# The International System for Reporting Serous Fluid Cytopathology

October 18, 2021## Information

October 14, 2021

Yale Pathology Grand Rounds

Ashish Chandra, MD, DNB FRCPath DirRCPath (Cytol)

ID7048

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- 00:09I think you should go ahead baby.
- 00:12Yeah, thank you. So thank you
- 00:14everybody and it's my great pleasure
- 00:17to introduce Dr Ashish can a gender
- 00:21I hope it's right pronunciation.
- 00:25Ajendra got a medical degree from
- 00:29University of Delhi in 1989 and got
- 00:33a FRCP diploma in Psychology in 1960
- 00:37and diploma in histopathology in 2000.
- 00:41He is a very active leader nationally
- 00:45and internationally in the field,
- 00:48both psychopathology and
- 00:51Europe urological pathology.
- 00:54He published 100 publication.
- 00:57I hope I'm right.
- 01:00182 publication and thank you
- 01:02and he is the deputy editor
- 01:05for very procedures anthology,
- 01:08journal Psychopathologie, he's.
- 01:10Executive Member of British
- 01:14Association of Psychopathology,
- 01:16and more importantly,
- 01:18he is the vice President of International
- 01:22Academy of Psychopathologie and
- 01:24its chairperson elect for British
- 01:28Association for Urological Pathology.
- 01:30He has participated in so many
- 01:34terminology inside pathology,
- 01:37including professor system for
- 01:39thyroid Paris system for urine.
- 01:42Menards system plan and and
- 01:46International Classification of zeros.
- 01:49I don't know what is next,
- 01:50but anyway, let's wait.
- 01:52So we are very fortunate to have
- 01:55a she's here to talk about the
- 01:58International classification
- 01:59of serious set of pathology.
- 02:01Thank you.
- 02:06Thank you so much Doctor Wang for
- 02:09that very kind introduction and
- 02:11thank you Doctor Prasad for inviting me
- 02:14to contribute to today's grand round.
- 02:16It is my great pleasure and privilege
- 02:18to be speaking to an audience at the
- 02:22prestigious Yale University and I would
- 02:24have loved to have been there in person.
- 02:27But of course you know times don't
- 02:29allow that. So as it happens,
- 02:31I'm attending a an executive board meeting of
- 02:34the British Association of Psychopathology.
- 02:36Today, not in London,
- 02:37but in Nottingham and so I'm
- 02:39sitting here from my hotel room,
- 02:42which is why it might.
- 02:43I might appear to be sitting
- 02:45in a dark room somewhere.
- 02:47But we've just finished a board
- 02:50meeting and I'm here at your
- 02:53disposal to introduce you to the.
- 02:55International system for reporting
- 02:58serious fluid psychopathology.
- 03:00So this was announced in active
- 03:03cytological in June 2019 and I'm very
- 03:06pleased to say that the book is now
- 03:10available both as an electronic book as
- 03:13well as in paperback through Springer.
- 03:17Who are the publishers?
- 03:19And if you do decide to buy the book
- 03:21please do buy it from Springer and not
- 03:24other websites which are more expensive.
- 03:26It is my duty to first acknowledge
- 03:30my Co editors, Dr.
- 03:32Barbara Crowther's,
- 03:33doctor Daniel Curtis and abroad
- 03:35Dr Fernando Schmidt who were the
- 03:39leading lights in bringing this this
- 03:42project together which is jointly
- 03:45sponsored by the American Society of
- 03:47Cyto Pathology and the International
- 03:50Academy of Psychology and I'm very,
- 03:52very much indebted to all the chapter
- 03:55authors who have contributed.
- 03:57To this book,
- 03:59during a particularly difficult time
- 04:01over the pandemic, and we were very,
- 04:05very fortunate to see it come to
- 04:08fruition and publication at the
- 04:10end of last chair.
- 04:12So what was the need for this project?
- 04:15You know, we when we thought about,
- 04:17you know,
- 04:18do we really need a terminology
- 04:20system for serious fluid cytology?
- 04:23We had to have a discussion I had
- 04:25to put forward a proposal to say,
- 04:27you know?
- 04:27What would be the point of doing
- 04:29this and what motivated me was
- 04:31the need for some answers to very
- 04:34practical clinical questions.
- 04:36The parish system had set a really
- 04:38good precedent to evaluation of
- 04:41adequacy criterion, fluid samples,
- 04:43urine in the case of the parish system
- 04:46and had linked it to volume and celularity,
- 04:49and to my mind there would was a link
- 04:52to fluid samples and adequacy taking
- 04:55into account both volume the cell content.
- 04:58And this in turn I thought would help
- 05:00us define what is a true negative
- 05:02sample for a particular patient.
- 05:04That is to say,
- 05:05if the cytology sample from
- 05:06a pleural fluid is negative,
- 05:09then it does in fact mean that
- 05:12the patient is free of metastatic
- 05:15disease to the pleural cavity.
- 05:17There was also the issue of the use
- 05:20of the existing terminology systems,
- 05:23which weren't internationally accepted,
- 05:25so everyone was doing their own thing.
- 05:29In particular,
- 05:30the tippy and suspicious categories
- 05:31showed a great degree of overlap
- 05:34in published literature,
- 05:35and I thought that the time had
- 05:37come to try
- 05:38and define a tipiya and suspicious.
- 05:41As you know, individual categories and define
- 05:44some criteria for putting cases into these.
- 05:47Categories I also thought that visiting
- 05:50revisiting the value of cytology in Miso,
- 05:53thi Lio Ma was very timely.
- 05:56Now, given that the diagnosis of mesothelioma
- 05:59rests on ancillary work up and fish,
- 06:03and although the gold standard
- 06:06still remains a biopsy,
- 06:08I do not contest that.
- 06:09But it is possible to reach a
- 06:12conclusive diagnosis of mesothelioma
- 06:13based on a psychology sample.
- 06:16And then there was this, really.
- 06:17Tricky question about peritoneal washings
- 06:20and how to report the presence of
- 06:23epithelial cells in these specimens.
- 06:25So there were a good number of reasons
- 06:28in the proposal and I was very,
- 06:29very pleased that both the American
- 06:32Society of Psychopathology and
- 06:34the International Academy thought
- 06:36this was a project worth doing.
- 06:38And So what does the system look like?
- 06:40Happily,
- 06:41it is a very familiar looking terminology
- 06:45system where you have the nondiagnostic.
- 06:47Category or and where you have the
- 06:51negative for malignancy category
- 06:53followed by atypia suspicious.
- 06:55Just like you have in Paris,
- 06:57Bethesda Thyroid and Milan terminologies.
- 07:00With the only difference being that
- 07:03the malignant category in fluid
- 07:05cytology is split into primary,
- 07:07which of course includes MISO.
- 07:09Thi Lio,
- 07:10Ma mainly and also secondary which
- 07:12includes metastatic cost numbers
- 07:14but also secondary involvement by
- 07:16hematopoietic neoplasms such as leukemia.
- 07:18And then foamers and hence the choice
- 07:21of secondary rather than meta static.
- 07:25So what are the factors involved in
- 07:28adequacy in serious fluid cytology samples?
- 07:30As I said, there's of course sample volume,
- 07:32but then there's also sell
- 07:35content and cellular preservation.
- 07:36So is there a recommended volume
- 07:39for serous fluid samples?
- 07:41Was the question that we wanted to answer,
- 07:43and for this there was already existing
- 07:46evidence that came from Doctor Ruper
- 07:49at all from Johns Hopkins who had
- 07:51demonstrated through a very large
- 07:53volume study of big sample size.
- 07:56That 75 male was probably an optimal
- 08:00volume for psychological assessment
- 08:02and exclusion or confirmation of
- 08:04milling malignancy between 50 and 75
- 08:07was probably an acceptible volume
- 08:10to request the clinicians to send
- 08:13for psychological evaluation in
- 08:15a couple of years time.
