Announcement: The International System for Reporting Serous Fluid Cytopathology

The International System for Serous Fluid Cytopathology (TIS) survey in preparation for TIS 2.0

INTRODUCTION

The International System for Serous Fluid Cytopathology (TIS) has gained acceptance and has led to literature validating original concepts and suggesting refinements. In preparation for the second edition of TIS, editors generated a survey to solicit experience with and opinions about TIS.

MATERIALS AND METHODS

An online survey available from March 8 to June 15, 2024, included 56 questions, offered in 7 languages, related to the practice of serous fluid cytopathology.

RESULTS

A total of 598 respondents accessed the survey. Information was collected regarding certification, work setting, work volume and years in practice. In the respondent group, 78% (401 of 513) were pathologists, 18% (92 of 513) cytologists of cytotechnologists, 2% (10 of 513) trainees, and 2% (10 of 513) medical scientists. A total of 23% of participants came from academia. Also, 59% of respondents were (280 of 474) from Asia, 17% Europe, 12% North America, and 10% South America. In all, 61% (287 of 474) have adopted TIS. Over 50% issue a preliminary report awaiting ancillary test results. Another 20% issue such a report depending on circumstance. The most frequent request for refinement of criteria centered around Atypia of Uncertain Significance (AUS). Only small numbers of participants provided data on diagnostic category percentage and risk of malignancy (ROM); however, those that did reported a decrease in nondiagnostic and atypical results with corresponding decreases in ROM for those categories. Variable use of cytochemical and immunocytochemical stains for resolving mesothelial proliferations was reported. Respondents indicated a desire for incorporation of recommendations on clinical management and extension of TIS into body fluid types beyond pleural, pericardial, and peritoneal.

CONCLUSIONS

This survey examines acceptance of TIS and advice for future directions.

Weakly Supervised Multiple Instance Learning Model With Generalization Ability for Clinical Adenocarcinoma Screening on Serous Cavity Effusion Pathology

Accurate and rapid screening of adenocarcinoma cells in serous cavity effusion is vital in diagnosing the stage of metastatic tumors and providing prompt medical treatment. However, it is often difficult for pathologists to screen serous cavity effusion. Fixed agglutination cell block can help to improve diagnostic sensitivity in malignant tumor cells through analyzing larger volumes of serous cavity effusion, although it could accordingly lead to screening of more cells for pathologists. With the advent of whole slide imaging and development of artificial intelligence, advanced deep learning models are expected to assist pathologists in improving diagnostic efficiency and accuracy. In this study, so far as we know, it is the first time to use cell block technology combined with a proposed weakly supervised deep learning model with multiple instance learning method to screen serous adenocarcinoma. The comparative experiments were implemented through 5-fold cross-validation, and the results demonstrated that our proposed model not only achieves state-of-the-art performance under weak supervision while balancing the number of learnable parameters and computational costs and reduces the workload of pathologists but also presents a quantitative and interpretable cellular pathologic scene of serous adenocarcinoma with superior interpretability and strong generalization capability. The performances and features of the model indicate its effectiveness in the rapid screening and diagnosis of serous cavity effusion and its potential in broad clinical application prospects, eg, in precision medical applications. Moreover, the constructed 2 real-world pathologic data sets would be the first public whole slide imaging data sets of serous cavity effusion with adenocarcinoma based on cell block sections, which can help assist colleagues.

The Role of Immunohistochemistry in Reducing the "Atypia of Undetermined Significance (AUS)" Category in Serous Fluid Cytology

Background and Aims

The International Serous Fluid Cytopathology Reporting System aimed to establish standardized protocols to ensure consistency in the reporting of serous fluid cytological specimens. In the search for higher diagnostic accuracy and a reduction in indeterminate categories, such as atypia of undetermined significance (AUS), ancillary tests like immunohistochemical (IHC) staining panels were performed. In our study, we aimed to evaluate whether the category of cases diagnosed as AUS by initial examination would change at the end of IHC studies.

Materials and Methods

In total, 375 serous fluid cytology samples were examined in our laboratory for 10 months. Of these, 37 cases that were initially diagnosed as AUS were included in the study. A control group, comprising 20 cases initially diagnosed as negative for malignancy (NFM) was used. For the IHC study, sections from cell blocks were used for each group Then, the slides were stained with Ep-CAM/epithelial specific antigen (MOC31), Hector Battifora mesothelial-1 (HBME-1), and cluster of differentiation 68 (CD68).

Results

Following the IHC study involving MOC31, HBME-1, and CD68, a significant reclassification was observed in cases initially diagnosed as AUS. Specifically, in 86.1% of these cases, a definitive categorization into either NFM or malignant was achieved. Statistical analysis revealed a significant difference between the two groups in terms of achieving a definitive category after the IHC study (P < 0.05).

Conclusion

Our study emphasizes the critical importance of enhancing the initial IHC panel, initially composed of epithelial and mesothelial markers, with CD68. This strategic addition contributed significantly to the reduction of cases categorized as AUS.

Application of the international system for reporting serous fluid cytopathology on pleural effusion cytology with paired pleural biopsy: A new insight and novel approach on risk of malignancy

INTRODUCTION

The risk of malignancy (ROM) remains an area of interest for further evaluation in reporting systems including in International System for reporting serous fluid cytopathology (TIS), which is a standardized system for reporting effusion cytology. Herein, we report our findings in further investigation of ROM in TIS by studying on paired pleural effusion specimens and corresponding pleural biopsies with emphasis on negative for malignancy, and atypia of undetermined significance categories.

MATERIALS AND METHODS

The  Johns Hopkins Hospital pathology database was retrospectively searched for patients with a pleural biopsy (PBX) and a paired pleural effusion (PF) cytology specimens over a 4-year period. We employed the TIS categories. The following statistical parameters were evaluated: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and ROM.

RESULTS

A total of 223 patient cases were included. Effusions TIS reclassification and ROM were as follows: 1.8% non-diagnostic (ROM 75%), 75.8% negative for malignancy (ROM 23%), 4.9% atypical cells of undetermined significance (ROM 45%), 2.2% suspicious for malignancy (ROM 80%), and 15.2% malignant (ROM 100%). Overall accuracy, sensitivity, specificity, PPV and NPV were calculated and were 79.4%, 45%, 97.7%, 91.2% and 77%, respectively. Among, discordant cases diagnosed negative for malignancy on PF and positive for malignancy on PBX, there were significant number of lymphomas, mesotheliomas, and sarcomas. Lung cancer was the most common carcinoma; however, rare types of carcinomas were noted. Cells blocks and immunohistochemistry (IHC) studies were utilized to confirm either malignant conditions or rule out malignancy in both cell blocks and histology biopsies.

CONCLUSION

This study demonstrates the high specificity and ROM for 'malignant' and 'suspicious for malignancy' categories in the TIS reporting system and highlights the modest negative predictive value for the 'negative for malignancy' category. Although Tissue biopsies are usually considered as 'gold standard', any definitive diagnosis of malignancy of body fluid should be considered positive for malignancy in further clinical decision-making.

Current role of cytopathology in the molecular and computational era: The perspective of young pathologists

Cytopathology represents a well established diagnostic approach because of its limited cost, reliability, and minimal invasiveness with respect to other methodologies. The evolving complexity of the different classifications systems and the implementation of ancillary techniques to refine the diagnosis is progressively helping in the risk of malignancy stratification, and the adoption of next-generation sequencing techniques contributes to enrich this valuable tool with predictive information, which is always more essential in the tailored medicine era. The recent introduction of digital and computational pathology is further boosting the potentialities of cytopathology, aiding in the interpretation of samples to improve the cost effectiveness of large screening programs and the diagnostic efficiency within intermediate/atypical categories. Moreover, the adoption of artificial intelligence tools is promising to complement molecular investigations, representing a stimulating perspective in the cytopathology field. In this work, the authors tried to summarize the multifaceted nature of this complex and evolving field of pathology, synthesizing the most recent advances and providing the young pathologists' perspective on this fascinating world.

Application of algorithmic cytomorphological assessment and immunocytochemistry with the international system for reporting serous fluid cytopathology on pericardial fluid cytology

AIMS

The international system for reporting serous fluid cytopathology (ISRSFC) set forth a five-tiered reporting system with comprehensive validation on pleural and peritoneal fluid cytology. An algorithmic approach for cytomorphological assessment and immunocytochemistry was also described in ISRSFC. Limited data on pericardial fluid are supportive but would benefit from further investigation.

METHODS

Consecutive pericardial fluid cytology over a 4-year period was reviewed by multiple board-certified pathologists according to the ISRSFC. Cytomorphology and immunocytochemistry were assessed sequentially, with respective diagnostic performances computed and compared. Literature review was performed.

