knowledge regarding the different behavior patterns of lepidic predominant adenocarcinomas.

Clinically undetected plasmacytoid urothelial carcinoma of the urinary bladder with non-mass-forming metastases in multiple organs: an autopsy case.

This case report outlines a clinically undetected urinary bladder plasmacytoid urothelial carcinoma (PUC) with multiple metastases detected at autopsy. An 89-year-old man presented with edema in the lower limbs. Pleural fluid cytology revealed discohesive carcinomatous cells, although imaging studies failed to identify the primary site of tumor. The patient died of respiratory failure. Autopsy disclosed a prostate tumor and diffusely thickened urinary bladder and rectum without distinct tumorous lesions. Histologically, the tumor consisted of acinar-type prostate adenocarcinoma with no signs of metastasis. Additionally, small, plasmacytoid tumor cells were observed in the urinary bladder/rectum as isolated or small clustering fashions. These metastasized to the lungs, intestine, generalized lymph nodes in a non-mass-forming manner. Combined with immunohistochemical studies, these tumor cells were diagnosed PUC derived from the urinary bladder. Both clinicians and pathologists should recognize PUC as an aggressive histological variant, which can represent a rapid systemic progression without mass-forming lesions.

Comparison of the Effectiveness of the Cell Block Method with Core Tissue Biopsy for Adequate Diagnosis of Lung Malignant

BACKGROUND: An adequate diagnosis of lung malignancy can be detected through examination of pleural fluid and Transthoracic needle aspiration (TTNA) based on the cell block method and tissue core biopsy. The cell block method is an immunocytochemical examination method that is useful for the adequate diagnosis of lung malignancy.
 AIM: This study was to compare the effectiveness of the cell block method with tissue core biopsy on pleural fluid cytology and TTNA cytology to establish the diagnosis of lung malignancy.
 METHODS: This study is a diagnostic test with an analytical cross-sectional approach on 15 respondents suspected of lung cancer at Dr. Moewardi Hospital Surakarta in September 2021. Subjects underwent pleural fluid cytology, TTNA cytology based on the cell block method, and tissue core biopsy examination. Data analysis used the Kappa test and bivariate analysis to calculate the p-value.
 RESULTS: The results of the combined examination of pleural fluid cytology and TTNA cytology based on the cell block method gave a very good level of conformity to the tissue core biopsy with a Kappa value of 0.857 and a p-value of 0.001. The results of the combined examination of pleural fluid cytology and TTNA cytology with cell block method showed the highest percentage for sensitivity (100%), NPV (100%), and accuracy (93%); while the results of the TTNA cytology examination using the cell block method showed the highest percentage of specificity (100%) and PPV (100%) of the tissue core biopsy method.
 CONCLUSION: The cell block method is very effective and significant in assessing the results of combined pleural fluid cytology and TTNA cytology against the tissue core biopsy method so that it is useful for the adequate diagnosis of lung malignant

Risk Stratification of Pleural Fluid Cytology Based on the International System for Reporting Serous Fluid Cytology in a Tertiary Care Centre

Background: The International Academy of Cytology and the American Society of Cytopathology proposed the international system for reporting serous fluid cytology (TISRSFC) in 2019 to form uniform reporting terminologies for fluid cytology. This system defines a spectrum of diagnostic categories to be used in daily clinical practice. Fluid cytology is a widely accepted, cost-effective, minimally invasive earliest diagnostic method for the investigation that aids management decisions. The present study aims to reclassify pleural fluid cytology and calculate the risk of malignancy (ROM) for each diagnostic category. Material and Methods: It is a retrospective 2 years observational study comprising 690 pleural fluid specimens. Retrospective reviews were performed, and cases were reclassified into five categories as per TISRSFC. Immunohistochemistry was applied whenever needed. Cytological diagnosis was correlated with respective histopathology and/or clinical and/or radiological diagnosis. ROM was calculated for all diagnostic categories. Results: In the present study of 690 cases, 7.97% were non-diagnostic (ND), 84.1% cases were negative for malignancy (NFM), 0.87% were atypia of undetermined significance (AUS), 1.16% were suspicious for malignancy (SFM), and 5.94% were malignant (MAL). Cell blocks were prepared in 33 (4.8%) cases and immunohistochemistry was applied in 7 cases. The commonest site for pleural fluid metastasis was the lungs, accounting for 4.64% (32/690) cases. Further, ROM was calculated for all diagnostic categories as follows: (1) ND: 30.9%, (2) NFM: 12.9%, (3) AUS: 100%, (4) SFM: 100%, and (5) MAL: 90.2%. Conclusion: Cytological examination of pleural fluids is an accurate, prompt, and affordable technique. This standardized ISRSFC reporting system will maintain uniformity and reproducibility in reporting, leading to improved clinical decision-making of pleural fluids.