- 08:16They also published data to
- 08:18show that for pericardial fluid,
- 08:2060 mil was an acceptable volume,
- 08:23but that is not to say that smaller
- 08:25volume samples should be rejected.
- 08:27Perhaps you know everything does have
- 08:29have to be booked in and accessioned in
- 08:32the cytology laboratory and reported upon.
- 08:34But if the sample volume is very small
- 08:37and normal agency is demonstrated,
- 08:39then perhaps a comment is warranted
- 08:41to say that you know if the clinical
- 08:44suspicion of malignancy is high,
- 08:46then perhaps a 50 to 75 mil volume
- 08:49of sample should be sent.
- 08:52Also,
- 08:52on that point worth mentioning that
- 08:55aliquoting specimens for other
- 08:57investigations on serious fluid samples
- 09:00such as microbiology and biochemistry,
- 09:03should all be done at the same time.
- 09:06So when you collect the sample from the
- 09:08patient on the ward or in the clinic,
- 09:10split it up into sample to go to
- 09:12psychology and biochemistry and
- 09:14microbiology separately and not send
- 09:16it all to microbiology and expect
- 09:18them to then split it and send it to
- 09:21cytology and biochemistry because.
- 09:22That delay of course causes a
- 09:25deterioration in the quality of
- 09:27the sample for cytology and equally
- 09:30for microbiology or biochemistry.
- 09:32Cell content.
- 09:33Big question was do we have to see
- 09:36me that email cells in serous fluids
- 09:38in order to call them adequate?
- 09:41And the short answer to that is no,
- 09:44you don't because it is completely
- 09:46acceptable to find only lymphocytes,
- 09:48say in a tuberculosis or chylous effusion,
- 09:51or neutrophils,
- 09:52or in an empire from an acute
- 09:55bacterial infection,
- 09:56and you may have benign effusions
- 09:59without major female cells.
- 10:00So and conversely,
- 10:01also you could have malignancies
- 10:03where there's a single cell.
- 10:05Population of malignant cells only,
- 10:07without mesothelial cells,
- 10:08so it's nice to see me the serial
- 10:10cells because it does give you the
- 10:13confidence that the the plural or
- 10:15pericardial or peritoneal cavity
- 10:16has been sampled,
- 10:18but you do not pronounce the specimen
- 10:20as being non diagnostic simply because
- 10:22you don't see me as a theory of cells.
- 10:25Perhaps the most important feature,
- 10:28very much like FNA samples or samples
- 10:32fluid samples from other sides you know.
- 10:35You could have a very cellular specimen,
- 10:37but it is poorly preserved and it
- 10:39could still be non diagnostic and
- 10:41this could be because there's a
- 10:43loss of quality
- 10:44due to degenerative changes because
- 10:45of delays in reaching the laboratory.
- 10:48There could be bacterial overgrowth and of
- 10:51course technical artifacts and contaminants.
- 10:54So I'm going to walk you through the
- 10:57terminology system using six cases,
- 10:59one for each of the diagnostic categories,
- 11:01and then at the end.
- 11:02I'd be very pleased to take any questions
- 11:05during the time that we have a discussion,
- 11:07so let's start with the first case of 54
- 11:10year old man with a left sided pleural
- 11:12effusion is a smoker and suffers from
- 11:14cough and chest pain for one week.
- 11:17I will take a moment here to talk
- 11:19about the importance of macroscopic
- 11:21findings in serious effusion samples.
- 11:24Because this is frequently overlooked,
- 11:26as soon as we get the request form and
- 11:28the slides we read the clinical data
- 11:30and we start to look at the slide,
- 11:33perhaps without even turning the form
- 11:35over or scrolling down the screen to
- 11:37see what was the macroscopic appearance
- 11:39of this fluid or cytotechnology
- 11:41colleagues work very hard in the
- 11:43laboratory to record the volume and the
- 11:46physical appearances of old samples,
- 11:48in particular fluid samples,
- 11:50and their descriptions are important
- 11:52and clinically.
- 11:54Meaningful so you could have,
- 11:55you know a stroke alert fluid,
- 11:58which is probably just a a transit date.
- 12:00Or you could have apparent diffusion,
- 12:03which is almost certainly an exit date.
- 12:06You could have a heavily bloodstained fluid
- 12:09you could have Milky or chylous fluid,
- 12:12and all of these words have meanings
- 12:14and so it is important to look at the
- 12:18macroscopic appearance of the sample and
- 12:21also in the light of what I've just said.
- 12:24About the volume of sample to see
- 12:26if a sufficient sample was sent,
- 12:28because based on a small volume sample you
- 12:31may not get the full representative picture.
- 12:34The second point I want to mention
- 12:36on this slide again is the the fact
- 12:39that you should ideally examine
- 12:41a combination of a panda.
- 12:42Games are for serious fluid cytology samples,
- 12:45pretty much the same as you probably already
- 12:48do for FNA samples from various sites.
- 12:52So it doesn't matter.
- 12:53What the PAP stain is,
- 12:55whether it's on a direct spread or it's
- 12:57on a cytospin or it's a liquid based
- 13:01preparation such as either thin prep
- 13:03or show pad up app is a PAP and in
- 13:06the same way your romanowsky based dye
- 13:08orgainzer stain could either be a diff,
- 13:10quik or hemo color or main may Grunwald
- 13:13games are preparation so as long
- 13:15as you are using a combination of a
- 13:19romanowsky die and a PAP you should get
- 13:21the best information on that particular.
- 13:24Sample having said all of that,
- 13:26in this particular case, of course,
- 13:28you probably don't even need to put
- 13:29this slide under the microscope,
- 13:30because you can simply look at it,
- 13:32glance at it,
- 13:33hold it up to the light,
- 13:34and say there's not much there.
- 13:35It looks like there's probably just
- 13:37some lies.
- 13:37Red blood cells at the periphery
- 13:39of this thin prep,
- 13:41and there are no major fetal cells
- 13:43or macrophages or any other kind
- 13:46of cells to give you any confidence
- 13:48that this is a representative sample.
- 13:51It's probably just a traumatic aspirate.
- 13:54And therefore nondiagnostic,
- 13:55even on the games are,
- 13:57you will probably just see a red
- 14:00and white cells. Again.
- 14:01A point to mention at this step is
- 14:04that when you see the neutrophils and
- 14:07lymphocytes which are probably all
- 14:09just part of the peripheral blood.
- 14:11Don't call them inflammatory
- 14:13cells because that to a clinician
- 14:15breeds like oh so there is an
- 14:18inflammatory pathology in this sample.
- 14:19These are simply white blood
- 14:21cells from the peripheral blood.
- 14:22They're not indicative or a
- 14:24pathology in the pleura,
- 14:25so you know simply calling it blood
- 14:28and non diagnostic is adequate.
- 14:30Rather than listing all the white blood
- 14:32cells that you might be seeing on the sample.
- 14:35So of course the terminology systems
- 14:38are all about standardizing,
- 14:40uh, you know, reports,
- 14:42and so the structure of a report,
- 14:45whether it's Paris but Esther or Milan,
- 14:47follows a certain protocol,
- 14:49and so the sample report here
- 14:52should include an adequacy comment,
- 14:55a diagnostic category,
- 14:57and a clinical comment where appropriate.
- 15:00So in a case like the one I've
- 15:02just shown you,
- 15:03a sample report might read as follows
- 15:06evaluation limited by heavy blood staining,
- 15:08likely non representative sample
- 15:10and it is then assigned to the non
- 15:13diagnostic category in the international
- 15:15system and as a clinical comment you
- 15:18would be advising for repeat sample
- 15:20and stating in your report until your
- 15:23clinicians begin to get used to the
- 15:25idea that they really need to try
- 15:27and send 50 to 75 mil volume sample.
