{"id":45714,"date":"2025-09-18T13:44:24","date_gmt":"2025-09-18T05:44:24","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=45714"},"modified":"2025-09-18T13:47:05","modified_gmt":"2025-09-18T05:47:05","slug":"bcf-2","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/cytopath\/cyto-mystery-cases\/bcf-2\/","title":{"rendered":"Mystery cases &#8211; Body Cavity Fluids 2"},"content":{"rendered":"\n<h2>\n\t\tBody Cavity Fluids 2\n\t<\/h2>\n\t<h1>A Pleural Effusion<\/h1>\n\t<p><strong>Clinical history<\/strong>: 63 Chinese lady, Complained of general malaise and shortness of breath. Non-smoker.\u00a0<\/p>\n<p>Imaging revealed a large left pleural effusion. Pleural fluid sent for cytologic evaluation. \u00a0<\/p>\n\t1. Air-dried smear (Hemacolor)\n\n<iframe loading=\"lazy\" width=\"1050\" height=\"600\" src=\"https:\/\/www.youtube.com\/embed\/29PuB74wlbM?si=5sqDfpGHKFfPntUm\" title=\"38M Mediastinal mass core imprint\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n\n\t2. Alcohol-fixed smear (Pap)\n    \n<iframe loading=\"lazy\" width=\"1050\" height=\"600\" src=\"https:\/\/www.youtube.com\/embed\/RqSRe28ymVI?si=d8qikwPylSTwrfqf\" title=\"38M Mediastinal mass core imprint\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n\n\t<p>You have just screened this case. What would you do next?\u00a0<\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Discussion<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t<p>&nbsp;<\/p>\n<p>The smears show a population of highly atypical cells, which are likely malignant.<\/p>\n<p>In a pleural effusion, the main differentials would be malignant mesothelioma vs metastatic carcinoma (most often adenocarcinoma). Some morphologic features that suggest mesothelioma include the cell groups with scalloped (&#8216;knobby&#8217;) borders, the absence of marked nuclear pleomorphism and, in some areas, a suggestion of two-toned cytoplasm (seen in the air-dried smear).\u00a0<\/p>\n<p>It would be good practice to look up the clinical details &#8211; imaging results, whether there is pleural nodularity or thickening, or a history of occupational or home exposure to asbestos. Also, previous history of known malignancy, or concurrent history of suspected malignancy should be sought.<\/p>\n<p>A cell block should then be ordered, and some immunocytochemical stains employed to answer 2 questions:<\/p>\n<p>1. Carcinoma vs Mesothelial cells<\/p>\n<p>Suggested panel: EP4, MOC31, Tag72 \u00a0vs Calretinin, WT1<\/p>\n<p>TTF1 may be helpful as well, both serving to support adenocarcinoma \u00a0and suggest lung origin. \u00a0\u00a0<\/p>\n<p>2. Mesothelioma vs Reactive mesothelial cells (reactive atypia)<\/p>\n<p>Suggested panel EMA (membrane staining), Desmin (negative in mesothelioma)\u00a0<\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-1\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-1\">Description and Diagnosis<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-1\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t<p>\u00a0<\/p>\n<p>Highly\u00a0cellular smears show numerous moderately sized 3 dimensional clusters of atypical cells. The clusters exhibit scalloped borders. The cells contain moderately pleomorphic nuclei with relatively smooth nuclear membranes, prominent nucleoli and raise N\/C ratios. The cytoplasm varies from fairly pale to dense, and in some areas, exhibits a two-toned appearance with a finely bubbly outer edge. The nuclei are fairly centrally located within the cells. Some cell-in-cell arrangements are noted. Windows are not readily identified. No definite population of benign mesothelial cells is seen.<\/p>\n<p><strong>Diagnosis: Left pleural effusion: Malignant mesothelioma\u00a0<\/strong><\/p>\n<p>Note: Being a relatively uncommon diagnosis in most areas, the first time diagnosis of malignant mesothelioma should be made in the context of clinicopathologic correlation (history, imaging) and with immunocytochemical corroboration.\u00a0<\/p>\n\tHere is the video demonstration with voiceover.\n    \n<iframe loading=\"lazy\" width=\"1050\" height=\"600\" src=\"https:\/\/www.youtube.com\/embed\/Ltc0w4EAOhQ?si=Jhjsy_hf5G2lqiyb\" title=\"38M Mediastinal mass core imprint\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n\n\tThe video below shows the results of immunocytochemistry on the cell block.\n    \n<iframe loading=\"lazy\" width=\"1050\" height=\"600\" src=\"https:\/\/www.youtube.com\/embed\/gOGg8P_F8UE?si=PBy6xBPYeRqX4rZ5\" title=\"38M Mediastinal mass core imprint\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n\n\n","protected":false},"excerpt":{"rendered":"<p>Body Cavity Fluids 2 A Pleural Effusion Clinical history: 63 Chinese lady, Complained of general malaise and shortness of breath. Non-smoker.\u00a0 Imaging revealed a large left pleural effusion. Pleural fluid sent for cytologic evaluation. \u00a0 1. Air-dried smear (Hemacolor) 2. Alcohol-fixed smear (Pap) You have just screened this case. What would you do next?\u00a0 Discussion [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":44933,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-45714","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/cytopath\/cyto-mystery-cases\/bcf-2\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"Body Cavity Fluids 2 A Pleural Effusion Clinical history: 63 Chinese lady, Complained of general malaise and shortness of breath. 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