Evaluation of pleural fluid cytology for the diagnosis of malignant pleural effusion: a retrospective cohort study.

BackgroundCytological examination of pleural fluid has good specificity, but imperfect sensitivity for the diagnosis of malignant pleural effusion (MPE). Published estimates of sensitivity vary and predictors of false negative cytology are not well established.AimsTo estimate pleural fluid cytology sensitivity and identify risk factors for false negative cytology.MethodsWe conducted a retrospective cohort study of patients who had cytology testing of pleural fluid at Christchurch Hospital, New Zealand, from July 2017 to October 2019. Data on clinical and pleural fluid characteristics were collected. MPE was defined by positive pleural fluid cytology, tissue histology or multidisciplinary meeting consensus. We estimated sensitivity of the first pleural cytology assessment. We performed multivariate logistic regression to ascertain patient groups at greatest risk of false negative results.ResultsInitial pleural fluid cytology was diagnostic in 117 of 156 patients, providing a sensitivity (95% confidence interval (CI)) of 75.0% (67.4–81.6%). The sensitivity was 79.0% (66.8–88.3%) for lung cancer, 91.3% (72.0–98.9%) for breast cancer and 33.3% (95% CI 11.8–61.6%) for mesothelioma. Cloudy appearance of pleural fluid (odds ratio (OR) 0.12; 95% CI 0.03–0.54) and yellow/gold pleural fluid (OR 0.24; 95% CI 0.06–0.96) reduced the odds of false negative pleural cytology. Pleural thickening on computed tomography scan (OR 3.3; 95% CI 1.2–9.4) was a risk factor for false negative cytology.ConclusionSensitivity of pleural fluid cytology was greatest in primary lung and breast cancer, and lowest in mesothelioma. Clinicians should be alert to false negative results when suspecting mesothelioma or if pleural thickening is present.

Comparison of Diagnostic Yield and Complications in Ultrasound-Guided Closed Pleural Biopsy Versus Thoracoscopic Pleural Biopsy in Undiagnosed Exudative Pleural Effusion.

IntroductionMalignancy, tuberculosis, and non-tubercular pleural infections account for most exudative pleural effusion. Pleural fluid cytology, biochemical tests and even pleural fluid cell block studies may fail to yield a diagnosis in certain cases. Medical thoracoscopy is the gold standard for the diagnosis of unexplained pleural effusions. However, access to medical thoracoscopy may be limited, particularly in developing countries. Also, certain patients may not be fit to undergo the procedure because of medical conditions. An ultrasound-guided pleural biopsy is an option in such conditions. The present study is intended to compare the diagnostic yield and complications of both methods of pleural biopsy in undiagnosed exudative pleural effusion under a randomized controlled trial.MethodAfter fulfilling all the inclusion criteria, participants were randomized to either ultrasound-guided closed pleural biopsy or thoracoscopic-guided pleural biopsy groups. The primary outcome was to compare the diagnostic yield of ultrasound-guided Tru-Cut® (Newtech Medical Devices, Faridabad, India) closed pleural biopsy versus thoracoscopic pleural biopsy, and the secondary outcomes were to compare the complications rate, duration of the procedure, and hospital stay in the patients undergoing ultrasound-guided pleural biopsy versus thoracoscopic pleural biopsy, and predictors of a positive biopsy result in both groups.ResultA total of 118 patients with pleural effusion were screened; 39 of them who were eligible, randomized into the ultrasound group (20 patients) and the thoracoscopic group (19 patients). The median age of participants was 53.5 (50-58) years and 55 (45-64) years in the ultrasound and thoracoscopic groups, respectively. Pleural fluid cell count, protein, adenosine deaminase (ADA), and lactate dehydrogenase (LDH) were similar in both groups, although pleural fluid glucose was low in the ultrasound group. Diagnostic yield was 90% (18/20) and 94.7% (18/19) in the ultrasound and thoracoscopic groups, respectively, which was statistically non-significant (p=0.963). The median duration of hospital stay was 9.5 (5.3-27) days and 15 (12-22) days in ultrasound and thoracoscopic groups respectively. The thoracoscopic group had a more prolonged stay compared to the ultrasound group, but it was statistically non-significant (p=0.09). The duration of the procedure was significantly longer in the thoracoscopic group 90 (85-105) minutes, in comparison to ultrasound 47.5 (41.3-55) minutes (p=0.001). No major complications were seen in both groups. Subcutaneous emphysema was the most common complication in the thoracoscopic group (10%), followed by hemorrhage (5.3%), and respiratory failure (5.3%). Hypotension was the only complication in the ultrasound group (5%). The rate of complications was significantly higher in the thoracoscopic group (p<0.01).ConclusionUltrasound-guided closed pleural biopsy is as good as thoracoscopic pleural biopsy in undiagnosed exudative pleural effusion. It was associated with a shorter procedure duration, a shorter hospital stay, and fewer complications as compared to thoracoscopic biopsy. Both the procedures were safe in experienced hands and a hospital setup, but the thoracoscopic pleural biopsy was associated with complications.