- 15:30And not just two or five mil of sample
- 15:33'cause they may not get their answer.
- 15:36So that was nondiagnostic
- 15:38moving on to case number two,
- 15:40and here's a clinical history of a 64 year
- 15:43old man with liver cirrhosis and ascites.
- 15:46We've got 60 mil or straw colored
- 15:48fluid and two sided spins have
- 15:50been prepared a PAP and a games.
- 15:53A combination as I said is ideal and here
- 15:56on this games of preparation you can see
- 15:59some beautiful basophilic mesothelial cells.
- 16:02You will appreciate their peripheral,
- 16:06Lacy borders.
- 16:07You could appreciate.
- 16:09Perhaps there are the gaps or windows
- 16:12between the mesothelial cells,
- 16:14the music penal cells show,
- 16:16or two tone staining
- 16:18pattern of the cytoplasm,
- 16:20their nuclei,
- 16:20or very much of the same size and
- 16:23shape without much pleomorphism,
- 16:26and they are infiltrated by these
- 16:29neutrophils and lymphocytes.
- 16:30So there is this interaction between the
- 16:33inflammatory cells and mesothelial cells.
- 16:36You can appreciate the same features.
- 16:37On the papanikolau cytospin,
- 16:40where again you are able to pay more
- 16:44attention to the nuclear detail,
- 16:47which is the strength of the PAP
- 16:48stain and you will see that the
- 16:51nuclei have very smooth margins.
- 16:52The nuclear membrane is very regular,
- 16:55the chromatin is finally dispersed
- 16:57with the presence of small multiple
- 16:59nuclei rather than a single
- 17:01large prominent nucleolus.
- 17:03And again, these groups are
- 17:06infiltrated by inflammatory cells.
- 17:08So no obvious signs of malignancy.
- 17:13The sample is certainly
- 17:14adequate for evaluation,
- 17:16and you saw some neutrophils,
- 17:18mesothelial cells, and lymphocytes,
- 17:20and so this will go into the
- 17:23negative for malignancy category.
- 17:25And given that there was a history of
- 17:27cirrhosis and ascites in this patient,
- 17:29you could put in a comment about the high
- 17:31proportion of neutrophils being present,
- 17:33which may represent spontaneous bacterial
- 17:36peritonitis and therefore correlation.
- 17:38With clinical and microbiological
- 17:40findings would be advised.
- 17:44So the negative for malignancy
- 17:47category you would expect to
- 17:49see normal or the expected cell
- 17:51populations in variable numbers,
- 17:53and these could be lymphocytes.
- 17:56Macrophages means a female cells,
- 17:58neutrophils and eosinophils.
- 18:01Doctor Evil Chick,
- 18:02who is one of the lead
- 18:03authors of the Paris system,
- 18:04was also the lead author for the
- 18:08negative for Malignancy Chapter
- 18:10and she created this awesome
- 18:14algorithm for effusions and once you
- 18:17separated out the inadequate ones,
- 18:20the remainder that are adequate
- 18:22could be just broadly divided into
- 18:25two main categories of those having
- 18:28the expected cellular findings.
- 18:30Uh, and so here you would just
- 18:33have variable numbers of the,
- 18:35you know,
- 18:36lymphocytes or mesothelial cells etc.
- 18:39And on the other hand you could
- 18:41have some unexpected cellular
- 18:42and non cellular findings if
- 18:45you have malignant cells.
- 18:47Obviously you've got a diagnosis and
- 18:48then you've got to do your ancillary
- 18:51work up to confirm the diagnosis.
- 18:53But you could also have some noncellular
- 18:55findings which do indicate a careful
- 18:58search in the background formula.
- 19:00And see because some of these
- 19:02non cellular findings may be
- 19:04associated with malignancy,
- 19:05but if you don't see malignancy
- 19:07you don't have to call the
- 19:09sample atypical or suspicious.
- 19:11You should still sign it out as negative.
- 19:13Having done a careful search to exclude
- 19:17malignancy and As for the reactive effusions,
- 19:21you could have different patterns
- 19:23based on the relative preponderance
- 19:25of a particular cell type.
- 19:27So whether it's eosinophilic
- 19:29or lymph ascitic.
- 19:30You would need to state you know
- 19:32what the possible causes of this
- 19:35cinephilic preponderance might be,
- 19:36whether there's been a recent
- 19:39pleural fluid aspiration,
- 19:40or whether there is an allergic
- 19:43condition in the patient.
- 19:44And likewise as I said earlier,
- 19:47for lymphocytic and neutrophilic effusions.
- 19:51So that's a negative for malignancy category,
- 19:55moving onto a third case.
- 19:56And here's the history of a 46
- 19:58year old female with a history
- 20:00of breast carcinoma six years
- 20:02ago and now presents with cough
- 20:04and a small pleural effusion.
- 20:05We've received 20 Miller stroke,
- 20:07bullet fluid and sitis pins have
- 20:11been prepared and on the side
- 20:14of spins at high magnification.
- 20:16This is times 20.
- 20:18You have a very cellular sample
- 20:20in the background you can see.
- 20:22Blood and you can see quite
- 20:23a few years cinefile,
- 20:24so it's possible that this is
- 20:27a repeat aspirate.
- 20:29In the center fielder,
- 20:31simply a reaction to the introduction
- 20:33of small amounts of air during
- 20:35the previous procedure and which
- 20:37irritates the pleura and insights
- 20:39in your cinephilic reaction.
- 20:41But what you also see are of course
- 20:43these means arterial cells with
- 20:45the gaps or windows between them,
- 20:47some of them showing by nucleation.
- 20:49Overall looking very,
- 20:50very bland indeed and then also some
- 20:53other cells which by their association
- 20:56with the same group of material
- 20:59cells are probably just degenerate.
- 21:01But they all showing micro valuation
- 21:03of the cytoplasm and and so you know
- 21:06there's some doubt in your mind given
- 21:08the history of breast carcinoma,
- 21:10should I really worry
- 21:11about these or can I write
- 21:13these off as degenerative
- 21:14changes in medial cells?
- 21:16And then you look at your thin prep PAP?
- 21:18And again you see this population
- 21:20of likely means arterial cells,
- 21:23but scattered within.
- 21:24These are also some cells which
- 21:26draw your attention because they
- 21:29have slightly prominent nucleoli.
- 21:31Although the nuclear chromatin overall
- 21:33is not cause and so you're not strongly
- 21:36suspicious that these are malignant,
- 21:38you believe that these amazing serial cells,
- 21:40but there is a clinical history
- 21:43that is making you pause and wonder
- 21:46whether you need to investigate the
- 21:49sample further through ancillary
- 21:51tests to exclude the possibility
- 21:53of small volume metastases from the
- 21:57known previous breast carcinoma,
- 21:59and so that is the sort of clinical.
- 22:01Scenario or setting for the use of
- 22:04the atypical category when you have
- 22:07occasional body preserved cells
- 22:08with some nuclear enlargement,
- 22:11subtle changes like hyperchromasia,
- 22:13but no obvious chromatin and
- 22:15nuclear membrane abnormalities.
- 22:18You believe that these are
- 22:19lightly degenerated macrophages,
- 22:20amazing theater cells and you're
- 22:23performing ancillary tests to exclude the
- 22:26possibility of metastatic cost Sonoma.
- 22:29So you do your epithelial markers
- 22:31and mesothelial markers.
- 22:33And you can then downgrade the
- 22:35sample to negative for malignancy.
- 22:37Once the epithelial markers
- 22:39are shown to be negative.
- 22:40So in this case you prepare a cell block
- 22:43and again all you see or miso thi lio cells,
- 22:45macrophages some fiber in a few
- 22:48lymphocytes and your epithelial
- 22:50markers come back negative and so
- 22:54the atypical category really is an
- 22:58uncommonly used category in effusions.
