Pleural and Pericardial fluids a one year analysis

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1 Pleural and Pericardial fluids a one year analysis Dr Olafsdottir Dr J Williams Department of Cytology, Llandough Hospital

2 Contents Background Standards Aims/Questions Investigation group Results Conclusions Further work

3 Background Pleural fluid cytology is a significant component of the annual workload in any cytology department. The primary question posed by the clinician when submitting pleural or pericardial fluid for cytological examination is that of: Is there malignancy, and if so what type is it?

4 Sample preparation Cytological specimens are processed and examined: Clot present - Removed upon receipt, fixed, and sent for histological processing. No clot - The decision for submitting a pellet to histology is made on a case by case basis. The clot can provide diagnostic information and act as a internal control for cytological interpretation. Mesothelioma vs reactive proliferation Primary vs Secondary neoplasm

5 Fluid received in cytology department Clot present Histology Centrifuged and a pellet formed X2 Giemsa s produced (if pellet big enough) If heavily blood stained, RBC s lysed Submitted to thin prep fluid

6 Standards How much fluid should be sent? Minimum of 25mls. If malignancy suspected 50 75ml. How many clots should be analysed? Variable If no clot - individual decision to centrifuge the fluid and form a pellet. If the case is straight forward a clot may not be processed.

7 Aims/Questions To analyse the quantity of fluid submitted for cytology. Quantity of malignant specimens, and the type of malignancy is present? What proportion of specimens have a clot analysed? Is there an acceptable correlation between the cytological interpretation and (any) subsequent clot histology?

8 Investigation group Analysis of one years worth of pleural and pericardial fluid cytology 1/6/07 30/6/08 Draft list from cytology telepath, subsequent analysis from clinical portal.

9 Results Pleural fluid

10 Initial data analysis Total number of pleural fluid specimens = 444 Total number of patients = 318 Number of specimens per patient:

11 Specimen categorisation Negative (NMCS) = 327 (73%) malignant cells seen = 65 (15%) suspicious = 40 (9%) atypical = 12 (3%)

12 Average specimen volume Negative: 37.6 ml (1 1500ml) Malignant: 76 ml (3 2000ml) Suspicious: 74.3 ml (8 1600) Atypical: 85.2 ml (17 600ml)

13 Analysis of the malignant specimen subgroup

14 Type of malignancy and histological clot confirmation Total patients Clot confirms diagnosis Clot refutes diagnosis No clot analysed Adenocarcinoma (66%) 2 (both mesothelioma) 10 Mesothelioma 5 5 (100%) Non small cell carcinoma 4 3 (75%) 1 Small cell carcinoma 5 3 (60%) 1 (Further FNAC +ve) 1 (Further biopsy +ve) Total (69%) 3 (6%) 12 (25%)

15 Lymphoma 6 patients had specimens described as suspicious for lymphoma : Clot analysed in all 6 Lymphoma confirmed in 3 NMCS in 3

16 Suspicious for malignancy 23 in total: Clot analysed in 18 (78%): Confirmed malignancy in 6 (33%) Adenocarcinoma 2 Mesothelioma 2 Primary lung cancer 1 Metastatic non small carcinoma 1 NMCS in 12 (66%) Subsequent biopsy:» Negative in 2» Mesothelioma in 2

17 Suspicious for malignancy No clot analysed in 5: Subsequent biopsy of squamous cell carcinoma (1) and mesothelioma (1) 3 no further follow up on clinical portal

18 Atypical specimens 10 in total: Clot analysed in 6 (60%) NMCS 3 Insufficient 1 Mesothelioma 1 Primary lung cancer 1 No clot analysis - 4

19 Results Pericardial Fluid

20 Pericardial Fluid 12 specimens from 11 patients 5/12 (42%) NMCS (average 29 ml/specimen) 5/12 (42%) malignant (average 61 ml/specimen) 3 adenocarcinoma, 1 non-small cell carcinoma, 1 metastatic breast cancer 1 suspicious clot primary lung neoplasm 1 atypical clot - adenocarcinoma

21 Conclusions Pleural fluid analysis forms a significant volume of the annual workload at the department. Pericardial fluid analysis is a much smaller quantity of work. There appears to be a greater volume of fluid (almost double) submitted for those specimens that are abnormal v s NMCS. The clinicians are aware of our requirements The volume of fluid is important 74% of patients have a single specimen submitted only More than one specimen may be sent for a number of reasons

22 Conclusions The vast majority of specimens (73%) are negative for malignancy. The most commonly diagnosed malignancy was adenocarcinoma (66%) Histological clot analysis was performed on 67/88 (76%) of all abnormal specimens. Not all specimens from a single patient will have clot analyses performed cost/laboratory work Material submitted may be to small a volume for clot analysis ICC may not work on the material

23 Conclusions There were no recognised missed diagnosis within the NMCS group There were no overcalls in the malignant group There were 2 instances of adenocarcinoma diagnosed on cytology, with subsequent mesothelioma diagnosed on histology.

24 Conclusions The suspicious and atypical group comprise a diverse group of eventual diagnosis. Clot analysis was performed on 73% of specimens - could this be improved?

25 Conclusions Cases are discussed at the lung cancer MDT, Offering an opportunity to highlight difficult cases - especially those in which a definite diagnosis is difficult to make. Liaison with clinicians and radiologists is essential in cancer diagnosis. Discussion may stimulate further work e.g. clot analysis for primary or secondary adenocarcinoma.

26 Previous work Examination of cytological smears and clot sections prepared from pleural fluids: a comparative study patients with effusions and clot No statistically significant difference, however recommended the use of clot sections.

27 Further work Compare our results to other similar audits carried out in this field (any here today?) Re-audit the rate of clot analysis (especially in suspicious and atypical subgroup).

28 Thankyou Dr Olafsdottir Teressa Russell All for listening!

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