How much is enough: investigation of pleural fluid cytology findings related to sample volume.

Cytologic evaluation of pleural effusion samples plays an invaluable role in patient care. Despite this, only a few robust studies have investigated the optimal specimen volume for cytologic evaluation. It is not unusual for our laboratory to receive low-volume pleural effusion samples. Thus, as a part of ongoing quality assurance studies, we examined the performance of low-volume samples. All pleural effusion samples received during a 1-year period from January 1, 2020 to December 31, 2020 were reviewed. The case data collected included the clinical indications, diagnostic categorization, cell block performance, and adequacy notations. Follow-up data were also collected. The cases were placed into low-volume (≤10 mL, 11-25 mL, and 26-50 mL) and higher volume (>50 mL) groups for analysis. A total of 226 samples were included in the present study. Of the 226 samples, 89 had a volume of ≤50 mL, including 32 with a very low volume of ≤10 mL. Significantly fewer positive cases were diagnosed in the ≤10-mL group relative to the >50-mL group (6.3% versus 27.7%) with significantly fewer cell blocks performed (15.6% versus 57.7%). However, only 7 of the ≤10 mL cases (21.9%) had been performed to rule out malignancy, significantly less than that for the >50 mL group (81 of 137; 59.1%). Additionally, none of the very-low-volume cases had an upgraded follow-up effusion sample. The exact role of the sample volume is not entirely clear as there are many factors are at play beyond volume itself. Although larger specimen volumes might be more optimal for a number of reasons, malignancy can be diagnosed at even low sample volumes. Thus, there is value to examining all samples regardless of the volume received. Insertion of an adequacy comment might be prudent for low-volume cases, especially those with a high clinical concern for malignancy.

Does pleural fluid cell block is an alternative to Thoracoscopy guided diagnostic techniques in malignant pleural effusion? Study of 500 cases in tertiary care setting in India

Background: Malignant pleural effusion missed routinely because of less diagnostic yield of conventional fluid cytology like fluid cytology. Fluid cell block is underutilsed techniques routinely and less utilized in diagnostic panel due to lack of expertise in filed of cytopathology. Materials and methods: Prospective multicentric study conducted during Jan 2014 to June 2020 in Venkatesh chest hospital, and Pulmonary Medicine, MIMSR medical college Latur, to find out diagnostic yield of conventional pleural fluid cytology&amp; pleural fluid ‘cell block’ in malignant pleural effusion and compare yield of pleural fluid cell block with conventional cytology technique. The study included 500 cases of unexplained, exudative pleural effusion with ADA&lt;30/IU/liter and pleural fluid cytology is either positive for malignant cell with or without cell type differentiation, or cytology suspicious for malignant cell. All cases were subjected to cell block preparation. Statistical analysis was done by using chi-test. Observation and analysis: In study of 500 cases, mean age of group was 68±9.5 years and adenocarcinoma were predominant malignancy in 79% cases, mesothelioma in 6% cases, squamous cell carcinoma in 7% cases &amp; 8% cases were having primary tumor outside the thoracic cavity. In study cases pleural fluid cytology was positive in 42% cases (210/500), and pleural fluid cell block was positive in 96% cases (480/200) in detecting malignant pleural effusion (p&lt;0.0001), Remaining six and two cases were diagnosed by using image guided and thoracoscopy guided pleural biopsies respectively. IHC was done in all pleural fluid cell block preparation for calretinin, cytokeratin and EGFR. Conclusion: Pleural fluid cell block is sensitive, superior, cost effective and specific diagnostic method over conventional pleural fluid cytology. 'Cell block' specimens are enough for primary diagnosis and IHC analysis necessary for cell typing. It will decrease need for more invasive and costlier diagnostic methods like thoracoscopy and image guided pleural biopsies. We recommend cell block for every exudative pleural fluid sample with ADA&lt;30 IU/liter.