RESULTS

In total 358 specimens, including 53 with immunocytochemistry available, were reviewed. There were 137 benign and 221 malignant (MAL) cases. The risks of malignancy were 23.5% non-diagnostic (ND), 29.2% negative for malignancy (NFM), 56.0% atypia of undetermined significance (AUS), 82.6% suspicious for malignancy (SFM) and 99.2% (MAL) for cytomorphological assessment, improving to 23.5% (ND), 29.1% (NFM), 56.8% (AUS), 78.9% (SFM) and 99.3% (MAL) incorporating immunocytochemistry. Ten cases (2.8%) received a change in diagnosis after review of immunocytochemistry. All revisions of diagnostic category were appropriate upgrades/downgrades referenced against clinical information. Cytomorphological typing was accurate for adenocarcinoma (n=81/83, 97.6%), while other carcinomas and lymphomas required immunocytochemistry. Certain subcategories within AUS and SFM pertaining to bland indeterminate epithelial cells or mucinous material were not seen for pericardial fluid.

CONCLUSIONS

The ISRSFC shows robust diagnostic performance for pericardial fluid cytology. For pericardial effusion, disease composition and applicable cytological subcategories differ from its peritoneal and pleural counterparts. Incorporating immunocytochemistry by an algorithmic approach improves diagnostic accuracy. Cytomorphology is accurate for identifying adenocarcinomas, but further typing necessitates immunocytochemistry is necessary.

Diagnostic accuracy of International System for Reporting Serous Fluid Cytopathology: A systematic review and meta-analysis in malignancy diagnosis

This study conducts the first meta-analysis to assess the aggregated risk of malignancy associated with each category of the International System for Reporting Serous Fluid Cytopathology (ISRSFC) for reporting serous effusion cytology, while also evaluating diagnostic accuracy. PubMed/MEDLINE and Embase were systematically searched using the keywords "(pleural, peritoneal, and pericardial effusions) AND (serous effusion cytology) OR (International System for Reporting Serous Fluid Cytopathology)". Articles underwent risk of bias assessment using the QUADAS-2 tool. After excluding inadequate samples, a meta-analysis determined sensitivity and specificity for different cutoff points, including "atypical considered positive," "suspicious of malignancy considered positive," and "malignant considered positive." Summary receiver operating characteristic curves assessed diagnostic accuracy, and the diagnostic odds ratio was pooled. Sixteen retrospective cross-sectional studies, totaling 19,128 cases, were included. Sensitivity and specificity for the "atypical and higher risk categories" considered positive were 77% (95% confidence interval [CI], 68%-84%) and 95% (95% CI, 93%-97%) respectively. For the "suspicious for malignancy and higher risk categories" considered positive, sensitivity and specificity were 57% (95% CI, 49%-65%) and 100% (95% CI, 99%-100%) respectively. Sensitivity and specificity for the "malignant" category considered positive for malignancy were 70% (95% CI, 60%-77%) and 99% (95% CI, 98%-99%), respectively. The pooled area under the curve ranged from 85% to 89.5% for each cutoff. This meta-analysis underscores the ISRSFC's accuracy in reporting serous fluid cytology. It emphasizes the diagnostic importance of the "suspicious" and "malignant" categories in identifying malignancy, and the role of the "benign" category in ruling out malignancy.

Risk of Malignancy in Effusions according to the International System for Serous Fluid Cytopathology: A Review

INTRODUCTION

The International Serous Fluid Cytopathology Reporting System (TIS) was developed to standardize communication among health professionals reporting analyses of serous fluid samples. The categories include non-diagnosis (ND), negative for malignancy (NFM), atypia of undetermined significance (AUS), suspected malignancy (SFM), and malignant (MAL). Each category was characterized by a risk of malignancy (ROM).

METHODS

We performed a literature review to analyze studies related to TIS using several sources, including PubMed, followed by a search of relevant cytopathology journal websites (American Cancer Society, Diagnostic Cytopathology, Journal of the American Society of Cytopathology, and Acta Cytologica and Cytopathology). The search included articles published between January 2020 and December 2023, using the terms "international AND serous fluid system."

RESULTS

We identified 257 articles, of which 20 addressed the inclusion and exclusion criteria. The overall ROMs for each category were 23.55% for ND, 16.46% for NFM, 50.78% for AUS, 91.34% for SFM, and 98.21% for MAL.

CONCLUSION

Considering the TIS-recommended ROM rates, the ND category was between the suggested intervals, while the SFM category rate was bigger than expected. The other categories (NFM, AUS, and MAL) were below expected values. SFM and MAL had a stronger association with MAL results. New studies are needed to determine each category's ROM rate from TIS accurately.

Application of the newly published International System for Reporting Serous Fluid Cytopathology in atypical and suspicious diagnosis: a four-year retrospective analysis

INTRODUCTION

Serous fluids offer crucial diagnostic insights, but inconsistent analysis hampers reporting quality, especially in indeterminate (ID) categories like atypia of undetermined significance (AUS) and suspicious for malignancy (SFM). The 2020 International System for reporting Serous Fluid Cytopathology (TIS) aims to standardize communication and reduce reporting disparities. This study evaluates TIS's role in AUS and SFM categories within our institution.

MATERIALS AND METHODS

A 4-year retrospective search of cytopathology reports from December 2015 to December 2019 for AUS and SFM diagnoses in pleural, ascitic, pericardial fluids, and peritoneal washings was performed and results reclassified using TIS definitions. The risk of malignancy (ROM) was calculated for existing and reclassified diagnoses.

RESULTS

Over 4 years, we received 2998 serous fluid specimens. AUS constituted 2.3% (70 cases), while SFM constituted 0.5% (16 cases). Excluding repeats, 80 cases were TIS-reviewed. Sixteen cases of ID diagnoses were reclassified. Two cases of AUS were changed to negative for malignancy (NFM) and 12 to SFM. Two SFM cases were upgraded to malignancy. ROM shifted from 63% to 60% for AUS and 100% to 85% for SF (TIS's ROM range: AUS: 66% ± 10%; SFM: 82% ± 4.8%).

CONCLUSIONS

This institution's ID diagnosis rate is low. AUS ROM is challenging but aligns with TIS, primarily favoring benign. All SFM diagnoses are highly suspicious but quantitatively inadequate for definitive malignancy, explaining the elevated ROM. AUS rate should gauge quality, not serve as a catch-all category. Algorithmic cytology with cell blocks and ancillary studies aids reclassification. TIS is user-friendly and is a consistent methodology for standardized reporting. Further studies are needed to evaluate ROM and define reproducible diagnostic criteria for each category for better system utilization.

Deciphering Serous Effusions Using the New International System for Reporting Serous Fluid Cytopathology

Introduction Serous effusion cytopathology is a minimally invasive, cost-effective procedure and plays a crucial role in diagnosing a spectrum of pathological conditions, ranging from benign to malignant. The International System for Reporting Serous Fluid Cytopathology (ISRSFC) offers a standardized framework for reporting serous effusions, aiding in better communication and clinical decision-making. Aims and objectives This study aimed to categorize effusions using the ISRSFC reporting system. In addition, we sought to estimate the risk of malignancy (ROM) for each diagnostic category and evaluate the diagnostic performance of conventional smear versus cell block techniques. Materials and methods This cross-sectional study was conducted in the Department of Pathology over one year. We applied the ISRSFC criteria to serous effusions and categorized them accordingly. The ROM for each category was assessed with histopathology serving as the gold standard. Then, the diagnostic performance including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy was evaluated using conventional smear and cell block techniques. Results The study included 185 serous effusion cases, with ages ranging from two months to 85 years. The male-to-female ratio was 1.1:1. Most effusions were pleural fluids constituting about 133 cases (71.9%), followed by peritoneal fluids (47 cases, 25.4%) and pericardial fluids (five cases, 2.7%). Among the fluids, four (2.2%) were diagnosed as non-diagnostic (ND), 152 (82.2%) as negative for malignancy (NFM), four (2.2%) as atypia of undetermined significance (AUS), nine (4.8%) as suspicious for malignancy (SFM), and 16 (8.6%) as malignant (MAL). The overall ROM was 25% for ND, 8.5% for NFM, 50% for AUS, 77% for SFM, and 100% for MAL. The sensitivity, negative predictive value (NPV), and diagnostic accuracy were superior when combining conventional smear with the cell block technique. Conclusions Our findings underscore the use of ISRSFC in categorizing effusion samples, assessing the ROM, and guiding clinical management. Moreover, our study highlights the benefits of employing a combined approach using conventional smears and cell blocks for enhanced diagnostic accuracy in serous effusions.