- 23:00Some experience title pathologists
- 23:02don't like to use it.
- 23:03At all,
- 23:04and in fact,
- 23:05one of the biggest questions for me for
- 23:07this particular terminology system was,
- 23:09could we simply just collapse the
- 23:11atypia and suspicious category
- 23:13into one and do away with it appear
- 23:15completely because they just didn't
- 23:17seem to be good diagnostic criteria
- 23:19in literature for a for a tipiya.
- 23:21However,
- 23:22before we embarked on the project
- 23:24and our literature search,
- 23:26we conducted a survey which was sent
- 23:29out by the University of Wisconsin
- 23:31doctor Dan Curtis's department.
- 23:33And we got about 600 respondents
- 23:35telling us that they would like us
- 23:38to include the tipiya category in
- 23:41the terminology system because they
- 23:42do use it and they have clinical
- 23:44circumstances in which they use it.
- 23:47And so for the time being,
- 23:48we decided to include it in
- 23:50the terminology system.
- 23:51But we're going to watch its progress
- 23:53and the performance of this category.
- 23:55What was becoming increasingly
- 23:57apparent from the survey was that
- 23:59in our minds we are following the
- 24:02two step process for the atypical.
- 24:04And suspicious cases where we were
- 24:06putting a case aside while we
- 24:09were doing the ancillary work up
- 24:11and some colleagues were actually
- 24:13issuing a preliminary report,
- 24:15which is of course optional and
- 24:17not mandated by the international
- 24:19system simply to give them the
- 24:23time to assess this sample.
- 24:25And in order to prevent, you know,
- 24:28clinical queries and emails,
- 24:30and you know where's the result to put
- 24:32something out there for the clinicians.
- 24:34To receive to say we're working on this case,
- 24:37there's something odd about it,
- 24:39and we need a little bit more time to come
- 24:43to a final conclusion about this case.
- 24:46And so the diagnostic algorithm
- 24:48for the atypical category really
- 24:51is that you you're you perform a
- 24:53preliminary assessment over tipiya,
- 24:55and then if your immuno chemistry
- 24:57demonstrates these atypical cells to
- 25:00be just macrophages or mesothelial
- 25:02cells you just downgrade that
- 25:04report to a negative for malignancy
- 25:06in a small number of cases.
- 25:07If the immuno chemistry demonstrates that
- 25:10the atypical cells are epithelial then you
- 25:13can upgrade your diagnosis too suspicious.
- 25:17Or malignant secondary.
- 25:18And then you would be left with a very
- 25:21small number of cases where there are
- 25:24insufficient representative cells or
- 25:26the you know chemistry is equivocal,
- 25:28and so you reduce the burden of the
- 25:31cases that you would sign out as that
- 25:34appear on serious fluid cytology.
- 25:37And so that is the kind of reasoning behind
- 25:40both the tibia and as I will show you,
- 25:44the suspicious category.
- 25:45In my next case,
- 25:47a 68 year old man with pleural
- 25:49fluid history of lung carcinoma,
- 25:5130 mil of blood tinged fluid is received.
- 25:54And here on the map you can appreciate
- 25:59that there are just two cells,
- 26:01but these two cells stand out
- 26:04in the background because they
- 26:06are much larger than the.
- 26:08Inflammatory cells,
- 26:09the UM, the macrophages,
- 26:12and the means of teal cells in the
- 26:14background on the games are again.
- 26:16You see that these nuclei, or quite large,
- 26:19irregular and again the cells are much,
- 26:21much louder than the surrounding
- 26:24lymphocytes and macrophages,
- 26:26and made me feel cells.
- 26:27So these three cells,
- 26:28or you know,
- 26:29on the PAP and on the games
- 26:31are or to an experienced I at
- 26:34least suspicious for malignancy.
- 26:36Depending on your experience.
- 26:38And expertise.
- 26:39Of course, you could say I'm
- 26:41pretty sure that's malignant.
- 26:42Uhm,
- 26:43you know,
- 26:44but I need to do my immunostains
- 26:46to be able to just confirm that
- 26:49these cells are indeed epithelial.
- 26:51Before I make a diagnosis of metastatic
- 26:54cost Sonoma in this particular patient.
- 26:57And so you were suspicious while
- 26:59you were appreciating just the uh,
- 27:01the cytological appearances.
- 27:03But you needed backup from
- 27:05your ancillary work up.
- 27:07To upgrade the diagnosis from
- 27:09suspicious to malignant,
- 27:11and so the suspicious scenarios in
- 27:13serous fluid cytology is where you
- 27:16have either small numbers of cases
- 27:18or groups with nuclear pleomorphism
- 27:20that require ancillary tests
- 27:22for confirmation of malignancy.
- 27:24Sometimes you may have cells with
- 27:28relatively bland appearances
- 27:29or mild plum Orphism.
- 27:31They may even be numerous,
- 27:33but they look very bland,
- 27:34or they may be simply in small.
- 27:37Numbers like we talked about in
- 27:39the case of breast or another
- 27:41scenario where you have music in
- 27:44the background but very few or
- 27:46no cells or very bland looking
- 27:48cells in ascitic fluid in say
- 27:50a pseudomyxoma pair tonight.
- 27:52But in the absence of cells you can't
- 27:54really make a diagnosis of malignancy,
- 27:56but you could certainly raise
- 27:58the suspicion of pseudomyxoma
- 28:01based simply on the museum scene,
- 28:04lymph ascitic effusions with
- 28:06the monotonous population.
- 28:07Again, would need a a an ancillary.
- 28:10Work up to confirm the diagnosis of lymphoma
- 28:12or exclude the diagnosis of lymphoma,
- 28:15and so again till you get the
- 28:16results of your ancillary work up.
- 28:18You could put that into the
- 28:22suspicious category provisionally.
- 28:23And so similar to the algorithm for
- 28:25atypia in the suspicious category.
- 28:27Again, we are basically worried
- 28:30about a small number of cells
- 28:33or preliminary assessment is.
- 28:36In the favor of malignancy rather
- 28:38than in favor of benign as
- 28:40opposed to the atypical category.
- 28:43And then once you do your immunostains
- 28:45you confirm malignancy and your final
- 28:47report would be malignant and so again
- 28:49you would be only left with a very
- 28:52small number of cases where there is
- 28:54insufficient material or the immuno
- 28:57chemistry is not supportive of the
- 28:59diagnosis where you would be left
- 29:02with a suspicious category as the
- 29:04final diagnosis and you could of course.
- 29:06Just request further sample
- 29:09to confirm the diagnosis.
- 29:11At this point I would just take a
- 29:13moment to talk about answer retesting
- 29:15of lung padmakar Sonoma in this case
- 29:17because in such a case you might
- 29:19be able to arrive at the diagnosis
- 29:21of metastatic lung carcinoma.
- 29:22A once you've done your TTF one immunostain,
- 29:25but you may not have sufficient
- 29:28material remaining for PDL 1 alpenrose,
- 29:30and for doing your next generation
- 29:33sequencing which may be needed
- 29:35for targeted chemotherapy.
- 29:36In this particular case,
- 29:37and so my plea to you is to restrict the.
- 29:41Amount of immuno chemistry.
- 29:43You perform in a posse,
- 29:46cellular samples or samples that have
- 29:48small numbers of malignant cells.
- 29:50Because you really want to try
- 29:52and conserve material as far as
- 29:55possible for molecular testing,
- 29:56it may still not be possible given
- 29:58on the small number of malignant
- 30:00cells in such a sample,
- 30:02but at least we should not exhaust all
- 30:05of our cells doing immuno chemistry.
- 30:08So just to summarize,
- 30:10the difference between the atypical.