Value of Adenosine Deaminase in the diagnosis of tuberculous pleurisy at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia

Objectives: Tuberculous (TB) pleurisy is a common form of extrapulmonary tuberculosis in high burden countries including Ethiopia. Adenosine deaminase (ADA) has been used in the early diagnosis of TB pleurisy. This study was designed to evaluate the diagnostic role of ADA in TB pleurisy at Tikur Anbessa Specialized Hospital (TASH). Materials and Methods: A cross-sectional hospital-based study was designed to evaluate the diagnostic value of ADA in consecutive adult patients with unexplained pleural effusions presenting to Chest Clinic at TASH from June 2016 to August 2018. All referred patients underwent thorough clinical and laboratory examinations including assessment of pleural fluid ADA, where a value of ≥40 IU/I was used to suggest TB pleurisy (per manufacturer’s recommendation). A final diagnosis of TB pleurisy was made based on pleural fluid Gene Xpert, AFB smear, pleural biopsy, and cytology results in addition to a clinical and radiologic response to anti-TB therapy. Results: A total of 67 patients were included in the study. The median age was 38.5(±14.5) years; 36 (53.7%) of the participants were males. TB pleurisy was confirmed in 38 (56.7%) subjects. The mean pleural fluid ADA levels was significantly higher in those with TB pleurisy as compared to those without TB pleurisy, 65.8 IU/l versus 28 IU/I (P &lt; 0.05), respectively. Pleural fluid ADA had a sensitivity of 84% and specificity of 79%, resulting in a positive predictive value of 84.2%, a negative predictive value of 79.3%, and an overall test accuracy of 82% in our study population. Conclusion: In our study, pleural fluid ADA played a useful role in the diagnosis of TB pleurisy.

Adequacy of pleural fluid cytology for comprehensive molecular analysis of lung adenocarcinoma: Experience of a large health-care system.

Objectives:Pleural fluid evaluation is an effective modality for identifying actionable genetic mutations to guide therapy in lung carcinoma. Clinicians requesting molecular studies often send large volumes of fluid to be processed that is not possible or cost effective and is hence not standard of practice in most cytopathology laboratories. We wanted to establish the characteristics of an adequate specimen that would yield reliable results with current molecular testing platforms.Material and Methods:A review of 500 malignant pleural effusions, from pulmonary and non-pulmonary sources, was undertaken over a 4-year period. Of these 44 cases (from 42 patients) that were positive for primary lung adenocarcinoma were included in the study. Molecular analysis was performed on 42 specimens. A complete next generation sequencing (NGS) panel was performed on 36 specimens. Individual testing for estimated glomerular filtration rate, KRAS, anaplastic lymphoma kinase, and ROS1 was performed on six specimens. The number of malignant cells and proportion of tumor to non-tumor nucleated cells (T: NT) on cell blocks was recorded as <20%, 20–50% and >50%.Results:The minimum volume on which a complete NGS panel could be performed was 20 ml with cell count of 1000 and T: NT proportion of 20–50%. The minimum number of tumor cells required for successful molecular analysis for T: NT proportion of <20%, 20–50%, and >50% was 300, 250, and 170 cells, respectively.Conclusion:We concluded that tumor cell proportion, rather than specimen volume, is of prime importance for determining the efficacy of pleural fluid for molecular studies. Evaluation of both absolute and relative numbers of tumor cells is critical for assessing the adequacy and predicting successful yield for molecular analysis.

Diagnostic sensitivity of pleural fluid cytology in malignant pleural effusions: systematic review and meta-analysis

BackgroundPleural fluid cytology is an important diagnostic test used for the investigation of pleural effusions. There is considerable variability in the reported sensitivity for the diagnosis of malignant pleural effusions...