The Implementation of Nongynecologic Reporting Systems in Cytopathology Laboratories Is Highly Variable: Analysis of Data From a 2020 Supplemental Survey of Participants in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology

CONTEXT

In recent years, several reporting systems have been developed by national and international cytopathology organizations to standardize the evaluation of specific cytopathology specimen types.

OBJECTIVE

To assess the current implementation rates, implementation methods, and barriers to implementation of commonly used nongynecologic reporting systems in cytopathology laboratories.

DESIGN

Data were analyzed from a survey developed by the College of American Pathologists Cytopathology Committee and distributed to participants in the College of American Pathologists Nongynecologic Cytopathology Education Program mailing.

RESULTS

Nongynecologic reporting systems with the highest rate of adoption were the Bethesda System for Reporting Thyroid Cytopathology, 2nd edition (74.1%; 552 of 745); the Paris System for Reporting Urinary Cytology (53.9%; 397 of 736); and the Milan System for Reporting Salivary Gland Cytopathology (29.1%; 200 of 688). The most common reason given for not adopting a reporting system was satisfaction with a laboratory's current system. Implementation varied among laboratories with regard to which stakeholders were involved in deciding to implement a system and the amount of education provided during the implementation process.

CONCLUSIONS

The implementation of nongynecologic reporting systems in cytopathology laboratories was highly variable.

Optimal Volume Assessment for Serous Fluid Cytology

OBJECTIVE

This study aimed to investigate the optimal volume of serous fluid needed for accurate diagnosis using The International System for Reporting Serous Fluid Cytopathology (TIS), as well as to provide information on the distribution of serous effusion cases in the TIS categories (ND: non-diagnostic, NFM: negative for malignancy, AUS: atypia of undetermined significance, SFM: suspicious for malignancy, MAL: malignant) and relevant epidemiological data.

METHODS

A retrospective analysis of 2340 serous effusion cases (pleural, peritoneal, and pericardial) from two hospitals between 2018 and 2020 was conducted. TIS categories were assigned to each case, and for 1181 cases, these were correlated with the volume of the analyzed fluid.

RESULTS

Our study found statistically significant differences in volume distributions between certain TIS categories. Statistically lower volumes were observed in NFM compared to MAL, in UNCERTAIN (ND, AUS, SFM) compared to both MAL and NFM, and in NOT MAL (ND, NFM, AUS, SFM) compared to MAL. However, these differences were not substantial enough to hold any clinical relevance.

CONCLUSIONS

This study suggests that while fluid volume may slightly influence the TIS category, it does not impact the diagnostic accuracy of serous effusion cytology. Therefore, the ideal serous effusion specimen volume can be defined solely by practical parameters.

BAP1 Loss, Nuclear Grading, and Nonepithelioid Features in the Diagnosis of Mesothelioma in Italy: Nevermore without the Pathology Report

The pathologic diagnosis of pleural mesothelioma is generally based on international guidelines, but no compulsory points based on different drugs approvals in different European countries are required to be reported. According to the last (2021) edition of the World Health Organization classification of pleural tumors, the nuclear grade of epithelioid-type mesothelioma should be always inserted in the pathologic report, while the presence of BRCA-associated protein-1 (BAP1) (clone C4) loss and a statement on the presence of the sarcomatoid/nonepithelioid component are fundamental for both a screening of patients with suspected BAP1 tumor predisposition syndrome and the eligibility to perform first-line immunotherapy at least in some countries. Several Italian experts on pleural mesothelioma who are deeply involved in national scientific societies or dedicated working groups supported by patient associations agreed that the pathology report of mesothelioma of the pleura should always include the nuclear grade in the epithelioid histology, which is an overt statement on the presence of sarcomatoid components (at least 1%, in agreement with the last classification of pleural mesothelioma) and the presence of BAP1 loss (BAP1-deficient mesothelioma) or not (BAP1-retained mesothelioma) in order to screen patients possibly harboring BAP1 tumor predisposition syndrome. This review aims to summarize the most recent data on these three important elements to provide evidence regarding the possible precision needs for mesothelioma.

Cytopathological Features of Extensive Bilateral Pleural Effusions in Metastatic Prostate Cancer: Report of a Rare Case

We report a rare case of a 59-year-old male with a history of metastatic prostate cancer presenting with acute onset dyspnea due to extensive bilateral pleural effusions. This case highlights the rarity of metastatic prostate cancer with pleural involvement and underscores the importance of accurate diagnosis using cytopathology and immunohistochemical staining.

Comprehensive evaluation of benign and malignant etiologies of different serous effusions with the International System for Reporting Serous Fluid Cytopathology: A multi-institutional study in Taiwan

BACKGROUND

The International System for Reporting Serous Fluid Cytopathology (ISRSFC) was introduced globally in 2019 in response to the absence of a standardized reporting system for serous fluid cytology. This study presents experiences implementing this system across three distinct hospitals in Taiwan.

METHODS

A total of 6177 serous fluid specimens in three hospitals in Taiwan between 2018 and 2020 were retrospectively reviewed and reclassified according to the ISRSFC. Cytohistological correlation and chart review were further performed to investigate etiologies and risks of malignancy (ROMs).

RESULTS

Reclassification showed that 34 (0.7%) of 4838 pleural effusions were nondiagnostic (ND), 4086 (84.5%) were negative for malignancy (NFM), 201 (4.2%) were atypia of undetermined significance (AUS), 92 (1.9%) were suspicious for malignancy (SFM), and 425 (8.8%) were malignant (MAL). The 1231 ascites cases contained 13 (1.1%) ND, 1004 (81.6%) NFM, 53 (4.3%) AUS, 31 (2.5%) SFM, and 130 (10.6%) MAL specimens. In pleural effusions, the ROM was 2.9% for ND, 14.0% for NFM, 52.2% for AUS, 85.9% for SFM, and 95.1% for MAL. In ascites, it was 15.4% for ND, 19.1% for NFM, 52.8% for AUS, 83.9% for SFM, and 92.3% for MAL. In pericardial effusions, it was 0.0% for ND, 11.6% for NFM, 30.8% for AUS, 100.0% for SFM, and 95.2% for MAL. Different effusions' most common benign and malignant etiologies were also disclosed.

CONCLUSIONS

These multi-institutional data have determined the diagnostic usefulness of the ISRSFC, which provides pathologists and physicians with invaluable assistance in correctly classifying effusions for further management.

Claudin-4 immunocytochemistry is specific and sensitive for the diagnosis of malignant carcinomatous effusions: Results from a pilot study

BACKGROUND

Claudin-4, a tight junction associated protein expressed in epithelial cells, is purported as a highly specific and sensitive marker for epithelial malignancies. Our aim was to assess the sensitivity, specificity and real-time utility of claudin-4 immunocytochemistry (ICC) in the diagnostic work-up of suspected malignant effusions.

METHODS

Claudin-4 (3E2C1 clone) ICC was performed prospectively in effusion cell blocks where other ICC markers were being performed as part of reporting over 3 months. Based on claudin-4 staining in unequivocal malignant and reactive effusions, the sensitivity and specificity was calculated. In cases signed out as inconclusive encompassing atypia of undetermined significance (AUS) and suspicious for malignancy (SFM) and negative for malignancy, change in diagnostic category based on addition of claudin-4 ICC was assessed.

RESULTS

Study included 107 effusions. Claudin-4 stained 100% of metastatic adenocarcinomas including those with primaries in lung, breast, ovary, female genital tract, gastrointestinal tract and pancreatic-biliary tract, and was negative in all reactive mesothelial and mesothelioma effusions with sensitivity of 100% (48/48) and specificity of 95% (20/21) for adenocarcinoma. Claudin-4 upgraded the diagnostic category to positive in 70% (16/23) of SFM, 20% (1/5) of AUS, and in 50% (5/10) of negative effusions. Among cases with confirmed serosal involvement status on follow-up, claudin-4 showed sensitivity, specificity, positive predictive value and negative predictive values of 85% (11/13), 100% (3/3), 100% (10/10) and 75% (3/4), respectively, for metastatic adenocarcinoma.

CONCLUSION

Claudin-4 as a single marker is sensitive and specific for adenocarcinoma and is a valuable addition to the ICC armamentarium.

Review of the impact of the International System for Serous Fluid Cytopathology

The International System for Reporting Serous Fluid Cytology (TIS) has been proposed by an expert working team composed of the International Academy of Cytology and the American Society of Cytopathology, following an international survey. Since its introduction, the TIS has gained worldwide acceptance, and this review aims to assess its global impact. A literature search revealed 25 studies which have presented data on the impact of the TIS. Most of them provide data, including risk of malignancy (ROM) for each diagnostic category, separately for pleural, peritoneal and pericardial effusions, while a few do not separate them. A few studies focus on specific diagnoses like mesothelioma on specific types of fluids or more specific issues like the optimal fluid volume for cytology or interobserver variability. A synopsis of the data from the literature search is presented in four tables. The ROM assessment is discussed, as well as interobserver variability and the use of ancillary diagnostic immunochemistry. In conclusion, our review of the published data suggests that the TIS is a valid classification scheme that has been widely accepted by pathologists globally, is highly reproducible and makes a valuable contribution to clinical therapeutic management.

