Have you seen tumor cells in ascites routine?

foreword

foreword

Routine specimens of the serous cavity can be accessed by the laboratory almost every day.
The routine examination of these specimens not only includes routine physical examinations, such as specimen color, transparency, clot, pH, etc.
, as well as Li Fanta test, cell count,
etc.

Although there are many specimens of pleural and ascites sent by the laboratory every day, it is relatively rare to detect tumor cells from routine ascites.

case after

case after

On this day, the inpatient department sent an ascites for routine examination of ascites.
According to the routine operation procedure, I first observed the status of the specimen: yellow, turbid, no clot, Li Fanta test 1+, and then tested on the machine in the body fluid mode.
cell count
.

Figure 1 Yellow turbid ascites specimen

Fig.
1 Specimen of ascites with yellow turbidityFig.
1 Specimen of ascites with turbid yellow

After getting on the machine, it was found that the white blood cell count was too high, so the specimen was mixed and the smear microscope was started.
In addition to a large number of white blood cells, there were many clumps of cells under the wet film.
If you look closely, some clumps of cells can be vaguely seen "empty".
Because there are too many leukocytes in the mixed sample under the microscope, which affects the identification of cells, the supernatant is then centrifuged to absorb the supernatant and then look carefully.
There are indeed atypical cells: larger than leukocytes, round or irregular, single or clustered Yes, some single cells still seem to have "tumor-like protrusions" at the edges, and some clumped cells still have obvious vacuoles
.

Is this a tumor cell? With such doubts, Wright's staining microscopy was started

Figure 2 Under low magnification (10X), a large number of vacuolated clumped cells (wet slide) can be clearly seen

Fig.
2 Under the low magnification (10X), a large number of vacuolated clumps are clearly seen (wet film) Fig.
2 Under the low magnification (10X), a large number of vacuolated clumps are clearly seen (wet film)

Figure 3 Under high magnification (40X) vacuolated cells (wet slide)

Figure 3 Under high magnification (40X) vacuolated cells (wet slide) Figure 3 Under high magnification (40X) clumps with vacuoles (wet slide)

Figure 4 Single cells with irregular edges and "tumor-like protrusions" under high magnification (40X) (wet film)

Fig.
4 Under high magnification (40X), the edge is irregular, and the single cell like "tumor" (wet film) Fig.
4 The edge under high magnification (40X) is uneven, and the single cell like "tumor" (wet) piece)

Figure 5 Single large cell (wet slide) under high magnification (40X)

Fig.
5 Single large cell (wet slide) under high magnification (40X)Fig.
5 Single large cell (wet slide) under high magnification (40X)

After Wright staining, the morphological characteristics under oil microscope: the cell body is larger than the leukocyte, and the cells in clusters can be seen, the boundary is unclear, the nucleus is basophilic, and the size is different.
There are vacuoles inside, like "glandular cavity-like", and the edge of some single cells is incomplete, like "tumor-like protrusions", and mitotic figures can be seen in some cells
.

Figure 6 Wright's stained clumps of cells under low magnification (10X)

Fig.
6 The vacuolar-sensing agglomerates after Wright staining under low magnification (10X)Fig.
6 The vacuolar-sensing agglomerates after Wright staining under low magnification (10X)

Figure 7 The cells with vacuolar feeling after Wright staining under oil microscope

Fig.
7 Wright stained cells with vacuoles under oil microscopeFig.
7 Wright stained cells with vacuoles under oil microscope

Figure 8 Cells with irregular edges under the oil microscope

Fig.
8 The cells with irregular edges under the oil microscope, like "tumor-like protrusions" Fig.
8 The cells with irregular edges under the oil microscope, like "tumor-like protrusions"

Figure 9 Single cell with vacuolar feeling under oil microscope

Fig.
9 A single cell with vacuoles under oil microscopeFig.
9 A single cell with vacuoles under oil microscope

Seeing this, I believe that the experienced morphology teacher must know that this is a tumor cell, but for me, who is inexperienced, I am still not sure.
I then asked the clinician about the patient's condition.
It is indeed a tumor patient.
, with a history of "right ureteral mass resection"
.

According to the clinical manifestations of the patient and the reports of the morphological characteristics of tumor cells in the literature, it was considered as tumor cells
.