Isolated Myeloid Sarcoma and Intracardiac Thrombus Resulting in Superior Mediastinal Syndrome.

Superior mediastinal syndrome (SMS) is a relatively common emergency in the practice of Pediatric Oncology. It typically results from the compression of large airways and superior vena cava by a swiftly growing mass. T-lineage acute lymphoblastic leukemia or lymphoma, neuroblastoma, and germ cell tumor are the common etiologies of SMS in children. Occasionally, SMS can be an unexpected presentation of less common childhood cancers and a surprise for the diagnostic and treating teams. The present paper reports the diagnostic and therapeutic challenge of managing a 9-y-old boy with SMS resulting from mediastinal myeloid sarcoma. The presence of a sizeable intracardiac thrombus, in addition, contributed to the SMS. The initial pleural fluid cytology and image-guided fine-needle aspiration cytology of the mediastinal mass were nondiagnostic. A thoracotomy was subsequently performed to debulk the tumor for symptomatic relief and obtain tissue for diagnosis.

Cell HE staining smears and paired cell paraffin sections in detection of epithelial growth factor receptor gene of pleural fluid specimens.

The advanced non-small cell lung cancer (NSCLC) patients with pleural effusion have no opportunity for surgery treatment. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are the first-line drugs for these patients with EGFR-sensitive mutation. However, the disease progression and drug update during or after treatment of EGFR-TKIs bring more challenges and puzzles to clinical diagnosis and treatment, which inevitably requires archived pleural cell samples for EGFR re-examination or comparative study. Understanding the DNA quality of archived pleural fluid samples and effectively using archival data of pleural fluid cells are of great significance for tracing the origin of cases and basic medical research. This study aims to evaluate the consistency of EGFR mutant gene expression between the 2 methods, and to explore a reliable way for preserving cytological data and making full use of cytological archival data via cell HE staining smear and cell paraffin section. A total of 57 pleural fluid cytology cases in the Department of Pathology of China Aerospace Center Hospital from October 2014 to April 2021 were selected. Tumor cells were detected by cell HE staining smears and immunohistochemical staining for TTF-1 and Napsin A in the paired cell paraffin sections. There were more than 200 tumor cells in cell HE staining smear and the proportion of tumor cells were ≥70% in matched cell paraffin sections. Patients with 2 cell smears (one for cell data retention and the other for DNA extraction) were selected as the research subjects, and 57 pleural fluid samples were enrolled. EGFR gene mutation was detected by amplification refractory mutation system-polymerase chain reaction in 57 paired cell HE staining smears and cell paraffin sections. DNA concentration was 2 ng/μL. Cell HE smear was amplified side-by-side with DNA samples from paired cell paraffin sections. Result determination was according to the requirements of the reagent instructions. The external control cycle threshold (Ct) value of the No. 8 well of the samples to be tested was between 13 and 21, which was considered as successful and reliable samples. When the Ct value of EGFR gene mutation was <26, it was considered as positive; when the Ct value was between 26 and 29, it was critical positive; when the Ct value was equal or more than 29, it was negative. ΔCt value was the difference between mutant Ct value and externally controlled Ct value. The smaller the ΔCt value was, the better the quality of DNA of the detected sample was. Among the 57 pleural effusion samples, 42 patients were hospitalized with pleural effusion as the first symptom, accounting for 73.7% (42/57). EGFR mutation was detected in 37 samples [64.9% (37/57)]. The mutation rate for 19del was 37.8% (14/37) while for L858R was 48.6% (18/37). Females were 56.7% (21/37) of mutation cases. The mutation consistency rate of cell HE staining smear and matched cell paraffin sections was 100%. The ΔCt values of cell HE staining smears were less than those of matched cell paraffin sections. The mutation Ct values of 37 cytological samples were statistically analyzed according to the preservation periods of the years of 2014-2015, 2016-2017, 2018-2019, and 2020-2021. There were significant differences in cell paraffin section in the years of 2014-2015 and 2016-2017 compared with the years of 2018-2019 and 2020-2021, while no significant differences were found in cell HE staining smear. Statistical analysis of externally controlled Ct values of 57 cytological samples showed that there were significant differences between cell HE staining smears and cell paraffin section in the years of 2014-2015 and 2016-2017, compared with the years of 2018-2019 and 2020-2021. The mutational Ct values of 37 paired cell blocks and smears were all <26, and the externally controlled Ct values of 57 paired cell paraffin sections and HE staining smears were all between 13 and 21. The DNA quality of cell HE smears and matched cell paraffin section met the qualified requirements. Two methods possess show an excellent consistency in detecting EGFR mutation in NSCLC pleural fluid samples. The DNA quality of cell HE staining smear is better than that of cell paraffin sections, so cell HE staining smear can be used as important supplement of the gene test source. It should be noted that the limitation of cell HE staining smears is non-reproducibility, so multiple smears of pleural fluid are recommended to be prepared for multiple tests.