Application of international system for reporting serous fluid cytology (ISRSFC) in effusion samples-a prospective study in an oncology setting

INTRODUCTION

Serous fluid cytology is a cost-effective procedure that can help in the diagnosis, staging, and origin of the malignancy. Recently introduced International System for Reporting Serous Fluid Cytology (ISRSFC) standardizes the reporting of serous fluid cytology in the 5 categories: Category 1: Nondiagnostic (ND), Category 2: negative for malignancy (NFM), Category 3: atypia of undetermined significance (AUS), Category 4: suspicious for malignancy (SFM), and Category 5: malignant (MAL). Here, we present our experience adopting the ISRSFC.

MATERIALS AND METHODS

We implemented ISRSFC in December of 2019 at our institute and included a cohort of 555 prospective effusion samples. The pertinent surgical pathology, radiology, and clinical follow-up were also extracted to assess the risk of malignancy (ROM) and performance parameters.

RESULTS

The assessment of interobserver reliability indicated substantial concordance (κ = 0.717) between the 2 investigators for serous fluid categorization. A total of 555 effusion samples were classified as follows: ND, 14 (2.5%); NFM, 394 (71%); AUS, 12 (2.2%); SFM, 13 (2.3%); and MAL, 122 (22%). The ROM for the ND, NFM, AUS, SFM, and MAL categories was 57.1%, 9.9%, 66.7%, 66.7%, and 97.2%, respectively, in peritoneal effusions and 57.1%, 7.1%, 66.7%, 100%, 100%, respectively, in pleural effusions. The ROM for NFM and MAL was 0% and 100%, respectively, in pericardial effusion.

CONCLUSIONS

Application of the proposed ISRSFC can help in achieving uniformity and reproducibility in diagnoses and also help in risk stratification in cytology. ISRSFC was successfully adopted by our cytology laboratory and clinicians, with overall diagnostic performance similar to previous studies.

Application of the International System for Reporting Serous Fluid Cytopathology to pericardial fluid: Root cause analysis of indeterminate diagnoses, cytohistological correlation, and assessment of malignancy risk

BACKGROUND

This study investigates the utility of the International System for Reporting Serous Fluid Cytopathology (ISRSFC) in the categorization of pericardial fluid and assesses the diagnostic performance and risk of malignancy (ROM) for each of the diagnostic categories.

METHODS

All pericardial fluid cases at the Yale School of Medicine between January 1, 2017, and December 31, 2020, were reviewed. The diagnoses were reclassified into five categories according to the ISRSFC: nondiagnostic (ND), negative for malignancy (NFM), atypia of uncertain significance (AUS), suspicious for malignancy (SFM), and malignant (MAL). ROM and performance parameters of each category were calculated.

RESULTS

After reclassification, the distribution of 465 pericardial fluid cases in each category was as follows: ND, 19 (4.1%); NFM, 332 (71.4%); AUS, 21 (4.5%); SFM, 11 (2.4%); and MAL, 82 (17.6%). Confirmatory follow-ups were available for 16 ND (66.7%), 299 NFM (90%), 15 AUS (71%), 5 SFM (45.5%), and 30 MAL cases (36.6%). The ROM was 0% for ND, 1.3% for NFM (4 of 332), 20% for AUS (3 of 15), and 100% for both SFM (5 of 5) and MAL (27 of 27). The diagnostic performance was as follows: sensitivity, 87% (27 of 31); specificity, 100% (292 of 292); positive predictive value (PPV), 100% (27 of 27); negative predictive value (NPV), 98.6% (292 of 296); and diagnostic accuracy, 98.8% (319 of 323).

CONCLUSIONS

The ISRSFC is a highly useful system for the reporting of pericardial fluid and risk assessment, given that it offers high sensitivity, specificity, PPV, NPV, and diagnostic accuracy. The application of this system may help to better categorize pericardial fluid and facilitate the standardization of cytopathology reporting.

Categorisation of peritoneal serous effusions using the International System for Reporting Serous Fluid Cytopathology-A study on gynaecological samples

BACKGROUND

Cytology of serous effusions is an indispensable diagnostic tool for the diagnosis of non-neoplastic as well as neoplastic effusions, aiding in the categorisation, staging, and prognostication of the patient. This study focuses on reclassifying cases of peritoneal fluid cytology following the International System for Reporting Serous Fluid Cytopathology (TIS), highlighting various challenges encountered and adding to the body of data regarding the risk of malignancy (ROM), focussing on peritoneal effusions due to gynaecological causes.

METHODS

Peritoneal effusion samples were retrieved from our department's archives and reclassified according to the TIS. The ROM for each category was calculated based on available surgical follow-up.

RESULTS

A total of 818 peritoneal effusions were studied. Following the definitions and guidelines of the TIS, the cases were reclassified with 125 (15.2%) in the category of non-diagnostic (ND), 595 (72.7%) as negative for malignancy (NFM), 26 (3.2%) as atypia of undetermined significance (AUS), 12 (1.5%) as suspicious for malignancy (SFM), and 60 (7.3%) as malignant (MAL). The respective ROM values for each category were 16.9%, 12.1%, 50%, 80%, and 100%, respectively. By considering the MAL and SFM groups as positive, and the ND, NFM, and AUS groups as negative, the diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were determined as 85.2%, 36.7%, 99.1%, 91.7%, and 84.5%, respectively.

CONCLUSIONS

Peritoneal cytology categorisation following the proposed TIS offered a practical approach for categorisation of the fluids received. The ROMs reported in our study were mostly concordant with those published according to the TIS.

Risk of malignancy assessment of the International System for Reporting Serous Fluid Cytopathology: Experience in a community hospital setting and comparison with other studies

BACKGROUND

The International System for Reporting Serous Fluid Cytopathology (ISRSFC) was published recently to provide standard reporting terminology for serous fluid. To date, several ISRSFC reclassification studies have reported a wide range of diagnostic category frequency and the associated risk of malignancy (ROM). Herein, the authors applied the ISRSFC to report pleural and peritoneal effusions retrospectively in a community hospital setting.

METHODS

With Internal Review Board approval, 446 peritoneal effusion specimens and 299 pleural fluid specimens from 576 patients in three community hospitals over a 12-month period were reviewed and reclassified according to the ISRSFC.

RESULTS

After reclassification, in pleural effusions, 18 (5.0%) were nondiagnostic (ND), 273 (76.0%) were negative for malignancy (NFM), 18 (5.0%) were atypia of undetermined significance (AUS), 6 (1.7%) were suspicious for malignancy (SFM), and 44 (12.3%) were malignant (MAL). In peritoneal effusions, after reclassification, 11 (5.5%) were ND, 168 (77.1%) were NFM, 9 (4.1%) were AUS, 2 (0.9%) were SFM, and 27 (12.4%) were MAL. The calculated ROM was 0.0% for ND, 1.8% for NFM, 37.5% for AUS, 83.3% for SFM, and 100.0% for MAL in peritoneal effusions; and the ROM was 8.3% for ND, 1.2% for NFM, 44.4% for AUS, and 100.0% for both SFM and MAL in pleural effusions. Further analysis demonstrated notable heterogeneity among published ISRSFC reclassification studies, although the overall ROMs did not differ significantly from the ISRSFC-determined ROMs (all p values were > .05 for mean ROM comparisons).

CONCLUSIONS

The findings suggested the necessity for each laboratory to perform its own ROM analysis based on its statistics for ISRSFC-tiered classification terminology.

The evolving landscape of anatomic pathology

Anatomic pathology has changed dramatically in recent years. Although the microscopic assessment of tissues and cells is and will remain the mainstay of cancer diagnosis molecular profiling has become equally relevant. Thus, to stay abreast of the evolving landscape of today's anatomic pathology, modern pathologists must be able to master the intricate world of predictive molecular pathology. To this aim, pathologists have had to acquire additional knowledge to bridge the gap between clinicians and molecular biologists. This new role is particularly important, as cases are now collegially discussed in molecular tumor boards (MTBs). Moreover, as opposed to traditional pathologists, modern pathologists have also adamantly embraced innovation while keeping a constant eye on tradition. In this article, we depict the highlights and shadows of the upcoming "Anatomic Pathology 2.0" by placing particular emphasis on the pathologist's growing role in the management of cancer patients.