A few days later, the pathological results of the patient's ascites were tracked, and it was confirmed that the specimen had tumor cells, and a large stone in the heart also fell

case analysis

case analysis

The patient, male, 81 years old, was admitted to the hospital due to "recurrent left lower abdominal distension and pain for more than one month".
The postoperative pathological findings of "right ureteral mass resection" in our hospital in November 2021: 1.
(right kidney, ureter, bladder) ureter: invasive urothelial carcinoma, high grade
.

The tumor had a maximum diameter of 4.

2.
Immunohistochemistry : GATA-3 (+), CD10 (+), CK20 patch (+), P53 (mutant, +), Ki-67 (60%, +)
.

3.

immunity

Improve the relevant examination after admission, the current clinical diagnosis are: 1, left (after surgery) ureter cancer, 2, peritonitis, 3, benign prostatic hyperplasia, 4, hypertensive disease level 3 (high risk), 5, left lower extremity venous thrombosis formation
.

Diagnosing Hypertensive Thrombosis

Figure 10 Ascites pathology report

Figure 10 Ascites Pathology Report Figure 10 Ascites Pathology Report

Figure 11 Patient's test report

Figure 11 The patient's test report Figure 11 The patient's test report

Combined with the patient's previous "right ureteral tumor resection", elevated tumor markers, pathological examination of ascites, tumor cells in routine microscopic examination of ascites, imaging examinations, etc.
, it is considered that the patient may have tumor recurrence and ascites of tumor cells ( transfer)
.

So how to identify tumor cells? Experts with rich experience in morphology once summed up such a sentence, malignant tumor cells can have the typical morphological characteristics of "three three thousand three deep"
.

The three refer to a large cell body, a large nucleus, and a large nucleolus

Poorly differentiated tumor cells often fall off in clusters, and the nucleus is located at the edge of the cell, causing the edge cells to bulge, and the entire cancer cell cluster is arranged in a mulberry-like pattern
.

Some tumor cells adhere to more erythrocytes or lymphocytes, which is called the phenomenon of blood cell adhesion to tumor cells

Summarize

Summarize

Serous cavity effusion is a common clinical sign, and its etiology is more complicated
.

The main causes of peritoneal effusion are liver cirrhosis, tumor and tuberculous peritonitis, etc.

When malignant tumor cell infiltration or inflammation occurs in the thoracic and abdominal cavity, the effusion in the cavity will increase and gradually accumulate, and the nature of the effusion will also change
.
In recent years, the incidence of malignant tumors in China has been increasing year by year, and the cases of malignant pleural effusion are also increasing
.

Cancer cells are prone to invasion and metastasis with associated complications
.
When cancer cells invade the pleura and peritoneal tissue, it is easy to cause pleural effusion and ascites, and in severe cases, it will affect the patient's breathing and other functional activities
.

The compression of pleural effusion on the pleural cavity can lead to local alveolar relaxation disorders, local blood oxygen exchange is affected, and patients have different degrees of dyspnea symptoms
.
Patients with severe ascites may experience abdominal distention, bloating, and abdominal pain
.
However, pleural and ascites can also occur in clinical inflammatory diseases.
It is necessary to distinguish inflammatory pleural and ascites from cancerous pleural and ascites.
Therefore, the cytological test results of serous effusion have an important impact on the diagnosis
and treatment of diseases .

diagnosis and treatment

Cytological examination of serous cavity effusion is extremely important for the diagnosis of some diseases of unknown cause and nature, and its diagnosis mainly depends on pathological examination, while most laboratory departments still use routine examination for serous cavity effusion to differentiate it.
The mode of exudate or exudate is the main mode, and less attention is paid to cell morphology.
There are many and complex reasons for clinical serous cavity effusion.
Only identifying exudate or exudate is easy to be misled by clinical manifestations of diseases.
The mode of routine examination of the serous cavity has been difficult to meet the needs of clinical examination and disease diagnosis
.
The cytological examination of serous cavity effusion, the detection of tumor cells is one of the important methods to determine malignant effusion.
It has high specificity, simple and rapid method, and is more suitable for clinical needs.
The detection of tumor cells is important for the metastasis of malignant tumors.
And early detection of tumors is extremely important
.

Therefore, as an examiner, we should pay attention to the morphology of serous cavity effusion cells, strengthen their identification, and provide a timely basis for clinical diagnosis by "finding tumor cells"
.

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