Unusual cytologic manifestation of small-cell lung cancer in associated pleural effusion
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IMAGES IN CYTOLOGY Section Editor: Shahla Masood, M.D. Unusual Cytologic Manifestation of Small-Cell Lung Cancer in Associated Pleural Effusion Roxanne Smith, M.L.T., and Gia-Khanh Nguyen, M.D. * Small-cell lung cancer (SCLC) is rarely associated with a malignant pleural effusion in its clinical course. However, when it is, the suspended tumor cells are almost always seen in small clusters and in short rows with nuclear molding and display scant cytoplasm, round or oval nuclei with hyper- chromatic salt-and-pepper chromatin pattern and inconspic- uous nucleoli. These characteristic cellular features proved to be valid criteria for diagnosing SCLC invading the pleura in almost all cases. This brief communications reports three cases of SCLC with unusual pleural effusion cytology. The three cases were documented in the files of the cytology laboratory at the University of Alberta Hospitals, Edmonton, Alberta, Canada. Patients 1 and 2 were male and 67 and 71 years of age, respectively. They had a 50-year history of cigarette smoking and presented initially with pneumonia. Bronchoscopy with bronchial washes and brushes and mucosal biopsies of their right stem bronchi revealed an SCLC. The two patients developed right pleural effusions 3– 6 months after the completion of their radio- therapy and chemotherapy. A thoracocentesis was per- formed and drained about 1 liter of a blood-tinted serous fluid. Patient 3 was a 61-year-old nonsmoking woman who was admitted to a hospital for investigation of an important left pleural effusion that yielded 1 liter of slightly turbid serous fluid. Subsequent bronchoscopy with bronchial washes and brushes and mucosal biopsy of her left stem bronchus revealed an SCLC. In each case, 50 –100 mL of a serous fluid were submitted to the hospital cytology laboratory. Four cytospin smears were prepared from each sample and stained by the Papa- nicolaou method. The cytologic findings in the three effu- sions were similar and characterized by the presence of several large tridimensional ball-like clusters of malignant small cells displaying nuclear molding, admixed with a variable number of reactive mesothelial cells and lympho- cytes (Fig. 1). The tumor cells had scant ill-defined cyto- plasm, oval hyperchromatic nuclei with finely granular Department of Laboratory Medicine and Pathology, University of Al- berta Hospitals, Edmonton, Alberta, Canada * Correspondence to: Gia-Khanh Nguyen, M.D., Anatomical Pathology Division, University of Alberta Hospitals, Edmonton, Alberta, T6G 2R7, Canada. E-mail: [email protected] Received 10 April 2003; Accepted 26 July 2003 DOI 10.1002/dc.10403 Published online in Wiley InterScience (www.interscience.wiley.com). Fig. 1. A tridimensional large cluster of tumor cells with lobulated con- tours and nuclear molding (Papanicolaou stain, 250). 266 Diagnostic Cytopathology, Vol 30, No 4 © 2004 WILEY-LISS, INC.
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Transcript of Unusual cytologic manifestation of small-cell lung cancer in associated pleural effusion
IMAGES IN CYTOLOGYSection Editor: Shahla Masood, M.D.
Unusual Cytologic Manifestationof Small-Cell Lung Cancer inAssociated Pleural EffusionRoxanne Smith, M.L.T., and Gia-Khanh Nguyen, M.D.*
Small-cell lung cancer (SCLC) is rarely associated with amalignant pleural effusion in its clinical course. However,when it is, the suspended tumor cells are almost always seenin small clusters and in short rows with nuclear molding anddisplay scant cytoplasm, round or oval nuclei with hyper-chromatic salt-and-pepper chromatin pattern and inconspic-uous nucleoli. These characteristic cellular features provedto be valid criteria for diagnosing SCLC invading the pleurain almost all cases. This brief communications reports threecases of SCLC with unusual pleural effusion cytology.
The three cases were documented in the files of thecytology laboratory at the University of Alberta Hospitals,Edmonton, Alberta, Canada. Patients 1 and 2 were male and67 and 71 years of age, respectively. They had a 50-yearhistory of cigarette smoking and presented initially withpneumonia. Bronchoscopy with bronchial washes andbrushes and mucosal biopsies of their right stem bronchirevealed an SCLC. The two patients developed right pleuraleffusions 3–6 months after the completion of their radio-therapy and chemotherapy. A thoracocentesis was per-formed and drained about 1 liter of a blood-tinted serousfluid. Patient 3 was a 61-year-old nonsmoking woman whowas admitted to a hospital for investigation of an importantleft pleural effusion that yielded 1 liter of slightly turbidserous fluid. Subsequent bronchoscopy with bronchialwashes and brushes and mucosal biopsy of her left stembronchus revealed an SCLC.
In each case, 50–100 mL of a serous fluid were submittedto the hospital cytology laboratory. Four cytospin smearswere prepared from each sample and stained by the Papa-nicolaou method. The cytologic findings in the three effu-
sions were similar and characterized by the presence ofseveral large tridimensional ball-like clusters of malignantsmall cells displaying nuclear molding, admixed with avariable number of reactive mesothelial cells and lympho-cytes (Fig. 1). The tumor cells had scant ill-defined cyto-plasm, oval hyperchromatic nuclei with finely granular
Department of Laboratory Medicine and Pathology, University of Al-berta Hospitals, Edmonton, Alberta, Canada
*Correspondence to: Gia-Khanh Nguyen, M.D., Anatomical PathologyDivision, University of Alberta Hospitals, Edmonton, Alberta, T6G 2R7,Canada. E-mail: [email protected]
Received 10 April 2003; Accepted 26 July 2003DOI 10.1002/dc.10403Published online in Wiley InterScience (www.interscience.wiley.com).
Fig. 1. A tridimensional large cluster of tumor cells with lobulated con-tours and nuclear molding (Papanicolaou stain, �250).
266 Diagnostic Cytopathology, Vol 30, No 4 © 2004 WILEY-LISS, INC.
chromatin pattern and small but conspicuous nucleoli. In allcases, no single or loosely aggregated tumor cells werenoted in the smear background. The pleural effusions inpatients 2 and 3 showed, in addition, a few large cohesivetridimensional clusters of tumor cells displaying focal andvague acinar or glandular arrangement (Fig. 2). The tumorcells in pleural effusions in all three patients were morpho-logically similar to those present in the cytologic materialsobtained by bronchial brushes and washes, and a diagnosisof SCLC invading the pleura was made in all cases. Addi-tional cytospin smears were prepared from the residual fluidsamples in all three cases, and those smears were stainedwith commercial antibodies against neuron-specific enolaseand chromogranin using the routine avidin-biotin complextechnique. The tumor cells stained positively with these twoantibodies and further supported the initial cytodiagnosis ofSCLC. The three patients died within 18 months of thediagnosis of SCLC. Postmortem examinations in all threecases confirmed the presence of a pure bronchogenic SCLC;no other primary malignancies were found.
The cytologic manifestations of SCLCs in pleural effu-sions in those three patients were highly unusual and may bemistaken for a metastatic adenocarcinoma of small-celltype. Careful evaluation of individual cells within tumorcell clusters with comparison to those present in othercytologic materials obtained by bronchial wash or brush and
by fine-needle aspiration will lead to a correct cytodiagnosisof metastatic SCLC.
Fig. 2. A large ball-like cluster of cancer cells displaying scant cytoplasm,hyperchromatic nuclei, nuclear molding, and focal acinar arrangement(arrow) (Papanicolaou stain, �400).
UNUSUAL CYTOLOGIC MANIFESTATION
Diagnostic Cytopathology, Vol 30, No 4 267