Application of the international system for reporting serous fluid cytopathology on reporting various body fluids; experience of a tertiary care hospital

Objectives:

Cytological examination of effusion sample is a preliminary and minimally invasive method for the diagnosis of body fluids. Recently, the International System For Reporting Serous Fluid Cytopathology (ISRSFC) and the Indian Academy of Cytologist (IAC) have published guidelines for reporting effusion cytology and calculating the risks of malignancy (ROMs) for each defined category. We report our 2 years of experience in reclassifying and assessing the feasibility of applying ISRFSC and IAC categories to effusion fluid and to provide an estimate of the risk of malignancy for each diagnostic category.

Material and Methods:

Cytological reports of patients from January 2019 to December 2020 were retrieved and reclassified into a five-tiered classification scheme as per ISRSFC guidelines. Cellblock and immunohistochemistry were performed in selected cases. Clinico radiological and histopathological information were obtained and correlated with the cytological findings wherever available.

Results:

In the study, 652 cases were included during the 2 years. Out of these, 328 (50.3%) were women and 314 (47.3%) were men. Patient’s ages ranged between 2 92 years with a mean age of 47.4 years. There were 366 (56.1%) cases of ascitic fluid followed by 262 (40.1%) cases of pleural fluid and 24 (3.8%) cases of pericardial fluid in the analysis. Of all the cases, 13 (2%) were non-diagnostic (ND), 464 (71.6%) were negative for malignant (NFM) cells, 16 (2.4%) were atypia of uncertain significance, 31 (4.7%) were suspicious of malignancy, and 125 (19.3%) were malignant. Cellblock was prepared in 65 cases. Lung cancer followed by breast cancer was the most common malignancies involving the pleural effusion and ovarian cancer was the most common cause of peritoneal effusion. ROM for each diagnostic category was 23% for ND, 25% for NFM, 56% for the atypical category, 80.6% in suspicious, and 90% were for positive for malignancy category.

Conclusion:

The use of a five-tiered system as per the ISRFC and IAC guidelines are feasible for the standardized reporting of effusion samples, thus avoiding subjective variation of reporting.

Serous fluid: Reactive conditions

This chapter highlights the steps that would help to analyze any fluid. It highlights importance of knowing gross analysis of fluid along with biochemical information. These parameters along with clinical information are very important in arriving at a differential diagnosis. Morphologic appearances in the fluid can often become challenging and occasionally reactive conditions can reveal changes that may mimic malignancies. This chapter provides not only a framework of approach to assessment of fluid cytology but also shows how to distinguish some of the challenging reactive conditions from the diagnosis of carcinoma. The chapter also utilizes two cases to demonstrate approach to reactive conditions. This review article will be incorporated finally as one of the chapters in CMAS (CytoJournal Monograph/Atlas Series) #2. It is modified slightly from the chapter by the initial authors in the first edition of Cytopathologic Diagnosis of Serous Fluids.

Application of the International System for Reporting Serous Fluid Cytopathology (TIS): A Retrospective Institutional Study

BACKGROUND

Cytology of serous effusions is an important diagnostic tool for the diagnosis of cancer, staging and prognosis of the patient. Herein, we retrospectively applied the TIS on reporting serous cytopathology and provided the corresponding risk of malignancy (ROM).

METHODS

Pleural, pericardial and peritoneal effusion samples were retrieved from the archives of our department and reclassified according to the TIS. The ROM for each category was calculated based on available surgical follow-up.

RESULTS

A total 3790 effusions were available for the study. 1292 pleural samples were reclassified: 27 (2.1%) non-diagnostic (ND), 1014 (78.5 %) negative for malignancy (NFM), 86 (6.6 %) atypia of undetermined significance (AUS), 29 (2.3 %) suspicious of malignancy (SFM) and 136 (10.5%) malignant (M). 241 pericardial samples were reclassified: 4 (1.6 %) as ND, 173 (71.8 %) as NFM, 10 (4.1 %) as AUS, 7 (3 %) as SFM, and 47 (19.5%) as M. 2257 peritoneal cases were re-categorized as follows: 31 (1.4 %) as ND, 1897 (84 %) as NFM, 39 (1.7 %) as AUS, 53 (2.4 %) as SFM, and 237 (10.5 %) as M. The ROM was, respectively, for each of the aforementioned categories, 18.5%, 15%, 45.3%, 93%, 100% in pleural effusions, 25%, 13.2%, 35%, 100%, 100% in pericardial effusions and 19.3%, 10.4%, 43.5%, 100%, 100% in peritoneal effusions.

CONCLUSIONS

Pleural, pericardial, and peritoneal cytology show high specificity and moderate sensitivity in the evaluation of serous effusions. The ROM reported in our study was mostly concordant with ROM published by the TIS.

Approach to Diagnostic Cytopathology of Serous Effusions

Collection of most serous fluids from various effusions is a relatively simple procedure. Because of this, serous fluids are commonly submitted for pathologic examination including cytopathologic evaluation by various clinical institutions. As a consequence, even a general pathology laboratory which may not have expertise with highly trained cytopathologist would be confronted with serous fluids for cytologic evaluation.

However, cytopathologic evaluation of serous fluids is complex as compared to evaluation of fine needle aspiration cytology. This signifies the fact that all pathologists, irrespective of subspeciality cytopathology training and level of subspeciality expertise, should be conversant with the diagnostic challenges and pitfalls of effusion fluid cytology.

Although, majority of effusions are due to reactive and non-neoplastic etiologies, cancer is one of the causes of an effusion as a manifestation of advanced cancer. Detecting neoplastic cells in effusion specimens in most of clinical settings is related to the advanced status of the disease, which usually is equivalent to incurable stage. Thus, interpretation of cytopathology as positive for cancer cell is highly critical in planning the trajectory of the clinical management with an obvious negative impact of false positive interpretation.

Apart from cancer, effusions may be secondary to hemodynamic pathologies such as heart failure, hypoalbuminemia, cirrhosis etc. in addition to the different inflammatory conditions including parasitic infestations, bacterial, fungal, or viral infections, and other non-neoplastic etiologies including collagen diseases. Due to the cytomorphologic overlap of reactive mesothelial cells with malignant cells, general cytologic criteria for diagnosis of malignancy in single cells cannot be applied in most of the effusion specimens. This challenge is further amplified because of surface tension related phenomenon which ‘round up’ the cells after exfoliation in serous fluids. As a result, the native shapes of cancer cells cannot be a guiding feature. Thus the cytomorphologic features of cancer cells in serous fluids may not be same as seen in routine cytopathology of exfoliative, brushing, and fine-needle aspiration specimens.

The cancer cells may continue to proliferate after exfoliation in the nutrient rich effusion fluids and may form proliferation spheres. It is crucial to consider these factors when interpreting effusion cytology. Amongst malignant effusions, adenocarcinomas are the most common cause of metastatic cancers, but almost any type of malignancy including melanomas, hematopoietic neoplasms, sarcomas, and mesotheliomas may involve serous cavities. The interpreter must be aware of the wide range of the cytomorphologic appearances of reactive mesothelial cells in effusion fluids. It is essential to understand these and other nuances related to effusion fluid cytology. Understanding potential pitfalls during various stages from processing to application of ancillary studies would increase the diagnostic accuracy and minimize atypical interpretations and false positivity.

Application of the Indian academy of cytologists recommendations for reporting serous fluid cytopathology in routine reporting of ascitic fluid specimen and assessment of the risk of malignancy

Background:

A five-tiered reporting system for effusion fluid cytology has been published by the Indian Academy of Cytologists (IAC). Only a single study has evaluated the applicability of this system in routine reporting.

Aims:

We intend to evaluate the practical utility of this system in routine reporting of ascitic fluid cytology.

Materials And Methods:

Nine hundred and sixty-one cases of ascitic fluid cytology were included in this study. The clinical, radiological, cytomorphological, and follow-up data of these cases were reviewed. All cases were recategorized according to the proposed IAC system, and the risk of malignancy (ROM) for each category was estimated.

Results:

Age of the patients ranged from 1 to 92 years, and fluid volume ranged from 10 ml to 3 l. The number of cases included in each category and their respective ROM were as follows: category 1: 41, 21.42%; category 2: 805, 14.9%; category 3: 5, 33.3%; category 4: 31, 90%; and category 5:79, 96.4%.

Conclusions:

The new IAC guidelines for the serous fluid is representative, informative, and could be easily applied at our institutional level. We used the recommended diagnostic categories for reclassifying the ascitic fluid samples based on their cytosmear findings and conclude that the system has enormous utility at each level starting from the collection of fluid samples till the delivery of the report.