- 30:11In suspicious categories in
- 30:13the international system,
- 30:15in the atypical category we have
- 30:18subtle psychological abnormalities
- 30:20where we think we're dealing
- 30:23with a benign cell type,
- 30:25but we can't completely or confidently
- 30:28exclude malignancy because there
- 30:31may be a clinical factor that
- 30:33is influencing us to exclude it.
- 30:35But you do expect in the vast
- 30:38majority of cases that the outcome
- 30:40would be benign and so the.
- 30:42Suggested risk of malignancy in this
- 30:44category is to the tune of 20%.
- 30:46This needs to be borne out by future data,
- 30:49but we would like to maintain a
- 30:51good degree of separation from the
- 30:53suspicious category with a sort of a 20.
- 30:5680 split for the suspicious category
- 30:58so that in in the suspicious category
- 31:01we really expect that the outcome will
- 31:05be usually be malignant because we
- 31:07favored an epithelial origin of the cells,
- 31:10but we just needed more of the same,
- 31:14so it's a quantitative factor
- 31:16in the suspicious category,
- 31:18whereas it could be a qualitative
- 31:20factor in the atypical category
- 31:22where the cells that you see
- 31:24simply do not fulfill the criteria.
- 31:27Or high grade malignancy and therefore
- 31:29you are being cautious and you know,
- 31:32erring on the side of caution
- 31:34and calling it a typical.
- 31:36Whereas in suspicious you're fairly
- 31:38confident that if you had another 10
- 31:40cells or if the ancillary work up proves
- 31:43these suspicious cells to be malignant,
- 31:46then you would be shown to be
- 31:49correct in your assessment.
- 31:51OK, moving on to the last two cases,
- 31:53then #5 is a 68 year old man with a
- 31:56history of exposure to asbestos and a
- 32:00unilateral hemorrhagic pleural effusion.
- 32:0280 mil of blood fluid with a clot.
- 32:05And again,
- 32:06I'm just going to take a moment
- 32:07to say that if there is a cloth
- 32:09present within the sample,
- 32:11the lab should really automatically
- 32:13process it because it's very likely
- 32:16that the cytospin's may not contain the
- 32:18material that it is trapped within the cloth.
- 32:21And so getting additional value
- 32:24from processing the cloth should
- 32:26almost be an automatic procedure,
- 32:29whereas if you there isn't a
- 32:31spontaneous clot and you want to
- 32:34perform additional ancillary work up,
- 32:36you could request a cell block from
- 32:39the sample whereby you're actually
- 32:41adding thrombin or other chemicals
- 32:43to the sample to precipitate a clot
- 32:46from which you can then cut sections
- 32:48and perform immuno chemistry.
- 32:51So of course you know.
- 32:52The history there,
- 32:53you know is a very directed one
- 32:56and it is about mesothelial cells.
- 32:58And here is this,
- 32:59you know,
- 33:00really happy looking miso thi deal
- 33:02cell that's bursting at the edges with
- 33:04you know it's this sort of Lacy skirt,
- 33:06like peripheral blips.
- 33:07It's got the sub membranous
- 33:10glycogen vacuoles.
- 33:10It's got the two tone staining
- 33:13of the cytoplasm.
- 33:14It's got a relatively bland looking
- 33:16nucleus which is showing a relatively
- 33:19low nucleocytoplasmic ratio.
- 33:21You know, there there.
- 33:23Chromatin and the nuclear membrane,
- 33:25or look relatively smooth,
- 33:26but by looking at it you can't
- 33:28always tell whether this means
- 33:30ethereal cell is benign or malignant,
- 33:32and that is the challenge of
- 33:35mesothelial proliferations.
- 33:36Of course,
- 33:38there are features like hypercellularity,
- 33:41and you know if you have presence
- 33:44of significant pleomorphism abnormal
- 33:46mitotic figures in mesothelial cells,
- 33:49then of course you could suspect me
- 33:51the thielemier straight away based on.
- 33:52Morphology,
- 33:53but usually it is quite difficult
- 33:56because the morphology of medial
- 33:58cells can be very very bland even
- 34:01in neoplastic proliferations,
- 34:03but they also tend to be relatively
- 34:07monomorphic from one cell to the
- 34:10next from 1 nucleus to the next,
- 34:13and from one group to the next.
- 34:14The groups are typically very equal sized,
- 34:17unlike in adenocarcinomas,
- 34:19and of course at high magnification
- 34:22they will still.
- 34:23Then the properties of mesothelial cells,
- 34:25which are the gaps or windows
- 34:27between the cells,
- 34:28the clasping feature of mesothelial cells.
- 34:32They may begin to show very
- 34:34prominent single cherry,
- 34:35red large nucleoli which would
- 34:38alert you to the possibility
- 34:40of mesothelioma. But you are going
- 34:43to need your ancillary work up
- 34:45to confirm the diagnosis on say,
- 34:48a cell block and again you can
- 34:50appreciate all of those features
- 34:51of major female cells in this.
- 34:53Cell block here and so this is
- 34:55really the the panel that will help
- 34:58you arrive at the conclusion about
- 35:00what the nature of this means.
- 35:02Ethereal proliferation is.
- 35:03Is it just reactive and therefore
- 35:06to be put in the negative
- 35:08for malignancy category and.
- 35:10For this, uh,
- 35:11this is a suggested and commonly used panel.
- 35:15Immuno chemistry certainly in Europe
- 35:17and other parts of the world.
- 35:19Desmin is very frequently used thinking
- 35:22it is quite variably used in the states,
- 35:25but we certainly find it very
- 35:27valuable because Desmond retains its
- 35:30cytoplasmic positivity in reactive
- 35:32mesothelial cells and it is lost in
- 35:35a high proportion of mesotheliomas
- 35:37epithelial membrane antigen shows a dense,
- 35:41very thick membranous staining
- 35:44in mesothelioma.
- 35:46Which is not seen in mesothelial
- 35:48reactive medial cells,
- 35:50and it will show a diffuse cytoplasmic
- 35:53staining in adenocarcinoma.
- 35:54So it you know this is one stain
- 35:56that can help you distinguish
- 35:57between reactive means.
- 35:59Arterial cells, miso, thi Lio,
- 36:00Mars and adenocarcinomas,
- 36:01but of course we are now in
- 36:04the day and age of BAP.
- 36:05One bracket associated protein one,
- 36:09the loss of which is associated with
- 36:11a very high proportion of medium.
- 36:13As you know 80 to 90% of me is a theomars.
- 36:16Will show a loss of nuclear
- 36:18staining with BAP one which will
- 36:21be retained in a reactive measure.
- 36:23Theal cells and also interestingly
- 36:26in lung adenocarcinomas.
- 36:27So if BAP one is included in
- 36:30your panel and it is positive,
- 36:32it's almost certainly not miso,
- 36:34thi Lio Ma and your panel here could
- 36:36then help you distinguish between an
- 36:39adenocarcinoma and mesothelioma and
- 36:41back one is quite helpful in that regard,
- 36:44but of course you know ancillary.
- 36:46Testings using fish or mtap and
- 36:50P16 deletions are the ones which
- 36:53you know will clinch the diagnosis
- 36:56in the equivocal cases,
- 36:58and so this is the panel which I
- 37:01would recommend and is recommended in
- 37:04the international system for sorting
- 37:06out your mesothelial proliferations.
- 37:09I won't read out this slide to
- 37:11you of ancillary tests,
- 37:13but just to say that a good
- 37:15place to start if you have.
- 37:17A differential diagnosis of
- 37:19amazing theal proliferation versus
- 37:21carcinoma used to good miso,
- 37:25thi lio and epithelial marker,
- 37:26and a macrophage marker user panel
- 37:29that works well in your laboratory.
- 37:31Historically,
- 37:31if it's worked well for you know years
- 37:34and years and there's no reason to
- 37:37think of switching to something else.