Role of pleural fluid “Cell Block” in malignant pleural effusion: Underutilized, sensitive, and superior over conventional fluid cytology; Does it will decrease need for thoracoscopy guided procedures?

Background: Malignant pleural effusion missed routinely because of less diagnostic yield of conventional fluid cytology. Materials and Methods: Prospective multicentric study conducted during January 2014 to June 2016 in Venkatesh chest hospital, and Pulmonary Medicine, MIMSR medical college Latur, to find diagnostic yield of conventional pleural fluid cytology and pleural fluid “cell block” in malignant pleural effusion and compare yield of pleural fluid cell block with conventional cytology technique. The study included 200 cases of unexplained, exudative pleural effusion with Adenosine deaminase (ADA) ≤30/IU/l and pleural fluid cytology is either positive for malignant cell with or without cell type differentiation, or cytology suspicious for malignant cell. All cases were subjected to cell block preparation. Statistical analysis was done by using Chi-test. Observation and Analysis: In study of 200 cases, mean age of group was 68 ± 9.5 years and adenocarcinoma was predominant malignancy in 72% cases, mesothelioma in 10% cases, squamous cell carcinoma in 7% cases and 9% cases were having primary tumor outside the thoracic cavity. In study cases, pleural fluid cytology was positive in 42% cases (84/200), and pleural fluid cell block was positive in 96% cases (192/200) in detecting malignant pleural effusion (P < 0.0001). Remaining six and two cases were diagnosed by using image-guided and thoracoscopy-guided pleural biopsies, respectively. Immunohistochemistry (IHC) was done in all pleural fluid cell block preparation for calretinin, cytokeratin, and epidermal growth factor receptor. Conclusion: Pleural fluid cell block is sensitive, superior, cost-effective, and specific diagnostic method over conventional pleural fluid cytology. “Cell block” specimens are enough for primary diagnosis and IHC analysis necessary for cell typing. It will decrease the need for more invasive and costlier diagnostic methods like thoracoscopy and image-guided pleural biopsies. We recommend cell block for every exudative pleural fluid samples with ADA <30 IU/l.

Diagnostic Yield of Closed Pleural Biopsy Using Cope’s Needle in the Diagnosis of Exudative Pleural Effusion

Introduction: The aetiology of pleural effusion may be difficult to diagnose based on the pleural fluid cytology, biochemical and microbiological study. Pleural biopsy using Cope’s needle may help in such cases where definitive diagnosis can not be achieved with the help of cytology. Aim: To make aetiological diagnosis of undiagnosed exudative cases using Closed Pleural Biopsy (CPB) and to determine the diagnostic yield of CPB taken by Cope’s needle in aetiologically confirmed exudative pleural effusion. Materials and Methods: This prospective observation study was conducted in Department of Pulmonary Medicine at Burdwan Medical College and Hospital, Burdwan, West Bengal, India, from April 2021 to March 2022 among 52 patients. Under local anaesthesia, diagnostic and therapeutic thoracocentesis were done. The pleural fluid was sent for complete biochemical, microbiological analysis, and cytology. Later, pleural biopsy was also done using Cope’s pleural biopsy needle. The variables studied were age, gender, pleural fluid cytology, pleural fluid for acid fast bacilli, Gram stain, and culture and pleural biopsy histopathology. Results: Out of 52 patients, 34 (65.4%) were males and 18 (34.6%) were females. The majority of the patients (41, 78.8%) had a right-sided pleural effusion. The mean value of lymphocytes and polymorphs count was 57.7% and 32.7%, respectively. Histopathology showed granulomatous inflammation compatible with tuberculosis in 18 (34.6%) patients, non-specific inflammation in 17 patients (32.7%), and 5 (9.6%) patients as adenocarcinoma. Squamous cell carcinoma was seen in 4 (7.7%), 2 (3.8%) showed undifferentiated carcinoma, while 6 (11.5%) samples had inadequate tissue for opinion. In 6 (11.5%) cases pleural tissue was inadequate to give any opinion. 5 (9.6%) cases showed adenocarcinomas, 2 (3.8%) cases showed squamous cell carcinoma and 4 (7.7%) cases showed undifferentiated carcinoma. The true positives were 18 and 11 for tuberculous and malignant pleural effusion, respectively. The diagnostic yield of pleural biopsy was found to be 75% in case of tubercular pleural effusion and 78.6% for malignant pleural effusion. Conclusion: This study suggests that tuberculosis and malignancy are the two common aetiologies for exudative pleural effusion. Pleural biopsy plays an additional role in histopathological confirmation of aetiologically diagnosed exudative pleural effusion.