Application of the International System for Reporting Serous Fluid Cytopathology with Cytohistological Correlation and Risk of Malignancy Assessment

The International System for Reporting Serous Fluid Cytopathology (TIS) classifies serous effusions into five categories: non-diagnostic (ND), negative for malignancy (NFM), atypia of unknown significance (AUS), suspicious for malignancy (SFM) and malignant (MAL). The main objectives of this classification comprise the establishment of a universal code of communication between cytopathologists and clinicians and histopathologists, as well as between different laboratories worldwide, paving the way for the setting of clinical management guidelines based on the risk of malignancy assessment for each diagnostic category. We retrieved the total number of pleural and peritoneal effusion cases of our department for the three-year time period between 2018 and 2020, yielding a total of 528 and 500 cases, respectively. We then proceeded to reclassify each specimen according to TIS guidelines and calculate the risk of malignancy (ROM) for each category by searching each patients’ histology records, medical history and clinical follow-up. For pleural effusions, 3 (0.57%) cases were classified as ND, 430 (81.44%) cases as NFM, 15 (2.84%) as AUS, 15 (2.84%) as SFM and 65 (12.31%) as MAL. ROM amounted to 0%, 5.3%, 33.33%, 93.33% and 100% for each category, respectively. As far as peritoneal effusions are concerned, 6 (1.2%) were categorized as ND with ROM estimated at 16.66%, 347 (69.4%) as NFM (ROM = 9%), 13 (2.6%) as AUS (ROM = 38.46%), 12 (2.4%) as SFM (ROM = 83.33%) and 122 (24.4%) as MAL (ROM = 100%). Our results underline the utility of the current classification, both as a means of communication between doctors of different specialties and as general guidelines for the further clinical management of patients.

Application of the International System for Reporting Serous Fluid Cytopathology in routine reporting of pleural effusion and assessment of the risk of malignancy

INTRODUCTION

The International System for Reporting Serous Fluid Cytopathology (ISRSFC) was proposed by the International Academy of Cytology and the American Society of Cytopathology.

AIM OF THE STUDY

We have applied this system for reporting of pleural effusion cytology and report our experience.

MATERIALS AND METHODS

All the pleural effusions from January 2019 to June 2020 were retrieved from the database. All these cases were reviewed and recategorized according to the proposed system of 5 categories: non-diagnostic (ND), negative for malignancy (NFM), atypia of uncertain significance (AUS), suspicious for malignancy (SFM), and malignant (MAL). The risk of malignancy (ROM) for each category was evaluated.

RESULTS

A total of 939 cases were studied. The age of patients ranged from 2 to 88 years, and the volume of fluid ranged from 1 to 600 ml. There were 41 ND (4.37%), 697 NFM (74.23%), 44 AUS (4.69%), 27 SFM (2.88%), and 130 MAL (13.84%) cases. The ROM for the categories were found to be 87.5%, 51.61%, 88.23%, 87.5%, and 100% respectively.

CONCLUSIONS

The ISRSFC is a user-friendly system for use in reporting of pleural fluid. The criteria for defining the various categories need to be further elaborative and stricter for this system to be more effective. More studies are required for the estimation of the ROM for each category.

Cytohistological Correlation in Pleural Effusions Based on the International System for Reporting Serous Fluid Cytopathology

The International System for Reporting Serous Fluid Cytology (TIS) was recently developed. Given its novelty, most studies looking into the risk of malignancy (ROM) of serous effusion diagnostic categories were published before the development of TIS. We searched the database of our department for pleural effusions diagnosed in the last five years, excluding those without a corresponding pleural biopsy. Cases were reviewed and reclassified according to the TIS. A cytohistological correlation was performed. In total, 350 pleural effusion specimens with one or more corresponding pleural biopsies were included. After reclassification, 5 (1.43%) were nondiagnostic (ND), 253 (72.29%) were negative for malignancy (NFM), 7 (2.00%) had atypia of unknown significance (AUS), 14 (4.00%) were suspicious for malignancy (SFM), and 71 (20.57%) were malignant (MAL). Calculated ROM was 40% for ND, 20.16% for NFM, 42.86% for AUS, 78.57% for SFM, and 100% for MAL. Effusion cytology sensitivity and specificity were 60.29% and 98.56%, respectively. This is the first publication looking into the cytohistological correlation of a retrospective cohort of pleural effusions based on the TIS. We add to the body of data regarding the ROM for TIS categories, highlighting areas of potential future research.

The value of cytology in distinguishing malignant mesothelioma: An institutional experience of 210 cases reclassified according to the International System for Reporting Serous Fluid Cytopathology (ISRSFC)

OBJECTIVE

Malignant mesothelioma (MM) is usually diagnosed by histological examination of tissue samples; however, effusion cytology offers an opportunity to identify a strong possibility for mesothelioma diagnosis at an early stage. We conducted a retrospective analysis of cytological specimens from a large series of histologically proven MM diagnosed over 19 years. The cases were reviewed and reclassified according to the International System for Reporting Serous Fluid Cytopathology (ISRSFC).

METHODS

A total of 450 cases were identified. Cytological analysis was present in 210 patients (164 pleural and 46 peritoneal effusions). All cases were reviewed and reclassified according to the proposed ISRSFC scheme. A comparison among the cytomorphological features was made throughout the different diagnostic categories.

RESULTS

The 210 cases were histologically diagnosed as follows: 192 (91.4%) cases had an epithelioid type and 18 (8.6%) had a sarcomatoid subtype of MM. The cytological cases were reclassified as follows: 2 (0.9%) as non-diagnostic (ND), 81 (38.6%) as negative for malignancy (NFM), 4 (1.9%) as atypia of undetermined significance (AUS), 11 (5.2%) as suspicious for malignancy (SFM), 112 (53.4%) as malignant (MAL). Sarcomatoid cells in the MAL category were characterised cytomorphologically by more pronounced discohesion. In comparison with the epithelioid subtype, the tumour cells appeared solitary with moderate or marked nuclear pleomorphism, and irregular chromatin.

CONCLUSIONS

It is important to recognise the cytological characteristics of this aggressive entity to suggest an early and precise possible diagnosis. Morphological features, coupled with clinico-radiological data may help the clinicians in adequately managing the patients.

MOC31 Immunostaining in the Diagnosis of Metastatic Adenocarcinoma in Serous Fluid: Special Emphasis on Atypical Cytological Cases

BACKGROUND

The diagnosis of atypical cases in the effusion cytology sample often poses a challenge to the cytologists.

AIMS AND OBJECTIVES

We evaluated the diagnostic role of MOC31 in the metastatic adenocarcinoma in effusion fluid.

MATERIALS AND METHODS

The cytological examination and MOC31 immunostaining in the cell block sections were carried out in 64 cases of serous effusion. A total of 23 cases showed atypical cytology, out of which suspicious for malignancy (SFM) and atypia of undetermined significance (AUS) were 19 and 4 cases, respectively. In these cases, we also performed calretinin immunostaining. The cytological features, results of MOC31 immunostaining, and follow-up data were correlated to find out the sensitivity and specificity of MOC31 immunostaining in the diagnosis of metastatic adenocarcinoma.

RESULT

The sensitivity and specificity of MOC31 were 100%. MOC31 detected all the cases of metastatic adenocarcinoma. MOC31 showed strong positivity in 19 cases of SFM. All these cases had a malignant outcome in histopathology or follow-up data. In AUS cases, MOC31 immunostaining was negative with a benign outcome. In all the atypical but malignant cases calretinin stain showed diffuse cytoplasmic and nuclear positivity. In contrast, MOC31 showed strong membranous positivity and occasionally cytoplasmic positivity.

CONCLUSION

MOC31 is an excellent marker of metastatic adenocarcinoma in the serous effusion. The membranous positivity of MOC31 and negative calretinin immuno-staining are helpful in atypical cytological cases to avoid the diagnostic dilemma. The MOC31 positivity is significantly useful in discrete atypical cells which are more challenging to recognize.

A decade of change: Trends in the practice of cytopathology at a tertiary care cancer centre

OBJECTIVES

The practice of cytopathology has evolved over the past decade with a growing need for doing more with less tissue. Changes in clinical practice guidelines and evolving needs in tissue acquisition for diagnosis and treatment have affected various areas of cytopathology in different ways. In this study, we evaluated the changing trends in cytopathological practice at our institution over the past decade.

METHODS

We performed a retrospective review of our institutional database for cytopathology cases from calendar years 2009 (n = 28038) and 2019 (n = 31386) to evaluate the changing trends in practice.