- 37:39But bear in mind that there are some
- 37:41very good adenocarcinomas that are
- 37:43coming up all the time and perhaps one
- 37:45of these could replace some of the.
- 37:47Older ones that you may have
- 37:48been using in the laboratory.
- 37:50I'll come to the site specific markers later,
- 37:52but also to alert you to the
- 37:54fact that there can be an overlap
- 37:57with certain immunostains like
- 37:59WT1 GATA 3 which can overlap between
- 38:03carcinomas and mesothelial proliferation.
- 38:05So you do need to be aware
- 38:08of published literature,
- 38:08and of course the importance of clinical
- 38:12correlation and every single case.
- 38:14But by and large you could
- 38:16perform answer retests.
- 38:17To resolve the dilemma between Mesothelial
- 38:20proliferations and metastatic carcinoma.
- 38:22So a sample report for a MISO thi live
- 38:25proliferation in the international
- 38:26system would read something like
- 38:28this satisfactory for evaluation,
- 38:30you would give a brief description
- 38:32of the cellular findings,
- 38:34the fact that immunostains have
- 38:35been requested for confirmation
- 38:37either on the cell block.
- 38:38Of course, if there is an accompanying
- 38:40biopsy in the same department,
- 38:42there probably is no need to replicate.
- 38:45The same immunol work up on two different.
- 38:48Uh, you know specimens and you could
- 38:51just do them on either one of those two,
- 38:54and then if the immunostains
- 38:56are confirmatory,
- 38:57you can have a final diagnosis
- 39:00of malignant primary,
- 39:02which is means a theory OMA.
- 39:03And of course always always advise
- 39:06clinical correlation because.
- 39:08Radial radiological appearance is
- 39:10and the biopsy confirmation of
- 39:13invasive mesothelioma is still
- 39:14the gold standard for diagnosis,
- 39:17but it can be achieved with cytology with
- 39:21a confirmatory panel of immunostains.
- 39:24Anything that falls short of this
- 39:26mark should be called either
- 39:28suspicious or just left at a typical.
- 39:30So if you've got,
- 39:31you know some classic morphological features,
- 39:33but the immunostains are not confirm
- 39:36atory step back and advise biopsy.
- 39:39Advised correlation with clinical and
- 39:41radiological findings discussed at the
- 39:44clinical meetings or multidisciplinary
- 39:46meetings as we call them here in the UK.
- 39:49And of course,
- 39:50if the morphology is not classic
- 39:53and the immunostains are not
- 39:55confirm atory either then you stop
- 39:57at a typical musical proliferation
- 40:00and advise further investigation.
- 40:02So,
- 40:03uhm.
- 40:04A recognizable abnormal cell
- 40:07population should be present and
- 40:10adequate for a robust diagnosis on
- 40:13which clinical management may be
- 40:15based in the malignant categories.
- 40:18The cell types should be specified
- 40:20either on morphology alone or
- 40:22supported by immuno chemistry and
- 40:24which would allow you to reach a
- 40:27final diagnosis by the mesothelioma or
- 40:29metastatic cost. Sonoma lymphoma etc.
- 40:31And of course you would need to
- 40:33do some primary.
- 40:34Organ site investigation in terms
- 40:37of adenocarcinomas, which is,
- 40:39you know,
- 40:40not something that you can do for
- 40:42melanomas or small cell carcinoma
- 40:46or squamous customers.
- 40:48So final case then discussions case
- 40:50number 6 the 45 year old female with ascites,
- 40:5435 mil of bloodstained fluid and
- 40:57of course you know I'm sure this
- 40:59is a spot diagnosis.
- 41:01For those of you with experience in.
- 41:04Cyto pathology we have got large three
- 41:09dimensional variable sized cohesive
- 41:11clusters of the malignant epithelioid cells,
- 41:16displaying course abundant
- 41:19cytoplasmic vacuolation nuclear
- 41:22hyperchromasia irregularity,
- 41:23high NC ratio,
- 41:26and variation of the nucleus size
- 41:28and shape from one group and
- 41:30one nucleus to the next,
- 41:31which is not a feature of
- 41:33mesothelioma as I said.
- 41:34Earlier.
- 41:35And again on the games are you
- 41:37have the same features the large
- 41:40groups tightly cohesive,
- 41:42no gaps or windows,
- 41:44unlike me, they feel proliferations,
- 41:47and these may be infiltrated by
- 41:49lymphocytes and and neutrophils.
- 41:52But then. In the background,
- 41:55you still have some uh lymphocytes,
- 42:00A4 size comparison. Once you do,
- 42:03your cell block or your plot section,
- 42:04you will be able to appreciate the
- 42:07microarchitecture of these groups as
- 42:09well with little glandular formations.
- 42:10Or perhaps some signet ring cells.
- 42:13And once you do your TTF one
- 42:15stain and it comes back positive,
- 42:18you have confirmation of metastatic cost
- 42:21Sonoma adenocarcinoma from the lung.
- 42:24And so this isn't an ever growing
- 42:27list of site specific markers.
- 42:32And you know,
- 42:33this is again constantly renewed and updated
- 42:36as some of the older markers become.
- 42:39You know less favorable because
- 42:41there are increasing numbers of
- 42:43studies that show that they're not
- 42:45particularly specific to those sites,
- 42:46and as new emerging markers turn up,
- 42:50but this is a sort of a rough guide
- 42:53to ascertaining the primaries
- 42:55with adenocarcinomas,
- 42:55and so a sample report for such a case is,
- 43:00again as follows.
- 43:01You gave your description.
- 43:02You assign it to the
- 43:04malignant secondary category,
- 43:05and then you perform your immunostains
- 43:08to ascertain the primary site.
- 43:10So my last couple of slides,
- 43:11diagnostic categories linking to
- 43:13clinical management once on the
- 43:16routine preparations and stains you
- 43:18make final call of nondiagnostic.
- 43:21Then of course you would ask
- 43:23for a repeat sample,
- 43:24ideally 50 to 75 mil if it is a
- 43:28negative for malignancy sample then the
- 43:31patient might be discharged or simply.
- 43:33Clinically followed up if it is in the
- 43:36Gray zone of a tipiya and suspicious,
- 43:38you need your ancillary work up and
- 43:41correlation with biopsy and clinical
- 43:43data to try and push as many of
- 43:45the atypical into negative and as
- 43:48many of suspicious into malignant.
- 43:49Of course,
- 43:50for the malignant category you would
- 43:52be performing ancillary testing,
- 43:54not necessarily to confirm malignancy,
- 43:57but to establish the primary site
- 44:00of origin and also prognostic
- 44:02and predictive markers.
- 44:04Just as the you know,
- 44:06manuscript last year was
- 44:07about to go to the publishers,
- 44:09I came across this a great article by
- 44:12Doctor Farahani and Doctor Bellotte
- 44:15in diagnostic psychopathology,
- 44:16the journal and they looked at the
- 44:19historic data before the publication of
- 44:22the Serious of Fluids Phytopathology book,
- 44:25of course,
- 44:26which looked at the risk of
- 44:29malignancy across the different
- 44:31diagnostic categories as reported.
- 44:34In literature Pre TS and what was
- 44:37noticeable was how high the risk
- 44:41of malignancy was in the atypical
- 44:44category and that is probably
- 44:46because there is a big overlap
- 44:49between the atypical and suspicious
- 44:51categories and with the application
- 44:54of appropriate criteria.
- 44:55Perhaps the risk of malignancy in
- 44:57this category will move closer
- 44:59to that of the negative and that
- 45:01or the suspicious category would
- 45:03move closer to malignancy.
- 45:05And this separation of the risk of
- 45:08malignancy between the different
- 45:10categories is the basis for the
- 45:13justification of any reporting
- 45:15terminology system, be it the faster Milan,
- 45:17Paris or the international systems and.