Pathological Approach to Pleural Malignant Mesothelioma

Exposure to asbestos can lead to asbestosis or malignancy 10-40 years after initial exposure [1]. Although its use has been banned in multiple countries, past occupational exposure leads to most cases that we see in present time. Malignant mesothelioma is an insidious and rare neoplasm that can arise from mesothelial surface cells, being Malignant Pleural Mesothelioma (MPM) the most common type. Lifetime risk of developing mesothelioma among asbestos workers can be as high as 10 percent and latency period is approximately 30-40 years since time of exposure to development of disease [2]. Annual incidence in the united states is approximately 3,300 cases per year [3]. Median overall survival of patients with advanced unresectable disease is approximately 12 months [4]. Clinical suspicion should arise in patients with previous exposure to asbestos who present with pleural thickening and/or effusion with associated respiratory symptoms. Most symptoms are nonspecific such as chest pain, dyspnea, cough and night sweats. Initial evaluation includes chest x-ray, contrast enhanced CT of the chest to find pleural abnormalities, thoracentesis and closed pleural biopsy. However, difficulties establishing diagnosis have been illustrated on studies where thoracentesis and pleural fluid cytology only yields diagnosis in 26% of cases. The diagnosis, then, is established by morphologic and immunohistochemistry findings of cytologic and surgical specimens.

Histomorphological Spectrum of Pleural Biopsy Specimen of Exudative Pleural Effusion in a Tertiary Care Hospital in Bangladesh

Background: The commonest manifestation of pleural pathology is pleural effusion. Most of the time, in spite of routine biochemical and cytological examination of pleural fluid we can’t evaluate the etiology of pleural effusion. Aim: Aim of present study was to make an etiological diagnosis of exudative pleural effusion by pleural biopsy and histopathological examination. Study design and setting: Fifty consecutive patients of pleural effusion were selected from the outpatient and indoor department of a tertiary medical college hospital in Sylhet. It was a prospective and observational study. It was conducted over a period of one and a halfyears. Material and method: In all the cases, cytological examination of pleural fluid (for malignant cell) and pleural biopsy by Abram’s needle were done. Subsequently, histopathological diagnoses were made to determine the etiology of effusion. Results: Out of 50 subjects, males outnumbered females, Age is ranged between 19 and 85 years. According to the histopathological examination of the submitted pleural biopsy specimen, granulomatous inflammation is the most common etiology (40%) followed by chronic inflammation of non-specific origin (38%) and malignancy (22%). Conclusion: This study represents the result of the experience acquired over one and half years in the histopathological interpretation of pleural biopsies and its correlation with cytology of the pleural fluid. Pleural biopsy is a useful, minimally invasive procedure with no or little complication and has more sensitivity and specificity than pleural fluid cytology smears.