RESULTS

The overall number of exfoliative cases decreased 10% over the past decade, primarily due to a 64% decrease in gynaecological Pap testing. However, the volume of serous body cavity and cerebrospinal fluids increased 125% and 44%, respectively. The overall volume of fine needle aspiration (FNA) cases increased 38% from 2009 to 2019. The number of FNA cases increased across most body sites, driven primarily by a 180% increase in endobronchial ultrasound-guided transbronchial needle aspiration cases. In contrast, breast FNA volume decreased 43%. Ancillary studies increased substantially over the past decade, including immunostains (476%) and molecular testing (250%).

CONCLUSIONS

The trends in our cytopathological practice showed an increased volume of cases, especially in non-gynaecological specimens. As expected, the number of FNA cases used for immunostains and molecular testing increased substantially, indicating an upward trend in ancillary studies in cytopathological practice.

The International System for Reporting Serous Fluid Cytopathology: How to Incorporate Molecular Data in Cytopathology Reports

Serous effusion cytology is widely employed in the initial evaluation of the etiology of effusions with a high diagnostic sensitivity. To standardize practices, The International System for Reporting Serous Fluid Cytology (TIS) was developed following best international practices, the most up-to-date literature, and expert consensus. In the context of this system, ancillary techniques play an important role. Besides defining basic principles in laboratory specimen handling, adequacy criteria, and a standardized reporting terminology with five diagnostic categories, TIS provides an actionable framework for using immunohistochemical and molecular testing in effusion samples, namely, in atypical, suspicious of malignant samples. For diagnostic purposes, these tests may be employed to distinguish between a primary and secondary neoplasm, to confirm a diagnosis of malignant mesothelioma vs. reactive mesothelial hyperplasia, and to correctly classify and determine the primary location of a metastasis. Theranostic molecular tests may also be used for these samples to evaluate potential therapeutic targets. Pathologists play a central role in guiding this process by determining adequacy and selecting appropriate ancillary tests. The activity in this area of research should increase in the near future as new therapeutic targets are discovered and new drugs enter the clinical practice.

Diagnostic efficacy of ascites cell block for ovarian clear cell carcinoma

BACKGROUND

Ascites cytology is important for determining the stage and treatment methods for ovarian clear cell carcinoma (CCC) as defined by the 2014 International Federation of Obstetrics and Gynecology classification.

METHODS

Patients with CCC who underwent surgery at our hospital between January 2012 and December 2019 and who received cytodiagnosis of their ascites using Papanicolaou (Pap) and May-Grünwald-Giemsa (MGG) staining, and cell block methods were identified. The cell block technique was performed using hematoxylin-eosin (H&E) staining and immunohistochemical staining for hepatocyte nuclear factor-1β (HNF-1β), estrogen receptor (ER), progesterone receptor (PR), and Wilms tumor-1 (WT-1). Cancer cells of CCC were defined as tumor cells that were positive for HNF-1β and negative for ER, PR, and WT-1. The diagnostic accuracy of ascites cytology using Pap and MGG staining and cell block methods was examined.

RESULTS

Based on cytological data, our study included 17 patients: seven (41.1%) with malignant (MAL) ascites, eight (47.1%) with negative for malignancy (NFM), and two (11.8%) with atypia of undetermined significance (AUS) because of a few atypical cells based on Pap and MGG staining. Malignant cells diagnosed by cell blocks were detected in 7/7 patients with MAL ascites based on PAP and MGG staining, 2/8 (25.0%) patients with NFM, and 1/2 (50%) patients with AUS.

CONCLUSION

These findings show that the cell block method combined with the immunohistochemical investigation may be useful for increasing the diagnostic accuracy of malignant cells in CCC.

Application of Indian Academy of Cytologists Guidelines for Reporting Serous Effusions: An Institutional Experience

Background:

Recently, the Indian Academy of Cytologists (IAC) has published the guidelines for interpretation and reporting of serous effusions. Till date, there are no studies on its applicability.

Aims:

The present study was carried out to assess the feasibility of applying the IAC reporting categories to effusions, determine the frequency, and provide an estimate of the risk of malignancy (ROM) for individual diagnostic categories.

Materials and Methods:

All cases of serous effusion fluids reported in the year 2019 were retrieved from the archives and reassigned as per the IAC diagnostic categories. The clinical and histopathological follow-up information was obtained wherever possible.

Results:

A total of 1340 effusion samples were received from 1085 patients. There were 561 (51.7%) males and 524 (48.3%) females. Majority were pleural (1066, 79.5%), followed by peritoneal (187, 14%) and pericardial (87, 6.5%) effusions. The age ranged from 7 months to 92 years. There were 35 (2.6%) samples in category 1 (non-diagnostic), 954 (71.2%) in category 2 (benign), 17 (1.3%) in category 3 (atypical), 59 (4.4%) in category 4 (suspicious for malignancy) and 275 (20.5%) in category 5 (malignant). The estimated ROM in serous effusion samples was 20% for category 1, 16.7% for category 2, 50% for category 3, 94.4% for category 4 and 100% for category 5.

Conclusions:

The categorization of serous effusion cytology samples as per the IAC diagnostic categories and as per the reporting format developed by the IAC is feasible and the management recommendations are mostly appropriate.

The International Academy of Cytology Yokohama System for Reporting Breast Fine Needle Aspiration Biopsy Cytopathology: Analysis and discussion of the response to a web-based survey

BACKGROUND

A group of international experts in breast fine needle aspiration biopsy (FNAB) cytopathology, supported by the International Academy of Cytology (IAC), drafted a comprehensive system for reporting breast FNAB cytopathology in 2017-2018. The editorial team produced a survey to assess the international response to the proposed category structure, definitions, and management recommendations in this draft.

METHODS

A web-based survey of 186 questions was generated using the Qualtrics software package (Provo, Utah) supported by the Division of Information Technology at the University of Wisconsin-Madison. The survey was advertised widely-including through the IAC, American Society of Cytopathology, Japanese Society of Clinical Cytology, Papanicolaou Society of Cytopathology, and Australian Society of Cytology and to audiences at national and international meetings-and was available from April to June 2018. The data obtained from the 265 respondents was assessed by the editorial team.

RESULTS

The survey provided a snapshot of the current role and use of breast FNAB and the international variations. Demographic questions were followed by specific questions based on the draft category definitions and statements and focused on issues that had generated discussion among the authors, including the FNAB diagnosis of ductal carcinoma in situ.

CONCLUSION

The survey results strongly supported the development of the IAC Yokohama System and informed subsequent discussions among the authors regarding the final text.

The value of a tiered cytology diagnostic reporting system in assessing the risk of malignancy in indeterminate serous effusions

BACKGROUND

The International System for Reporting Serous Fluid Cytopathology was recently proposed as a tiered structure to provide consistent reporting terminology for serous effusions. Because of the variation in reporting practices for indeterminate serous effusions, namely, the atypia of undetermined significance (AUS) and suspicious for malignancy (SFM) groups, the authors retrospectively reviewed cases in these 2 categories at their institution and determined the associated risk of malignancy (ROM).

METHODS

Pleural, peritoneal, and pericardial effusions that were reported as AUS or SFM over a 1-year period were reviewed, and their associated ROMs were calculated based on confirmation of malignancy by previous and/or subsequent fluid and/or tissue biopsy specimens from the same general location.

RESULTS

In total, 145 AUS and 98 SFM serous effusion cases were identified. The AUS category was used when the cells in question lacked the requisite quantitative (cell number) and/or qualitative (morphologic) features for a definitive diagnosis. Immunohistochemistry (IHC) or flow cytometry (FCM) was available in 15% of cases (n = 22) with inconclusive results. The ROM based on 69 cases with available follow-up results was 39%. In contrast, the SFM category demonstrated cells that were morphologically suspicious for malignancy but sparse, precluding IHC or FCM (n = 63; 64%) or yielding inconclusive results (n = 35; 36%). The ROM in the SFM category, based on follow-up results of 61 cases, was 64%.

CONCLUSIONS

The ROM for SFM was significantly higher than that for AUS (P < .01), supporting separate diagnostic categories for these 2 groups.

Suspicious for Malignancy Diagnoses on Pleural Effusion Cytology

OBJECTIVES

A definitive diagnosis of malignancy may not be possible in pleural effusions. We report our experience with the diagnosis of suspicious for malignancy (SFM) in pleural effusion.

METHODS

A search for pleural effusions diagnosed as SFM (2008-2018) was performed. Patient records and pathology reports were reviewed. Specimens were subdivided into groups depending on volume (<75, 75-400, >400 mL). Diagnoses of malignant pleural effusion (MPE) served as controls.