- 45:20And so this really is the data that I
- 45:23would be hoping that you will be
- 45:26collecting through auditing your cases
- 45:29prospectively and retrospectively to
- 45:31see you know before and after that.
- 45:35Number of cases and the risk of
- 45:38malignancy that you put into the
- 45:40uh into into the reporting system.
- 45:43So with that I thank you.
- 45:45I am going to stop sharing my screen
- 45:48and I am available to take any.
- 45:52Questions or comments from the audience?
- 45:54Thank you so much.
- 45:55Thank you so much Ashish is.
- 45:58Wonderful, I really like it.
- 46:00It's many, many questions in
- 46:02my mind has been addressed,
- 46:04so while the people are preparing their
- 46:07question so maybe I can ask you too.
- 46:09Small question. Actually one of them.
- 46:12It's related to your last page,
- 46:15so the the risk of malignancy.
- 46:19The risk of malignancy in
- 46:21negative for malignancy category.
- 46:23According to my manager Palaj if about 20%.
- 46:30Well, he was 20% meaning if
- 46:33we say negative malignancy,
- 46:35one in every five we are wrong.
- 46:38So what in your mind, this, uh,
- 46:40for this negative mallegni should be?
- 46:43Absolutely, that that's a great question.
- 46:45Peter and I think what we have looked
- 46:48at in that table is the historic data
- 46:52of how we have over the last 50 years,
- 46:56reported serious fluid cyto pathology and
- 46:59what the clinical outcomes of these cases
- 47:02have been if we but we don't know what
- 47:05the sample volumes of these cases were,
- 47:08we don't know whether they would have
- 47:11fulfilled the the sort of site, the.
- 47:15The criteria for good cellular
- 47:19preservation and celularity,
- 47:21as suggested by the international
- 47:22system so we don't have that
- 47:25data in this reported literature,
- 47:27and that I hope, will be the strength
- 47:29of the system going forward.
- 47:30Once we link this risk of malignancy
- 47:34to volume and to sell content,
- 47:36we might have a clearer picture to
- 47:38be able to say to our clinicians.
- 47:39Well, if you send us a 5 mil sample,
- 47:42the risk of malignancy could be considerably.
- 47:45Different to when you send
- 47:46us a 50 to 75 mill sample,
- 47:48but the problem there is of course that,
- 47:51uh, the follow up of patients with
- 47:54negative cytology is typically very
- 47:56difficult across all terminology systems.
- 47:59Whether it's urine,
- 48:01cytology or FNA,
- 48:02cytology the patients who have any fusion
- 48:05that resolves do not have any Histology,
- 48:08may not have much clinical follow up,
- 48:10and so you're left with this kind
- 48:12of no follow up of these cases.
- 48:15Or this kind of imagined follow up
- 48:16that we show that they were all
- 48:18right because they didn't come back
- 48:20to us with malignancy in the next.
- 48:22You know, two or three years,
- 48:23so we need to agree to certain
- 48:26surrogate markers and goal posts
- 48:27and we don't know what those are in
- 48:30terms of the negative categories.
- 48:32So that's a great question in terms
- 48:34of calculating the sensitivity
- 48:36and the negative predictive value
- 48:38over serious fluid sample.
- 48:40We don't really have great data,
- 48:42but I suspect it would be linked to volume.
- 48:45And a sample quality.
- 48:47Thank you for a great question,
- 48:48Peter,
- 48:49thank you. Thank you so much.
- 48:51Uh, another question from my end.
- 48:55Is that special staying for P16 so.
- 48:59P-16 you agree with a fish analysis
- 49:03kind of fish usually is pretty
- 49:06challenging for cytology sample
- 49:09and many people like immunostains.
- 49:12And I see this debating like animal Stampede.
- 49:1616 How you know how useful?
- 49:18How placable was your position here?
- 49:22So thank you. Another great question.
- 49:24Very very specialist and technical.
- 49:29I have to say the published data really
- 49:33mostly supports using P-16 mutation,
- 49:39you know, so we're not talking
- 49:41about the wild type P-16.
- 49:42We're talking about the mutated
- 49:44P-16 demonstrated by fish.
- 49:46So if you're using the appropriate
- 49:49immuno chemistry, of course not.
- 49:50For the wild type P-16,
- 49:52but for for the mutated one you
- 49:56should get you know good data.
- 49:59And I think that is something that
- 50:01we want to see more work done on
- 50:04before it can be accepted as a
- 50:07recommended clinical practice.
- 50:08You're absolutely right,
- 50:09there is a growing body of evidence
- 50:12and data that is suggesting that we
- 50:14could perhaps just do immuno chemistry
- 50:16rather than fish and that would solve
- 50:18a big problem because as you say,
- 50:20access to cytogenetics and fish
- 50:23is not easy for all laboratories.
- 50:26You know we're lucky to work in
- 50:28institutions where we do have.
- 50:30As to genetics and ancillary tests,
- 50:32uh, but you know,
- 50:34we these international terminology
- 50:36systems are meant to be used by the
- 50:40global psychopathology community,
- 50:41and if we set our benchmark,
- 50:43which is unachievable,
- 50:44then the project sort of loses its
- 50:46value because we've set the bar so
- 50:48high that it is completely unachievable by,
- 50:51you know,
- 50:51by the vast majority of our
- 50:54colleagues practicing cyto pathology.
- 50:56So I think we do have to be realistic,
- 50:58I think.
- 51:00Using that and that's why I emphasized
- 51:03so much the use of you know commonly
- 51:06used immunochemical immuno histo and
- 51:09cytochemical panels that include
- 51:12desmin and epithelial membrane antigen
- 51:14and bap one which it is easier for a
- 51:18smaller psychopathology laboratory
- 51:20to standardize and validate and
- 51:23be able to perform reproducibly
- 51:25and accurately within their own
- 51:27laboratory or at least have access.
- 51:30To the immunostains,
- 51:31but I know there are parts of the
- 51:33world where, uh,
- 51:34the diagnosis of MISO?
- 51:35Thi Lio Ma actually is just based on
- 51:38cyto morphology and perhaps some immuno
- 51:41cytochemical stains like oil red O
- 51:43positive iti in in in in mesothelioma.
- 51:46And that was a great point that
- 51:49Professor Claire Michael who's the
- 51:50lead chapter also for me the helium
- 51:52appointed out and she said you
- 51:54know we should try and find good
- 51:57cheap and easy stains for you know,
- 52:00mesothelioma.
- 52:00Because not everybody will have
- 52:03access to cytogenetics and to even
- 52:06immuno chemistry and to you know some
- 52:09colleagues practicing in constrained
- 52:12resources just histochemistry with
- 52:14oil red O and some other immunity
- 52:16and some other stains could be very
- 52:19very beneficial in the context of
- 52:21a good strong clinical suspicion
- 52:23of a mesothelioma for instance.
- 52:25So thank you for bringing up
- 52:27that very pertinent question.
- 52:29Thank you, thank you thank
- 52:30I have a question. Copying.
- 52:37OK, can you hear me now?
- 52:39Yeah yeah OK alright
- 52:44thanks for your great this great talk so.
- 52:49So based on this you know that international
- 52:53reporting systems and since we know,
- 52:57recommend the volume of the
- 53:00specimen is you know 75.
- 53:05Uh CC, which is you know,
- 53:07largely based on the.
- 53:10The Hopkins study recommended.
- 53:13But there's other study out
- 53:15there in the literatures.
- 53:16They actually recommend larger variance,
- 53:19you know, talk about 200 or 250 miles,
- 53:23and you know in in the age now is
- 53:28proficient precision medicines.
- 53:31You know a lot this specimen.
- 53:32Not only you know,
- 53:34Rick required health diagnostic work
- 53:37up also for the answering tests which
- 53:40may guide clinical management patient.