Early Prediction of Malignant Mesothelioma: An Approach Towards Non-invasive Method

Background: Malignant Mesothelioma (MM) is a rare but aggressive tumor that arises in the lungs. Commonly, costly imaging and laboratory resources, i.e. (X-rays imaging, Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET) scans, biopsies, and blood tests) have already been utilized for the diagnosis of MM. Even though these diagnostic measures are expensive and unavailable in distant areas, some of these diagnosis methods are also very painful for the patient, i.e., biopsy and cytology of pleural fluid. Objective: In this study, we proposed a diagnosis model for early identification of MM via machine learning techniques. We explored the health records of 324 Turkish patients, which show the symptoms related to MM. The data of patients include socio-economic, geographical, and clinical features. Methods: Different feature selection methods have been employed for the selection of significant features. To overcome the data imbalance problem, various data-level resampling techniques have been utilized to obtain efficient results. The Gradient Boosted Decision Tree (GBDT) method has been used to develop the diagnostic model. The performance of the GBDT model is also compared with traditional machine learning algorithms. Results : Our model's results outperformed other models, both on balance and imbalance data. The results clearly show that undersampling techniques outperformed by imbalanced data even without resampling based on accuracy and Receiving Operating Characteristic (ROC) value. Conversely, it has also been observed that oversampling techniques outperformed undersampling and imbalanced data based on accuracy and ROC. All classifiers employed in this study achieved efficient results utilizing feature selection-based methods (OneR, information gain, and Relief-F), but the results of the other two methods (gain ratio and Correlation) were not entirely promising. Finally, when the combination of Synthetic Minority Oversampling Technique (SMOTE) and OneR was applied with GBDT, it gave the most favorable results based on accuracy, F-measure, and ROC. Conclusion: The diagnosis model has also been deployed to assist doctors, patients, medical practitioners, and other healthcare professionals for early diagnosis and better treatment of MM.

571 Case of A Rare Presentation of Solitary Fibrous Tumour of the Pleura (SFTP)

Abstract Presentation A 69-year-old male presented with rapidly worsening symptoms of breathlessness, productive cough, and weight loss. Examination revealed a deviated trachea, and no breath sounds on auscultation of the left side of the chest. Investigations Chest X-ray revealed a giant mass associated with a large pleural effusion, subtotal lung collapse and mediastinal shift. FEV1 was 39% predicted and DLCO 62% predicted. Management Due to the severity of presentation, urgent pleural inspection, drainage, and biopsy were carried out. Compression of the heart resulting in tamponade with increased heartrate and breathlessness was suspected Further investigations and management Pleural biopsies and pleural fluid cytology were negative for malignancy. PET-CT showed mild avidity. Definitive management was tumour mass resection via left double space open thoracotomy. Macroscopy/Microscopy/Immunohistopathology Intra-operatively, the tumour was giant, occupying three quarters of the chest cavity. It measured 21 × 14×8 cm. The whole lung was attached to the chest wall with adhesions. Microscopy revealed patternless architecture, high vascularity, hypercellularity, necrosis, elongated nuclei, pale cytoplasms and mitotic activity of 2-3 mitotic figures per 10-highpower-fields. Immunohistochemistry stained positive with CD34, BCL2, CD99, Ki-67 and STAT6. Diagnosis of SFT was suspected; malignant potential could not be predicted. Follow-up was with repeat CT scans for five years. Recurrence risk was given as 20%. Learning points

Burkitt Lymphoma: A Case Report

Introduction: Burkitt lymphoma is highly metastatic active malignant B- cell Non-Hodgkin’s Lymphoma characterized by translocation and deregulation of the d- MYC gene on chromosome no.8 on DNA strand.&#x0D; Background: Burkitt lymphoma (BL) accounts for 30–50% of all peadiatric lymphomas, and non-Hodgkin lymphoma (NHL) is the fourth most common malignant tumor in children. In the sex distribution, there was a male predominance, especially among children&#x0D; Case Presentation: A 12 year old female child was brought to Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, Maharashtra, India on date 12/01/2020 with complaints of breathlessness since 5 days, high grade fever since 10 days and retrosternal chest pain since 10- 15 days along with anorexia. The patient had a complete blood count, which revealed that his hemoglobin percent, total red blood count, hematocrit and Mean Corpuscular Hemoglobin were all low. Pleural Fluid cytology analysis, Virology investigation, CECT Chest and Cytopathological Examination (USG guided FNAC) done from left axillary lymph node were all performed for diagnostic purposes. The patient was diagnosed as Burkitt Lymphoma after comprehensive examinations. He was treated Tab. Tablet Augmentin, Tab. Pantoprazole, Tab. Prednisolone, Tab. Brufen, and Tab. Emset, Syrup Gelusil, Injection Cyclophosphamide and Injection Vincristine as well as nursing care was provided based on his needs.&#x0D; Conclusion: Patient showed spontaneous recovery.