RESULTS

We identified 90 patients, with a mean age of 60.6 years. Diagnoses included suspicious for involvement by carcinoma/adenocarcinoma in 64.4%, leukemia/lymphoma in 15.6%, melanoma in 2.2%, sarcoma in 3.3%, germ cell tumor in 1.1%, and not otherwise specified in 13.3%. Immunostains were performed in 47.8% and considered inconclusive in 24%. Average sample volume was 419 mL. There was a statistically significant difference between the SFM vs MPE groups for volumes greater than 75 mL (P = .001, χ 2 test), with SFM having increased proportion of volumes  greater than 400 mL, compared with the MPE group. There was no statistically significant difference in mean overall survival when the groups were compared (P = .49).

CONCLUSIONS

Samples with low cellularity, scant cell blocks, and inconclusive immunostains may contribute to a suspicious category diagnosis in pleural effusions.

Role of CD68 immunohistochemistry in categorizing benign nonmesothelial cell population and refining "atypical" category in serous fluid cytology

BACKGROUND

Body fluids are rich in histiocytes and may mimic atypical epithelial cells morphologically. Histiocytes can pose a significant challenge in serous fluid cytology as they tend to appear atypical due to prolonged accumulation in serous fluids in vivo and processing by liquid-based cytology in vitro. Not many studies have documented the utilization of histiocytic marker such as CD68 in serous fluid cytology, which can subsequently reduce the "atypical" diagnostic category.

METHODS

One thousand one hundred and twenty-nine cases of serous fluid cytology from 2016 to 2019 were reviewed and reclassified based on proposed classification of the international system for reporting serous fluid cytology. There were 133 cases with atypical diagnoses, out of which 51 cases had cellblocks. An immunohistochemistry (IHC) panel, including two mesothelial markers, two epithelial markers, and one histiocytic marker was applied to the atypical samples. Same IHC panel was utilized to evaluate 15 cases each from negative for malignancy (NFM), suspicious for malignancy (SFM), and malignant (MAL) categories for further comparison.

RESULTS

After reevaluation of the cytology material with IHC stains, 924 (82%), 133 (12%), 23 (2%), and 49 (4%) of the cases were reclassified as NFM, atypia of uncertain significance, SFM, and MAL, respectively. Twenty-five out of 51 atypical cases (49%) were downgraded to "benign" after reevaluation with CD68 IHC.

CONCLUSION

Histiocytes can mimic atypical epithelial cells in body fluids. Effective utilization of CD68 IHC will be beneficial in further refining the "atypical" diagnostic category in serous fluid cytology.

Current classification systems and standardized terminology in cytopathology

The history of classification systems and the search for a unified nomenclature in cytopathology spans several decades and expresses the preoccupation of all those involved to make cytopathology a reliable diagnostic tool and a trusted screening method. Early classification schemes, applicable to exfoliative and aspiration cytology, attempted to set some basic standards for how non-gynecological cytopathology findings should be reported. While useful in establishing some basic guidelines, these were not specific to the various fields of non-gynecologic cytopathology, often burdened with specific problems. Cytopathology has evolved tremendously in the last couple of decades, undoubtedly boosted by the emergence of various classification schemes that, more than ever, are based on evidence gathered by professionals across the globe. The benefit of classification systems and standardized nomenclature in cytopathology is to provide useful, clear, and clinically relevant information for clinicians and ultimately to provide the best patient care. Standardized reporting systems make cytopathology reports more meaningful and robust. It now became standard that these include by default elements, such as adequacy criteria, diagnostic groups, risk of malignancy (ROM), and recommendations for patient management. In this brief review, we attempted to summarize how these classification schemes emerged and how they are reshaping the landscape of diagnostic cytopathology.

The international system for reporting serous fluid cytopathology-diagnostic categories and clinical management

INTRODUCTION

Effusions can develop inside serous cavities in several pathologic states, both neoplastic and non-neoplastic. They are easy to drain and can provide useful diagnostic information. However, the reported diagnostic efficacy of these specimens has not been uniform across different laboratories. To standardize practices, the international system for reporting serous fluid cytology (TIS) was developed in accordance with the best international practices, the most up-to-date reported data, and expert consensus.

RESULTS

TIS has set the basic principles for laboratory handling of serous effusion specimens, defined the adequacy criteria, and set a standardized reporting terminology with well-defined criteria for each diagnostic category. These include nondiagnostic, negative for malignancy, atypia of undetermined significance, suspicious for malignancy, and malignant. Each can provide useful inherent information for appropriate clinical management and follow-up, with a defined expected diagnostic category incidence and risk of malignancy.

CONCLUSIONS

TIS applies to serous fluids collected from the pleura, peritoneal, and pericardial cavities. Using TIS, indeterminate categories are presented as either preliminary or as options of last resource. TIS has emphasized the role of ancillary tests in arriving at the correct interpretation within each category. It also has emphasized the importance of a malignant diagnosis as a definitive diagnosis, comparable to histologic examinations. Because of the well-documented outcomes in the adoption of uniform cytology terminology for other organ systems, we recommend the use of the upcoming TIS and believe its use will be paramount to improving the diagnostic yield in this area of cytology.

Cytohistological correlation in serous effusions using the newly proposed International System for Reporting Serous Fluid Cytopathology: Experience of an oncological center

BACKGROUND

Cytological analysis is part of the initial etiological evaluation of serous effusions. The newly proposed International System for Reporting Serous Fluid Cytopathology (ISRSFC) aims to standardize reporting.

METHODS

All pleural and peritoneal effusion samples admitted for cytological analysis at our institution between 2012 and 2016, and pericardial effusion samples admitted between 2008 and 2018, were reviewed and reclassified according to the ISRSFC. Risk of malignancy (ROM) and performance parameters were calculated.

RESULTS

1496 pleural effusion samples were reclassified: 12(0.8%) non-diagnostic (ND), 944(63.1%) negative for malignancy (NFM), 9(0.6%) atypia of undetermined significance (AUS), 54(3.6%) suspicious of malignancy (SFM) and 477(31.9%) malignant (M). 64 pericardial effusion samples were reclassified: 23(35.9%) NFM, 1(1.6%) AUS, 4(6.3%) SFM and 36(56.2%) M. 763 peritoneal effusion samples were reclassified: 5(0.7%) ND, 457(59.9%) NFM, 12(1.6%) AUS, 37(4.8%) SFM and 252(33%) M. The ROM was, respectively, for each of the aforementioned categories, 57.1%, 23.9%, 50%, 76.2%, 100% in pleural effusions, 100%, 26.3%, 62.5%, 91.7%, 100% in peritoneal effusions and 0% for NFM, 0% for AUS and 100% for M in pericardial effusions. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were, respectively, 61.6%, 100%, 100%, 73.3%, 81.3% for pleural, 100%, 100%, 100%, 100%, 100% for pericardial and 61.2%, 100%, 100%, 70%, 79.7% for peritoneal effusion samples.

CONCLUSION

Serous effusion cytology has a high specificity and positive predictive value and a modest sensitivity and negative predictive value, supporting its role in confirming the diagnosis of malignancy. The ISRSFC will increase standardization and reproducibility in reporting, leading to improved clinical decision-making.

Cytology Reporting System for Lung Cancer from the Japan Lung Cancer Society and Japanese Society of Clinical Cytology: An Interobserver Reproducibility Study and Risk of Malignancy Evaluation on Cytology Specimens

INTRODUCTION

The classification of lung carcinoma is based on small biopsies and/or cytology in 80% of patients with non-small cell carcinoma. However, there is no widely accepted classification system for respiratory cytology. The Japan Lung Cancer Society (JLCS) and Japanese Society of Clinical Cytology (JSCC) have proposed a new four-tiered cytology reporting system for lung carcinoma with the following categories: (1) "negative for malignancy," (2) "atypical cells," (3) "suspicious for malignancy," and (4) "malignancy."

OBJECTIVE

The aim of this work was to perform an interobserver reproducibility study to confirm the utility of the four-tiered reporting system on respiratory cytological samples.

METHODS

We analyzed 90 cytological samples obtained with bronchoscopy. Seven observers classified these cases into each category by reviewing one Papanicolaou-stained slide per case according to the three-, four-, and five-tiered reporting systems.

RESULTS

The interobserver agreement was fair in the three- (κ = 0.50), four- (κ = 0.45), and five-tiered (κ = 0.45) reporting systems. However, the four-tiered reporting system provided more precise information than the three-tiered reporting system in patient management. The risk of malignancy in the four-tiered reporting system was also stratified well: 19.3% for "negative for malignancy," 45.6% for "atypical cells," 74.7% for "suspicious for malignancy," and 88.1% for "malignancy."

CONCLUSIONS

The reporting system proposed by the JLCS and JSCC was designed to enhance the communication between clinicians and pathologists and among different institutions. It is simple and applicable to cytological diagnosis of any respiratory diseases. We propose establishing an international classification for respiratory cytology, harmonizing the reporting systems proposed by different countries.