- 53:43So I just wonder,
- 53:44you know for this kind of system out there,
- 53:47you kind of flat out recommended you
- 53:50know 75 mil specimen weather you know.
- 53:55You know whether you're consider
- 53:57you know whether this you know,
- 54:00particularly in the setting of the,
- 54:02you know malignancy and weather,
- 54:05has any room.
- 54:06You know I, because the the the the one.
- 54:11The issue would be,
- 54:12you know clinical thing and look at
- 54:15the old you are you even you are
- 54:17report you are sitting recommended
- 54:19only 75 and mail you know specimen.
- 54:22So that's one one of my question.
- 54:24The other question I had.
- 54:26One day I notice,
- 54:27you know,
- 54:27in this system you don't have a
- 54:30category you know call for new problem,
- 54:33which many other system has this category
- 54:36robust sister you know Milan and you know,
- 54:40PSC, you know,
- 54:41and because particularly you talk about
- 54:44one the sample you you talk about in your,
- 54:48you know presentation is.
- 54:50You know pseudo makes Soma,
- 54:53which you know you ****.
- 54:56Basically you see them using or
- 54:59missing like material without without,
- 55:01you know,
- 55:02without absolute component you put in the
- 55:05category called suspicious for malignancy.
- 55:07The same issue will be also raised
- 55:11for like a borderline tumors and
- 55:13which also shows this kind of you
- 55:17know sales or material in your.
- 55:21Uh, and aside, is opera Tonio you know,
- 55:23public watch specimen?
- 55:25So, because this particular category
- 55:27is switched from Milligan and carry,
- 55:29the risk is about 80%,
- 55:32so I don't know how this will
- 55:34have any clinical impact.
- 55:35How you do on clinic,
- 55:37because basically there's no surgical
- 55:39diagnosis clad out malignancy,
- 55:41but you called speech for Magnus.
- 55:44Thank you.
- 55:45Yeah,
- 55:46great questions.
- 55:46I'll try and be brief in the
- 55:48interest of time, but I acknowledge.
- 55:50The limitations of the data that we
- 55:54have at the moment at the time of
- 55:58publication of the first edition,
- 55:59but what it has done is opened up
- 56:02this conversation that we're having
- 56:05today and which is what I was
- 56:08asked at the European Congress of
- 56:10Psychology in in Poland just last
- 56:12week where we had a whole session
- 56:15devoted to a tipiya versus NEO
- 56:17plasm in serious effusion cytology.
- 56:19Well seriously, in.
- 56:20All specimen doubts,
- 56:21but also addressing serious fluids,
- 56:24and that's a great question about
- 56:26taking your second question first,
- 56:27and I'll go back to the first
- 56:29time in a moment.
- 56:31So the new plasm category for fluids
- 56:34is is quite a tricky one to use.
- 56:37It will be very rarely used and
- 56:39in the kind of scenarios where
- 56:41you pointed out you know you've
- 56:42got mucinous material and you
- 56:44know it could be a NEO plasm,
- 56:46which may or may not be malignant,
- 56:47and so you know should that
- 56:49go into the tipiya category.
- 56:51Should that go into suspicious category,
- 56:52should that be in a NEO plasm category,
- 56:55I think at the moment what
- 56:57we are suggesting is that we
- 56:59put the query new plasm.
- 57:01The bland neoplasms including the
- 57:03borderline tumors into the atropia of
- 57:06undetermined significance category.
- 57:08So that is your sort of surrogate
- 57:11new plasm category for the moment.
- 57:13Let's see by the time of the second edition,
- 57:16in four or five years,
- 57:17if there is enough data out there
- 57:20to justify having an additional
- 57:23NEO plasm category.
- 57:25In addition to ATYPIA,
- 57:26we would be very much prepared to
- 57:28consider it. So that is a great question.
- 57:31But it wasn't something that we
- 57:34had enough data on to be able
- 57:36to address in the first issue.
- 57:38In the first edition,
- 57:39and so we have actually just put them
- 57:42or suggest that we put those under tipiya,
- 57:44but the discussion that we had in
- 57:47Poland was that a tip here actually
- 57:49includes the kind of cases which
- 57:52probably sit better in a NEO plasm category.
- 57:55Also, for instance,
- 57:57benign music Thielen preparations,
- 57:58though well differentiated papillary miso?
- 58:01Thi lio ma.
- 58:02Or the localized musically OMERS,
- 58:04which are essentially benign tumors?
- 58:06Should they all be called miso?
- 58:08Thi Lio Ma's,
- 58:09where do you know a typical or benign
- 58:12mesothelial proliferations go in the system,
- 58:15so those were all questions
- 58:17that are now being raised,
- 58:18and we hope that we will have
- 58:21more data in in the next few
- 58:24years to be able to answer that.
- 58:26Going back to your first question in
- 58:28terms of volumes of recommended sample.
- 58:31Again at the time of publication,
- 58:33we had a good study which you know
- 58:35was based on a very large sample size,
- 58:38and so we've gone with it.
- 58:40And since the publication of
- 58:42the international system,
- 58:43and even while it was in publication,
- 58:45there was a whole flurry of
- 58:48articles that suggested different
- 58:49volumes, some smaller volumes
- 58:51and some higher volumes,
- 58:52which in their institutional data was.
- 58:56A better marker for the sub you
- 58:59know for for the optimal volume,
- 59:01and I think there will be an institutional
- 59:04bias depending on whether you work in
- 59:07a Cancer Center or whether you work
- 59:09in a Community Hospital because your
- 59:11caseload is completely different.
- 59:14You're you know the sample volumes
- 59:16that you might get in a Cancer
- 59:18Center may be small volume samples,
- 59:21but they're all almost positive samples,
- 59:23so you know that they're not being
- 59:25sent to you for making a diagnosis.
- 59:27You already know the diagnosis they're
- 59:29actually sending you the sample just
- 59:31for the ancillary World Cup and as long
- 59:33as the sample is high in cell content,
- 59:35it doesn't matter whether it is 50
- 59:37mil or it's 75 mil or it's 200 mil.
- 59:40So the 75 mil optimal volume sample
- 59:43was really based on that curve which
- 59:46showed that once you have reached
- 59:49the 50 to 75 mil mark after that,
- 59:52there is no particular advantage
- 59:54because if the sample is negative.
- 59:57It is probably going to be negative,
- 59:58even if it's 200 mill.
- 60:00That is where you know that data came from,
- 01:00:03but the converse is also true.
- 01:00:05You might, you know,
- 01:00:08have a sample that's really really
- 01:00:10cellular and rich in malignant cells,
- 01:00:12for which you could get away with
- 01:00:14a much smaller sample.
- 01:00:15So I think the it's opened up
- 01:00:18a conversation around volumes
- 01:00:19around cell content,
- 01:00:21and I think there is quite a lot of work to
- 01:00:24be done before the 2nd edition comes out,
- 01:00:26but they're all.
- 01:00:27Things that I'm taking on board
- 01:00:28from our discussion today.
- 01:00:30So thank you very,
- 01:00:31very much.
- 01:00:32Thank you, thank you,
- 01:00:34uh, any more questions.
- 01:00:38So send I think Doctor Lu will
- 01:00:40have a separate zoom meeting, yes.
- 01:00:45So thank you so much, Ashish.
- 01:00:46So it's very nice to meet you and like
- 01:00:49you say we have so many discussions.
- 01:00:52Kind of good discussion and we're
- 01:00:54looking forward to your second edition.
- 01:00:57Thank you so much.
- 01:00:58Thank you very much.
- 01:00:59It's been a great honor and
- 01:01:01privilege to be able to talk
- 01:01:02to you this afternoon.
- 01:01:03Many Many thanks again for inviting me.
- 01:01:06Thank you, thank you.